IEP Project: Final IEP Assignment Instructions Overview Special education teachers are responsible for developing and implementing Individualized Education Programs (IEPs) for students with exceptiona

IEP Project: Final IEP Assignment Instructions Overview Special education teachers are responsible for developing and implementing Individualized Education Programs (IEPs) for students with exceptiona
EDSP 521 IEP Project: Final IEP Assignment Instructions Overview Special education teachers are responsible for developing and implementing Individualized Education Programs (IEPs) for students with exceptionalities. Individual abilities, interests, learning environments, and cultural and linguistic factors should be fully considered in the development of the IEP to ensure it meets the academic and functional needs of the student. This assignment allows you to demonstrate your ability to use multiple types of assessment information from a provided case study to develop an IEP for a student with an exceptionality. Instructions Review Elli’s information in the provided Present Level of Academic Achievement and Functional Performance (PLAAFP) for Elli Smith document. Using the IEP Project: Final IEP Template provided with this assignment, develop a finalized version of Elli’s IEP. The template document is a modified version of the Virginia Department of Education’s IEP Form. Complete only the portions highlighted in yellow. The information you will provide in Elli’s IEP includes the following: Present Levels of Academic Achievement and Functional Performance Use the assessment data provided in the Present Level of Academic Achievement and Functional Performance (PLAAFP) for Elli Smith document to identify Elli’s interests, preferences, strengths, and areas of need, including assistive technology and/or accessible materials. Fully describe the effect of Elli’s disability on her involvement and progress in the general education curriculum, including her performance in academic as well as functional areas. Measurable Annual Goals (at least 3) List measurable and observable annual goals for each area where Elli’s disability impacts her progress in the general curriculum. These goals are to be the ones you submitted for your IEP Project: IEP Goals Assignment, with any instructor feedback implemented. There must be a direct relationship between the goals and the PLAAFP. Be sure to include: The student’s name (Elli) The condition under which the behavior will be performed The specific observable behavior to be performed The criterion to which the level of performance at the goal will be achieved The target date/timeline for goal attainment (note that for an ANNUAL goal, this should be at the next annual review meeting for the IEP). Instructional Accommodations/Modifications Develop accommodations/modifications that will allow Elli equal opportunity to access the curriculum and demonstrate achievement. Accommodations/ modifications also provide access to nonacademic and extracurricular activities and educationally related settings. Accommodations may include but are not limited to time, scheduling, setting, presentation, and response, including assistive technology and/or accessible materials. Identify frequency, location, instructional setting, and duration. Identify school personnel supports (e.g., equipment, consultation, or training for school staff to meet the student’s unique needs). Participation in the State and Divisionwide Accountability/Assessment System Based on Elli’s PLAAFP, determine if Elli will participate in state and/or division-wide assessments or if Elli meets the criteria for an alternative assessment program. If Elli will participate in statewide assessment, determine if accommodations will be provided. For the accommodations that may be considered, refer to the Virginia Department of Education’s Students with Disabilities: Guidelines for Assessment Participation link provided with this assignment. If Elli will not participate in the state or division-wide assessments, include a statement of justification. Least Restrictive Environment Services and Placement Based on the Least Restrictive Environment (LRE) principle, identify all special education and related services Elli will receive, including frequency, location, and duration. Include a statement of justification for each/all services provided and how your placement decisions reflect the principles of LRE with respect to the student’s PLAAFP. Be sure to carefully review the IEP Project: Final IEP Grading Rubric to ensure each section of the IEP fully addresses the required criteria. Note: Your assignment will be checked for originality via the Turnitin plagiarism tool. Alignment: This IEP assignment and each assignment component is aligned with CEC 2012 Initial Preparation standards: CEC 3.3: Beginning special education professionals modify general and specialized curricula to make them accessible to individuals with exceptionalities. CEC 4.2: Beginning special education professionals use knowledge of measurement principles and practices to interpret assessment results and guide educational decisions for individuals with exceptionalities. CEC 4.3: Beginning special education professionals, in collaboration with colleagues and families, use multiple types of assessment information in making decisions about individuals with exceptionalities. CEC 5.1: Beginning special education professionals consider individual abilities, interests, learning environments, and cultural and linguistic factors in the selection, development, and adaptation of learning experiences for individuals with exceptionalities. CEC 6.1: Beginning special education professionals use professional ethical principles and professional practice standards to guide their practice. CEC 6.4: Beginning special education professionals understand the significance of lifelong learning and participate in professional activities and learning communities. CEC 7.3: Beginning special education professionals use collaboration to promote the well-being of individuals with exceptionalities across a wide range of settings and collaborators. Page 4 of 4
IEP Project: Final IEP Assignment Instructions Overview Special education teachers are responsible for developing and implementing Individualized Education Programs (IEPs) for students with exceptiona
EDSP 521 Virginia Department of Education’s Sample IEP Form For Use with Students up to Age Thirteen, as Appropriate COMPLETE ALL COMPONENTS HIGHLIGHTED IN YELLOW Teacher Candidate Name: Course: Date: INDIVIDUALIZED EDUCATION PROGRAM PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE Student Name__________________________________________________________ Date____/____/____ Page ___of___ Student ID Number_____________________________________________________ The Present Level of Academic Achievement and Functional Performance summarize the results of assessments that identify the student’s interests, preferences, strengths and areas of need, including assistive technology and/or accessible materials. It also describes the effect of the student’s disability on his or her involvement and progress in the general education curriculum, and for preschool children, as appropriate, how the disability affects the student’s participation in appropriate activities. This includes the student’s performance and achievement in academic areas such as writing, reading, mathematics, science, and history/social sciences. It also includes the student’s performance in functional areas, such as self-determination, social competence, communication, behavior and personal management. Test scores, if included, should be self-explanatory or an explanation should be included, and the Present Level of Academic Achievement and Functional Performance should be written in objective measurable terms, to the extent possible. There should be a direct relationship among the desired goals, the Present Level of Academic Achievement and Functional Performance, and all other components of the IEP. _______________________________________________________________________________________________ INDIVIDUALIZED EDUCATION PROGRAM (IEP) PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE, continued Student Name________________________________________________________ Date ____/____/____ Page ___of___ Student ID Number__________________________________ PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE, continued. INDIVIDUALIZED EDUCATION PROGRAM (IEP) MEASURABLE ANNUAL GOALS, PROGRESS REPORT Student Name_______________________________________________________ Date____/____/____ Page ___of___ Student ID Number________________________________ Area of Need________________________________________ # _____ MEASURABLE ANNUAL GOAL: The IEP team considered the need for short-term objectives/benchmarks.  Short-term objectives/benchmarks are included for this goal. (Required for students participating in the VAAP)  Short-term objectives/benchmarks are not included for this goal. SHORT-TERM OBJECTIVES: Objective/Benchmark #___ Objective/Benchmark #___ Objective/Benchmark #___ How will progress toward this annual goal be measured? (check all that apply) ____ Classroom Participation ____ Checklist ____ Classwork ____ Homework ____ Observation ____ Special Projects ____ Tests and Quizzes ____ Written Reports ____ Criterion-referenced test:_________________________ ____ Norm-referenced test: ___________________________ ____ Other: ________________________________________ Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using progress report comment form located in section two. Anticipated Date of Progress Report* Actual Date of Progress Report Progress Code SP -The student is making Sufficient Progress to achieve this annual goal within the duration of this IEP. IP -The student has demonstrated Insufficient Progress to meet this annual goal and may not achieve this goal within the duration of this IEP. ES – The student demonstrates Emerging Skill but may not achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction on this goal. M -The student has Mastered this annual goal. * Progress reports will be provided at least as often as parents are informed of the progress of children without disabilities. INDIVIDUALIZED EDUCATION PROGRAM (IEP) MEASURABLE ANNUAL GOALS, PROGRESS REPORT Student Name_______________________________________________________ Date____/____/____ Page ___of___ Student ID Number________________________________ Area of Need________________________________________ # _____ MEASURABLE ANNUAL GOAL: The IEP team considered the need for short-term objectives/benchmarks.  Short-term objectives/benchmarks are included for this goal. (Required for students participating in the VAAP)  Short-term objectives/benchmarks are not included for this goal. SHORT-TERM OBJECTIVES: Objective/Benchmark #___ Objective/Benchmark #___ Objective/Benchmark #___ How will progress toward this annual goal be measured? (check all that apply) ____ Classroom Participation ____ Checklist ____ Classwork ____ Homework ____ Observation ____ Special Projects ____ Tests and Quizzes ____ Written Reports ____ Criterion-referenced test:_________________________ ____ Norm-referenced test: ___________________________ ____ Other: ________________________________________ Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using progress report comment form located in section two. Anticipated Date of Progress Report* Actual Date of Progress Report Progress Code SP -The student is making Sufficient Progress to achieve this annual goal within the duration of this IEP. IP -The student has demonstrated Insufficient Progress to meet this annual goal and may not achieve this goal within the duration of this IEP. ES – The student demonstrates Emerging Skill but may not achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction on this goal. M -The student has Mastered this annual goal. * Progress reports will be provided at least as often as parents are informed of the progress of children without disabilities. INDIVIDUALIZED EDUCATION PROGRAM (IEP) MEASURABLE ANNUAL GOALS, PROGRESS REPORT Student Name_______________________________________________________ Date____/____/____ Page ___of___ Student ID Number________________________________ Area of Need________________________________________ # _____ MEASURABLE ANNUAL GOAL: The IEP team considered the need for short-term objectives/benchmarks.  Short-term objectives/benchmarks are included for this goal. (Required for students participating in the VAAP)  Short-term objectives/benchmarks are not included for this goal. SHORT-TERM OBJECTIVES: Objective/Benchmark #___ Objective/Benchmark #___ Objective/Benchmark #___ How will progress toward this annual goal be measured? (check all that apply) ____ Classroom Participation ____ Checklist ____ Classwork ____ Homework ____ Observation ____ Special Projects ____ Tests and Quizzes ____ Written Reports ____ Criterion-referenced test:_________________________ ____ Norm-referenced test: ___________________________ ____ Other: ________________________________________ Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using progress report comment form located in section two. Anticipated Date of Progress Report* Actual Date of Progress Report Progress Code SP -The student is making Sufficient Progress to achieve this annual goal within the duration of this IEP. IP -The student has demonstrated Insufficient Progress to meet this annual goal and may not achieve this goal within the duration of this IEP. ES – The student demonstrates Emerging Skill but may not achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction on this goal. M -The student has Mastered this annual goal. * Progress reports will be provided at least as often as parents are informed of the progress of children without disabilities. INDIVIDUALIZED EDUCATION PROGRAM (IEP) SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT ACCOMMODATIONS/MODIFICATIONS Student Name_________________________________________________________ Date____/____/____ Page ___of___ Student ID Number___________________________________ This student will be provided access to general education classes, special education classes, other school services and activities, including nonacademic activities, extracurricular activities, and education-related settings: ___ with no accommodations/modifications ___ with the following accommodations/modifications Accommodations/modifications provided as part of the instructional and testing/assessment process will allow the student equal opportunity to access the curriculum and demonstrate achievement. Accommodations/modifications also provide access to nonacademic and extracurricular activities and educationally related settings. Accommodations/modifications based solely on the potential to enhance performance beyond providing equal access are inappropriate. Accommodations may be in, but not limited to, the areas of time, scheduling, setting, presentation and response including assistive technology and/or accessible materials. The impact of any modifications listed should be discussed. ACCOMMODATIONS/MODIFICATIONS (list, as appropriate) Accommodation(s)/Modification(s) Frequency Location (name of school *) Instructional Setting Duration m/d/y to m/d/y * IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns about the location of the services or refuses the proposed site. A listing of more than one anticipated location is permissible, if the parents do not indicate that they will object to any particular school or state that the team should identify a single school. Supports for School Personnel: (Describe supports such as equipment, consultation, or training for school staff to meet the unique needs for the student) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ INDIVIDUALIZED EDUCATION PROGRAM (IEP) SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM Student Name________________________________________________________ Date ____/____/____ Page ___of___ Student ID Number__________________________________ This student’s participation in state and division-wide assessments must be discussed annually. During the duration of this IEP: Will the student be at a grade level or enrolled in a course for which the student must participate in a state and/or division-wide assessment? If yes, continue to next question. Yes No Based on the Present Level of Academic Achievement and Functional Performance, is this student being considered for participation in the Virginia Standards of Learning (SOL)Assessments (select appropriate content area)  Reading  Math  Science  History/Social Science  Grade 8 Writing Yes No Based on the Present Level of Academic Achievement and Functional Performance, is this student being considered for participation in the Special Permission Request Virginia Substitute Evaluation Program (VSEP)? If yes, complete the “VSEP Participation Criteria” for each content area considered. (Grades 3-8 only)  Reading  Math  Science  History/Social Science  Grade 8 Writing Yes No Does the student meet the VSEP participation criteria? If yes, determine for specific content area.  Reading  Math  Science  History/Social Science  Grade 8 Writing Special permission for eligible students with disabilities in grades 3-8. refer to VDOE’s Students with Disabilities: Guidelines for Assessment Participation for guidance. Yes No Based on the Present Level of Academic Achievement and Functional Performance, is this student being considered for participation in the Virginia Alternate Assessment Program (VAAP), which is based on Aligned Standards of Learning? If yes, complete the “VAAP Participation Criteria”. Yes No Does the student meet VAAP participation criteria? Yes No If “yes” to any of the above, check the assessment(s) chosen and attach (or maintain in student’s educational record) the assessment page(s), which will document how the student will participate in Virginia’s accountability system and any needed accommodations and/or modifications.  State Assessments:* ___ SOL Assessments  Reading  Math  Science  History/Social Science  Grade 8 Writing ___ Virginia Substitute Evaluation Program (VSEP)  Reading  Math  Science  History/Social Science  Grade 8 Writing ___ Virginia Alternate Assessment Program (VAAP)  Division-wide Assessment (list): ____________________________________________________________________________________________________________________________________________________________________________________________________________________ *Refer to Students with Disabilities: Guidelines for Assessment Participation for additional guidance on the assessment programs. INDIVIDUALIZED EDUCATION PROGRAM (IEP) PARTICIPATION IN THE STATE AND DIVISIONWIDE ACCOUNTABILITY/ASSESSMENT SYSTEM (continued) Student Name________________________________________________________ Date ____/____/____ Page ___of___ Student ID Number__________________________________ PARTICIPATION IN STATEWIDE ASSESSMENTS Test Assessment Type* (SOL, VSEP,VAAP) Accommodations** If yes, list accommodation(s) Reading  _______________________________________  Not Assessed at this Grade Level Yes No Math  _______________________________________  Not Assessed at this Grade Level Yes No Science  _______________________________________  Not Assessed at this Grade Level Yes No History/SS  _______________________________________  Not Assessed at this Grade Level Yes No Writing  _______________________________________  Not Assessed at this Grade Level Yes No * Students with disabilities are expected to participate in all content area assessments that are available to students without disabilities. The IEP Team determines how the student will participate in the accountability system. ** Accommodation(s) must be based upon those the student generally uses during classroom instruction and assessment, including assistive technology and/or accessible materials. For the accommodations that may be considered, refer to VDOE’s Students with Disabilities: Guidelines for Assessment Participation for guidance.  Division-wide Assessment (list): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ EXPLANATION FOR NON-PARTICIPATION IN REGULAR STATE OR DIVISION-WIDE ASSESSMENTS If an IEP team determines that a student must take an alternate assessment instead of a regular state assessment, explain in the space below why the student cannot participate in this regular assessment; why the particular assessment selected is appropriate for the student, including that the student meets the criteria for the alternate assessment; and how the student’s nonparticipation in the regular assessment will impact the child’s promotion; or other matters. Refer to the VDOE’s Students with Disabilities: Guidelines for Assessment Participation for guidance.  Alternate/Alternative Assessments Participation Criteria is attached or maintained in the student’s educational record ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ INDIVIDUALIZED EDUCATION PROGRAM (IEP) SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued Student Name________________________________________________________ Date____/____/____ Page ___of___ Student ID Number ___________________________________ Least Restrictive Environment (LRE) When discussing the least restrictive environment and placement options, the following must be considered: To the maximum extent appropriate, the student is educated with children without disabilities. Special classes, separate schooling or other removal of the student from the regular educational environment occurs only when the nature or severity of the disability is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily. The student’s placement should be as close as possible to the child’s home and unless the IEP of the student with a disability requires some other arrangement, the student is educated in the school that he or she would attend if he or she did not have a disability. In selecting the LRE, consideration is given to any potential harmful effect on the student or on the quality of services that he/she needs. The student with a disability shall be served in a program with age-appropriate peers unless it can be shown that for a particular student with a disability, the alternative placement is appropriate as documented by the IEP. Free Appropriate Public Education (FAPE) When discussing FAPE for this student, it is important for the IEP team to remember that FAPE may include, as appropriate: Educational Programs and Services Proper Functioning of Hearing Aids Assistive Technology and/or accessible materials Transportation Nonacademic and Extracurricular Services and Activities Physical Education Extended School Year Services (ESY) Length of School Day SERVICES: Identify the service(s), including frequency, duration and location that will be provided to or on behalf of the student in order for the student to receive a free appropriate public education. These services are the special education services and as necessary, the related services, supplementary aids and services based on peer-reviewed research to the extent practicable, assistive technology and/or accessible materials, supports for personnel*, accommodations and/or modifications* and extended school year services* the student will receive that will address area(s) of need as identified by the IEP team. Address any needed transportation and physical education services including accommodations and/or modifications. * These services are listed on the “Accommodations/Modifications” page and “Extended School Year Services” page, as needed. Service(s) Frequency **School/location Instructional Setting (classroom) Duration m/d/y to m/d/y ** IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns about the location of the services or refuses the proposed site. A listing of more than one anticipated location is permissible, if the parents do not indicate that they will object to any particular school or state that the team should identify a single school. SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued Student Name_________________________________________________ Date____/____/____ Page ___of___ Student ID Number ___________________________________ Extended School Year Services (ESY): (see attached summary sheet as a means to document discussion) The IEP team determined that the student needs ESY services. The IEP team determined that the student does not need ESY services. Describe. The IEP team will determine and/or address ESY services at a later date. Addressed by date:______________ Explain: PLACEMENT No single model for the delivery of services to any population or category of children with disabilities is acceptable for meeting the requirement for a continuum of alternative placements. All placement decisions shall be based on the individual needs of each student. The team may consider placement options in conjunction with discussing any needed supplementary aids and services, accommodations/modifications, assistive technology and/or accessible materials, and supports for school personnel. In considering the placement continuum options, check those the team discussed. Then, describe the placement selected in the PLACEMENT DECISION section below. Determination of the Least Restrictive Environment (LRE) and placement may be one or a combination of options along the continuum. PLACEMENT CONTINUUM OPTIONS CONSIDERED: (check all that have been considered): general education class(es) special class(es) special education day school state special education program / school Public residential facility Private residential facility Homebound Hospital Other ____________________________ Based upon identified services and the consideration of least restrictive environment (LRE) and placement continuum options, describe in the space below the placement. Additionally, summarize the discussions and decision around LRE and placement. This must include an explanation of why the student will not be participating with students without disabilities in the general education class(es), programs, and activities. Attach additional pages as needed. Explanation of Placement Decision: INDIVIDUALIZED EDUCATION PROGRAM (IEP) PRIOR NOTICE AND PARENT CONSENT Student Name__________________________________________________________ Date____/____/____ Page ___of___ Student ID Number___________________________________ PRIOR NOTICE The school division proposes to implement this IEP. This proposed IEP will allow the student to receive a free appropriate public education in the least restrictive environment. This decision is based upon a review of current records, current assessments and the student’s performance as documented in the Present Level of Academic Achievement and Functional Performance. Other options considered, if any, and the reason(s) for rejection are attached, or can be found in the Placement Decision section of this IEP. Additionally, other factors, if any that are relevant to this proposal are attached. Parent and adult student rights are explained in the Procedural Safeguards. If you, the parent(s) and adult student, need another copy of the Procedural Safeguards or need assistance in understanding this information please contact ________________________________ at (___) ____________ or e-mail ________________________________ or ________________________________ at (___) ____________ or e-mail ________________________________ . ____ Parent(s) initials here indicate that the parent(s) has read the above prior notice and attachments, if any, before giving permission to implement this IEP. PARENT/ADULT STUDENT CONSENT: Indicate your response by checking the appropriate space and sign below. ___ I give permission to implement this IEP. ___ I do not give permission to implement this IEP. ____________________________________________________ ____/____/____ Parent Signature Date TRANSITION INDIVIDUALIZED EDUCATION PROGRAM (IEP) PRIOR WRITTEN NOTICE Student Name__________________________________________________________ Date____/____/____ Page ___of___ Student ID Number___________________________________ Describe the action that the school division proposes or refuses to take: (Required upon graduation with a standard or advanced diploma) Explanation of why the school division is proposing or refusing to take action: Description of each evaluation procedure, assessment, record or report the school division used in deciding to propose or refuse the action: Description of any other choices that the Individualized Education Program (IEP) team considered and the reasons why those choices were rejected: Description of other reasons or other factors relevant as to why the school division proposed or refused the action: Resources for the parent to contact for help in understanding the Individuals with Disabilities Education Act (IDEA) and the related federal and Virginia Regulations: If this notice is not the initial referral for evaluation, document when the parent was provided a copy of the procedural safeguards and how a copy maybe obtained, if the parent requests an additional copy: SECTION 2 Additional Forms To Be Used As Needed ELEMENTARY INDIVIDUALIZED EDUCATION PROGRAM (IEP) PROCESS CHECKLIST Meeting notices sent to parent and agency representatives, as appropriate Acquire written consent from parent for an agency representative to attend the IEP meeting Welcome and introductions of team members Review purpose of meeting Review meeting agenda Review rights and procedural safeguards pertaining to special education and the IEP meeting Review of special factors to be considered by the IEP team Develop Present Level of Academic Achievement and Functional Performance Develop measurable annual goals (Discuss progress report on previous annual goals, as needed.) Determine progress report schedule Document that the IEP team considered the need for short-term objectives or benchmarks for students other than those who take alternate assessments aligned to alternate achievement standards Develop short-term objectives or benchmarks for the annual goals, as needed Determine any needed accommodations and/or modifications in instruction and assessment Determine participation in state and divisionwide assessments Determine services and placement Determine if student needs ESY services Review any requests proposed and/or refused Provide prior written notice and obtain parental consent Identify how staff will be informed of their responsibilities for implementation of the IEP Special Education Meeting Notice (School Division Letterhead) Date: To: ____________________________________ and ______________________________________ Parent(s)/Adult Student Student (if appropriate or if transition will be discussed) You are invited to attend a meeting regarding ____________________________________________ Student’s Name PURPOSE OF MEETING (check all that apply): IEP Development or Annual Review IEP Amendment Team Review of Referral Team Review of Existing Data Transition: PartC to Part B Eligibility Determination Team Determination of Needed Data Transition: Postsecondary Goals, Transition Services Manifestation Determination Other: ____________________________ The meeting has been scheduled for: Date Time Location Meetings are scheduled at a mutually agreed upon place and time by you and the school division. If you are unable to attend this meeting you may request participation through other means. If you are unable to attend this meeting, please contact: Special Education Staff Contact / IEP Case Manager Title Phone You and the school division may invite individuals to participate in the team meeting who have knowledge or expertise about the student’s educational needs. The determination of the knowledge or special expertise shall be made by the party who invited the individual. For IEP Meetings, if the division intends to invite a representative of an agency that is likely to be responsible for providing or paying for transition services to the IEP meeting, written consent of the parent or adult student is required. Below is a list of the participants (by name or position) the division will be inviting to attend the meeting: Please review and return the following page to assist the school staff in preparing for the meeting. Special Education Meeting Notice Parent/Student Response Form To the Parent(s) / Guardian(s) / Student: Student:       Date of Meeting:       Please check your choice and return this page to:       at       I the parent student will attend the meeting as scheduled. I the parent student cannot attend the meeting as scheduled. Please reschedule this meeting. I can attend on       at       (date) (time and place) Please contact me at       to determine a mutually agreeable date, time, and place for this IEP meeting. I the parent student do not wish to attend this meeting even though I understand the importance of attending. You may hold this meeting in my absence. I the parent student would like my preferences, interests, and concerns shared with the team. I will provide my input to you by: Mail Telephone Other means:       prior to the meeting.  An IEP worksheet is enclosed.  I will need the following accommodations for this IEP meeting:  I plan to bring _______ individuals that I believe have knowledge or expertise regarding my child. ______________________________________ ___________________________________ Parent Signature Date Date received by the school:       SAMPLE School Division Letterhead CONSENT TO INVITE AGENCY PERSONNEL Date: _____________ If the division intends to invite a representative of any agency that is likely to be responsible for providing or paying for transition services to the IEP meeting, written consent from the parent or adult student is required prior to the meeting date. _____ I give my consent for an agency representative(s) named on the meeting notice to be invited to the IEP meeting. _____ I do not give my consent for an agency representative(s) named on the meeting notice to be invited to the IEP meeting. Parent/Adult Student Signature Date ________________________________________ ______________________ Parent/Adult Student Signature Date **Please sign and return this page to your child’s IEP Case Manager. INDIVIDUALIZED EDUCATION PROGRAM (IEP) COVER PAGE – MEDICAID ELIGIBLE STUDENTS Student Name_________________________________________________________________________ Page ___ of ___ Student ID Number__________________________________ Medicaid/FAMIS # ____________________ Grade_______ DOB ____/____/____ Age* ________ Disability(ies) (if identified) ____________________________________________ Parent (s)Name_____________________________________________________Email ____________________________ Home Address_____________________________________________________ Primary (____)_____________________ _____________________________________________________ Secondary (____)___________________ Date of IEP meeting………………………………………….…………………………..……..………….._____/_____/_____ Date parent notified of IEP meeting………………………………..………………………………………_____/_____/_____ This IEP will be reviewed no later than ………..…………………….……………..……….……………_____/_____/_____ Most recent eligibility date…………………………….…………………………………….……………._____/_____/_____ Next re-evaluation, including eligibility, must occur before ………..……..…………..…..…………….._____/_____/_____ Copy of IEP given to parent (Name) _____________________________________________ On (Date)_____/_____/_____ IEP Teacher/Manager_________________________________________ Phone Number (____)______________________ Summary of previous treatment if not addressed elsewhere: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Intervention, treatment, and modalities if not addressed elsewhere: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ PARTICIPANTS INVOLVED: The list below indicates that the individual participated in the development of this IEP and the placement decision; it does not authorize consent. Parent consent is indicated on the “Prior Notice” page. NAME OF PARTICIPANT POSITION _____________________________________________________ ____________________________________ _____________________________________________________ ____________________________________ _____________________________________________________ ____________________________________ _____________________________________________________ ____________________________________ _____________________________________________________ ____________________________________ Required for Billable Services ICD9 Code _________________________ Medicaid Discharge Plan/Disposition _______________________________ PARENTAL CONSENT FOR BILLING PUBLIC INSURANCE LANGUAGE FOR THE IEP or IEP AMENDMENT One-Time Consent (This document is optional and is not a necessary component of the IEP annual review) For Medicaid or FAMIS (Family Access to Medical Insurance Securities) Insured Only If your child is now or later becomes eligible for Medicaid or FAMIS and he or she receives health-related services written in an Individual Education Program (IEP), the federal government can help the public school division pay for these health-related services, such as, but not limited to physical, occupational or speech therapy; audiology, nursing, psychological or personal care services and health screening associated with Early Periodic Screening Diagnosis and Treatment (EPSDT). Parent/Guardian consent is required before the public school system can bill Medicaid or FAMIS. Additional information about the one-time parental consent, the parental consent form and the procedural safeguards can be found at http://www.doe.virginia.gov/support/health_medical/medicaid/index.shtml. If prior consent has been given, no further action is required. INDIVIDUALIZED EDUCATION PROGRAM (IEP) MEASURABLE ANNUAL GOALS, PROGRESS REPORT, continued Student Name_______________________________________________________ Date____/____/____ Page ___of___ Student ID Number________________________________ Area of Need________________________________________ # _____ MEASURABLE ANNUAL GOAL: The IEP team considered the need for short-term objectives/benchmarks.  Short-term objectives/benchmarks are included for this goal. (Required for students participating in the VAAP)  Short-term objectives/benchmarks are not included for this goal. How will progress toward this annual goal be measured? (check all that apply) ____ Classroom Participation ____ Checklist ____ Class work ____ Homework ____ Observation ____ Special Projects ____ Tests and Quizzes ____ Written Reports ____ Criterion-referenced test:_________________________ ____ Norm-referenced test: ___________________________ ____ Other: ________________________________________ Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using progress report comment form located in section two. Anticipated Date of Progress Report* Actual Date of Progress Report Progress Code SP -The student is making Sufficient Progress to achieve this annual goal within the duration of this IEP. IP -The student has demonstrated Insufficient Progress to meet this annual goal and may not achieve this goal within the duration of this IEP. ES -The student demonstrates Emerging Skill but may not achieve this goal within the duration of this IEP. NI -The student has Not been provided Instruction on this goal. M -The student has Mastered this annual goal. * Progress reports will be provided at least as often as parents are informed of the progress of their children without disabilities. INDIVIDUALIZED EDUCATION PROGRAM (IEP) SHORT TERM OBJECTIVES OR BENCHMARKS, as determined by IEP Team (Required for students participating in the VAAP) Student Name__________________________________________________________ Date____/____/____ Page ___of___ Student ID Number________________________________ Goal # _____ Area of Need: ___________________________ Short Term Objectives or Benchmarks, as needed Objective/Benchmark #___ Objective/Benchmark #___ Objective/Benchmark #___ Objective/Benchmark #___ INDIVIDUALIZED EDUCATION PROGRAM (IEP) PROGRESS REPORT COMMENTS, Continued (This document is optional) Student Name__________________________________________________________ Date____/____/____ Page ___of___ Student ID Number________________________________ Goal #___ Progress Report Code ___ Goal #___ Progress Report Code ___ Goal #___ Progress Report Code ___ Goal #___ Progress Report Code ___ Goal #___ Progress Report Code ___ INDIVIDUALIZED EDUCATION PROGRAM (IEP) EXTENDED SCHOOL YEAR SERVICES (ESY) (Optional) Student Name_________________________________________________________ Date____/____/____ Page ___of___ Student ID Number___________________________________ Summarize the IEP team’s discussions and decision about ESY: If ESY services are to be provided identify which goals in the current IEP will be addressed by the ESY services: Identify the Extended School Year services needed to meet these goals: Service(s) Frequency **School/location Instructional Setting (classroom) Duration m/d/y to m/d/y ** IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns about the location of the services or refuses the proposed site. A listing of more than one anticipated location is permissible, if the parents do not indicate that they will object to any particular school or state that the team should identify a single school. Virginia Department of Education — Sample IEP Form—Revised August, 2015 Page 34 of 27