PURPOSE: The IEP is designed to clearly communicate to the parents, the student, and providers the type and

amount of special
education and any necessary related services or supports that will be made available to the student. The most recent evaluation
report is used to develop the IEP. The IEP is individualized to reflect the unique needs of the student and how these needs will be
addressed to permit the student to be included and progress in the general education curriculum. A meeting to review and revise
the IEP must occur, at a minimum, on an annual basis.

INDIVIDUALIZED EDUCATION PROGRAM

Student Date of IEP meeting:
name:
Student IEP annual review date:
ID:
Eligibility Evaluation Date:
category:
Primary Birthdate: Age: Grade:
language:
Distric Serving School:
t:
Parent(s) Resident School:
name(s):
Primary language at Interpreter needed? Yes No
home:
Surrogate parent: Yes No If yes, name:
Primary staff contact Title:
name:

PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL POINTS THAT MUST

BE CONSIDERED IN
PERFORMANCE DEVELOPING THE
(including the strengths of the student and the concerns of the parents for enhancing the education of IEP (refer to WAC
their student) 392-172A-03110):
Present levels of academic achievement:  Strengths of the
student.
 Concerns of the
parents for enhancing
the education of their
student.
 Results of the most
current evaluation,
and the academic,
developmental, and
functional needs of
the student.
 Other special
factors, including
the use of positive
behavioral
supports/interventio
ns; language needs
of students with
limited English
proficiency; supports
for students with
visual impairments;
Present levels of functional performance (e.g., communication, motor, social, the communication
behavior, life/adaptive skills, etc.):

Form 6c - IEP (without Transition) Page 1 August 2008 (Rev. 8/2018)

 needs of the
student; assistive
technology devices
and services; and
supplementary
aids/services,
program
modifications, and
support for school
personnel.

Effect of the disability on the student’s involvement and progress in the general education
curriculum (or for preschool children, as appropriate, how the disability affects the child’s
participation in appropriate activities):

CONSIDERATION OF SPECIAL FACTORS:

If yes, describe (if not addressed on the service
1. Does this student require special matrix):
Yes No
transportation?
Yes No
2. Does this student require
To be determined If ESY is determined by the IEP team to be necessary,
Extended School Year (ESY)
by: complete and attach the ESY addendum.
services?
Date:
If yes, consider the student’s need for positive
behavioral supports/ interventions, a Functional
3. Does the student’s behavior
Behavioral Assessment (FBA), and/or a Behavioral
negatively impact his/her learning Yes No
Intervention Plan (BIP).
or the learning of others?
A Behavioral Intervention Plan has been developed
for this student (refer to the BIP addendum).
4. For a student with limited English If yes, describe those needs as they relate to the
proficiency, does the student Yes No student’s IEP:
have language needs?
5. For a student with a visual If yes, describe:
impairment, is the student in need
Yes No
of Braille instruction and/or use of
Braille?
6. Does the student have Yes No If yes, describe:
communication needs? (Consider
the communication needs of the
student, and in the case of a
student that is deaf or hard of
hearing, consider the language
and communication needs,
opportunities for direct
communication with peers/

Form 6c - IEP (without Transition) Page 2 August 2008 (Rev. 8/2018)

 professional personnel in the
child’s language and
7. Does the student need assistive If yes, describe:
technology devices and/or Yes No
services?
If yes, describe:
8. Are there any other factors not
already addressed (such as
Yes No
medical concerns or other issues),
or other adaptations needed?

The parent and the school district have agreed that this student requires advanced educational
planning that may involve the use of isolation, restraint, or a restraint device. Refer to the Emergency
Response Protocol addendum to this IEP.

Form 6c - IEP (without Transition) Page 3 August 2008 (Rev. 8/2018)

PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet
each of the student’s educational needs that result from the student’s disability to enable the student to be involved and make
progress in the general education curriculum. In order to be measurable, the goal should include a baseline, a target, and a unit of
measure. For students using an alternate assessment aligned to alternate achievement standards, the IEP team should use the
“Measurable Annual Goal(s) with Short-term Objectives/Benchmarks” page (see next page).

MEASURABLE ANNUAL GOAL(S)

Method/ Progress Notes POINTS TO
Criteria for (if not maintained separately) CONSIDER:
Subject Evaluating Date Date Date Date  Measurable
Measurable Annual
Area & Progress annual goals stem
Goal
Goal # (if not addressed from the
in a separate recommendations
document) for specially
designed
instruction in the
evaluation report.
 Measurable
annual goals must
relate to the
general education
curriculum or, for
preschool
students,
participation in
appropriate
activities.
 Measurable
annual goals must
also address other
educational needs
that result from
the student’s
disability.
 The IEP must
include a
description of how
the district will
measure the
student’s progress
and when
progress will be
reported to
parents.

Copy additional pages as necessary

Form 6c - IEP (without Transition) Page 4 August 2008 (Rev. 8/2018)

PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet
each of the student’s educational needs that result from the student’s disability to enable the student to be involved and make
progress in the general education curriculum. For students using an alternate assessment aligned to alternate achievement
standards, benchmarks or short-term objectives in the areas being assessed must also be included. In order to be measurable, the
goal should include a baseline, a target, and a unit of measure.

MEASURABLE ANNUAL GOAL(S) WITH SHORT-TERM OBJECTIVES/BENCHMARKS

Method/ Progress Notes POINTS TO
Criteria for (if not maintained separately) CONSIDER:
Subject Evaluating Date Date Date Date  Measurable
Measurable Annual
Area & Progress annual goals
Goal
Goal # (if not addressed stem from the
in a separate recommendatio
document) ns for specially
designed
instruction in
the evaluation
report.
 Measurable
annual goals
must relate to
the general
education
curriculum or,
for preschool
students,
participation in
appropriate
activities.
 Measurable
annual goals
must also
Benchmarks or Short-Term Objectives
address other
educational
needs that
result from the
student’s
disability.
 The IEP must
include a
description of
how the district
will measure
the student’s
progress and
when progress
will be reported
to parents.

Copy additional pages as necessary

Form 6c - IEP (without Transition) Page 5 August 2008 (Rev. 8/2018)

PURPOSE: The purpose of the report of student progress is to inform the parents and the student of the student’s progress
toward meeting the measurable annual goal(s) and to specify how and when parents will be informed (WAC 392-172A-03090(1)
(c)).

POINTS TO CONSIDER: Parents should be provided periodic reports on

the student’s progress (such as through the use of quarterly or other
REPORT OF STUDENT PROGRESS: periodic reports, concurrent with the issuance of report cards).
State how the student’s progress toward meeting the annual goal(s) will be measured (if not already
addressed on measurable annual goal page(s)):

State how and when the parents will be periodically informed of the student’s progress toward
meeting the annual goal(s):

PARTICIPATION IN STATE AND DISTRICTWIDE ASSESSMENTS

State Assessments – The student will participate in the following state POINTS TO
CONSIDER:
assessment(s) during this annual IEP:
 The IEP team makes
English/ the determination of
Lang Arts Math Science what type of
assessment the
Regular State Assessment
student will take and
Regular State Assessment with what administrative
Accommodations modifications and
individual
Alternate Assessment accommodations are
necessary.
Other:  Accommodations
Other statewide assessments (e.g., Washington Kindergarten Inventory of provided on state and
districtwide
Developing Skills (WaKIDS), English language proficiency assessment):
assessments should
be those that are
provided as part of
the regular
Districtwide Assessments – The student will participate in the following instructional program.
districtwide assessment(s) during this annual IEP:  For further
information regarding
the state assessment
system, including
WaKIDS, English
Accommodations – List any individual accommodations in the administration language proficiency
assessment,
of the state or districtwide assessments that are necessary for the student to allowable
participate: accommodations, and
graduation
requirements, please
refer to OSPI’s
website
If the student: (a) will not participate in the regular state assessment (with or (www.k12.wa.us/assess
ment).
without accommodations) or (b) is unable to participate in a regular districtwide
assessment, explain why the student cannot participate in the regular
assessment and why the selected assessment option is appropriate:

PURPOSE: The purpose of this page is to document the modifications and/or accommodations that the student requires,

Form 6c - IEP (without Transition) Page 6 August 2008 (Rev. 8/2018)

based on the student’s assessed needs, in order to advance appropriately toward attaining the identified annual goals, to be
involved and make progress in the general education curriculum, and to be educated with non-disabled peers to the maximum
extent appropriate.

ACCOMMODATIONS AND MODIFICATIONS

Accommodations/ Accommodations/ POINTS TO

Subject Subject CONSIDER:
Modifications Needed Modifications Needed
Presentation Setting  The IEP team
makes the
Use large print/Braille/audio books Individualized/small group determination
instruction of what
Audio Digital Books Preferential seating modifications
Alter format of materials (highlight, Reduce environmental distractions and individual
type, spacing, color-code, etc.) (test/ study in separate location, noise accommodatio
buffers, etc.) ns are
Provide study Other: necessary for
the student.
outlines/guides/graphic organizers
 Copies of this
Cloze Reading Strategy Response page should be
Read class materials orally Speech to Text provided to the
general
Low-vision devices (magnifiers, Text to Speech education
Closed Circuit TV, etc.) Allow dictation to a scribe teacher(s) or
Sign Language – ASL or SEE Allow use of a calculator other staff who
Shortened assignments Allow use of digital recordings will be
responsible for
Limited multiple choice Utilize oral responses to making these
Modify/repeat/model directions assignments/assessments accommodatio
Rephrase test questions and/or Spelling and grammar check ns.
directions Hands-on assignments  Accommodatio
Provide test/assessment study Other: ns provided on
guide state and
districtwide
Provide extra credit options assessments
Simplify text wording/language Other (as noted on
Read class materials orally Provide desktop list of tasks the previous
page) should
Assign peer tutor/note taker Provide homework lists be those that
Other: Behavior plan/contract are provided as
part of the
Provide daily assignment regular
list/schedule instructional
Timing/Scheduling Modified grading (describe below): program.
Prior notice of
assignments/assessments
Extra time to complete
assignments
Modify student’s schedule Other:
(describe below):
Other:

Other:
Extra time on
assignments/assessments
Allow breaks (during work, between Other:
tasks, during testing, etc.)

Other: Other:

a. All subjects e. Math i. Health m. Vocational p. Extracurricular Activities

b. Reading f. Science j. Economics n. Lunch/ q. Other:
c. English g. Social k. Physical Recess r. Other:
d. Spelling Studies Education o. Library
h. History l. Music/Art

Form 6c - IEP (without Transition) Page 7 August 2008 (Rev. 8/2018)

PURPOSE: The information on this page is a summary of the student’s program/services, including when services will begin,
where they will be provided, who will be responsible for providing them, and when they will end.

SUMMARY OF SERVICES MATRIX

Staff POINTS TO
Initiation Frequency Duration Responsible CONSIDER:
Location
Service (e.g., minutes per (end  If the position
Date week)
(setting)
date)
for Delivering responsible
Service for delivering
Special Education (specially designed instruction): the specially
designed
instruction is
anyone other
than a
certificated
special
education
teacher or
related
service
provider, then
the
certificated
special
education
teacher/relate
d service
Related Services (i.e. – speech, motor, counseling, vision/hearing, transportation, provider must
interpreting services, orientation/mobility, parent training, etc.): design and
supervise the
instruction,
and monitor
and evaluate
the student’s
progress.
 For definitions
of special
education,
related
services, and
supplementar
Supplementary Aids and Services (allows student to be educated with non- y aids and
disabled peers to the maximum extent in general education or other educational services, refer
to WAC 392-
setting): 172A-01020
through -
01200.

Program Modifications or Support for School Personnel (i.e. – staff

development/training, technical assistance, etc.):

Form 6c - IEP (without Transition) Page 8 August 2008 (Rev. 8/2018)

PURPOSE: The purpose of this page is to document the extent to which the student will be involved and progress in the
general curriculum, participate in extracurricular and nonacademic activities and be educated and participate with other special
education students and non-disabled students.

LEAST RESTRICTIVE ENVIRONMENT:

Students ages 3 to 5 Choose one: POINTS TO
CONSIDER:
A Regular Early
 Children should
Childhood (REC) In a REC program: Not in a REC be educated
program means a program: with non-
program outside the REC Program ≥ 10 hours per disabled peers
child’s home that week &: Separate class to the maximum
extent
includes at least 50% Special education services with In separate day appropriate.
children without non-disabled peers school (public or  The IEP Team,
disabilities. Special education services private) including the
elsewhere Residential facility parent(s), is
responsible for
If the child attends a (public or private) determining the
REC program, check REC Program <10 hours per Home educational
the appropriate box week &: Service provider placement of
from the first four Special education services with location the child.
choices. If the child non-disabled peers  The placement
should provide a
does not attend a REC Special education services reasonably high
program, check the elsewhere probability of
appropriate box from assisting the
the five remaining student in
attaining the
options. annual goals.
Students ages 6 and above Choose one:  The IEP team
should consider
any potential
= Total minutes per week of building
In general ed. setting 80 to harmful effect of
A. instructional time available for this the placement
100% of the time
student (excluding lunch) on the student
In general ed. setting 40 to or on the quality
79% of the time of services
= Total of those minutes in A. above In general ed. setting 0 to received.
39% of the time  Job placements
B. in which this student is in a special and community-
education setting (excluding lunch) In separate day school (public based
or private) instruction are
Residential facility (public or considered to be
private) general
education
= Percent of time spent in a general Correctional facility settings, unless
education setting (A minus B divided Homebound/hospital only disabled
by A) Home-school/parentally-placed individuals are
private school present (such as
in a sheltered
workshop).
 For additional
information on
LRE for students
ages 3 to 5 and
An explanation of the
ages 6 and
extent, if any, to which above, refer to
the student will not the LRE
participate with Calculator.
nondisabled students
in the general
education classroom,
and in nonacademic
and extracurricular
activities:

Form 6c - IEP (without Transition) Page 9 August 2008 (Rev. 8/2018)

 PARTICIPANTS IN IEP MEETING (Signatures are used to document participation in the
meeting and do not constitute agreement or disagreement):
POINTS TO CONSIDER:
 IEP team membership is
described in WAC 392-
Parent/Guardian Name/Title 172A-03095.
 School district must give
prior written notice when
proposing or refusing to
Parent/Guardian Name/Title initiate or change the
identification, evaluation,
educational placement, or
provision of FAPE.
Student Name/Title  A required team member
may be excused from
attending an IEP meeting
with the agreement/
Special Education Teacher Name/Title consent of the parent(s)
and the district, depending
upon whether that
member’s area is being
discussed or modified at
General Education Teacher Name/Title the meeting. See WAC
392-172A-03095 (5) for
additional related
requirements.
District Representative Name/Title  The IEP must include the
district’s procedures for
notifying parents regarding
the use of restraint or
Name/Title Name/Title isolation. Districts must
also provide parents with a
copy of the district’s policy
on the use of isolation and
Name/Title Name/Title restraint.

Other individuals who should be informed of his/her responsibilities in implementing the IEP (bus
driver, librarian, etc.):

The district has procedures for notifying parents regarding the use of restraint or isolation. A copy of
those procedures is attached to this IEP.

The parent was provided a copy of the special education procedural safeguards in his/her native
language or other mode of communication. Offered and accepted Offered and declined

*Note: Before providing initial special education services to a student, the district must
obtain informed written parental consent. (See model form 3)

Individualized Education Program without Transition by Office of Superintendent of Public

Instruction is licensed under a Creative Commons Attribution 4.0 International License.

Form 6c - IEP (without Transition) Page 10 August 2008 (Rev. 8/2018)