IEP DATES

IEP Team Meeting Initial IEP Annual/Review IEP Reevaluation IEP

Offer of a FAPE: ___________ Offer of a FAPE:__________ Offer of a FAPE: ___________
_______________ Implementation: __________ Implementation: _________ Implementation: __________

Individualized Education Program (IEP)

Section 1
DEMOGRAPHIC INFORMATION

Student Last: First: M: Birth Date: Gender: Grade:

Address: City: State: Zip:

Phone:

Resident District: Operating District:

County: Attending Building:

Parent Last: First: M: Relationship to Student:

Native Language or Other Communication Mode:

Address:(if different) City: State: Zip:

Home Phone: Work Phone: Cell Phone:

Email:

PURPOSE OF MEETING
Check one of the following: Check all others that apply:

___ Initial IEP ___ Change of Placement

___ Annual/Review IEP ___ Suspension/Expulsion ___ Graduation ___ Other
___ Reevaluation IEP ___ Secondary Transition
___ Change of Eligibility
___ Other: ___________________________________________

PARENT CONTACT
The parent/adult of the student was contacted to explain the purpose of the meeting and the roles and responsibilities of each
participant via (check all that apply):
___ IEP Invitation ___ Letter ___ Phone ___ Other: ______________________________________________

Results: ___________________________________________________________________________________________________
 PARENTAL RIGHTS AND AGE OF MAJORITY
Check all that apply:
___ The student will be age 17 during this IEP and the student was informed of parental rights that he or she will receive at age 18.
___ The student has turned age 18 and the student and parent were informed of parental rights that were transferred to the
student at age 18, including the right to invite a support person such as a parent, advocate, or friend.
___The student has turned 18 and there is a guardian established by court order. The guardian is:
____________________________________
___ The student has turned age 18 and a legally designated representative has been appointed. The representative is:
_______________________________________________ as ______________________________.

IEP MEETING PARTICIPANTS IN ATTENDANCE

Check the box indicating the IEP participant(s) who can explain the instructional implications of evaluation results.

___________________________________________________ ___________________________________________________
Student ▭ District Representative/Designee

___________________________________________________ ___________________________________________________
Parent ▭ General Education Teacher

___________________________________________________ ___________________________________________________
Parent ▭ Special Education Teacher

___________________________________________________ ___________________________________________________
▭ Agency Providing Secondary Transition Services ▭ Other
(consent on file)

___________________________________________________ ___________________________________________________
▭ Other ▭ Other

Parent and District Agreement on Attendance Not Necessary

These members are absent; their curricular area/related services are not being modified or discussed in the meeting: ____________
____________________________________________________________________________________________________________

Parent and District Agreement on Excusal Prior to Meeting

These members are absent and have submitted written input t the IEP team, including the parent, prior to the meeting: __________
____________________________________________________________________________________________________________

ELIGIBILITY FOR SPECIAL EDUCATION

▭ Eligible ▭ Ineligible

Area of disability: _____________________________________________________________________________________________

If the student is determined ineligible as a student with a specific learning disability (SLD), provide a statement of the basis for the
determination of ineligibility:
___________________________________________________________________________________________________________
If the student is determined eligible as a student with an SLD, check all that apply:
▭ Oral expression ▭ Listening comprehension ▭ Written expression ▭ Basic reading skill
▭ Reading fluency skills ▭Reading comprehension ▭ Mathematics calculation ▭ mathematics problem solving

Determination of eligibility was made in accordance with IDEA regulation at § 300.306 ©(1).
 Section 2
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

FACTORS TO CONSIDER

Progress on most recent goals and objectives?

Area of Need Subarea of Need Goal?

Data Sources and Description of Need Report and describe baseline data such as curriculum-based assessments,
student work, teacher observations, parent input, and other relevant data for each area of need.

Adverse Impact Describe how the student’s academic, developmental, and functional needs affect involvement and
progress in the general education curriculum or participation in appropriate activities for preschool students.

Area of Need Subarea of Need Goal?

Data Sources and Description of Need Report and describe baseline data such as curriculum-based assessments,
student work, teacher observations, parent input, and other relevant data for each area of need.

Adverse Impact Describe how the student’s academic, developmental, and functional needs affect involvement and
progress in the general education curriculum or participation in appropriate activities for preschool students.

Area of Need Subarea of Need Goal?

Data Sources and Description of Need Report and describe baseline data such as curriculum-based assessments,
student work, teacher observations, parent input, and other relevant data for each area of need.

Adverse Impact Describe how the student’s academic, developmental, and functional needs affect involvement and
progress in the general education curriculum or participation in appropriate activities for preschool students.

Special Factors
The IEP Team must consider the following for the student (check boxes to indicate consideration):
 ● The communication needs of the student
● The need for assistive technology devices and services for the student

The IEP Team must consider the following for the student, as appropriate (check all that apply):

● The use of positive behavior interventions and supports, and other strategies, to address behavior because the student
has behavior that impedes his or her learning or the learning of others.
● The language needs of the student because the student has limited English proficiency.
● Braille instruction because the student is blind or visually impaired.
● The mode of language and communication because the student is deaf or hard of hearing.
 Section 3
SECONDARY TRANSITION CONSIDERATIONS

Transition Assessments Completed: Date of Most Recent Assessment:

Assessments: Student/Parent Input School Observation Data

Date of Educational Development Plan (EDP):

If student did not attend IEP, describe steps taken to ensure consideration of students’ preferences/vision:

STUDENTS POST-SECONDARY VISION AND TRANSITION ACTIVITIES

Career/Employment: As an adult, what kind of work will you do?

Career/Employment Assessment Results: Present level assessment related to this vision statement.

Is there a need for activities or services for Career/Employment? ⬜ Yes ⬜ No

Type of Activity Explanation of Responsible Expected Completion Date

activity/service Agency/Persons

Post-Secondary Education/Training: After leaving school, what additional education and training will you do?

Post-Secondary Education/Training Assessment Results: Present level assessment related to this vision statement.

Is there a need for activities or services for Post-Secondary Education/Training? ⬜ Yes ⬜ No

Type of Activity Explanation of Responsible Expected Completion Date

activity/service Agency/Persons

Adult Living: As an adult, what kind of living arrangements will you have?

Adult Living Assessment Results: Present level assessment related to this vision statement.

Is there a need for activities or services for Adult Living? ⬜ Yes ⬜ No

Type of Activity Explanation of Responsible Expected Completion Date

activity/service Agency/Persons

Community Participation: As an adult, how ill you want to be involved in your community?

Community Participation Assessment Results: Present level assessment related to this vision statement.
Is there a need for activities or services for Community Participation? ⬜ Yes ⬜ No

Type of Activity Explanation of Responsible Expected Completion Date

activity/service Agency/Persons

COURSE OF STUDY
Describe how the student’s course of study aligns with the post-secondary vision:

Check One Only:

⬜ Michigan Merit Curriculum leading to a high school diploma
⬜ Course of Study leading to Certificate of Completion

Is the student expected to graduate with a regular diploma during this IEP year? ⬜ Yes ⬜ No

Will the student complete the age of eligibility for Special Education services? ⬜ Yes ⬜ No

COMMUNITY AGENCY INVOLVEMENT

Was there a need to invite a community agency representative likely to provide current or future services? ⬜ Yes ⬜ No
If YES, did the agency representative attend? ⬜ Yes ⬜ No
Consent signature date:

Please list any additional steps taken to ensure that the student has made connections with any appropriate outside programs
and services:

Did parent invite a community agency representative? ⬜ Yes ⬜ No

PARENT RIGHTS AND AGE OF MAJORITY

Check only one:
⬜ The student will be age 17 during this IEP and the student was informed of parental rights that he or she will receive at age 18.
⬜ The student has turned age 18 and the student and parent were informed of parental rights that were transferred to the
student at age 18, including the right to invite a support person such as a parent, advocate, or friend.
⬜ The student has turned age 18 and there is a guardian established by court order. The guardian is:
⬜ The student has turned age 18 and a legally designated representative has been appointed.
 Section 4

ANNUAL GOALS AND SHORT-TERM OBJECTIVES

Use as much of the outline for this section as you need, delete the rest
Area:
Goal:
Short-term objective:
Short-term objective:
Short-term objective

Area:
Goal:
Short-term objective:
Short-term objective
Short-term objective:

Area:
Goal:
Short-term objective:
Short-term objective
Short-term objective:

Area:
Goal:
Short-term objective:
Short-term objective
Short-term objective:

SCHEDULE FOR REPORTING PROGRESS

When:
● Every Marking Period
● Other _______________________________________

Position(s) responsible for implementing goal activities and reporting progress on goal(s) (check all that
apply):
● Special Education Teacher
● School Social Worker
● Teacher Consultant
● Occupational Therapist
● Speech and Language Provider
● Physical Therapist
● Other: _______________________________________________________________
Section 5

SUPPLEMENTARY AIDS AND SERVICES

 Supplementary aids and services are provided to enable the student:

● To advance appropriately toward attaining the annual goals.

● To be involved and progress in the general education curriculum and to participate in
extra-curricular and other nonacademic activities.
● To be educated and participate in activities with other students with disabilities and
nondisabled students.

Supplementary aids and services are needed at this time.

Ongoing Instruction and Assessment Time/Frequency/Condition Location

Scheduling, Presentation, Response, etc.

Curriculum Supports and Adjustments

Directions, Grading, Handwriting, Assignments, Tests, Time/Frequency/Condition Location
Books, etc.

Supports and Modifications to the Environment

Classroom Environment, Health-Related Needs, Physical Time/Frequency/Condition Location
Needs, Assistive Technology, Behavioral, Training Needs,
Social Interaction Supports for the Student, etc.

Other Supports, Accommodations, and

Time/Frequency/Condition Location
Modifications
 All aids and services identified will begin on the implementation date of the IEP and continue for the duration of the IEP.

● Supplementary aids and services are not needed at this time.

Explain the extent, if any, to which the student will not participate with nondisabled students:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
 Section 6

Assessment - Participation and Provisions

GENERAL EDUCATION ASSESSMENTS

Content Areas Accommodations

List the content area(s) in which the student will be List the appropriate accommodation(s).
administered the general education assessment.

ALTERNATE ASSESSMENTS

Content Area
List the content area in which the student will be administered an alternate assessment.

Need for Alternate Assessment Accommodations

Assessment State the alternate assessment that List the appropriate
State why the student cannot will be used and explain why it is accommodation(s).
participate in the general education appropriate.
assessment.

Content Area
List the content area in which the student will be administered an alternate assessment.

Need for Alternate Assessment Accommodations

Assessment State the alternate assessment that List the appropriate
State why the student cannot will be used and explain why it is accommodation(s).
participate in the general education appropriate
assessment.

Content Area
List the content area in which the student will be administered an alternate assessment.

Need for Alternate Assessment Accommodations

Assessment State the alternate assessment that List the appropriate
State why the student cannot will be used and explain why it is accommodation(s).
participate in the general education appropriate
assessment.

Content Area
List the content area in which the student will be administered an alternate assessment.

Need for Alternate Assessment Accommodations

Assessment State the alternate assessment that List the appropriate
State why the student cannot will be used and explain why it is accommodation(s).
participate in the general education appropriate
assessment.

Section 7

SPECIAL EDUCATION SERVICES AND PROGRAMS

Specific
Amount of
Related Services Location Duration*
Time and
Frequency

Does the student have needs that require placement with a teacher with a particular
endorsement? ____ Yes ____ No

Specific Amount
Depart-
Program of Time and Location Duration*
mentalized
Frequency
____ Yes ____ No

____ Yes ____ No

____ Yes ____ No

____ Yes ____ No

● All programs and services listed above will begin on the implementation date of the IEP and continue for the duration
of the IEP, unless otherwise indicated above in the column “Duration”.

EXTENDED SCHOOL YEAR (ESY) SERVICES

Extended School Year (ESY) Services were considered.
● It was determined that no ESY services are needed
● Current annual goals address one or more skills that require ESY services.

Specific Amount
Service of Time and Location Duration
Frequency

INSTRUCTIONAL TIME

(+) Special Education

General Education Instruction (=) Total
(minutes/hours per week)
Instruction (minutes/hours per week)
(minutes/hours per week)

+ =

EDUCATIONAL ENVIRONMENT
The district ensures that, to the maximum extent appropriate, the student will be educated with students who are
non-disabled; and special classes, separate schools, or other removal of the student from the general education
environment occurs only when the student’s needs cannot be met satisfactorily in the general education setting with
supplemental aids and services.

Participation in a Regular Early Childhood Program (students ages 3-5)

● At least 10 hours per week and:
● receives the majority of special education and related services IN a regular early childhood
program.
● receives the majority of special education and related services OUTSIDE of a regular early childhood
program
● Less than 10 hours per week and:
● receives the majority of special education and related services IN a regular early childhood
program.
● receives the majority of special education and related services OUTSIDE of a regular early childhood
program

Participation in General Education (students age 6-26)

● 80% of the day or more
● 79% to 40% of the day
● less than 40% of the day
● separate facility

SPECIAL TRANSPORTATION

● Yes (specify): ______________________________________________________________

● No