Example IEP

DATE OF MOST RECENT EVALUATION:______/______/______DATE OF NEXT REEVALUATION:______/______/_____

PURPOSE OF CONFERENCE (Check all that apply)
	Review of Existing Data	Reevaluation	IEP Review/Revision	Manifestation Determination	Termination of Placement
	Initial Eligibility	Initial IEP	Transition	Graduation	Other (e.g. FBA/BIP)________
STUDENT IDENTIFICATION INFORMATION

STUDENT’S ADDRESS (Street, City, State, Zip Code)

STUDENT’S DATE OF BIRTH

SIS ID NUMBER

MALE

FEMALE

ETHNICITY

LANGUAGE/MODE OF COMMUNICATION USED BY STUDENT

CURRENT GRADE LEVEL

ANTICIPATED DATE OF HS GRADUATION

PLACEMENT(To be completed after placement determination)

YES NO Placement is in Resident School

DISABILITY(S)

MEDICAID NUMBER

RESIDENT DISTRICT

SERVING DISTRICT

RESIDENT SCHOOL

SERVING SCHOOL

PARENT/GUARDIAN INFORMATION

(1) PARENT’S NAME Educational Surrogate Parent

(2) PARENT’S NAME Educational Surrogate Parent

(1) PARENT’S ADDRESS (Street, City, State, Zip Code)

(2) PARENT’S ADDRESS (Street, City, State, Zip Code)

(1) PARENT’S TELEPHONE NUMBER (include Area Code)

(2) PARENT’S TELEPHONE NUMBER (Include Area Code)

(1) LANGUAGE/MODE OF COMMUNICATION USED BY PARENT(S)

Yes No Interpreter

(2) LANGUAGE/MODE OF COMMUNICATION USED BY PARENT(S)

Yes No Interpreter

PARTICIPANTS

Signature indicates attendance. Check appropriate boxes to indicate which meetings were attended. Anyone serving in a dual role should indicate so on the following lines. If a required participant participates through written input or is excused from all or part of the IEP meeting, the required excusal and written report, as necessary, is attached.

ELIG. REVIEW	IEP		ELIG. REVIEW	IEP

		Parent			School Social Worker

		Parent			Speech-Language Pathologist

		Student			Bilingual Specialist

		LEA Representative			Interpreter

		General Education Teacher			Other (specify)

		Special Education Teacher			Other (specify)

		School Psychologist			Other (specify)

If the parent(s) did not attend the IEP meeting, document the attempts to contact the parent(s) prior to the IEP meeting.

PROCEDURAL SAFEGUARDS

Explanation of Procedural Safeguards were provided to/reviewed with the parent(s) on _____________________________________________________

Transfer of Rights - Seventeen-year old student informed of his/her rights that will transfer to the student upon reaching age 18. Yes NA

Parent(s) were given a copy of the: Evaluation report and eligibility determination IEP

District’s behavioral intervention policies District’s behavioral intervention procedures (initial IEP only)

DOCUMENTATION OF EVALUATION RESULTS

Complete for initial evaluations, reevaluations, or a review of an independent or outside evaluation.

Considering all available evaluation data, record the team’s analyses of the student’s functioning levels. Only those areas which were identified as relevant to the current evaluation must be completed. All other areas should be noted as “Not Applicable”. Evaluation data may include: parental input, teacher recommendations, physical condition, social or cultural background, adaptive behavior, record reviews, interviews, observations, testing etc. Describe the observed strengths and/or deficits in the student’s functioning in the following domains.

Academic Achievement (Current or past academic achievement data pertinent to current educational performance)

Functional Performance (Current or past functional performance data pertinent to current functional performance)

Cognitive Functioning (Data and other information regarding intellectual ability; how the student takes in information, understands information, and expresses information)

Communicative Status (Information regarding communicative abilities (language, articulation, voice, fluency) affecting educational performance)

For ELL students explain ELL STATUS: Has Linguistic status Changed YES NO

Health (Current or past medical difficulties affecting educational performance)

Hearing/Vision (Auditory/visual problems that would interfere with testing or educational performance. Include dates and results of last hearing/vision test)

Motor Abilities (Fine and gross motor coordination difficulties, functional mobility, or strength and endurance issues affecting educational performance)

Social/Emotional Status/Social Functioning (Information regarding how the environment affects educational performance (life history, adaptive behavior, independent functioning, personal and social responsibility, cultural background)

ELIGIBILITY DETERMINATION

(ALL DISABILITIES OTHER THAN SPECIFIC LEARNING DISABILITY)

DETERMINANT FACTORS
The determinant factor for the student’s suspected disability is:
	Yes	No	Lack of appropriate instruction in reading, including the essential components of reading instruction (Evidence Provided)_______________________________________________________________________

	Yes	No	Lack of appropriate instruction in math (Evidence Provided)________________________________________

	Yes	No	Limited English Proficiency (Evidence Provided):________________________________________________

If any of the above answers is “yes,” the student is not eligible for services under IDEA and the team must complete Step 1 and 4 below. If all of the answers are “no,” complete Steps 1-4.

COMPLETE FOR STUDENTS SUSPECTED OF HAVING A DISABILITY UNDER IDEA.

STEP 1 - DISABILITY

No Disability Identified (Complete Step 4 and write “Not Eligible for Special Education Services” in the Disability section of the Conference Summary Report page.)

Disability Identified

Based on the team’s analysis, identify the disability(s):

Primary Secondary

? Autism (O) ?

? Cognitive Disability (A) ?

? Deaf/Blindness (H) ?

? Deafness (G) ?

? Developmental Delay (3-9) (N) ?

? Emotional Disability (K) ?

? Hearing Impairment (F) ?

Primary Secondary

? Multiple Disabilities (M) ?

? Orthopedic Impairment (C) ?

? Other Health Impairment (L) ?

? Speech or Language Impairment (I) ?

? Traumatic Brain Injury (P) ?

? Visual Impairment including Blindness (E) ?

STEP 2 - ADVERSE EFFECTS

No Adverse Effect Identified

(Complete Step 4 and write “Not Eligible for Special Education Services” in the Disability section of the Conference Summary Report page.)

Adverse Effect Identified

For each disability identified, describe how the disability adversely affects the student’s educational performance

STEP 3 - EDUCATIONAL NEEDS

State to what extent the student requires special education and related services to address educational needs.

STEP 4 - ELIGIBILITY

Based on the steps above, the student is entitled to special education and related services.

No (Not Eligible) Yes (Eligible)

DOCUMENTATION OF INTERVENTION/EVALUATION RESULTS

(SPECIFIC LEARNING DISABILITY)

(Required as of the 2010-2011 School Year)

Complete for initial evaluations, reevaluations, or a review of an independent or outside evaluation when a specific learning disability is suspected.

	As part of the evaluation process, relevant behavior noted during observation in the child’s age-appropriate learning environment, including the general education classroom setting for school-age children, and the relationship of that behavior to the child’s academic functioning and educationally relevant medical findings, if any, must be documented.
Problem Identification / Statement of Problem: Using baseline data, please provide an initial performance discrepancy statement for all identified areas of concern in the relevant domains (academic performance; functional performance; cognitive functioning, communicative status (for ELL students includes an explanation of ELL status and any change in linguistic status); social/emotional status/functioning, motor abilities, health, hearing and vision) including information about the student’s performance discrepancy prior to intervention. Attach evidence.
Problem Analysis / STRENGTHS AND WEAKNESSES: Describe student’s skill strengths and weaknesses in the identified area(s) of concern within the relevant domains. Attach evidence, including evidence of skills deficit versus performance deficit.
Plan Development / Intervention(s): Describe the previous and current intervention plans (core/Tier 1, supplemental/Tier 2, and intensive/Tier 3) including evidence that the intervention is scientifically based and was implemented with integrity. Attach plan/evidence.
Plan Evaluation / Educational Progress: Provide documentation of student progress over time as a result of the intervention. Attach evidence/graphs.
Plan Evaluation / Discrepancy: State the current performance discrepancy after intervention, i.e., the difference between a student’s level of performance compared to the performance of peers or scientifically-based standards of expected performance. Attach evidence.
Plan Evaluation / Instructional Needs: Summarize the student’s needs in the areas of curriculum, instruction, and environment. Include a statement of whether the student’s needs in terms of materials, planning, and personnel required for intervention implementation are significantly different from those of general education peers. Attach evidence.
Additional Information Necessary for Decision-Making (INCLUDE AS APPROPRIATE): Report any educationally relevant information necessary for decision-making, including information regarding eligibility exclusionary and inclusionary criteria. Attach evidence.

ELIGIBILITY DETERMINATION (SPECIFIC LEARNING DISABILITY) (Required as of the 2007-2008 School Year)
Complete for initial evaluations, reevaluations, or a review of an independent or outside evaluation when a specific learning disability is suspected.
DETERMINANT FACTORS
The determinant factor for the student’s suspected disability is:
	Yes	No	Lack of appropriate instruction in reading, including the essential components of reading instruction (Evidence Provided)_______________________________________________________________________

	Yes	No	Lack of appropriate instruction in math (Evidence Provided)________________________________________

	Yes	No	Limited English Proficiency (Evidence Provided)_________________________________________________

If any of the above answers is “yes,” the student is not eligible for services under IDEA and the team must complete the Eligibility Determination section accordingly. If all of the answers are “no,” complete the following sections.
EXCLUSIONARY CRITERIA
The team determined that the following factors are the primary basis for the student’s learning difficulties. Document the source of evidence in each area:
	Yes	No	A visual, hearing or motor disability:
	Yes	No	Cognitive Disability:
	Yes	No	Emotional disability:
	Yes	No	Cultural factors:
	Yes	No	Environmental or economic disadvantage:
If any of the boxes immediately above is checked “yes,” the student cannot have a primary eligibility of specific learning disability and the team must complete the Eligibility Determination section accordingly.
inclusionary CRITERIA
Educational Progress (Over Time)
*Evidence in the Documentation of Evaluation Results should support the team’s answer to this question*.
Is the student progressing at a significantly slower rate than is expected in any areas of concern? (Select One) No Yes - The student is progressing at a significantly slower rate than expected Yes - The student is currently making an acceptable rate of progress but only because of the intensity of the intervention that is being provided. If yes, in which area(s)?
Discrepancy (At One Point in Time)
*Evidence in the Documentation of Evaluation Results should support the team’s answer to this question.*
Is the student’s performance significantly below performance of peers or expected standards in any areas of concern? (Select One) No Yes - The student’s performance is significantly discrepant. Yes - The student’s performance is not currently discrepant but only because of the intensity of the intervention that is being provided. If yes, in which area(s)?

ELIGIBILITY DETERMINATION

(SPECIFIC LEARNING DISABILITY)

(Required as of the 2007-2008 School Year)

Instructional Need
*Evidence in the Documentation of Evaluation Results should support the team’s answer to this question.*
Are this student’s needs in any areas of concern significantly different from the needs of typical peers and of an intensity or type that exceeds general education resources? (Select One) No Yes - The student’s instructional needs are significantly different and exceed general education resources. If yes, in which area(s)? If any of the boxes in this section (Inclusionary Criteria) are marked “No”, the student does not have a Specific Learning Disability and the team must complete the Eligibility Determination section accordingly.
Optional Criteria After determining that the criteria in the preceding section are met, the district may choose to use an IQ-achievement discrepancy model. If using this model, complete this section.
IQ-Achievement Discrepancy:
Yes No NA Does a severe discrepancy exist between achievement and ability that is not correctable without special education and related services? (Please refer to evidence in Documentation of Evaluation Results) If yes, in which area(s)?
ELIGIBILITY DETERMINATION
Step 1: Disability Adversely Affecting Educational Performance
Yes No Based on the answers to the questions in the “Determinant Factors, Exclusionary Criteria,” and “Inclusionary Criteria,” sections, does the student have a specific learning disability?

If the answer is “no” the student is not eligible for special education services under the category of Specific Learning Disability and the team must complete Step 2 below.

If the answer is “yes,” indicate the area below and complete Step 2.

Basic reading skills

Reading fluency skills

Reading comprehension

Mathematical calculation

Mathematical problem solving

Written expression

Oral expression

Listening comprehension

Step 2: Special Education and Related Services

Specialized instruction is required in order for the student to make progress and reduce discrepancy (Eligible)

Specialized instruction is not required in order for the student to make progress and reduce discrepancy (Not Eligible)

Each team member must sign below to certify that the report reflects his/her conclusions for specific learning disability. Any participant who disagrees with the team’s decision must submit a separate statement presenting her/his conclusions.

Yes	No	Yes	No
Yes	No	Yes	No
Yes	No	Yes	No
Yes	No	Yes	No

DATA CHART

(OPTIONAL)

REPORT OF PERFORMANCE (READING, WRITING, MATH)

Insert a data chart that displays the student’s performance in reading, writing, and/or math relative to his/her peer group. Data charts may be provided for other areas, as well.

REPORT OF PERFORMANCE

(INSERT DATA CHART)

REPORT OF PERFORMANCE

(INSERT DATA CHART)

PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Complete for initial IEPs and annual reviews.

When completing this page, include all areas from the following list that are impacted by the student’s disability: academic performance, social/emotional status, independent functioning, vocational, motor skills, and speech and language/communication. This may include strengths/weaknesses identified in the most recent evaluation.

Student’s Strengths

Parental Educational Concerns/Input

Student’s Present Level of Academic Achievement (Include strengths and areas needing improvement)

Student’s Present Levels of Functional Performance (Include strengths and areas needing improvement)

Describe the effect of this individual’s disability on involvement and progress in the general education curriculum and the functional implications of the student’s skills.

For a preschool child, describe the effect of this individual’s disability on involvement in appropriate activities.
By age 14½, describe the effect of this individual’s disability on the pursuit of post-secondary expectations (living, learning, and working).

SECONDARY TRANSITION

Complete for students age 14½ and older, and when appropriate for students younger than age 14½. Post-school outcomes should guide the development of the IEP for students age 14½ and older.

Age-Appropriate Transition Assessments

Transition Assessments (Including student and family survey/interview)	Assessment Type	Responsible Agency/Person	Date Conducted	Report Attached	Goal #
EMPLOYMENT None needed
EDUCATION None needed
TRAINING None needed
INDEPENDENT LIVING SKILLS None needed

POST-SECONDARY OUTCOMES (address by age 14½ )

Indicate and project the desired appropriate measurable post-secondary outcomes/goals as identified by the student, parent and IEP team. Goals are based upon age appropriate transition assessments related to employment, education and/or training, and where appropriate, independent living skills.

Employment (e.g., competitive, supported shelter, non-paid employment as a volunteer or training capacity, military): AND

Post-Secondary Education (e.g., community college, 4-year university, technical/vocational/trade school): AND/OR

Post-Secondary Training (e.g., vocational or career field, vocational training program, independent living skills training, apprenticeship, OJT, job corps): AND

IF APPLICABLE, Independent Living (e.g., independent living, health/safety, self-advocacy/future planning, transportation/mobility, social relationships, recreation/leisure, financial/income needs):

COURSE OF STUDY (address by age 14½)

Identify a course of study that is a long-range educational plan or multi-year description of the educational program that directly relates to the student's anticipated post-school goals, preferences and interests as described above.

Year 1 – Age 14/15	Year 2 – Age 15/16	Year 3 – Age 16/17	Year 4 – Age 17/18	Extended – Age 18-21

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transition Services (address by age 141/2)

Please include, if appropriate, needed linkages for outside agencies, (e.g., DMH, DRS, DSCC, PAS, SASS, SSI, WIC, DHCFS, etc.)

INSTRUCTION (e.g., tutoring, skills training, prep for college entrance exam, accommodations, adult basic ed.)

(If none, indicate “none”)

Provider Agency and Position

Goal #(s) if appropriate

Date/Year to be Addressed

Date/Year Completed

RELATED SERVICES (e.g., transportation, social services, medical services, technology, support services)

(If none, indicate “none”)

Provider Agency and Position

Goal #(s) if appropriate

Date/Year to be Addressed

Date/Year Completed

COMMUNITY EXPERIENCES (e.g., job shadow, work experiences, banking, shopping, transportation, tours of post-secondary settings)

(If none, indicate “none”)

Provider Agency and Position

Goal #(s) if appropriate

Date/Year to be Addressed

Date/Year Completed

DEVELOPMENT OF EMPLOYMENT AND OTHER POST-SCHOOL ADULT LIVING OBJECTIVES (e.g., career planning, guidance counseling, job try-outs, register to vote, adult benefits planning)

(If none, indicate “none”).

Provider Agency and Position

Goal #(s) if appropriate

Date/Year to be Addressed

Date/Year Completed

APPROPRIATE ACQUISITION OF DAILY LIVING SKILLS AND/OR

FUNCTIONAL VOCATIONAL EVALUATION (e.g., self-care, home repair, home health, money, independent living, / job and career interests, aptitudes and skills)

Provider Agency and Position

Goal #(s) if appropriate

Date/Year to be Addressed

Date/Year Completed

LINKAGES TO AFTER GRADUATION SUPPORTS/SERVICES (e.g. DRS, DMH, DSCC, PAS, SASS, SSI, WIC, DHCFS, CILs)

Provider Agency and Position

Goal #(s) if appropriate

Date/Year to be Addressed

Date/Year Completed

home-based support services program

Yes

The student has a developmental disability and may become eligible for the program after reaching age 18 and

when no longer receiving special education services.

If yes, complete the following statements:

Plans for determining the student’s eligibility for home-based services:

Plans for enrolling the student in the program of home-based services:

Plans for developing a plan for the student’s most effective use of home-based services after reaching age 18 and when no longer receiving special education services:

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FUNCTIONAL BEHAVIORAL ASSESSMENT (AS APPROPRIATE)

Complete when gathering information about a student’s behavior to determine the need for a Behavioral Intervention Plan. When used in developing a Behavioral Intervention Plan, the Functional Behavioral Assessment must be reviewed at an IEP meeting and should be attached to the IEP.

The Functional Behavioral Assessment must include data collected through direct observation of the target behavior. Attach documentation of data collection.

	Participant/Title	Participant/Title

Student’s Strengths – Include a description of behavioral strengths (e.g., ignores inappropriate behavior of peers, positive interactions with staff, accepts responsibility, etc.)
Operational Definition of Target Behavior – Include a description of the frequency, duration and intensity of the behavior.
Setting – Include a description of the setting in which the behavior occurs (e.g., physical setting, time of day, persons involved.)
Antecedents – Include a description of the relevant events that preceded the target behavior.
Consequences – Include a description of the result of the target behavior (e.g. removed from classroom and did not complete assignment. What is the payoff for the student?)
Environmental Variables – Include a description of any environmental variables that may affect the behavior (e.g., medication, weather, diet, sleep, social factors.)
Hypothesis of Behavioral Function - Include a hypothesis of the relationship between the behavior and the environment in which it occurs.

BEHAVIORAL INTERVENTION PLAN (AS APPROPRIATE)

Complete when the team has determined a Behavioral Intervention Plan is needed.

Student’s Strengths – Describe student’s behavioral strengths

Target Behavior

Is this behavior a Skill Deficit or a Performance Deficit

Skill Deficit: The student does not know how to perform the desired behavior.

Performance Deficit: The student knows how to perform the desired behavior, but does not consistently do so.

Hypothesis of Behavioral Function – Include hypothesis developed through the Functional Behavioral Assessment (attach completed form). What desired thing(s) is the student trying to get? OR What undesired thing(s) is the student trying to avoid?

Summary of Previous Interventions Attempted – Describe any environmental changes made, evaluations conducted, instructional strategy or curriculum changes made or replacement behaviors taught.

Replacement Behaviors – Describe which new behaviors or skills will be taught to meet the identified function of the target behavior (e.g. student will slap his desk to replace striking out at others). Include description of how these behaviors/skills will be taught.

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BEHAVIORAL INTERVENTION PLAN (AS APPROPRIATE)

Behavioral Intervention Strategies and Supports

Environment – How can the environment or circumstances that trigger the target behavior be adjusted?

Instruction and/or Curriculum – What changes in instructional strategies or curriculum would be helpful?

Positive Supports – Describe all additional services or supports needed to address the student’s identified needs that

contribute to the target behavior.

Motivators and/or Rewards – Describe how the student will be reinforced to ensure that replacement behaviors are more motivating than the target behavior.

Restrictive Disciplinary Measures – Describe any restrictive disciplinary measures that may be used with the student and any conditions under which such measures may be used (include necessary documentation and timeline for evaluation.)

Crisis Plan – Describe how an emergency situation or behavior crisis will be handled.

Data Collection Procedures and Methods – Describe expected outcomes of the interventions, how data will be collected and measured, timelines for and criteria to determine success or lack of success of the interventions.

Provisions For Coordination with Caregivers – Describe how the school will work with the caregivers to share information, provide training to caregivers if needed, and how often this communication will take place.

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GOALS AND OBJECTIVES/BENCHMARKS

Complete for initial IEPs and annual reviews. (Anyone responsible for implementing the IEP (e.g., goals and objectives/benchmarks, accommodations, modifications and supports) must be notified of her/his specific responsibilities.)

reporting on goals

The progress on annual goals will be measured by the short-term objectives/benchmarks. Check the methods that will be used to notify parents of the student’s progress on annual goals and if the progress is sufficient to achieve the goals by the end of the IEP year:

Report cards		Progress reports	Parent conference	Other (specify) __________________________
	current academic achievement and functional performance
	*Results of the initial or most recent evaluation and results on district-wide assessments relevant to this goal; performance in comparison to general education peers and standards.*

	goals and objectives/benchmarks
	The goals and short-term objectives or benchmarks shall meet the student’s educational needs that result from the student’s disability, including involvement in and progress in the general curriculum, or for preschool students, participation in appropriate activities.
	Goal Statement #____of_____ Indicate Goal Area: Academic Functional Transition Illinois Learning Standard: #___________
	Title(s) of Goal Implementer(s)

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

Evaluation

Criteria

Evaluation

Procedures

Schedule for

Determining Progress

Dates Reviewed/

Extent of Progress (Optional)

% Accuracy

Observation Log

Daily

# of attempts

Data Charts

Weekly

Other (specify)

Tests

Quarterly

Other (specify)

Semester

Other (specify)

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

Evaluation

Criteria

Evaluation

Procedures

Schedule for

Determining Progress

Dates Reviewed/

Extent of Progress (Optional)

% Accuracy

Observation Log

Daily

# of attempts

Data Charts

Weekly

Other (specify)

Tests

Quarterly

Other (specify)

Semester

Other (specify)

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

Evaluation

Criteria

Evaluation

Procedures

Schedule for

Determining Progress

Dates Reviewed/

Extent of Progress (Optional)

% Accuracy

Observation Log

Daily

# of attempts

Data Charts

Weekly

Other (specify)

Tests

Quarterly

Other (specify)

Semester

Other (specify)

EDUCATIONAL ACCOMMODATIONS AND SUPPORTS

Complete for initial IEPs and annual reviews. (Anyone responsible for implementing the educational accommodations must be notified of her/his specific responsibilities).

TRANSITION

Yes

Consideration of service needs, goals, and support/services is required (by age 14 ½ , the team must address transition

service needs). If yes, complete the “Transition Services” section of the IEP.

Yes

Consideration of “Home-Based Support Services Program for Mentally Disabled Adults” for eighteen-year-old student is

required. If yes, complete the “Home-Based Support Services Program” section of the IEP.

CONSIDERATION OF SPECIAL FACTORS

Check the boxes to indicate if the student requires any supplementary aids and/or services due to the following factors. For any box checked “yes,” specify the special factors in the “Supplementary Aids, Accommodations and Modifications” section listed below.

Yes	No		assistive technology devices and services
Yes	No		communication needs
Yes	No		deaf/hard of hearing – languages and communication needs
Yes	No		limited English proficiency – language needs
Yes	No		blind/visually impaired – provision of Braille instruction
Yes	No		behavior impedes student’s learning or that of others. If yes, the team must consider strategies, including positive behavioral interventions and supports to address behavior. This may include a Functional Behavioral Assessment and/or a Behavioral Intervention Plan. If, so attach any completed forms.

linguistic and cultural accommodations
Yes		No		The student requires accommodations for the IEP to meet her/his linguistic and cultural needs.
				If yes, specify any needed accommodations:

Yes		No		Special education and related services will be provided in a language or mode of communication other
				than or in addition to English. If yes, specify any needed accommodations:
SUPPLEMENTARY AIDS, ACCOMMODATIONS, AND MODIFICATIONS

Specify what aids, accommodations, and modifications are needed for the child to make progress toward annual goals, to progress in the general education curriculum, participate in extracurricular and other non-academic activities, and to be educated and participate with other children with disabilities and/or nondisabled children (e.g., accommodations for daily work, environmental accommodations, moving from class to class, etc.). Supplementary aids, accommodations, and modifications must be based upon peer-review research to the extent practicable.

Supports for school personnel
Yes	No	Program trainings and/or supports for school personnel are needed for the student to advance appropriately toward attaining
		the annual goals, participate in the general curriculum, and be educated and participate with other students in educational activities. If yes, specify what trainings and/or supports are needed, including when appropriate, the information that clarifies when the trainings and/or supports will be provided, by whom, in what location, etc.

ASSESSMENT

CLASSROOM-BASED ASSESSMENTS

Yes	No	Student requires accommodations to participate in classroom-based assessments.
Yes	No	Student requires alternate assessment/methods to participate in classroom-based assessments

DISTRICT-WIDE ASSESSMENTS
		District does not administer district-wide assessments
		District does not administer district-wide assessments at this grade level: _________

Student will:

	Participate in the entire district-wide assessment with no accommodations
	Participate in the entire district-wide assessment with accommodations
	Participate in part(s) of the district wide assessment (specify)
	Participate in the district-wide alternate assessment

STATE ACADEMIC ASSESSMENTS

The State academic assessments are the Illinois Standards Achievement Test (ISAT) at grades 3-8 and the Prairie State Achievement Exam (PSAE) at grade 11, Illinois Measure of Annual Growth in English (IMAGE) in grades 3-8 and 11 (for English Language Learner (ELL) students), and Illinois alternate Assessment (IAA) in grades 3-8 and 11.

State academic assessments are not administered at this grade level __________

Student will:

	Participate in the ISAT/PSAE/IMAGE with no accommodations
	Participate in the ISAT/PSAE/IMAGE with accommodations
	Participate in the IAA

If the student will participate in the IAA, the following were met:

	The ISAT/PSAE/IMAGE is not appropriate (specify)
	The IAA participation guidelines were met
	The alternate assessment selected is appropriate for the student (explain)

STATE ASSESSMENT OF LANGUAGE PROFICIENCY

The State assessment of language proficiency is Assessing Comprehension and Communication in English State to State (ACCESS) in grades K-12

Yes

ENGLISH LANGUAGE LEARNER (ELL). If “NO”, skip to next section

Student will:

	participate in the ACCESS with no accommodations
	participate in the ACCESS with accommodations

ASSESSMENT ACCOMMODATIONS

If the student is participating in any of the above assessment(s) with accommodations, specify the needed accommodations (e.g., extended time, alternate setting, auditory testing) necessary to measure the student’s academic achievement and functional performance. The accommodations should be appropriate for that particular assessment and reflective of those already identified for the student in the Supplementary Aids, Accommodations, and Modifications section.

EDUCATIONAL SERVICES AND PLACEMENT

Initiation Date:______/_______/______ Duration Date: ______/_______/_______

PARTICIPATION IN GENERAL EDUCATION CLASSES

The IEP must address all content areas, classes, and specify if the student will participate in general physical education.

General Education with No Supplementary Aids

(Specify content areas, classes, whether or not the child will participate in general physical education, and extracurricular and other nonacademic activities.)

Minutes Per Week in Setting

(Optional)

General Education with Supplementary Aids (as specified in the Supplementary Aids section)

(Specify content areas, classes, whether or not the child will participate in general physical education, and extracurricular and other nonacademic activities with supports, if applicable.)

Minutes Per Week in Setting

(Optional)

Special Education and Related Services within the General Education Classroom

(Specify content areas and classes in which the child will participate with the provision of special education and related services. List each special education and related service that will be provided during each class. )

Minutes Per Week in Setting

PARTICIPATION IN SPECIAL EDUCATION CLASSES/services

The IEP must address all special education and related services.

Special Education Services – Outside General Education		Minutes Per Week in Setting
		A.
Related Services – Outside General Education		Minutes Per Week in Setting
		B.
Educational Environment (EE) Calculation (Ages 3-5) _________ 1. Minutes spent in regular early childhood program _________ 2. Minutes spent receiving special education and related services outside regular early childhood (A+B)	Educational Environment (EE) Calculation (Ages 6-21) _________ 1. Total Bell to Bell Minutes _________ 2. Total Number of Minutes Outside of the General Education Setting (A+B)

EDUCATIONAL services and placement

EDUCATIONAL ENVIRONMENT CONSIDERATIONS

To the maximum extent appropriate, all students shall be educated and participate with students who are non-disabled. Provide an explanation of the extent, if any, to which the student will not participate in general education classes and activities.

Yes	No	Special education classes, separate schooling, or removal from the regular education environment is required because the nature or severity of the student’s disability is such that education in general classes with the use of supplementary aids and services cannot be achieved satisfactorily. Explain:________________________________________________________________________________________________________
Yes	No	Will participate in nonacademic activities with nondisabled peers and have the same opportunity to participate in extracurricular activities as nondisabled peers? If no, explain:____________________________________________________________________________________________________
Yes	No	Will attend the school he or she would attend if nondisabled? If no, explain:____________________________________________________________________________________________________
PLACEMENT CONSIDERATIONS

When determining the placement, consider any potentially harmful effect either on the student or the quality of services that he/she needs. After determining the student’s placement, complete the “Placement” section on this cover sheet.

Yes NA For a child who is deaf, hard or hearing, blind or visually impaired, parents have been informed of existence of the Illinois School for the Deaf or the Illinois School for the Visually Impaired, and other local schools that provide similar services.
Placement Options CONSIDERED	POTENTIALLY HARMFUL EFFECT/ REASONS REJECTED	TEAM ACCEPTS PLACEMENT
		Yes No
		Yes No
		Yes No

TRANSPORTATION

Check all that apply

Yes

Special transportation is required to and from schools and/or between schools.

Yes

Special transportation is required in and around school buildings.

Yes

Specialized equipment (such as special or adapted buses, lifts, and ramps) is required.

Please explain and/or detail transportation plan:

Extended school year SERVICES

Yes

Extended school year services are needed. The IEP team must document the consideration of the need for extended school year services and the basis for the determination.

If yes, the IEP must indicate the type, amount and duration of services to be provided.

special education SERVICE(s)	LOCATION	amount/frequency of services	initiation of services	Duration of Services	Goal(s) Addressed

MANIFESTATION DETERMINATION (AS APPROPRIATE)

Complete when determining whether a student’s behavior was a manifestation of her/his disability.

Disability:

Incident(s) that Resulted in Disciplinary Action

The Student’s IEP and Placement (include a review of all relevant information in the child’s file, including the child’s IEP)

Observations of the Student (include a review of staff observations regarding the student’s behavior)

Information provided by the Parents (include a review of any relevant information provided by the parent(s)

Based upon the above information, the team has determined that:

Yes	No	The conduct was caused by or had a direct and substantial relationship to the student’s disability.
Yes	No	The conduct was the direct result of the school district’s failure to implement the IEP.

If “Yes” to either of the above, the behavior must be considered a manifestation of the student’s disability.

Check the appropriate box:

The student’s behavior WAS NOT a manifestation of her/his disability. The relevant disciplinary procedures applicable to students without disabilities may be applied to the student in the same manner in which they are applied to students without disabilities. If the district initiates disciplinary procedures applicable to all students, the district shall ensure that the special education and disciplinary records of the student with a disability are transmitted for consideration by the person or persons making the final determination regarding the disciplinary action.

	The student’s behavior WAS a manifestation of her/his disability. The team must review and revise the student’s IEP as appropriate and the district must take appropriate action. A functional behavior analysis will or has been completed. The behavior intervention plan shall be completed or modified/reviewed as required to address behavior.

ADDITIONAL NOTES/INFORMATION

REPORT OF PROGRESS ON ANNUAL GOALS (OPTION 1)

Specify the extent to which the student’s progress is sufficient to enable the student to achieve the goals by the end of the IEP year. Districts may use this page to report on student progress OR may use the option two page that would include data charts to indicate a student’s progress.

Student’s Name			Type of Report

Date			Report Card			1 2 3 4 Quarter

Staff Name			Progress Report			1 2 3 4 Quarter

Title			Parent Conference

GOAL NUMBER	MEASURABLE ANNUAL GOAL	*REPORT OF PROGRESS:*					ADDITIONAL COMMENTS
		Completed		Making Expected Progress	Not Making Expected Progress

REPORT OF PROGRESS ON ANNUAL GOALS (OPTION 2)

Student’s Name			Type of Report

Date			Report Card	1 2 3 4 Quarter

Staff Name			Progress Report	1 2 3 4 Quarter

Title			Parent Conference

GOAL NUMBER	MEASURABLE ANNUAL GOAL	REPORT OF PROGRESS (INSERT DATA CHARTS)