School District Identifying Information

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

STUDENT NAME: Tashawna
DATE OF BIRTH: LOCAL ID #:
DISABILITY CLASSIFICATION:
PROJECTED DATE IEP IS TO BE IMPLEMENTED: PROJECTED DATE OF ANNUAL REVIEW:
PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL NEEDS
DOCUMENTATION OF STUDENT'S CURRENT PERFORMANCE AND ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS
EVALUATION RESULTS (INCLUDING FOR SCHOOL-AGE STUDENTS, PERFORMANCE ON STATE AND DISTRICT-WIDE ASSESSMENTS)
2014 DRA Level F First !rade
2014 "ath #elow !rade Level
ACADEMIC ACHIEVEMENT, FUNCTIONAL PERFORMANCE AND LEARNING CHARACTERISTICS
LEVELS OF KNOWLEDGE AND DEVELOPMENT IN SUBJECT AND SKILL AREAS INCLUDING ACTIVITIES OF DAILY LIVING, LEVEL OF INTELLECTUAL
FUNCTIONING, ADAPTIVE BEHAVIOR, EXPECTED RATE OF PROGRESS IN ACQUIRING SKILLS AND INFORMATION, AND LEARNING STYLE:
Tashawna is inde$endent in all areas of living% She is a&le to manage her clothing' $ac( her s)$$lies for school' and feed herself witho)t any
assistance% Tashawna actively $artici$ates in $hysical activities s)ch as gym and recess% Tashawna*s academic $erformance is &elow grade level%
She has diffic)lty with most reading and math conce$ts% In reading' Tashawna shows diffic)lties in &asic s(ills and as of +an)ary her DRA score is a
level F' 10 levels &elow grade level% In math' Tashawna str)ggles with &asic com$)tations and $ro&lem solving% Tashawna needs constant re$etition
and reinforcement% Tashawna $resents strengths in com$leting wor( in small gro)$ sessions that involve reading sim$le $assages with vis)al aids%
STUDENT STRENGTHS, PREFERENCES, INTERESTS:
Tashawna $ersists in decoding words% She $refers to wor( in a small gro)$ setting rather than whole class% She en,oys reading fictional stories and
li(es )sing her imagination to $lay%
ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS OF THE STUDENT, INCLUDING CONSIDERATION OF STUDENT NEEDS THAT ARE OF
CONCERN TO THE PARENT:
Tashawna demonstrates diffic)lty in form)lating grammatically correct sentences in conversation% Tashawna needs to im$rove her ver&al e-$ression
and $rod)cing a$$ro$riate res$onses to logical .)estions% Tashawna str)ggles with most reading and math assignments% Tashawna needs to
im$rove form)lating gramatically correct sentences in her s$eech and her writing%
SOCIAL DEVELOPMENT
THE DEGREE (EXTENT) AND QUALITY OF THE STUDENT'S RELATIONSHIPS WITH PEERS AND ADULTS FEELINGS ABOUT SELF AND SOCIAL
ADJUSTMENT TO SCHOOL AND COMMUNITY ENVIRONMENTS:
Tashawna is a fo)rth grade st)dent who $resents herself in a friendly manner% She en,oys hel$ing others and res$onds well to small gro)$
instr)ction% Tashawna is well&ehaved and rela-ed% She res$onds well to $raise and $ositive reinforcement%
STUDENT STRENGTHS:
/ew 0or( State 1d)cation De$artment I12 Form
Tashawna is a&le to follow school ro)tines and acce$ts limits that are given &y teachers or administration% After g)ided instr)ction' Tashawna ma(es
corrections to her wor( and strives for im$rovement%
SOCIAL DEVELOPMENT NEEDS OF THE STUDENT, INCLUDING CONSIDERATION OF STUDENT NEEDS THAT ARE OF CONCERN TO THE PARENT:

PHYSICAL DEVELOPMENT
THE DEGREE (EXTENT) AND QUALITY OF THE STUDENT!S MOTOR AND SENSORY DEVELOPMENT, HEALTH, VITALITY AND PHYSICAL SKILLS OR
LIMITATIONS WHICH PERTAIN TO THE LEARNING PROCESS:
Tashawna is a ten year old girl who is slightly smaller than her $eers% She $resents ade.)ate fine motor s(ills and has no $hysical limitations%
STUDENT STRENGTHS:
Tashawna $resents with ade.)ate fine motor s(ills and she en,oys o)tdoor activities%
PHYSICAL DEVELOPMENT NEEDS OF THE STUDENT, INCLUDING CONSIDERATION OF STUDENT NEEDS THAT ARE OF CONCERN TO THE PARENT:
There are no concerns with regards to Tashawna*s $hysical needs% 2arent did not e-$ress any concerns%
MANAGEMENT NEEDS
THE NATURE (TYPE) AND DEGREE (EXTENT) TO WHICH ENVIRONMENTAL AND HUMAN OR MATERIAL RESOURCES ARE NEEDED TO ADDRESS
NEEDS IDENTIFIED ABOVE: Tashawna will &enefit from direct modeled instr)ction' redirection and refoc)sing' fre.)ent re$etition' scaffolding' and
re$hrasing%
EFFECT OF STUDENT NEEDS ON INVOLVEMENT AND PROGRESS IN THE GENERAL EDUCATION CURRICULUM OR, FOR A PRESCHOOL
STUDENT, EFFECT OF STUDENT NEEDS ON PARTICIPATION IN APPROPRIATE ACTIVITIES
Tashawna*s
1s
t grade reading level ma(es it diffic)lt for her to com$lete assignments inde$endently% She still demonstrates diffic)lties in $rod)cing
fl)ent s$eech and gramatically correct sentences in s$ea(ing and writing% Tashawna*s state scores from
3r
d grade indicate that she is &elow grade
level which affects her a&ility to access the general ed)cation c)rric)l)m at the same rate as her $eers%
STUDENT NEEDS RELATING TO SPECIAL FACTORS
BASED ON THE IDENTIFICATION OF THE STUDENT'S NEEDS, THE COMMITTEE MUST CONSIDER WHETHER THE STUDENT NEEDS A PARTICULAR
DEVICE OR SERVICE TO ADDRESS THE SPECIAL FACTORS AS INDICATED BELOW, AND IF SO, THE APPROPRIATE SECTION OF THE IEP MUST
IDENTIFY THE PARTICULAR DEVICE OR SERVICE(S) NEEDED"
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,% &'$9 +$0,&$ &# &'$ IEP6
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/ew 0or( State 1d)cation De$artment I12 Form
#11#+&(*.&.$% 5#+ ).+$/& .*%&+(/&.#* .* &'$ %&()$*&'% 0,*-(,-$ ,*) /#44(*./,&.#* 4#)$6
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BEGINNING NOT LATER THAN THE FIRST IEP TO BE IN EFFECT WHEN THE STUDENT IS AGE ;< (AND AT A YOUNGER AGE IF DETERMINED APPROPRIATE)
MEASURABLE POSTSECONDARY GOALS
LONG=TERM GOALS FOR LIVING, WORKING AND LEARNING AS AN ADULT
EDUCATION/TRAINING:
EMPLOYMENT:
INDEPENDENT LIVING SILLS (WHEN APPROPRIATE):
TRANSITION NEEDS
I* /#*%.)$+,&.#* #5 1+$%$*& 0$2$0% #5 1$+5#+4,*/$, &+,*%.&.#* %$+2./$ *$$)% #5 &'$ %&()$*& &',& 5#/(% #* &'$ %&()$*&'% /#(+%$% #5
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%/'##0 ,/&.2.&.$%:
MEASURABLE ANNUAL GOALS
THE FOLLOWING GOALS ARE RECOMMENDED TO ENABLE THE STUDENT TO BE INVOLVED IN AND PROGRESS IN THE GENERAL EDUCATION
CURRICULUM, ADDRESS OTHER EDUCATIONAL NEEDS THAT RESULT FROM THE STUDENT'S DISABILITY, AND PREPARE THE STUDENT TO MEET
HIS:HER POSTSECONDARY GOALS"
ANNUAL GOALS
WHAT THE STUDENT WILL BE EXPECTED TO ACHIEVE
BY THE END OF THE YEAR IN WHICH THE IEP IS IN
EFFECT
CRITERIA
MEASURE TO DETERMINE
IF GOAL HAS BEEN
ACHIEVED
METHOD
HOW PROGRESS WILL BE
MEASURED
SCHEDULE
WHEN PROGRESS WILL
BE MEASURED
S$eech and Lang)age% In one year' Tashawna will
im$rove her ver&al e-$ression' incl)ding grammer' and
sentence str)ct)re &y form)lating clear and a$$ro$riate
res$onses to sim$le .)estions%
456 Acc)racy% Teacher made materials
incl)ding sentence
starters% Lang)age
activities%
2 times $er year%
S$eech and lang)age% In one year' Tashawna will
form)late gramatically correct' sentences in s$eech and
writing &y )sing ad,ectives' ver&s' and $re$ositions given
e-$licit modeling and g)ided $ractice%
706 Acc)racy% Teachermade materials%
8eterogeneo)s gro)$ing
d)ring active engagement%
3 times $er year%
Social s(ills% In one year' Tashawna will ma(e and
maintain meaningf)l friendshi$s thro)gh ac.)istion of
social s(ills s)ch as initiating conversation and as(ing
706 Acc)racy% Teacher o&servations%
9lass activities%
3 times $er year%
/ew 0or( State 1d)cation De$artment I12 Form
her $eers to $lay a $artic)lar activity%
Social s(ills% In one year' Tashawna will im$rove her self
esteem and confidence' $artic)larly with regard to $eer
relations' and will have an increased motivation to
$artici$ate in class disc)ssions and as( for clarification
when needed%
456 Acc)racy% Teacher o&servations%
9lass activities%
1 time $er month%
"ath% In one year' Tashawna will show )nderstanding of
solving word $ro&lems &y )nderlining the im$ortant
details' circling what the .)estion is as(ing' $ic(ing and
strategy' and solving the $ro&lem%
456 Acc)racy% :nit tests and math drills% 1 time $er month%





REPORTING PROGRESS TO PARENTS
I)$*&.59 7'$* 1$+.#)./ +$1#+&% #* &'$ %&()$*&'% 1+#-+$%% &#7,+) 4$$&.*- &'$ ,**(,0 -#,0% 7.00 3$ 1+#2.)$) &# &'$ %&()$*&'%
1,+$*&%:
/ew 0or( State 1d)cation De$artment I12 Form
ALTERNATE SECTION FOR STUDENTS WHOSE IEPS WILL INCLUDE SHORT-TERM INSTRUCTIONAL OBJECTIVES AND/OR BENCHMARS
(RE!UIRED FOR PRESCHOOL STUDENTS AND FOR SCHOOL-AGE STUDENTS WHO MEET ELIGIBILITY CRITERIA TO TAE THE NEW YOR STATE
ALTERNATE ASSESSMENT)
MEASURABLE ANNUAL GOALS
THE FOLLOWING GOALS ARE RECOMMENDED TO ENABLE THE STUDENT TO BE INVOLVED IN AND PROGRESS IN THE GENERAL EDUCATION
CURRICULUM OR, FOR A PRESCHOOL CHILD, IN APPROPRIATE ACTIVITIES, ADDRESS OTHER EDUCATIONAL NEEDS THAT RESULT FROM THE
STUDENT'S DISABILITY, AND, FOR A SCHOOL=AGE STUDENT, PREPARE THE STUDENT TO MEET HIS:HER POSTSECONDARY GOALS"
ANNUAL GOAL
WHAT THE STUDENT WILL BE EXPECTED TO ACHIEVE
BY THE END OF THE YEAR IN WHICH THE IEP IS IN
EFFECT
CRITERIA
MEASURE TO DETERMINE
IF GOAL HAS BEEN
ACHIEVED
METHOD
HOW PROGRESS WILL BE
MEASURED
SCHEDULE
WHEN PROGRESS WILL
BE MEASURED

SHORT=TERM INSTRUCTIONAL OBJECTIVES AND:OR BENCHMARKS (INTERMEDIATE STEPS BETWEEN THE STUDENT!S PRESENT LEVEL OF
PERFORMANCE AND THE MEASURABLE ANNUAL GOAL):




ANNUAL GOAL CRITERIA METHOD SCHEDULE

SHORT=TERM INSTRUCTIONAL OBJECTIVES AND:OR BENCHMARKS (INTERMEDIATE STEPS BETWEEN THE STUDENT!S PRESENT LEVEL OF
PERFORMANCE AND THE MEASURABLE ANNUAL GOAL):




ANNUAL GOAL CRITERIA METHOD SCHEDULE

SHORT=TERM INSTRUCTIONAL OBJECTIVES AND:OR BENCHMARKS (INTERMEDIATE STEPS BETWEEN THE STUDENT!S PRESENT LEVEL OF
PERFORMANCE AND THE MEASURABLE ANNUAL GOAL):




(DUPLICATE TABLE:ROWS AS NEEDED)
/ew 0or( State 1d)cation De$artment I12 Form
REPORTING PROGRESS TO PARENTS
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1,+$*&%:
RECOMMENDED SPECIAL EDUCATION PROGRAMS AND SERVICES
SPECIAL EDUCATION PROGRAM/SERVICES
SERVICE DELIVERY
RECOMMENDATION
S"
FRE!UENC
Y
HOW OFTEN
PROVIDED
DURATIO
N
LENGTH OF
SESSION
LOCATION
WHERE SERVICE WILL BE
PROVIDED
PROJECTED
BEGINNING/
SERVICE
DATE(S)
SPECIAL EDUCATION PROGRAM:
Integrated coteaching All academic $eiods f)lltime 35 2eriods !eneral ed)cation Se$tem&er 4th




RELATED SERVICES:
S$eechLang)age Thera$y !ro)$ of three
st)dents
2-;wee( 30 min% Fle-i&le setting< s$eech
room;classroom
Se$tem&er 4th
9o)nseling Services 1-;individ)al 1-;wee( 30 min% Fle-i&le setting<
co)nseler*s
room;classroom
Se$tem&er 4th
1-;gro)$ 1-;wee( 30 min% Fle-i&le setting<
co)nseler*s
room;classroom
Se$tem&er 4th


SUPPLEMENTARY AIDS AND
SERVICES/PROGRAM
MODIFICATIONS/ACCOMMODATIONS:



ASSISTIVE TECHNOLOGY DEVICES AND/OR
SERVICES:


/ew 0or( State 1d)cation De$artment I12 Form
SUPPORTS FOR SCHOOL PERSONNEL ON
BEHALF OF THE STUDENT:


? I)$*&.59, .5 ,110./,30$, /0,%% %.@$ (4,A.4(4 %&()$*&=&#=%&,B +,&.#), 0,*-(,-$ .5 #&'$+ &',* E*-0.%', -+#(1 #+ .*).2.)(,0 %$+2./$%,
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#$-MONTH SERVICE AND/OR PROGRAM % S&()$*& .% $0.-.30$ &# +$/$.2$ %1$/.,0 $)(/,&.#* %$+2./$% ,*):#+ 1+#-+,4 )(+.*-
J(09:A(-(%&: N# Y$%
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S&()$*& 7.00 +$/$.2$ &'$ %,4$ %1$/.,0 $)(/,&.#* 1+#-+,4:%$+2./$% ,% +$/#44$*)$) ,3#2$"
OR
S&()$*& 7.00 +$/$.2$ &'$ 5#00#7.*- %1$/.,0 $)(/,&.#* 1+#-+,4:%$+2./$%:
SPECIAL EDUCATION
PROGRAM/SERVICES
SERVICE DELIVERY
RECOMMENDATION
S FRE!UENCY
DURATIO
N LOCATION
PROJECTED
BEGINNING/
SERVICE
DATE(S)




N,4$ #5 %/'##0:,-$*/9 1+#2.)$+ #5 %$+2./$% )(+.*- J(09 ,*) A(-(%&:
F#+ , 1+$%/'##0 %&()$*&, +$,%#*(%) &'$ /'.0) +$C(.+$% %$+2./$% )(+.*- J(09 ,*) A(-(%&:
TESTING ACCOMMODATIONS (TO BE COMPLETED FOR PRESCHOOL CHILDREN ONLY IF THERE IS AN ASSESSMENT PROGRAM FOR NONDISABLED
PRESCHOOL CHILDREN):
INDIVIDUAL TESTING ACCOMMODATIONS, SPECIFIC TO THE STUDENT!S DISABILITY AND NEEDS, TO BE USED CONSISTENTLY BY THE STUDENT
IN THE RECOMMENDED EDUCATIONAL PROGRAM AND IN THE ADMINISTRATION OF DISTRICT=WIDE ASSESSMENTS OF STUDENT ACHIEVEMENT
AND, IN ACCORDANCE WITH DEPARTMENT POLICY, STATE ASSESSMENTS OF STUDENT ACHIEVEMENT
TESTING ACCOMMODATION CONDITIONS" IMPLEMENTATION RECOMMENDATIONS""
/ew 0or( State 1d)cation De$artment I12 Form
NONE
1-tended time Standardi=ed assessments The st)dent will have do)&le time for state e-ams and
will have the directions read to them%





?C#*).&.#*% D T$%& C',+,/&$+.%&./%: D$%/+.3$ &'$ &91$, 0$*-&', 1(+1#%$ #5 &'$ &$%& (1#* 7'./' &'$ (%$ #5 &$%&.*- ,//#44#),&.#*%
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,//#44#),&.#*%, .5 ,110./,30$"
BEGINNING NOT LATER THAN THE FIRST IEP TO BE IN EFFECT WHEN THE STUDENT IS AGE ;< (AND AT A YOUNGER AGE, IF DETERMINED APPROPRIATE)"
COORDINATED SET OF TRANSITION ACTIVITIES
NEEDED ACTIVITIES TO FACILITATE
THE STUDENT&S MOVEMENT FROM
SCHOOL TO
POST-SCHOOL ACTIVITIES SERVICE/ACTIVITY
SCHOOL DISTRICT/
AGENCY RESPONSIBLE
I*%&+(/&.#*
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,110./,30$)

F(*/&.#*,0 V#/,&.#*,0 A%%$%%4$*& (.5
,110./,30$)

PARTICIPATION IN STATE AND DISTRICT-WIDE ASSESSMENTS
(TO BE COMPLETED FOR PRESCHOOL STUDENTS ONLY IF THERE IS AN ASSESSMENT PROGRAM FOR NONDISABLED PRESCHOOL STUDENTS)
T'$ %&()$*& 7.00 1,+&./.1,&$ .* &'$ %,4$ S&,&$ ,*) ).%&+./&=7.)$ ,%%$%%4$*&% #5 %&()$*& ,/'.$2$4$*& &',& ,+$ ,)4.*.%&$+$)
/ew 0or( State 1d)cation De$artment I12 Form
&# -$*$+,0 $)(/,&.#* %&()$*&%"
T'$ %&()$*& 7.00 1,+&./.1,&$ .* ,* ,0&$+*,&$ ,%%$%%4$*& #* , 1,+&./(0,+ S&,&$ #+ ).%&+./&=7.)$ ,%%$%%4$*& #5 %&()$*&
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%$0$/&$) .% ,11+#1+.,&$ 5#+ &'$ %&()$*&:
PARTICIPATION WITH STUDENTS WITHOUT DISABILITIES
REMOVAL FROM THE GENERAL EDUCATION ENVIRONMENT OCCURS ONLY WHEN THE NATURE OR SEVERITY OF THE DISABILITY IS SUCH THAT,
EVEN WITH THE USE OF SUPPLEMENTARY AIDS AND SERVICES, EDUCATION CANNOT BE SATISFACTORILY ACHIEVED"
FOR THE PRESCHOOL STUDENT:
EA10,.* &'$ $A&$*&, .5 ,*9, &# 7'./' &'$ %&()$*& 7.00 *#& 1,+&./.1,&$ .* ,11+#1+.,&$ ,/&.2.&.$% 7.&' ,-$=,11+#1+.,&$ *#*).%,30$)
1$$+% ($"-", 1$+/$*& #5 &'$ %/'##0 ),9 ,*):#+ %1$/.59 1,+&./(0,+ ,/&.2.&.$%):
FOR THE SCHOOL-AGE STUDENT:
EA10,.* &'$ $A&$*&, .5 ,*9, &# 7'./' &'$ %&()$*& 7.00 *#& 1,+&./.1,&$ .* +$-(0,+ /0,%%, $A&+,/(++./(0,+ ,*) #&'$+ *#*,/,)$4./
,/&.2.&.$% ($"-", 1$+/$*& #5 &'$ %/'##0 ),9 ,*):#+ %1$/.59 1,+&./(0,+ ,/&.2.&.$%):
I5 &'$ %&()$*& .% *#& 1,+&./.1,&.*- .* , +$-(0,+ 1'9%./,0 $)(/,&.#* 1+#-+,4, .)$*&.59 &'$ $A&$*& &# 7'./' &'$ %&()$*& 7.00
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EXEMPTION FROM LANGUAGE OTHER THAN ENGLISH DIPLOMA REQUIREMENT: N# Y$% = T'$ C#44.&&$$ ',% )$&$+4.*$) &',& &'$
%&()$*&'% ).%,3.0.&9 ,)2$+%$09 ,B$/&% '.%:'$+ ,3.0.&9 &# 0$,+* , 0,*-(,-$ ,*) +$/#44$*)% &'$ %&()$*& 3$ $A$41& 5+#4 &'$
0,*-(,-$ #&'$+ &',* E*-0.%' +$C(.+$4$*&"
SPECIAL TRANSPORTATION
TRANSPORTATION RECOMMENDATION TO ADDRESS NEEDS OF THE STUDENT RELATING TO HIS:HER DISABILITY
N#*$"
S&()$*& *$$)% %1$/.,0 &+,*%1#+&,&.#* ,//#44#),&.#*%:%$+2./$% ,% 5#00#7%:





S&()$*& *$$)% &+,*%1#+&,&.#* &# ,*) 5+#4 %1$/.,0 /0,%%$% #+ 1+#-+,4% ,& ,*#&'$+ %.&$:
PLACEMENT RECOMMENDATION
/ew 0or( State 1d)cation De$artment I12 Form

/ew 0or( State 1d)cation De$artment I12 Form