IEP Form - Hudson Falls Central School District

Hudson Falls Central School
Committee on Special Education
Individualized Education Program
Student Name M F Race/Ethnicity
Date of Birth
Age
Parent/Guardian
Address
Parent/Guardian
Address
Dominant Language Parent Child
Special Alerts
Current Placement
Classification
Phone
Phone
Double Notification
Triennial Date
Interpreter
Needed
Transportation: According to District Policy Y N
Special
Y N
Targeted Case Management
Y N
Expected School Credential: Regents Diploma Local Diploma
GED IEP Diploma
Carnegie Units to Date
Anticipated Date of High School Completion
Exemptions: Foreign Language Y N
Rationale:
State / District-wide Test
Rationale:
Y N
Alternate Assessment:
Test Modifications
Y N
IEP Date
Program Start Date
Projected Annual Review Date
Type of Review: New Referral Annual Review
IEP Addendum Nexus Triennial Review
CSE
Subcommittee
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Annual Goals Progress Report:
Quarterly by written report card
Placement / Grade Level /
10 month
District Program: Grade BOCES Program: Grade
High School
Elementary
Middle School
Secondary
Intermediate School
Private Placement
Primary Building
Home/Hospital
Kindergarten Center
Residential
Extended School Year (ESY) Services (12 Mo.):
Recommended July-August Placement:
Rationale
Y N
Related Service Only
Full Program/Services
ESY Start Date
Present Levels of Performance- Academic-Educational Achievement - Learning Characteristics
- Addresses current levels of knowledge and development in subject and skill areas and
expected rate of progress in acquiring skills and information.
Intellectual Functioning:
Significantly
Below Average
Comment:
Below
Average
Low
Average
Average
HIGH
Average
HIGH
Average
Learning Characteristics:
Academic Functioning:
Scores
Test Date S.S. A.E. G.E. %
Reading Decoding
Reading Comprehension
Written Language
Spelling
Math Computation
Math Application
Other
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Current Academic Levels continued (including abilities and needs)
SOCIAL DEVELOPMENT (Present Levels)- Describes quality of relationships with
peers, adults, feelings about self-social adjustment to school and community and behaviors
that may impede learning and any needs related to the above.
MANAGEMENT NEEDS (Present Levels) - Describes the nature of and degree to which
environmental modifications and human or material resources are required to address
academic, social, and physical needs.
SUPERVISION:
Severe physical, mental Aggressive, self-abusive, Classroom Behavior Classroom Behavior
or multiple handicaps withdrawn or other seriously interferes does not seriously
requiring habilitation behaviors requiring with instructional interfere with
and treatment. Problems highly intensive process requiring instruction.
necessitate highly supervision. added adult supervision.
intensive supervision.
SUPPORT:
Intensive assistance needed from Moderate assistance needed Minimal assistance needed
support personnel and/or related from support personnel and/or from support personnel and/
service provider. related service provider. or related service provider.
ENVIRONMENTAL ADAPTATION:
To accommodate need for To accommodate behavioral needs To accommodate
structured learning environment
physical needs.
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Comments On Management Needs:
Physical Development: as it pertains to the learning process.
SIZE
-Small for age - Average for age - Large for age -Physically mature for age
MOBILITY:
-Nonambulatory -Needs mechanical aids -Poor balance -Adequate gross
(crutches, braces, etc.
motor ability
to ambulate)
VISION:
-Blind - Partially sighted -Needs Corrective -Normal
HEARING:
-Deaf - Hearing impaired -Mild hearing loss -Normal
HEALTH/VITALITY:
-Poor - Fair -Good -Excellent
ACTIVITY LEVEL:
-Lethargic - Active -Very Active -Average
COMMENTS:
Skills/Limitations - physical accommodation needs:
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DESCRIPTION OF EDUCATIONAL AND RELATED SERVICES
Program/Services Frequency (wk/mo) Duration Location (Push-in/Pullout)
Speech
Physical Therapy
Occupational Therapy
Adaptive P.E.
Counseling
Audiological
Orientation/Mobility
Itinerant for Visually Impaired
Skilled Nursing Services
Consultant Teacher Service
Resource Room
15:1+1
15:1+2
12:1+1
12:1+2
12:1+4
8:1+1
8:1+2
6:1+1
1 to 1 Aide
Other
SUPPLEMENTARY AIDS AND SERVICES
Type Frequency Duration Location
Program Modifications and Supports (to student or school personnel) to be provided on behalf of students to
address annual goals and participate in general curriculum and activities:
Specialized Equipment- Assistive Technology and/or Services:
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Extent of Non-Participation with non-disabled peers in general education programs and activities (Describes the
participation of disabled students in programs and services with other disabled students.)
Explanation of how the child’s disability affects involvement and progress in the general curriculum.
Transition Service Needs Statement: (Reflects students course of study beginning at age 14.
Transition Services
(Beginning at 15 years or sooner when appropriate)
Coordinated Set of Activities Leading To Long Term Adult Outcomes:
Instruction
Related Services
Employment/Post-Secondary
Community Experiences
(if appropriate)
Activities of Daily Living
(if appropriate)
Functional Vocational Evaluation
PARTICIPATING AGENCIES
Agency Name:
Service:
Agency Name:
Service:
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ALTERNATIVE TESTING ACCOMODATIONS
MODIFICATIONS TO MANNER OF PRESENTATION
Flexible Scheduling
Flexible Setting
Revised Test Format
Revised Test Directions
Use of Aids
Extended time to complete test
Administer test in several sessions in one day
Administer test in several sessions over several days
Administer test individually in separate location
Administer test in small group in separate location
Braille Edition
Large print edition
Increase spacing between items
Reduce number of items per page
Omit questions, which cannot be revised, pro-rate credit
Read directions to student
Reread directions for each page of questions
Simplify language in directions
Provide additional examples
Visual magnification devices
Auditory amplification devices
Questions read to student
No penalty for spelling errors
MODIFICATIONS TO MANNER OF RESPONSE
Use of Aids
Revised Format
Answers written for student
Tape recorder
Word processor
Record answers in test booklet
Increase spacing
Increase size of answer blocks
MODIFICATIONS TO DERIVE RESPONSE
Use of Aids
Calculator
Arithmetic tables/charts
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LEAST RESTRICTIVE ENVIRONMENT JUSTIFICATION SHEET
Student
We have considered the options of:
Regular Education
Regular Education with Supplemental Aides and Services
Regular Education with Related Services
Regular Education with Consultant Teacher
Regular Education with Resource Room Services
Special Class 15:1+1 District
Special Class 15:1+2 District
Special Class 12:1+2 District
Special Class 12:1+1 District
Out of District Special Class (BOCES – UCP-)
Residential Setting
Home or Hospital Setting
and have determined they would not meet the student’s needs because of the following potential harmful
effects:
increased student frustration/stress
decreased student self-esteem/worth
increased difficulty with distractions/disruptions of regular environment
large student/teacher ratio v. need for attention
increased safety concerns caused by physical aspects
lack of emotional control
lack of social skills
increased difficulty completing tasks
excessive time required to master educational objectives
lack of specialized setting required for related services
other students, including nondisabled, distracted
other
Therefore,
is considered the most appropriate option for this student.
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STUDENT NAME:
YEAR:
ANNUAL GOAL:
Objectives
Evaluation
Method
Criteria For
Performance
Initiated
Progress Code
Evaluation Methods:
A. Teacher Made Tests G. Check Lists Progress Code
B. Standardized Tests H. Teacher made materials 1. Poor
C. Class Discussions I. Commercially prepared materials 2. Work Continuing
D. Class Activities J. Verbal explanation 3. Satisfactory
E. Publisher’s tests/ questions K. Observed demonstration 4. Strong
F. Teacher observations of specific skills L. Other (specify) 5. Mastered
6. Maintained
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STUDENT NAME:
YEAR:
ANNUAL GOAL:
Objectives
Evaluation
Method
Criteria For
Performance
Initiated
Progress Code
Evaluation Methods:
A. Teacher Made Tests G. Check Lists Progress Code
B. Standardized Tests H. Teacher made materials 1. Poor
C. Class Discussions I. Commercially prepared materials 2. Work Continuing
D. Class Activities J. Verbal explanation 3. Satisfactory
E. Publisher’s tests/ questions K. Observed demonstration 4. Strong
F. Teacher observations of specific skills L. Other (specify) 5. Mastered
6. Maintained
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STUDENT NAME:
YEAR:
ANNUAL GOAL:
Objectives
Evaluation
Method
Criteria For
Performance
Initiated
Progress Code
Evaluation Methods:
A. Teacher Made Tests G. Check Lists Progress Code
B. Standardized Tests H. Teacher made materials 1. Poor
C. Class Discussions I. Commercially prepared materials 2. Work Continuing
D. Class Activities J. Verbal explanation 3. Satisfactory
E. Publisher’s tests/ questions K. Observed demonstration 4. Strong
F. Teacher observations of specific skills L. Other (specify) 5. Mastered
6. Maintained
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