IEP Meeting Date - DOC by niusheng11

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									                                 Individual Education Plan (IEP) Checklist

Student Name                                                       IEP Date
To help you remember the required components for IEPs, follow this list for each student.
 Invite student’s regular education teacher(s) who will assist with IEP goals/objectives on Standards.
 Invite an administrator and related service personnel. If special transportation is needed, invite
  Transportation Director.
 Invite parents ahead of due date…reasonable amount of time…send Conference Request and Procedural
  Safeguards Notice (PSN).
 Complete correct IEP form for grade level. (Transition included for students who will be 16 years of age, or
  older, before the next IEP date.)
 Address Majority Age requirement if student is 17 or older…provide letter (copies will be made). Parent
  must initial Majority Age statement on IEP.
 Complete Summary of Performance (SOP) and turn original in to Special Services Office.
 Address the need for a Functional Behavior Assessment.
 Develop a Behavior Improvement Plan, if needed. Note: Behavior goals are required for all Emotionally
  Disabled (ED) students.
 Attach a list of Accommodations.
 Address state and district testing…be VERY CLEAR about the current IDEA requirements.
 Address special bus transportation for those students who qualify. Be sure it is appropriate…complete
  Transportation Form and Checklist if needed.
 Prepare Related Services section with assistance and input from related service providers.
 Write Service Summary at end of meeting which outlines the student’s specific program.
 Check documentation section for additional components to include.
 Address Extended School Year (ESY) for all students. Be sure student qualifies under the guidelines. The
  team must consider the need for ESY services at the annual IEP meeting. However, under some
  circumstances, the need for ESY services may not be known at the time of IEP meeting. In that case, the
  team may identify the date it will reconvene to determine needs and services, but that date must be no later
  than 45 calendar days from the end of the school year. The team may also plan what data should be gathered
  to assist them in making the later determinations. When the ESY determination is ultimately made, the IEP
  team must document the decision on the IEP.
 Write a Conference Summary Report during the meeting and list anything that was discussed but not
  addressed on the IEP. This is where you will state addressing the Functional Behavior Assessment,
  disagreements and resolutions.
 Be sure students who are transitioning to another district school have the correct information for minutes and
  classes. Be specific on the Least Restrictive Environment (LRE) section.
 Provide a Prior Written Notice (PWN) for IEP to the parents at the end of the meeting.
 Offer a copy of the PSN to parents and document on the first page by having parent initial. They do not have
  to take it.
 Provide an IEP survey to the parents and a place for them to drop it off.
 Provide a copy of entire IEP to parent.
 Return the original IEP, with this list, to the Special Services office.
                        CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                                                        PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363
INDIVIDUAL EDUCATION PLAN

 Date of last IEP:                                                                                                          SAIS #

 IEP Meeting Date:                                    Student Name:                                                                   Birth date:

 Current Grade:                                       School of Attendance:                                                           Home School:

 Parent(s)/Guardian(s):                                                                                                     Relationship:

 Mailing Address:                                                                                  City:                                        Zip:

 Address (Street):                                                                                 City:                                        Zip:

 Home Phone:                                                   Work Phone:                                 Latest Hearing/Vision Screening:

 Ethnicity:                                     Sex:         M        F      MET Date:

 Eligibility Category:                                         % of Regular Education:                     Related Services Eval.. Date (s):

 Primary Home Language:                                        Service Type:

 Primary Language of Student:                                  Parents have received/declined Procedural Safeguards: _____________(parent initials)

PARENTAL PARTICIPATION                                    (Attach documentation to this page)

                                                1st                2nd            3rd                                 1st             2nd attempt      3rd attempt
Notification: Date(s) Notice Sent                                                                   Phone Contact

    Parent Unable to Attend                              Individual Or Conference Call              Home Visits                      Written Notice
    Other

SPECIFIC EDUCATIONAL SERVICES SUMMARY (NOTE: This section to be completed LAST)
 AMOUNT OF TIME               INITIATION DATE             DURATION                                             DESCRIPTION OF PROGRAM & SERVICES
                                                                                LOCATION
   PROVIDED                     MO/DAY/YR                 MO/DAY/YR                                        EXTENT OF PARTICIPATION IN REGULAR PROGRAM




PARTICIPANTS (NOTE: *Must Attend)
      MULTIDISCIPLINARY TEAM                                                                MULTIDISCIPLINARY TEAM
            MEMBERS                                              SIGNATURE                        MEMBERS                                      SIGNATURE
*Parent/Guardian/Surrogate                                                               Student

*School Administrator/LEA Rep.                                                           Speech/Language Therapist

*Special Education Teacher                                                               Physical Therapist

*Regular Education Teacher                                                               Occupational Therapist
*Interpreter of instructional implications of                                            Counselor
evaluation data AND/OR Psychologist

Special Education Director                                                               Teacher

School Nurse                                                                             Other




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                  CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                                            PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363
INDIVIDUAL EDUCATION PLAN
Grade:                                                                                                                                     IEP Date:
Student’s Name:                                             Staff Responsible for Implementation:
Present Level of Performance in:
    Written Language       Reading         Math      Other:


Measurement of Progress:
    Observation        State Standards Assessments         Checklist        Testing         Daily Performance/Work Samples                 Brigance

    School Personnel Interviews         Other:

The Annual Goal is related to Arizona State Standards for Content area at the                                      Level and will allow Name to
     .
Standard:

Measurable Annual Goal including how the student’s progress toward this                             Review of Progress * Mastery Status
annual goal will be measured. §300.347(a)(2).                                                QTR 1        QTR2          QTR3              QTR4         ESY
                                                                                             Date Sent    Date Sent     Date Sent         Date Sent       Yes
                                                                                             to Parents   to Parents    to Parents        to Parents
                                                                                                                                                       Targeted

                                                                                                      %          %                %              %           %

                                                                                                *            *               *               *           *

* M=Goal Met      SPM = Sufficient Progress Made to Meet Goal          IPM = Insufficient Progress Made to Meet Goal             NA = Goal Not Yet Addressed

Progress comments:
                   100
                    90
                    80
                    70
                    60
                    50
                    40
                    30
                    20
                    10
                     0
                                  Aug      Sept      Oct        Nov        Dec        Jan       Feb       Mar          Apr          May          Jun


                                                                                                    Review of Progress * Mastery Status
Short term objectives or benchmarks (Minimum of 2) §300.347(a)(2).
                                                                                             QTR 1        QTR2          QTR3              QTR4
                                                                                                      %          %                %              %

                                                                                                      %          %                %              %

                                                                                                      %          %                %              %

                                                                                                      %          %                %              %



____________________________________________________________
Teacher/Therapist Signature


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                   CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                                              PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363
INDIVIDUAL EDUCATION PLAN
Student Name:                                                                                                                            IEP Date:
LEAST RESTRICTIVE ENVIRONMENT (LRE)
              CONTINUUM OF ALTERNATIVE PLACEMENT (check all sites and settings in which services will be provided)
                                  SITE                                      INSTRUCTIONAL SETTING
    Regular school within the district                   Regular education
    Regular school outside the district                                                Supplementary aids & consultant services
    Special school within the district                                                 Supplementary services (Itinerant support)
    Special school outside the district                                                Supplementary services (Resource support)
    Home instruction
    Community based site
    Residential school                                                            Special education
    Hospital or treatment center                                                       Self contained
    Other:                                                                             Other:
Explain why alternative placement(s) selected above is/are appropriate and least restrictive, taking into account any potential harmful effects on the
student or on the quality of services needed:



                                           SITE AND SETTING/DETERMINATION (Select all that apply)
    The site selected is the school that student would attend if he/she did not have a disability.
    The site selected is as close as possible to the child’s home.
    The setting selected is based on the child’s IEP.
    To the maximum extent, the child will be educated with nondisabled students.
If any responses are NOT checked, explain the selection of the site/setting:

EXTENT OF PARTICIPATION IN REGULAR EDUCATION
Please indicate the regular education classes in which the student will NOT participate with non-disabled students in the general curriculum:
   Reading               English            Writing           Math                Science             Social Studies      Physical Ed.        Other
Check any PROGRAM OPTIONS below in which students will NOT be participating with students who do not have disabilities. If less than 100%,
indicate time per week in program:
    Vocational                            m.wk          Music                               m.wk             Other          m.wk
    Library                               m.wk          Art                                 m.wk             WILL participate in all programs
Check any nonacademic services in which the student will NOT participate with students who do not have disabilities.
    Recess                  Lunch                Assemblies           Athletics              Clubs                     Employment           Other
                                                      CONSIDERATION OF SPECIAL FACTORS
                                                                                                                         NEEDED             NOT NEEDED
The need for assistive technology devices and services has been considered.
Any special communication needs of the child have been considered.
Any transition service (school to adult life) needs of the child have been considered.
For a student whose behavior impedes his/her learning, or that of others, positive behavior interventions,
strategies and supports have been considered.
For student with limited English proficiency, the effect of his/her language needs on the IEP have been
considered.
For student who is blind or visually impaired, an evaluation, the need for instruction, and the use of
Braille have been considered.
For a student who is deaf or hard of hearing, his/her needs for communicating with peers and professional
personnel in his/her mode of communication have been considered.




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                    CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                                              PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363
INDIVIDUAL EDUCATION PLAN
Student Name:                                                                                                                      IEP Date:
STUDENT STRENGTHS


PARENT’S EDUCATIONAL CONCERNS


          RELATED SERVICES/ANCILLARY SERVICES/SUPPLEMENTARY AIDS & SERVICES
    CHECK IF NO RELATED SERVICES ARE NEEDED

          TYPE              INITIATION DATE          FREQ/TIME                                   ANTICIPATED SPECIALIST
SPEECH
O.T.
P.T.
H.I.
V.I.
TRANSPORTATION
SOCIAL
OTHER

LIMITED ENGLISH PROFICIENT (LEP)
    CHECK IF LEP SERVICES ARE NEEDED
    Language of instruction if other than English:

DOCUMENTATION INCLUDED AS ADDENDA
    Behavior Plan                                       Accommodation List                                     Other
    Braille Instruction                                 Reintegration Plan Developed
    Exit Criteria For Residential Facility              Specialized Transportation Plan
    Summary of Performance                              Transition Plan (All Students ≥ 16 Years Of Age)

ESY CONSIDERATION
    YES          The checked short-term objectives/benchmarks will be considered for ESY
    NO           The student’s IEP was screened and no objectives were found to be eligible for ESY
    To be determined in

    Parents have been informed that a quarterly written report of their child’s progress toward annual goals will be provided           (Parent Initial)

PROGRAM SUPPORTS FOR SCHOOL PERSONNEL
Describe services needed, include initiation date, amount of time, location, and providers position. State the type of supports necessary for school
personnel to work with student or to provide appropriate services. If none need, check here      None if needed:




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                  CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                                           PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363
INDIVIDUAL EDUCATION PLAN

                                        STATE/DISTRICT TESTING FOR STUDENT
Student Name:                                                                              IEP Date:
(Pick only one below.)
    1.      The student will participate in state/district assessment(s) without accommodation(s).
    2.        The student will participate in state/district assessment(s) with the following accommodation(s):
The student will participate in assessment(s) with the following accommodation(s).
Standard Accommodations                                             Universal Accommodations
The following standard accommodations are available to Special          The following universal accommodations are available to all students,
Education students and 504 students:                                    including Special Education students and 504 students, as deemed
   more breaks and/or several shorter sessions                          needed by the teacher:
   extended time for Terra Nova testing in Grades 2 and 9                  a separate location or study carrel
   test at a different time of day                                         preferential seating
   small group administration or one-on-one testing
                                                                           special lighting
   simplify directions in English
   read or sign directions                                                 student wears noise buffers (after directions)
   exact sign language interpretation of the writing prompt,               special furniture or pencil
   mathematics test items+, or science test items+                         familiar test administrator
   magnification device
                                                                           repeat directions
   amplification equipment
   place marker use                                                        clarify directions
   read aloud in English the writing prompt, mathematics test              color overlay
   items+, or science test items+
   large print or Braille edition of test
   for a student who is blind, use of an abacus for mathematics test
   items
   for a student who is blind, use of an electronic dictionary and
   thesaurus with grammar check, spell check, encyclopedia,
   translation, and internet access turned off
   for a student who is blind, Braille writers*
   write answers directly into test booklet*
   record or dictate multiple choice responses to a scribe*
   use assistive technology with spell check, grammar check and
   predict ahead functions turned off
+ A test item includes both the question and corresponding answer choices. Any stimulus preceding the item may be read aloud.
* For these accommodations, the student’s responses must be transferred to the student’s answer document as directed in the corresponding
  Test Administration Directions manual.

    3.        The student will participate in alternate assessment using: (Determined by eligibility criteria page)
                 AIMS-A




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                    CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                                               PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363
INDIVIDUAL EDUCATION PLAN
                                                      Eligibility Determination Form
                                                           Alternate Assessments

Student Name:                                               DOB:                     Grade:                    IEP Date:

Significant cognitive disability (SCD) eligibility requirements: In order to be considered for alternate assessments, students must meet
all of the following criteria:

1. Evidence of a significant cognitive disability: Empirical evidence (formal testing results, multidisciplinary evaluation team
   results, etc.) of a significant cognitive disability that prevents the acquisition of the Arizona Academic Standards.
Check disability category:
  MIMR                 MOMR              SMR                 MD with MR component                 MDSSI with MR component
  TBI with MR component                  Autism with MR component
  Student functions like a student with MIMR across all areas-commensurate abilities in reading, writing, and mathematics,
Adaptive Behavior scores, and measures of intellectual abilities.
            Example 1: An 8th grade student functioning at 2nd grade in reading and writing and at 4th grade level in mathematics does
               not qualify under criteria 1.
            Example 2: A 10th grade student functioning at the 2nd grade level in reading, writing, and mathematics does qualify under
               criteria 1.
            Note: Students with learning disabilities who have overall intellectual and/or adaptive behavior abilities within the average
                range are not students with a significant cognitive disability.
          Yes           No       Comments:

2.    Intensity of Instruction: It is extremely difficult for the student to acquire, maintain, generalize, and apply academic skills across
      environments even with extensive/intensive, pervasive, frequent, and individualized instruction in multiple settings.
         Yes            No Comments:

3.    Curricular Outcomes: The goals and objectives in the student’s IEP focus on enrolled grade-level Alternate Arizona Academic
      Standards (www.ade.az.gov/standards, click on AIMS-A).

Student meets the definition of significant cognitive disability (SCD)
     Yes
     No (If any response above is marked no, the student does not qualify to participate in alternate assessments.)

Most recent alternate assessment test results:

AIMS-A Test Year               Level I     Level II                   ASAT Test Year          Level I      Level II
Standards          Falls Far      Approaches       Meets   Exceeds   Standards      Falls Far     Approaches      Meets    Exceeds
Performance        Below                                             Performance    Below
Levels                                                               Levels
Reading                                                              Reading
Listening                                                            Listening
Speaking                                                             Speaking
Writing                                                              Writing
Math                                                                 Math
Comments:




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                                        CHINO VALLEY UNIFIED SCHOOL DISTRICT
                                      CONSENT TO CLAIM MEDICAID REIMBURSEMENT

Student Name:                                                             Birth Date:

School:                                                                   ID#:

The Chino Valley Unified School District #51 receives funding from the Medicaid Direct Service Claiming (DSC) program for IEP
covered services to eligible children through the Arizona Health Care cost Containment System (AHCCCS), Arizona’s Medicaid
agency. Examples of covered services include speech therapy, assistance with daily living skills, special education transportation and
nursing services.

The School District will need to determine if your child is eligible or should become eligible in the school-based Medicaid program.
With the consent below, the District will submit your child’s name to AHCCCS and their authorized agencies to verify eligibility for
the DSC program. The school may use Medicaid (AHCCCS) benefits in which a child participates to provide or pay for services in
the Individualized Education Program (IEP.) Parents are not required to sign up for or enroll in AHCCCS to receive IEP services or a
free appropriate public education, nor are they responsible for any out of pocket expenses for these IEP services. The schools use of
this reimbursement program does NOT in any way affect or impact other AHCCCS benefits to which the child is entitled, including
any otherwise eligible services outside of school. Parents’ refusal to allow access to their AHCCCS benefits does not relieve the
school of its responsibility to ensure that all required services are provided at no cost to the parents. Granting of consent is voluntary
on the part of the parent and may be revoked at any time. If consent is removed, that revocation is not retroactive (i.e., it does not
negate an action that has occurred after the consent was given and before the consent was revoked.) (300.154)

If my child is determined to be Title XIX (Arizona Long Term Care) eligible, the school district may submit a claim to my child’s
private insurance company for the sole purpose of determining whether or not any of the school based health related services being
provided as proscribed in the IEP are covered. If the insurance carrier denies the claim, I understand that the school district will be
able to seek reimbursement through AHCCCS.

The IEP services and scope of services for which this school is seeking AHCCCS reimbursement are:

SERVICES TO BE CLAIMED: From                         to              .
SERVICES TO BE CLAIMED                            ANNUAL AMOUNT OF SERVICE ON IEP


Speech Therapy                                                  sessions per week/mo x 37 weeks (circle one)

Occupational Therapy                                            sessions per week/mo x 37 weeks (circle one)

Physical Therapy                                                sessions per week/mo x 37 weeks (circle one)

Counseling                                                      sessions per week/mo x 37 weeks (circle one)
Attendant Care for health related needs           Check one:
(Specific activities as stated on IEP)               One to 5 hours per week (15-60 min/day)
   Eating/feeding        Positioning                 12 hours/week (1-2 hours/day)
   Dressing              Mobility
   Toileting             Grooming
   Transfers             Use of Assistive Devices

Transportation                                     188 days round trip

Nurse                                                  Daily medication or,      daily treatments X’s 188 days


I understand and agree to the carrying out of Medicaid/AHCCCS claims by the school for the services specified above.
Any increase in hours or addition of services must have my written consent:


Parent Signature                                       Date ___________________________________________________________



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                                   CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                                              PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363


                                    TRANSITION SERVICES: IEP REQUIREMENTS
Student Name:
Transition Services must begin not later than the first IEP to be in effect when the child is 16 or younger if determined appropriate by the IEP
team, and updated annually thereafter. Transition Services must include appropriate measurable postsecondary goals based upon age
appropriate transition assessments related to training, education, employment, and, where appropriate, independent living skills; the transition
services (including courses of study) needed to assist the child in reaching those goals.
ASSESSMENTS
Training:


Education:


Employment:


Independent Living Skills:
Assessment needed:       Yes             No (If yes, indicate assessment type below.)
Other:


STUDENT STRENGTHS, PREFERENCES, AND INTERESTS
Information about the student’s strengths, preferences, and interests were provided by:
     Student            Parent(s) and/or Family Members              School Staff
     Service Agency (        )           Other (        )


POST SECONDARY GOALS
Training          Education           Employment        Independent Living
1.
2.
3.
4.

                                 Statement of Transfer of Rights at the Age of Majority §300.520
Beginning not later than one year before the child reaches the age of majority (age 18 in Arizona), the child and his/her parents
were informed of the transfer of rights under Part B of IDEA (except for a child with a disability whose rights remain with a court
appointed guardian).

     Yes, Date:

Guardianship legally held by other:




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                             CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                                         PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363


                                                  Transition Services Activities
                                                                                  Person and/or Agency                         End
Transition Area                  Transition Activity/Strategy                                                 Start Date
                                                                                       Responsible                             Date
Education/
Instruction

Community
Experience


Employment


Adult Living


Daily Living Skills


Functional/
Vocational


Related Services


Other

COURSES OF STUDY
School Year:                        School Year:                        School Year:                     School Year:
Semester 1                          Semester 1                          Semester 1                       Semester 1
   World Geography or Health           English Elective                    English Elective                 Senior Research Project
   Freshman English                    World History                       American/AZ History              Free Enterprise
   CAT 9                               Int. Science II                     Fine Art/Vocational              (Economics)
   Int. Science I                      Geometry M                          Algebra II M                     Elective
   Algebra I M                         Elective                            Biology                          Elective
   Freshman Physical Education         Elective                            CAT 11                           CAT 12
   Elective                            CAT 10                           Semester 2                       Semester 2
Semester 2                                                                 English Elective                 Senior Research Project
                                    Semester 2
   World Geography or Health                                               American/AZ History              Free Enterprise
                                       English Elective
   Freshman English                                                        Fine Art/Vocational           (Economics)
                                       World History
   CAT 9                                                                   Algebra II M                     Elective
                                       Int. Science II
   Int. Science I                                                          Biology                          Elective
                                       Geometry M
   Algebra 1M                                                              CAT 11                           CAT 12
                                       Elective
   Freshman Physical Education
                                       Elective
   Elective
                                       CAT 10
ADDITIONAL EDUCATIONAL OPPORTUNITIES




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                      CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                                         PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363
CONFIDENTIAL EMERGENCY INFORMATION-SPECIAL SERVICES TRANSPORTATION FORM
NOTE: The Special Services Department and Transportation Department require that this form be completed
      entirely prior to the placement of a student on the Special Services Bus. The Transportation Director MUST
      be invited to the IEP meeting when transportation is being requested.
                                                                  Please Print Clearly
Meeting Date:         School Year:                 Grade:               Teacher:
Name of Student:           DOB:              Category:
School:         Specific Program:                      Full Day             AM            PM
Time to Drop Student Off at School:                 Time to Pick Student Up at School:
Parent Name(s):            Street Address:
City:         Home Phone #:
Mother Work #:          Father Work #:
Special Bus Equipment Required:
    Wheelchair Lift        Seat Belt               Car Seat               Harness/Parent Signature: _______________________________
    Aide assistance required during transportation
Pick-Up Location:                                                                                              Phone #:
Take Home Location:                                                                                            Phone #:
IEP goals/objectives or behavior plan that validate(s) need for transportation:
Information to assist driver in managing student:
TWO Emergency/Alternate Contacts
Name:______________________________ Address: _______________________________ Phone: __________________
Name:______________________________ Address: _______________________________ Phone: __________________
Emergency Medical Information
Student’s Doctor: ____________________________ Phone #: _____________________ Hospital: ____________________
Medications: _________________________________________________________________________________________


Special Services Approval:___________________________________________                                                 Date: _______________________
                             Signature of Dir./Assist. Dir. required prior to Transportation Dir. signature.


Transportation Approval:      __________________________________________                                              Date: _______________________




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                         CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                                      PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363
CONFIDENTIAL EMERGENCY INFORMATION-SPECIAL SERVICES TRANSPORTATION FORM




This checklist may be used to assist in the determination of eligibility for specialized transportation services:

                                                                                    YES             NO

Is this student eligible for and receiving services under IDEA?                                   
Does the student currently receive special transportation?                                        
Was the special transportation approved by the IEP Team?                                          
Was the parent informed of the LRE issue?                                                         
Does this student exhibit a seizure disorder?                                                     
Are there other health related concerns?                                                          
Is the need for specialized transportation related to the disability?                             
Is the specialized transportation a convenience issue?                                            
Is the specialized transportation needed to provide FAPE?                                         
Does regular transportation pose a safety hazard?                                                 

Does this student have a behavior plan?                                                           





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                    CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                                               PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363
INDIVIDUAL EDUCATION PLAN
Student Name:                                                                                                                              IEP Date:
ACCOMMODATIONS CHECKLIST
Accommodations are substantial changes in what a student is expected to learn. These changes must be made to provide a student opportunities to participate
meaningfully and productively in learning experiences and environments. Accommodations include instructional level, content, performance criteria, etc.
Accommodations are provisions made in how a student accesses and demonstrates learning. The changes are made in order to provide a student equal access to
learning opportunities. Accommodations include changes in and or provisions in time/schedule, equipment, presentation and/or response to format and procedures.
NOTE ALL APPLICABLE AREAS AND DOCUMENT SUGGESTED STRATEGIES/ACCOMMODATIONS – ADD SPECIFIC INFORMATION AS NEEDED
Some suggested accommodations are:
Environment                                              Offer step-by-step guidance through the work         Provide simplified and shortened test, at
 Preferential Seating                                  with personal instructions.                             academic instructional level of student.
 Eliminate distractions                               List the steps of a process on study sheet or          When testing, correct written work for concepts,
 Modify length of school day                           tape; allow student to refer to it as he/she works.     not for the area of disability (spelling, writing,
Academic                                               Provide lecture notes.                                  etc.)
 Ask the student to do work just beyond his/her       Provide extra practice.                                Provide extra time.
  current level of achievement.                        Encourage the student’s participation in setting       At teacher discretion, allow for assignments
 Reduce the number of assignments required.            his/her own goals.                                      and/or tests to be taken in resource room, with
 Focus instruction on main ideas & supporting         Allow use of a calculator or word processor.            special education teacher assistance, if needed.
  facts.                                               Provide flexibility of academic assignments as         Provide extra credit opportunities.
 Allow the student to work at his/her own pace.        indicated, based on performance/need.                  Hands-on projects instead of tests, if needed.
 Simplified, self-paced instruction.                  Allow more time to complete assignments.               Allow taping of reports or tests.
 Modify assignment; shorten, lesser degree of         Avoid forcing students with specific problems          Provide opportunities for oral reporting and
  difficulty.                                           into situations where failure is inevitable; i.e.       testing.
 Cut concepts into smaller steps than is done in       reading aloud, writing on the board, spelling         Behavioral/Additional
  most texts.                                           aloud, etc.                                            Weekly academic/behavioral progress report
 Allow students with learning problems to             Use visual devices to accompany oral                    sent to parents.
  concentrate on smaller amounts of material, but       presentations.                                         At discretion of teacher, student may be sent to
  require work to be done accurately and carefully    Testing/Grading                                           resource room to complete assignment, for
  done.                                                Modified grades that allow for differing                remainder of period only, to assist student in
 Allow individualized curriculum. Assignments          expectations.                                           gaining behavioral self-control.
  still are focused on the subject studied by the      Grades based on effort, work, and participation.       Allow for pullout time with special education
  entire class, but assignments are individualized     Provide study guides for tests.                         teacher, counselor, psychologist, or additional
  to the student’s academic level.                                                                              special services staff, on an as needed basis.
                                                       Provide prior notice of test content & questions.
 Encourage the student to seek help from other        Provide open book tests.
  students; peer-tutoring.
                                                       Provide opportunity to redo assignments &
                                                        retake tests.
Please personalize below to reflect the individual student’s needs.
                   READING                                              MATHEMATICS                                               WRITING


                 ASSIGNMENTS                                           TESTING/GRADING                           BEHAVIORAL/ADDITIONAL CONCERNS


                       ***ACCOMMODATIONS MUST BE DISTRIBUTED TO EACH TEACHER***




Rev.4/2008                                                                  Page 12         File Name: 9d261827-efa1-485b-860e-6bbc19cc0b90.doc
         CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                         PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363
INDIVIDUAL EDUCATION PLAN

Student Name:                                                                        IEP Date:


MULTIDISCIPLINARY EVALUATION TEAM CONFERENCE SUMMARY
Present at meeting: ______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Purpose of meeting: _____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Present levels: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
ACTIONS/Recommendations: _____________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Signatures of those present:
____________________________________                  ____________________________________
____________________________________                  ____________________________________
____________________________________                  ____________________________________
____________________________________                  ____________________________________


Rev. 4/2008                                            Page 13File Name: 9d261827-efa1-485b-860e-6bbc19cc0b90.doc
                    Chino Valley Unified School District
         P.O. Box 25  Chino Valley  AZ 86323  928-636-0363  FAX 928-636-7462

                                 Conference Request/Meeting Notice
Date of Notice:                       School: Del Rio Elementary                          Grade:
Name of Student:                                              Teacher:
Date:                                 Time:                   Location:
To the Parent/Guardian: In order to provide your child with appropriate services, we need for you to attend
the meeting as scheduled above. This will help in working together to develop a plan for your child’s
education. Please call the teacher or Special Education Office to confirm or reschedule this meeting OR
submit this signed notice. Thank you for your cooperation. We look forward to working together.
The Purpose of This Conference:
   Eligibility determination/continuation review results          Review Existing Data/consideration
                                                                  for Re-evaluation
   Development of IEP                                             Review/Revision of IEP
   Change of Placement                                            Address behavioral needs
   Transition Services                                            Write a functional behavior assessment
   Extended School Year services                                  Manifestation Determination
   Interim alternative Education Setting (IAES)                   General Meeting
   Other:
Those Present at the Conference May Include:
   Regular Classroom Teacher                                      Speech/Language Pathologist
   Special Education Teacher                                      Specialists: OT or PT
   Principal/LEA Representative                                   Specialists: VI or HI Teacher
   Special Education Director                                     School Counselor
   Student (Required for Transition, Age 16+)                     School Nurse
   Agency Representative                                          School Psychologist
   Other:

Additional contacts with parents: (dates/method)

Parent/Guardian/Surrogate Parent or adult student should complete the following.

Indicate your response regarding the meeting for            and return form to      Special Education Teacher,
or    Special Education Department.
 I will attend the meeting on (date) ___________________________ at (time) __________________________ .
 I am unable to attend on this date. I suggest we meet on (date) __________ at (time) ______________ .
 Please arrange for my participation in this meeting by telephone at (#) ____________________________ .
 I am unable to attend this meeting. Please have it without me.
 Other: __________________________________________________________________________________________ .


______________________________________________________________                   _________________
Signature of Parent/Guardian/Surrogate Parent or Majority Age Student                     Date



For Further information call:             at


Rev. 4/2008                                                    Page 14File Name: 9d261827-efa1-485b-860e-6bbc19cc0b90.doc
              Chino Valley Unified School District
              P.O. Box 225  Chino Valley  AZ 86323  928-636-0363  FAX 928-636-7462

                                       IEP Attendance Form

Date of Notice:                    School: Del Rio Elementary                Grade:
Name of Student:                                       Teacher:
Date of Parent Contact and Agreement
A. Non-Attending Team Members
The following IEP Team Member(s)
(Name and Position)
(Name and Position)
will not participate in the IEP meeting scheduled for (date)             , due to:
(check appropriate box)

1.       Attendance not necessary
         a. A member of the IEP team is not required to attend an IEP meeting, in whole
            or in part, if:
               i. The parent of a child with a disability and the LEA agree that the curriculum
                  or related services area is not being modified or discussed.

                                                  OR

2.       Excusal
         a. A member of the IEP team may be excused from attending an IEP meeting, in
            whole or in part, if:
               i.   their area of the curriculum or related services is being modified or
                    discussed; and
               ii. the parent and agency consent in writing; and
               iii. the member submits his or her input to the development of the IEP prior to
                    the meeting, in writing to both the parents and the team.

3.       IEP Meeting Not Necessary
         In making changes to the IEP after the annual IEP meeting for a school year, the
         parent of a child with a disability and the LEA agree not to convene an IEP
         Meeting for the purposes of making such changes, and instead will develop a
         written document to amend or modify the child’s current IEP.

Parent Approval and Signature _____________________________________________________

LEA Representative Signature _______________________________________________________




Rev. 4/2008                                            Page 15File Name: 9d261827-efa1-485b-860e-6bbc19cc0b90.doc
                     Chino Valley Unified School District
                   P.O. Box 225  Chino Valley  AZ 86323  928-636-0363  FAX 928-636-7462

                                                    PRIOR WRITTEN NOTICE
                                                                (I.E.P. Meeting)
A Prior Written Notice is required before a school district proposes or refuses to change the identification, evaluation, educational
placement, or the provision of a Free and Appropriate Public Education (FAPE) of a student with a disability.

Student’s Name:                                                          School:                                 Date:

Date Prior Written Notice (PWN) sent to parents:

Percentage of special services on I.E.P.:                            %              Changed to:                      %       N/A:

Chino Unified School District:                                                       Description of Action:
   Proposes to initiate or change items checked at right,                               Identification / Classification
   Refuses to initiate or change items checked at right.                                Evaluation / Reevaluation / Modified Reevaluation
                                                                                        Review/Revise I.E.P. (Individual Education Program)
                                                                                        and Provision of FAPE
                                                                                        Educational Placement
                                                                                        Other: ____________________________________

Chino Unified School District:          proposes -or-       refuses to take this action because:
The student qualifies for services under a special education category and should be provided a free and appropriate public education under
the direction of an MET (Multidisciplinary Evaluation Team), who will develop an IEP (Individualized Education Plan).
 ____________________________________________________________________________________________________________
 ____________________________________________________________________________________________________________
Chino Unified School District considered the following options prior to this proposal:
To discontinue special education services or to not place this student in special education.
 ____________________________________________________________________________________________________________
 ____________________________________________________________________________________________________________
Reasons the above listed options were rejected:
These options are not believed to be beneficial to the student’s educational needs. In order for the student to progress academically,
additional services are recommended.
 ____________________________________________________________________________________________________________
 ____________________________________________________________________________________________________________
Description of each evaluation procedure, test, record or report The Chino Unified School District used as a basis for the proposal
or refusal:
Evaluations from psychologists, related service providers, teachers, and information from the parent are all considered for this
recommendation.
 ____________________________________________________________________________________________________________
 ____________________________________________________________________________________________________________
Other factors relevant to the action proposed:
Parents are involved in the development of a student’s program as members of the MET/IEP team. They will be informed of further
recommendations and will participate in program changes.
 ____________________________________________________________________________________________________________
 ____________________________________________________________________________________________________________

Parents of a child with a disability have protection under the Procedural Safeguards:
_______ (parent initial receipt here)         A copy of your Procedural Safeguards is attached to this notice (required for initial evaluation,
reevaluation, I.E.P. meeting notification, and upon registration of a due process complaint at a minimum).

If you have questions or need assistance in understanding your Procedural Safeguards, you may contact the agency providing
educational services to your child or by contacting the agencies listed below:
Arizona Department of Education                 Arizona Center for Disability Law                 Raising Special Kids
Exceptional Student Services                    3724 N. 3rd St. Suite 300                         4750 N. Black Canyon Hwy., Suite 101
1535 West Jefferson St.                         Phoenix, AZ 85012                                 Phoenix, AZ 85017
Phoenix, AZ 85007                               1-800-927-2260                                    1-800-237-3007

Rev. 4/2008                                                          PWN File Copy                   File Name: 9d261827-efa1-485b-860e-
6bbc19cc0b90.doc
602-542-3084 or 1-800-352-4558




Rev. 4/2008                      PWN File Copy   File Name: 9d261827-efa1-485b-860e-
6bbc19cc0b90.doc
                     Chino Valley Unified School District
                   P.O. Box 225  Chino Valley  AZ 86323  928-636-0363  FAX 928-636-7462

                                                    PRIOR WRITTEN NOTICE
                                                                (I.E.P. Meeting)
A Prior Written Notice is required before a school district proposes or refuses to change the identification, evaluation, educational
placement, or the provision of a Free and Appropriate Public Education (FAPE) of a student with a disability.

Student’s Name:                                                          School:                                 Date:

Date Prior Written Notice (PWN) sent to parents:

Percentage of special services on I.E.P.:                            %              Changed to:                      %       N/A:

Chino Unified School District:                                                       Description of Action:
   Proposes to initiate or change items checked at right,                               Identification / Classification
   Refuses to initiate or change items checked at right.                                Evaluation / Reevaluation / Modified Reevaluation
                                                                                        Review/Revise I.E.P. (Individual Education Program)
                                                                                        and Provision of FAPE
                                                                                        Educational Placement
                                                                                        Other: ____________________________________

Chino Unified School District:          proposes -or-       refuses to take this action because:
The student qualifies for services under a special education category and should be provided a free and appropriate public education under
the direction of an MET (Multidisciplinary Evaluation Team), who will develop an IEP (Individualized Education Plan).
 ____________________________________________________________________________________________________________
 ____________________________________________________________________________________________________________
Chino Unified School District considered the following options prior to this proposal:
To discontinue special education services or to not place this student in special education.
 ____________________________________________________________________________________________________________
 ____________________________________________________________________________________________________________
Reasons the above listed options were rejected:
These options are not believed to be beneficial to the student’s educational needs. In order for the student to progress academically,
additional services are recommended.
 ____________________________________________________________________________________________________________
 ____________________________________________________________________________________________________________
Description of each evaluation procedure, test, record or report The Chino Unified School District used as a basis for the proposal
or refusal:
Evaluations from psychologists, related service providers, teachers, and information from the parent are all considered for this
recommendation.
 ____________________________________________________________________________________________________________
 ____________________________________________________________________________________________________________
Other factors relevant to the action proposed:
Parents are involved in the development of a student’s program as members of the MET/IEP team. They will be informed of further
recommendations and will participate in program changes.
 ____________________________________________________________________________________________________________
 ____________________________________________________________________________________________________________

Parents of a child with a disability have protection under the Procedural Safeguards:
_______ (parent initial receipt here)         A copy of your Procedural Safeguards is attached to this notice (required for initial evaluation,
reevaluation, I.E.P. meeting notification, and upon registration of a due process complaint at a minimum).

If you have questions or need assistance in understanding your Procedural Safeguards, you may contact the agency providing
educational services to your child or by contacting the agencies listed below:
Arizona Department of Education                 Arizona Center for Disability Law                 Raising Special Kids
Exceptional Student Services                    3724 N. 3rd St. Suite 300                         4750 N. Black Canyon Hwy., Suite 101
1535 West Jefferson St.                         Phoenix, AZ 85012                                 Phoenix, AZ 85017
Phoenix, AZ 85007                               1-800-927-2260                                    1-800-237-3007

Rev. 4/2008                                                        PWN Parent Copy                   File Name: 9d261827-efa1-485b-860e-
6bbc19cc0b90.doc
602-542-3084 or 1-800-352-4558




Rev. 4/2008                      PWN Parent Copy   File Name: 9d261827-efa1-485b-860e-
6bbc19cc0b90.doc
               CHINO VALLEY UNIFIED SCHOOL DISTRICT #51
                                  PO Box 225 · Chino Valley · AZ 86323 · 928-636-0363
PARENT SURVEY

Provide this survey to parents at the conclusion of each MET meeting or IEP meeting. Please check the box to
the right of each statement that best represents your opinion of this MET or IEP meeting.

My child’s name is ______________________________              Birthdate:_____________ Date: _______________


                                                                                                     Yes      No
1.    When my child was evaluated, I provided information and participated in the meeting.
2.    The IEP team members listen and consider my suggestions and ideas when developing
      or reviewing and revising my child’s IEP.
3.    The meeting notice and a procedural safeguards notice are sent to me before conducting
      a meeting to discuss my child’s evaluation or to develop, review and revise my child’s
      IEP.
4.    My child is making progress on the annual goals included in the IEP.
5.    I am regularly informed about my child’s progress on IEP goals (at least each report
      card period).
6.    I am satisfied with my level of participation in the evaluation and the IEP process.
7.    My child is receiving the services and supports agreed upon in the IEP meeting.
8.    One thing I really like about my child’s special education program is:




9.    One thing I would like to see improved in my child’s special education program is:




My name: _________________________________            Phone number: __________________________
      I have other concerns; please call me at the telephone number above.



Rev. 4/2008                                          Parent Survey File Name: 9d261827-efa1-485b-860e-6bbc19cc0b90.doc

								
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