IEP Individualized Education Program

THIS IEP WILL BE IMPLEMENTED DURING THE REGULAR SCHOOL TERM UNLESS NOTED IN GENERAL FACTORS

CHILD'S INFORMATION

MEETING INFORMATION

NAME:

ID NUMBER:

STREET:

GENDER:

CITY:

STATE: OH

MEETING DATE:

GRADE:

MEETING TYPE:
INITIAL IEP

ZIP:

ANNUAL REVIEW

DATE OF BIRTH:

REVIEW OTHER THAN ANNUAL REVIEW

DISTRICT OF RESIDENCE:

COUNTY OF RESIDENCE:
AMENDMENT
OTHER

DISTRICT OF SERVICE:
Will the child be 14 years old before the end of this IEP?

YES

NO

YES

NO

IEP TIME LINES

(Changes content of Sections 4 and 5)

Is the child a ward of the state?

ETR COMPLETION DATE:

NEXT ETR DUE DATE:

If yes, provide the name of the surrogate parent:

IEP EFFECTIVE DATES

START:
END:

PARENTS' / GUARDIAN INFORMATION

NEXT IEP REVIEW:

NAME:
STREET:

IEP BY 3rd BIRTHDAY ?

CITY:

(If transitioning from EI services)

STATE: OH

ZIP:

HOME PHONE:

WORK PHONE:

IEP FORM STATUS

CELL PHONE:

EMAIL:

(Check when complete)

YES

NO

1. FUTURE PLANNING

NAME:

2. SPECIAL INSTRUCTIONAL FACTORS

STREET:
CITY:

3. PROFILE

STATE: OH

ZIP:

4. POSTSECONDARY TRANSITION

HOME PHONE:

WORK PHONE:

5. POSTSECONDARY TRANSITION SERVICES

CELL PHONE:

EMAIL:

6. MEASURABLE ANNUAL GOALS

7. SPECIALLY DESIGNED SERVICES

OTHER INFORMATION:

8. TRANSPORTATION AS A RELATED SERVICE

9. NONACADEMIC AND EXTRA CURRICULAR
10. GENERAL FACTORS
11. LEAST RESTRICTIVE ENVIRONMENT
12. STATEWIDE AND DISTRICT TESTING
13. MEETING PARTICIPANTS
14. SIGNATURES

AMENDMENTS: (Complete only if amending the IEP)

IEP SECTION THE SCHOOL DISTRICT AND PARENTS HAVE AGREED
AMENDED TO MAKE THE FOLLOWING CHANGES TO THE IEP

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

DATE OF
AMENDMENT

PARTICIPANT & ROLE

PAGE 1 of 13

IEP

Individualized Education Program

FUTURE PLANNING

SPECIAL INSTRUCTIONAL FACTORS

CHILD'S NAME:

Items checked "YES" will be addressed in this IEP:

Does the child have behavior which impedes his/her learning or the learning of others?

YES

NO

Does the child have limited English proficiency?

YES

NO

Is the child blind or visually impaired?

YES

NO

Does the child have communication needs (required for deaf or hearing impaired )?

YES

NO

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

YES

NO

Does the child require specially designed physical education?

YES

NO

PROFILE

CHILD'S PROFILE:

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

PAGE 2 of 13

IEP

Individualized Education Program

CHILD'S NAME:

POSTSECONDARY TRANSITION

FOR 14 YEARS AND OLDER

(or younger if appropriate)

A STATEMENT OF TRANSITION SERVICE NEEDS OF THE CHILD THAT FOCUSES ON THE CHILD'S COURSE OF STUDY

FOR 16 YEARS AND OLDER

(or younger if appropriate)

AGE APPROPRIATE TRANSITION ASSESSMENTS

Summarize the results of the age-appropriate transition assessment data in the space below, indicating the source of the assessment(s) and
the relevant information for transition planning

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

PAGE 3 of 13

IEP

Individualized Education Program

POSTSECONDARY TRANSITION SERVICES

CHILD'S NAME:

POSTSECONDARY EDUCATION AND TRAINING (optional for 15 and younger)

MEASURABLE POSTSECONDARY GOAL:

COURSES OF STUDY:

TRANSITION SERVICE/ACTIVITY

NUMBERS OF ANNUAL GOAL(S)

PROJECTED BEGINNING
DATE

ANTICIPATED
DURATION

PERSON/AGENCY RESPONSIBLE

EMPLOYMENT (optional for 15 and younger)

MEASURABLE POSTSECONDARY GOAL:

COURSES OF STUDY:

TRANSITION SERVICE/ACTIVITY

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

NUMBERS OF ANNUAL GOAL(S)

PROJECTED BEGINNING ANTICIPATED

DATE
DURATION

PERSON/AGENCY RESPONSIBLE

PAGE 4 of 13

IEP

Individualized Education Program

CHILD'S NAME:

INDEPENDENT LIVING (As appropriate)

MEASURABLE POSTSECONDARY GOAL:

COURSES OF STUDY:

TRANSITION SERVICE/ACTIVITY

NUMBERS OF ANNUAL GOAL(S)

PROJECTED BEGINNING
DATE

ANTICIPATED
DURATION

PERSON/AGENCY RESPONSIBLE

Target date for child to Graduate:

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

PAGE 5 of 13

IEP

Individualized Education Program

CHILD'S NAME:

MEASURABLE ANNUAL GOALS

AREA:

NUMBER:

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

MEASURABLE ANNUAL GOAL

METHOD(S)

METHOD FOR MEASURING THE CHILD'S PROGRESS TOWARDS ANNUAL GOAL

a. Curriculum Based Assessment

e. Short-Cycle Assessments

i. Work Samples

b. Portfolios

f. Performance Assessments

j. Inventories

c. Observation

g. Checklists

k. Rubrics

d. Anecdotal Records

h. Running Records

MEASURABLE OBJECTIVES
NUM OBJECTIVE

.1
.2
.3
.4
.5
.6
METHOD AND FREQUENCY FOR REPORTING THE CHILD'S PROGRESS TO PARENTS
Written report
Email

Reported every

weeks

Phone call
Journal entry
The child's progress will be reported to the child's parents each time report cards are issued

Other
Note: Progress Reports must be provided to parents of a child with a disability at least as often as report cards are issued to all children. If the district
provides interim reports to all children, progress reports must be provided to all parents of a child with a disability.

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

PAGE 6 of 13

IEP

Individualized Education Program

CHILD'S NAME:

MEASURABLE ANNUAL GOALS

AREA:

NUMBER:

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

MEASURABLE ANNUAL GOAL

METHOD(S)

METHOD FOR MEASURING THE CHILD'S PROGRESS TOWARDS ANNUAL GOAL

a. Curriculum Based Assessment

e. Short-Cycle Assessments

i. Work Samples

b. Portfolios

f. Performance Assessments

j. Inventories

c. Observation

g. Checklists

k. Rubrics

d. Anecdotal Records

h. Running Records

MEASURABLE BENCHMARKS
NUM BENCHMARK

DATE OF MASTERY

.1
.2
.3
.4
.5
METHOD AND FREQUENCY FOR REPORTING THE CHILD'S PROGRESS TO PARENTS
Written report
Email

Reported every

weeks

Phone call
Journal entry
The child's progress will be reported to the child's parents each time report cards are issued

Other
Note: Interim Progress Reports must be provided to parents of a child with a disability at least as often as report cards are issued to all children. If the district
provides interim reports to all children, progress reports must be provided to all parents of a child with a disability.

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

PAGE 6 of 13

IEP

Individualized Education Program

CHILD'S NAME:

DESCRIPTION(S) OF SPECIALLY DESIGNED SERVICES

TYPE OF SERVICE

GOAL(s)
ADDRESSED

PROVIDER TITLE

LOCATION OF SERVICES

SPECIALLY DESIGNED INSTRUCTION:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

RELATED SERVICES:

ASSISTIVE TECHNOLOGY:

ACCOMMODATIONS:

BEGIN:

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

END:

AMOUNT OF TIME:

FREQUENCY:

PAGE 7 of 13

IEP

Individualized Education Program

BEGIN:

END:

CHILD'S NAME:

AMOUNT OF TIME:

FREQUENCY:

MODIFICATIONS:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

SUPPORT FOR SCHOOL PERSONNEL:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

SERVICE(S) TO SUPPORT MEDICAL NEEDS:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

KEY:

OPTIONAL ENTRY

NOT REQUIRED

TRANSPORTATION AS A RELATED SERVICE

Does the child have needs related to their identified disability that require special transportation?

YES

NO

YES

NO

Does the child need accommodations or modifications for transportation?

If yes, check any transportation accommodations/modifications that are needed.
The bus driver will be notified of the child's behavioral and/or medical concerns
Specially Adapted Vehicle

Wheelchair lift

Bus Aide

Securement Systems

Car Seat

Harness

Other

Specify:

Does the child need transportation to and from provider services?

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

YES

NO

PAGE 8 of 13

IEP

Individualized Education Program

CHILD'S NAME:

NONACADEMIC AND EXTRACURRICULAR ACTIVITIES

In what ways will the child have the opportunity to participate in nonacademic/extracurricular activities with his/her nondisabled peers?

Describe

If the child will not participate in non-academic/extracurricular activities, explain.

10

GENERAL FACTORS

HAS THE IEP TEAM CONSIDERED:

The strengths of the child?

YES

NO

The concerns of the parents for the education of the child?

YES

NO

The results of the initial or most recent evaluations of the child?

YES

NO

As appropriate, the results of performance on any state or district-wide assessments?

YES

NO

The academic, developmental, and functional needs of the child?

YES

NO

The need for extended school year (ESY) services

The team has determined that ESY services are not necessary.
The team has determined that ESY services are necessary for the following
Goals and Objectives or Benchmarks:
The team needs to collect further data before making a determination and
will meet again by:

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

PAGE 9 of 13

IEP

Individualized Education Program

11

LEAST RESTRICTIVE ENVIRONMENT

CHILD'S NAME:

Does this child attend the school (or for a preschool-age child, participate in the environment)
he/she would attend if not disabled?

YES

NO

If no, justify:

YES

Does this child receive all special education services with nondisabled peers?

NO

If no, justify (justification may not be solely because of needed modifications in the general curriculum):

12

STATEWIDE AND DISTRICT WIDE TESTING

For each subject tested in the child's grade, choose the method of assessment below. If "With Accommodations" is chosen for any subject,
provide a description of the Accommodations for each subject in the right column.
Alternate Assessment, if chosen, must apply to all tests taken.
Will the child participate in classroom, district wide and state wide assessments with accommodations?

AREA

GRADE

READING
WRITING
MATH
SCIENCE
SOCIAL STUDIES

CHILDREN WILL BE TESTED:

YES

NO

DETAIL OF ACCOMMODATIONS

WITH ACCOMMODATIONS
MODIFIED ASSESSMENT
WITH ACCOMMODATIONS
MODIFIED ASSESSMENT
WITH ACCOMMODATIONS
MODIFIED ASSESSMENT
WITH ACCOMMODATIONS
MODIFIED ASSESSMENT
WITH ACCOMMODATIONS
MODIFIED ASSESSMENT
WITH ACCOMMODATIONS

OTHER

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

MODIFIED ASSESSMENT

PAGE 10 of 13

IEP

Individualized Education Program

CHILD'S NAME:

Is the child to be excused from the consequences of not passing the Ohio Graduation Test (OGT)?

YES

NO

The child is completing a curriculum that is significantly different than the curriculum completed by other
children required to take the test.

YES

NO

The child requires accommodations that are beyond the accommodations allowed for children taking state
wide assessments.

YES

NO

YES

NO

YES

NO

The child is excused from the consequences of not passing the OGT in the following subjects:
Reading
Mathematics
Writing
Social Studies
Science

Met Testing Participation Requirement?

Date complete:

Is the child participating in alternate assessment?

Justify the choice of alternate assessment and address why it is appropriate:

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

PAGE 11 of 13

IEP

Individualized Education Program

13

MEETING PARTICIPANTS

CHILD'S NAME:

THIS IEP MEETING WAS:

IEP EFFECTIVE DATES

Face-to-Face Meeting

START:

Video Conference

END:

Telephone Conference/Conference Call

DATE OF NEXT IEP REVIEW:

Other

IEP MEETING PARTICIPANTS

THE FOLLOWING PEOPLE ATTENDED AND PARTICIPATED IN THE MEETING TO DEVELOP THIS IEP

POSITION

NAME

SIGNATURE

Student*
Parent
Parent
District Representative*
Intervention Specialist*
General Education Teacher*

PEOPLE NOT IN ATTENDANCE WHO PROVIDED INFORMATION AND RECOMMENDATIONS

POSITION

NAME

SIGNATURE

DATE

IF THE REGULAR EDUCATION TEACHER, INTERVENTION SPECIALIST, DISTRICT REPRESENTATIVE OR PERSON KNOWLEDGABLE ABOUT THE
INSTRUCTIONAL IMPLICATIONS OF THE EVALUATION DATA HAVE SIGNED AS NOT IN ATTENDANCE AT THE IEP MEETING, A WRITTEN EXCUSE
MUST BE ON FILE*.

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

PAGE 12 of 13

IEP

Individualized Education Program

14

SIGNATURES

CHILD'S NAME:

INITIAL IEP
I give consent to initiate special education and related services specified in this IEP.*
I give consent to initiate special education and related services specified in this IEP except for **
AREA:
I do not give consent for special education and related services at this time.**
DATE:

PARENTS' SIGNATURE:

ANNUAL REVIEW/REVIEW OTHER THAN ANNUAL REVIEW (Not a Change of Placement)

I agree with the implementation of this IEP.*
I am signing to show my attendance/participation at the IEP team meeting but I do not agree with the following
special education and related services specified in this IEP.**
AREA:
Note: Not a Change of Placement does NOT require a parents' signature to implement the IEP.

PARENTS' SIGNATURE:

DATE:

ANNUAL REVIEW/REVIEW OTHER THAN ANNUAL REVIEW (Change of Placement)

I give consent for the change of placement as identified in this IEP.*
I do not give consent for the change of placement as identified in this IEP.**
I revoke consent for all special education and related services.**
PARENTS' SIGNATURE:

DATE:

* This IEP serves as prior written notice if there is agreement.

**If there is not agreement or consent is revoked, the district must provide prior written notice to the parents.

TRANSFER OF RIGHTS AT MAJORITY

By the child's 17th birthday, the child and the child's parents or surrogate parent received a copy of their procedural
safeguards notice and notice of the transfer of procedural safeguard rights under IDEA will take place on the child's
18th birthday.
CHILD'S SIGNATURE:
DATE:
PARENTS' SIGNATURE:

YES

NO

YES

NO

YES

NO

DATE:

PROCEDURAL SAFEGUARDS NOTICE

A copy of the Procedural Safeguards Notice was given to the parents at the IEP Meeting.
IF NO, DATE SENT TO PARENTS:

COPY OF THE IEP

A copy of the IEP was given to the parents at the IEP meeting.
IF NO, DATE SENT TO PARENTS:

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012

PAGE 13 of 13

IEP

Individualized Education Program

15

CHILDREN WITH VISUAL IMPAIRMENTS

CHILD'S NAME:

This form shall be completed during the IEP meeting for each child who has a visual impairment, as defined by Ohio's Amended
Substitute House Bill Number 164, which requires a statement specifying one or more reading and writing media in which
instruction is appropriate to meet the child's educational needs. A copy of this completed form is part of, and must be attached to,
the child's IEP form.
1.Annual assessment of reading and writing skills was conducted with each child in all media considered appropriate.
YES
The results of these assessments are included in Present Levels of Development/Functioning/Performance on the
IEP and indicate both strengths and weaknesses.

NO

2.The IEP contains a requirement for instruction in Braille reading and writing when that medium is appropriate and is
indicated by adding Standard English Braille as a special service in Step 4, listing the date initiated and the
anticipated duration of services.

YES

NO

3.Instruction in Braille reading and writing was carefully considered for this child and pertinent literature describing the
educational benefits of instruction in Braille reading and writing was reviewed by the persons developing this
child's IEP.

YES

NO

4.The following visual condition(s) was taken into account and discussed in making the above decision:

YES

NO

Condition is degenerative and progressive loss is expected.

YES

NO

Condition is currently unpredictable in nature and will be reviewed if change in visual condition is noted.

YES

NO

Condition is temporary and expected to improve.

YES

NO

Condition is stable and will be monitored.

YES

NO

YES
YES
YES
YES
YES

NO
NO
NO
NO
NO

Annual goals provided

YES

NO

Short-term objectives provided

YES

NO

Date of initiation indicated

YES

NO

Frequency and duration of instructional sessions indicated

YES

NO

Level of competency to be achieved annually indicated

YES

NO

Objective determinants used to measure achievement provided

YES

NO

Documented visual acuity allowing the choice of larger type/regular type

YES

NO

Child is considered a pre-reader

YES

NO

Other

YES

NO

5.Indicate the appropriate instructional media

Standard English Braille
Large Print
Regular Print
Tape/auditory
Pre-reader
6.Complete if Braille reading and writing ARE appropriate at this time

7.Reasons Braille reading and writing ARE NOT appropriate this time

PR-07 IEP FORM REVISED BY ODE: MAY 22, 2012