Individualized Education Program (IEP) by djz44927

VIEWS: 43 PAGES: 10

									                                                       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: ____/____/____

Student/Child's Name: _________________________________________                                Date of Birth: ____/____/____
Disability Category: ___________________________________________                               Child Count ID #: ____________
School or Program: ____________________________________________                                Grade Assigned: _______
Parent/Guardian: ______________________________________________                                Telephone #: _______________
Address:__________________________________________________________________________________


Initiation and Duration of School Year IEP Services:                                 ____/____/____ to ____/____/____
                                                                                     ____/____/____ to ____/____/____
Initiation and Duration of Extended Year Services:                                   ____/____/____ to ____/____/____

                IEP Team Members                                  Printed Name/Position/Agency         (check box if in attendance)

Name:                                                             Parent(s)/Guardian/Surrogate/Adult Student (circle one)      

Name:                                                             Student (when appropriate)                                   

Name:                                                             Local Education Agency (LEA) Representative                  

Name:                                                             Special Education Teacher or Service Provider                

Name:                                                             General Education Teacher                                    
                                                                  Individual who can interpret the instructional
Name                                                              implications of evaluation results                           
                                                                  Individual who can conduct diagnostic
Name:                                                             Examinations (SLD requirement)                               

Others with knowledge of the child*                               Position/Agency

Name:                                                                                                                          

Name:                                                                                                                          

Name:                                                                                                                          

Name:                                                                                                                          

Name:                                                                                                                          

Name:                                                                                                                          
                                             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.




                                                             Page ___ of ___                                       Form 5


   Form 5: Individualized Education Program (September 1, 2009)                                                2
                                                       Vermont Department of Education


                                 Individualized Education Program
                          Annual Goals, Short-Term Objectives, Benchmarks
Student Name: _______________________________________________ IEP Meeting Date: ____/____/____


Measurable Annual Goals, Short-term                               Evaluation
Objectives, Benchmarks                                            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

                                                              Page __ of __                                         Form 5

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




                                                              Page __ of __                                      Form 5

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


                                       Individualized Education Program
                                   Post Secondary Transition Plan, Page Two
Coordinated, Measurable, Annual Transition Goals based upon student preference,                         Progress Review
interests and required transition assessments listed above. (Consider various options                        Dates
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 ):

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):




                                                              Page __ of __                                      Form 5

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


                                     Individualized Education Program
                                Post Secondary Transition Plan, Page Three
Coordinated, Measurable, Post-Secondary Transition Goals based upon student                      Progress Review
preference, interests and required transition assessments listed on the previous                      Dates
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):

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)                                           6
                                                       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:

                       Grade        Course Required for Graduation                      Credit     Alternative   Alternative
      School Year                                                                                                  Credit
                       Level       and/or Post-Secondary Annual Goal                   Required    Course or
                                                                                                    activity
     09-10             11        Algebra 2                                         2              Life-skills    2
     (Example)                                                                                    math 1




   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)                                                      7
                                                        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.


                                                               Page __ of __                                           Form 5

    Form 5: Individualized Education Program (September 1, 2009)                                                   8
                                                       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 40% to 79% of the time
 Inside regular class less than 40% of the time                        Separate day school – public or private
 Residential facility                                                  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 40-79% of the time
 Regular early childhood program less than 40% of the time             Special education separate class
 Special education separate school                                     Special education residential facility
 Receives special education at a service provider’s location           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:




                                                                       Page __ of __                              Form 5


   Form 5: Individualized Education Program (September 1, 2009)                                                        9
                                                       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):




                                                           Page __ of __                          Form 5


   Form 5: Individualized Education Program (September 1, 2009)                            10

								
To top