IEP FORM

Individualized Education Program (IEP)

INDIVIDUALIZED EDUCATION PROGRAM (IEP)School Age

Dates of Evaluations:

2002, May 2003, 5th January 2005

Fictional Name of Student:

Carrie Davis

Age of Student

19 years

Grade of Student:

10th

County of Residence:

Pennsylvania

Other Information:

Carrie was fifteen years old at the time of evaluation, i.e. 3/10/08. She is currently in special education program.

Using the information from your assessments, complete the special considerations portion of the IEP:

I. SPECIAL CONSIDERATIONS THE IEP TEAM MUST CONSIDER BEFORE DEVELOPING THE IEP. ANY FACTORS CHECKED AS “YES” MUST BE ADDRESSED IN THE IEP.

Is the student blind or visually impaired?

Yes

The IEP must include a description of the instruction in Braille and the use of Braille unless the IEP team determines, after an evaluation of the student's reading and writing skills, needs, and appropriate reading and writing media (including an evaluation of the student's future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use of Braille is not appropriate for the student.

No

Is the student deaf or hard of hearing?

Yes

The IEP must include a communication plan to address the following: language and communication needs; opportunities for direct communications with peers and professional personnel in the student's language and communication mode; academic level; full range of needs, including opportunities for direct instruction in the student's language and communication mode; and assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The Communication Plan must be completed and is available at www.pattan.net

No

Does the student have communication needs?

Yes

Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)

No

Does the student need assistive technology devices and/or services?

Yes

Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)

No

Does the student have limited English proficiency?

Yes

The IEP team must address the student's language needs and how those needs relate to the IEP.

No

Does the student exhibit behaviors that impede his/her learning or that of others?

Yes

The IEP team must develop a Positive Behavior Support Plan that is based on a functional assessment of behavior and that utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in the Present Levels section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially Designed Instruction sections of the IEP or in the Positive Behavior Support Plan if this is a separate document that is attached to the ...