Individualized Education Program _IEP_

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					Vermont Department of Education

Individualized Education Program (IEP)
School District: ___________________________________________ Annual Review Date: ____/____/____ IEP Case Manager: ____________________________________Effective date of Revision : ____/____/____ Next 3-year Re-evaluation Date: ____/____/____ Next Annual Review Date: ____/____/____ Date of Birth: ____/____/____ Child Count ID #: ____________ Grade Assigned: _______ Telephone #: _______________

Student/Child's Name: _________________________________________ Disability Category: ___________________________________________ School or Program: ____________________________________________ Parent/Guardian: ______________________________________________

Address:__________________________________________________________________________________ Initiation and Duration of School Year IEP Services: ____/____/____ to ____/____/____ ____/____/____ to ____/____/____ Initiation and Duration of Extended Year Services: IEP Team Members
Name: Name: Name: Name: Name: Name Name:

____/____/____ to ____/____/____
(check box if in attendance)       

Printed Name/Position/Agency

Parent(s)/Guardian/Surrogate/Adult Student (circle one) Student (when appropriate) Local Education Agency (LEA) Representative Special Education Teacher or Service Provider General Education Teacher Individual who can interpret the instructional implications of evaluation results Individual who can conduct diagnostic Examinations (SLD requirement)

Others with knowledge of the child*
Name: Name: Name: Name: Name: Name:

Position/Agency
     

Page __ of __ Form 5 *Including individuals for Family Infant Toddler Program or Post-Secondary Transition Planning
Form 5: Individualized Education Program (September 1, 2009) 1

Vermont Department of Education

Individualized Education Program Present Levels of Educational/Functional Performance
Student Name: _______________________________________________ IEP Meeting Date: ____/____/____
Identify the student’s present levels of educational performance including the student’s functional performance, abilities, acquired skills and strengths; and how the disability affects the student’s involvement and progress in the general curriculum. Use this section as further documentation of skills that will result in services changes. For preschool children, identify how the disability affects the child’s participation in activities appropriate for the child.

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Form 5

Form 5: Individualized Education Program (September 1, 2009)

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Vermont Department of Education

Individualized Education Program Annual Goals, Short-Term Objectives, Benchmarks
Student Name: _______________________________________________ IEP Meeting Date: ____/____/____ Measurable Annual Goals, Short-term Objectives, Benchmarks Evaluation Procedure(s)

Progress Review Dates

Progress Review Dates Code: A - Achieved the goal/objective as written; S –Sufficient progress on objective is being made, likely to achieve this goal; E – Emerging progress on the objective, continuing to work towards the goal; N – Objective/goal not as yet introduced

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Form 5: Individualized Education Program (September 1, 2009) 3

Form 5

Vermont Department of Education

Individualized Education Program Post Secondary Transition Plan, Page One
Student Name: __________________________________________ IEP Meeting Date: ____/____/____
Current Grade Level:_____________________ Expected Date of Graduation: _____/_____/_____ Evidence of involving student & related agencies: Identify method(s) of outreach to student and interagency partners, e.g., letter/date, phone call/date, email/date

List Age Appropriate Transition/Vocational Assessments (by name of the Assessment and the Date Administered):

Summary of Assessment results (what we learned about the student):

Student’s post graduation expected outcomes (These outcomes are developed in collaboration with the student and the family. They are generally understood to refer to those outcomes that a child hopes to achieve after leaving high school.) Post-Secondary Employment Outcome (required): Example- The summer after leaving high school, student will obtain a part-time position in a community retail environment.

Post-Secondary Education or Training Outcome (required): Example- Upon completion of high school, student will enroll in courses at Community College of Vermont.

Independent Living Outcome (as appropriate): Example- Upon completion of high school, student will independently prepare for work each day, including dressing, making his bed, making his lunch, and accessing transportation.

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Form 5: Individualized Education Program (September 1, 2009) 4

Form 5

Vermont Department of Education

Individualized Education Program Post Secondary Transition Plan, Page Two
Coordinated, Measurable, Annual Transition Goals based upon student preference, interests and required transition assessments listed above. (Consider various options
such part-time employment, supported job placements, service learning projects, work experience, job shadowing, internships, practice in resume writing and interviewing skills, the use of resource centers and job specific skills regarding customer service or technology ):

Progress Review Dates

Community Employment Goal (required):

Vocational Training Goal (if needed): (think “pre-employment” skills. For example: a
student may need to seek time with a mentor/counselor to develop anger management skills to deal with the work related frustrations. A student may need to spend time with an SLP to develop clear, appropriate speech and good eye contact while talking to co-workers. A student may need to acquire the skills to drive a fork lift before applying for a warehouse job. A student may have to practice community mobility in order to get to a job site independently.)

Post-Secondary Education Goal (if appropriate, if not indicate with an N/A):

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Form 5: Individualized Education Program (September 1, 2009) 5

Form 5

Vermont Department of Education

Individualized Education Program Post Secondary Transition Plan, Page Three
Coordinated, Measurable, Post-Secondary Transition Goals based upon student preference, interests and required transition assessments listed on the previous page. (Consider options such as participation in community based experiences, learning how to independently access community resources, building social relationships, managing money, understanding health care needs, utilizing transportation options and organizational skills): Progress Review Dates

Independent Living Goal (if appropriate, if not, indicate with an N/A):

Community Participation Goal (if appropriate, if not, indicate with an N/A):

Describe the Coordinated Interagency Linkages and Responsibilities (services provided or paid for from another agency and a timeline for completion):

If the student will be reaching age 17 during the duration of this IEP, they have been notified that parental rights will transfer to the student upon reaching the age of 18  Yes  No If not, please specify how they were notified):

State and Local Transition Course of Study Requirements:
Requirement: You must check the appropriate box below and develop the corresponding course of study form that follows for either specialized courses or alternative credits earned through a multi-year plan.  Standard Course of Study  Specialized Course of Study for Post-Secondary Annual Goals  Multi-year plan for Graduation Requirements Page __ of __ Form 5

Form 5: Individualized Education Program (September 1, 2009)

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Vermont Department of Education

Individualized Education Program Post Secondary Transition Plan, Page Four
Student Name: __________________________________________ IEP Meeting Date: ____/____/___

Document the specialized course of study or alternative credit courses/programming to support the transition plan:
School Year Grade Level

Course Required for Graduation and/or Post-Secondary Annual Goal

Credit Required

Alternative Course or activity

Alternative Credit

09-10 (Example)

11

Algebra 2

2

Life-skills math 1

2

If alternative credits are being granted through a multi-year plan, this page must be signed by the Superintendent or their designee: _______________________________________ Superintendent or Designee Signature _________________________ Date

Form 5: Individualized Education Program (September 1, 2009)

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Vermont Department of Education

Individualized Education Program Special Education Services, Related Services, Consent to Bill Medicaid
Student Name: ______________________________________________ IEP Meeting Date: ____/____/____
Special Education Services Frequency Duration Location Personnel or Provider Group Size

Related Services

Frequency

Duration

Location

Personnel or Provider

Group Size

Transition Services

Frequency

Duration

Location

Personnel or Provider

Group Size

Extended School Year Services

Frequency

Duration

Location

Personnel or Provider

Group Size

Parental Consent to Bill Medicaid
As the parent/guardian, I give permission __ or do not give permission __ to the school district to bill Medicaid for the eligible services listed above. This permission also allows the release necessary special education records to a physician or nurse practitioner in order for him/her to reach a determination that the services are medically necessary; as well as to individuals within the Department of Education and the Agency of Human Services charged with processing Medicaid bills for those services above that are considered medical services under Vermont Medicaid rules. I understand that if I refuse to consent, my refusal will not affect the school district’s responsibility to provide these services to my child at no cost to me. I understand that I may revoke this consent at any time and, if I revoke this consent, it will apply to billing for services from that date forward.

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Form 5: Individualized Education Program (September 1, 2009) 8

Form 5

Vermont Department of Education

Individualized Education Program Placement, Accommodations/Modifications for Assessments
Student Name: _____________________________________________ IEP Meeting Date: ____/____/____ If the student cannot participate full-time with non-disabled children in the regular class, extracurricular or other non-academic activities explain why full participation is not possible:

Description of the student/child’s placement:

The general characteristics of the student/child’s placement (check one, ages 6-21):
 Inside regular class at least 80% of the time  Inside regular class less than 40% of the time  Residential facility  Inside regular class 40% to 79% of the time  Separate day school – public or private  Homebound/Hospital

The general characteristics of the student/child’s placement (check one, ages 3-5):
 Regular early childhood program at least 80% of the time  Regular early childhood program less than 40% of the time  Special education separate school  Receives special education at a service provider’s location  Regular early childhood program 40-79% of the time  Special education separate class  Special education residential facility  Receives special education services at home

Accommodations, Modifications and Supplementary Aids State-level assessment (please check appropriate box or boxes): The team has determined that the student will be taking the on-level State assessment with the appropriate accommodations identified below. The team has determined that the student has multiple complex disabilities and should be considered for a portfolio assessment on Alternate Grade Expectations. The Documentation of Eligibility for Alternate Assessment is attached. Identify the accommodations, modifications and supplementary aids and services needed to participate in national, district-wide, and school assessments:

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Form 5

Form 5: Individualized Education Program (September 1, 2009)

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Vermont Department of Education

Program Modifications/Supports for the Student and School Personnel and Other Options Considered by the IEP Team
Student Name: _____________________________________________ IEP Meeting Date: ____/____/____ Identify other accommodations, modifications, or supplementary aids and supports needed for the student:

Identify the program modifications or supports that will be provided for school personnel and parents to implement the IEP:

Other Options Considered (include reasons why they were not included):

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Form 5: Individualized Education Program (September 1, 2009)

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