Confidential Student Information

ATTACHMENT 4

THE FOLLOWING SAMPLE COMPLETED IEP IS PROVIDED TO DEMONSTRATE HOW THE SAMPLE FORM WOULD BE COMPLETED AND SHOULD NOT BE CONSTRUED AS A MODEL IEP FOR ANY PARTICULAR CHILD OR DISABILITY.

PreSchool
Individualized Education Program (IEP)

Greenfield School District
888 Hobart Street
Greenshade, NY 10000
(518) 123-4567

Student Name: Alexis Martinez

Date of Birth: 7/5/99 Age: 3-1

 

Disability Classification:

[X] 

 Preschool Student with a Disability

 

Street: 127 Hill Street

City: Greenfield

Zip: 12345

Student ID#: ABC123

Medical Alerts: Seizures; Frequent ear infections

Telephone: (518) 123-8910

County of Residence: Green

Male [  ] Female [X]

Native Language of Student: English

Surrogate Parent Needed: Yes [  ] No [X]

 

Date of Committee on Preschool Special Education (CPSE) Meeting: 6/02/02

Type of Meeting:

[X] Initial  [  ] Requested Review  [  ] Annual Review  [  ] Reevaluation

[  ]___________

Date IEP is to be Implemented: 9/07/02
Projected Date of Next Review: 6/03
Projected Date of Reevaluation Meeting: 6/05

Other Information: Alexis is transitioning from Early Intervention (EI) Services. Parents choose to receive EI services through 8/31. Meets eligibility criteria for preschool child a disability - autism.

 

Present Levels of Performance and Individual Needs

Current functioning and individual needs in consideration of:

  • the results of the initial or most recent evaluation, the student’s strengths and the concerns of the parents;
  • the student’s needs related to communication, behavior, use of Braille, assistive technology, limited English proficiency; and
  • how the student’s disability affects participation in appropriate activities.

 

Academic/Educational Achievement and Learning Characteristics:
Current 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.
Language and Communication:

- Understanding of language is at 18-24 month level.
- Expressive language testing is at the 12-18 month level.
- Can identify (point to) familiar people and objects such as clothing, foods, utensils and toys.
- Follows one-step directions (e.g., close the door; give me ___; brush your teeth), but does not follow abstract commands (e.g., get ready for bed) or more than one-step directions (e.g., get your coat and go to the door).
- Uses one word phrases to communicate wants (e.g., milk, mommy, go, car, up, sing, water) when prompted.
- Prefers to point and then cry or hit or screech to get something.
- If asked questions, she repeats the question, then answers (echolalia).

Adaptive Behavior:

- Needs physical assistance to dress herself.
- Independently feeds herself.
- Needs a great deal of repetition to learn new tasks.
- Learns best through imitation and physically doing a task with prompting.

Cognitive:

- Attends to structured activities in which she is manipulating objects for an average of 5 minutes.
- Attention to verbal activities (e.g., stories) is very limited (30 seconds) and then only if a story is accompanied by a picture or other manipulative and she is sitting with an adult.
- Very distracted by visual stimuli.

 

Social Development:
The degree and quality of the student’s relationships with peers and adults, feelings about self and social adjustment to school and community environments.
Socio-Emotional:

- Is interested in other children, but mostly from a distance.
- Typically engages in parallel play and will imitate others.
- Frequently uses toys in a self-stimulatory manner (e.g., mouthing or spinning).
- Resists teachers attempts to include her in circle time with other children and will attempt to run away or fall to the floor.
- Likes to play in the sandbox and be pushed on the swings. Loves water play.
- Is affectionate with her mother (reaches for a hug) but is afraid of strangers and will hide or cry if approached.

Behavior:

- Is inquisitive.
- During free play and unstructured activities, moves quickly from one activity to another but rarely completes what she started to do.
- Often grabs toys from other children.
Tantrums (e.g., falls to the floor, cries, hits others) on the average of 3-5 times a day, mostly during the times she is to transition from one activity to the next. Her parents report similar behavior at home.

 

Physical Development:
The degree or quality of the student’s motor and sensory development, health, vitality and physical skills or limitations that pertain to the learning process.
Motor Skills:

- Fine motor skills have been assessed at the 18-month level.
- She has difficulty stacking small blocks and grasps crayons with her palm.
- Her gross motor skills are age appropriate.
- Likes tactile sensory stimulation (e.g., water, sand play, mouthing objects).

Health:

- Gets frequent ear infections (3-4 a year) - bangs her head when she has an ear infection.
- Puts nonedible objects in her mouth (e.g., crayons, toys) and frequently has the back of her hand in her mouth.
- Has seizures characterized by staring, facial grimacing on one side of her face, guttural noises lasting about 1 minute, followed by lethargy (sleepiness).

 

Management Needs:
The nature of and degree to which environmental modifications and human or material resources are required to enable the student to benefit from instruction. Management needs are determined in accordance with the factors identified in the areas of academic/educational achievement and learning characteristics, social development and physical development.
- Close proximity between adult and student during group activities.
- Spoken to at face level to maintain attention.
- Prompting to stay on task.
- Structured routines throughout the day.
- Picture schedule to assist with transitions to new activities.
- Limited visual stimuli in learning environment.

 

Measurable Annual Goals and Short-Term Instructional
Objectives/Benchmarks

 

Annual Goal: Alexis will sit and attend during circle time for 10 minutes independently.
Instructional Objectives or Benchmarks:

Evaluation

Criteria

Procedures

Schedule

Alexis will sit and attend for three minutes during circle time with verbal prompting by November.

Daily for 2 weeks

Charting

Once a month

Alexis will sit and attend for five minutes during circle time with verbal prompting by February.

Daily for 2 weeks

Charting

Once a month

Alexis will sit and attend for five minutes during circle time without prompting by April.

Daily for 2 weeks

Charting

Once a month

Alexis will sit and attend to circle time for 10 minutes without prompting by June.

Daily for 2 weeks

Charting

Once a month

 

Annual Goal: Alexis will follow a picture schedule to transition from one activity to the next without behavioral upsets (e.g., hitting, crying, screeching or falling to the floor).
Instructional Objectives or Benchmarks:

Evaluation

Criteria

Procedures

Schedule

Alexis will point to the picture of the activity on the schedule when named.

9/10 times over a 2 week period

Daily charting

Quarterly

Alexis will point to the picture of the next activity on the schedule when asked, "What activity comes next?"

9/10 times over a 2 week period

Daily charting

Quarterly

Alexis will transition from one activity to the next by following a picture schedule with no behavioral disruptions.

9/10 times over a 2 week period

Daily charting

Quarterly

 

Annual Goal: Alexis will take turns in unstructured play activities with a peer.
Instructional Objectives or Benchmarks:

Evaluation

Criteria

Procedures

Schedule

Alexis will take 3-4 turns in a structured play activity with a peer with physical and verbal prompting by November.

3/4 times over 5 trials

Observation charting

Every 8 weeks

Alexis will take 3-4 turns in a structured play activity with a peer with verbal prompting only by February.

3/4 times over 5 trials

Observation charting

Every 8 weeks

Alexis will take 3-4 turns in a structured play activity with a peer with no prompting by April.

3/4times over 5 trials

Observation charting

Every 8 weeks

Alexis will take 3-4 turns in an unstructured play activity with a peer with physical and verbal prompting by June.

3/4 times over 5 trials

Observation charting

Every 8 weeks

 
Annual Goal: Alexis will follow directions requiring 3 action steps without prompting.
Instructional Objectives or Benchmarks:

Evaluation

Criteria

Procedures

Schedule

When given a 2-step direction, Alexis will point to the pictures of the actions (e.g., get your coat and go to the door).

7/10 trials over a two week period

Observation charting

Every 8 weeks

When given a 2-step direction, Alexis will point to the pictures of the actions (e.g., get your coat and go to the door) and carry them as she completes the step.

7/10 trials over a two week period

Observation charting

Every 8 weeks

When given a 2-step direction, Alexis will point to the pictures of the actions (e.g., get your coat and go to the door) and complete the steps without carrying the pictures.

7/10 trials over a two week period

Observation charting

Every 8 weeks

When given a 2-step direction, Alexis will complete the steps without carrying the pictures.

7/10 trials over a two week period

Observation charting

Every 8 weeks

 

Annual Goal: Alexis will participate in circle time for 15 minutes without behavioral interruptions.
Instructional Objectives or Benchmarks:

Evaluation

Criteria

Procedures

Schedule

Alexis will point to the picture symbolizing "time away" (a break from work).

7/10 trials over two weeks

Observation charting

Every 8 weeks

Alexis will say "time away" when pointing to the picture.

7/10 trials over two weeks

Observation charting

Every 8 weeks

Alexis will stay in circle for 5 minutes before asking for "time away".

7/10 trials over two weeks

Observation charting

Every 8 weeks

Alexis will stay in circle for 10 minutes before asking for "time away."

7/10 trials over two weeks

Observation charting

Every 8 weeks

Alexis will stay in circle for 15 minutes before asking for "time away."

7/10 trials over two weeks

Observation charting

Every 8 weeks

 

Annual Goal: Alexis will use 3-word sentences to communicate her needs or wants.
Instructional Objectives or Benchmarks:

Evaluation

Criteria

Procedures

Schedule

Alexis will say, "I want ___" to indicate food preferences from two choices by November.

At least 1X daily during lunch for 2 consecutive weeks.

Observation; written log

quarterly

Alexis will say, "I want ___" to select a toy to play with from two choices by February.

At least 1X daily during lunch for 2 consecutive weeks.

Observation; written log

quarterly

Alexis will say, "Time for _____" to indicate the next activity on the picture schedule by April.

4/5 times daily over 2 consecutive weeks

Observation; written log

quarterly

Alexis will say, "I need ____" to indicate she needs to use the bathroom by June."

At least 1X daily for 2 consecutive weeks.

Observation; written log

quarterly

 

Annual Goal: Alexis will put on her shirt and pants independently.
Instructional Objectives or Benchmarks:

Evaluation

Criteria

Procedures

Schedule

Alexis will put on a pull over shirt without assistance by November.

3/4 trials over 1 week.

Observation; charting

monthly

Alexis will put on elastic waist pants without assistance by February.

3/4 trials over 1 week.

Observation; charting

monthly

Alexis will put on socks without assistance by April.

3/4 trials over 1 week.

Observation; charting

monthly

Alexis will put on her shoes (with velcro) without assistance by June.

3/4 trials over 1 week.

Observation; charting

monthly

 

Recommended Special Education Programs and Services

 

Special Education Program/Services

 

Frequency

Duration

Location

Initiation Date

Special Class – Integrated Setting: 6:1+1

Daily

Full day

Head start class

9/7/02

 

Related Services

 

Frequency

Duration

Location

Initiation Date

Speech and Language therapy - small group

5 x week

30 minutes

1 x week separate room; 4 x week in special class

9/7/02

Parent Counseling and Training

2x month

45 minutes

Special class

10/1/02

 
Program Modifications/Accommodations/Supplementary Aids and Services

 

Frequency

Duration

Location

Initiation Date

Use of picture schedule board

Daily

During transition times

Classroom

9/7/02

Seating close to adult/teacher

Daily

Duration of structured activities

Classroom

9/7/02

 

Assistive Technology Devices/Services

 

Frequency

Duration

Location

Initiation Date

Pencil grips

Daily

Duration of writing, coloring activities

Classroom

9/7/02

 

Supports for School Personnel On Behalf of Student

 

Frequency

Duration

Location

Initiation Date

Consultation from behavioral specialist to special education teacher, speech therapist and teacher of child care class

4 x year

1 hour student observation

Classroom

11/02

 

Special Transportation Needs: None

Other Preschool Transportation Needs: Parent transportation

 

Other: 

 

Testing Accommodations
The following testing accommodations will be used consistently:

  • in the student’s education program,
  • in the administration of districtwide assessments of student achievement, and
  • in the administration of State assessments of student achievement, consistent with State Education Department policy.

Testing Accommodation

Conditions

Specifications

Not applicable

..

.
. . .
. . .

 

Participation in Assessments

[ ]

Student will participate in the same State or local assessments that are administered to non-disabled preschool students. Does not apply.

[ ]

 The following State or local assessments (or part of an assessment) that are administered to non-disabled preschool students are not appropriate for the student:

Assessment(s):______________________________________

Reason not appropriate:_______________________________

How student will be assessed:___________________________

 

Participation With Age Appropriate Peers

Provision of special education services in a setting with no regular contact with age appropriate peers without disabilities should only be considered when the nature or severity of the child's disability is such that education in a less restrictive environment with the use of supplementary aids and services, cannot be satisfactorily achieved.

[X]

 Explanation of the extent, if any, to which the student will not participate in appropriate activities with age-appropriate non-disabled peers: Alexis will be removed from class 1 x week for individual speech and language therapy. Individual time in a separate setting is necessary for her to focus on new communication skills without the visual distractions in the preschool class. New learning requires frequent review.
Will the preschool student receive services in a setting with no regular contact with age-appropriate peers without disabilities? Yes [  ] No [X]

 

Reporting Progress to Parents

The student’s progress toward the annual goals and the extent to which the progress is sufficient to enable the student to achieve the goals will be reported to parents as follows:
Manner:
Parent – teacher conferences		 Frequency:
Three times a year
Written progress reports on IEP goals Every 3 months

 

Placement Recommendation

10 Month Placement: ABC Early Learning Preschool Program – Integrated Setting

Approved Preschool Program Provider: ABC BOCES

 

Extended School Year Eligible: Yes[ ] No [ ]TO BE DETERMINED AT NEXT ANNUAL REVIEW

If yes: Reason:_________________________________________________

Projected dates of services:   /  /   to   /  /

Provider:

Site:

 

Parent Information

Student’s Name: Alexis Martinez

Mother’s/Guardian’s Name: Janice Martinez

Street: 127 Hill Street

City: Greenfield

Zip: 12345

Telephone: (518) 123-8910

County of Residence: Green

Native Language of Parent/Guardian: Spanish

Interpreter Needed for Meeting: Yes [ ] No [X]

Father’s/Guardian’s Name: Joseph Martinez

Street: 127 Hill Street

City: Greenfield

Zip: 12345

Telephone: (518) 123-8910

County of Residence: Green

Native Language of Parent/Guardian: Spanish

Interpreter Needed for Meeting: Yes [X] No[ ]

NO Surrogate Parent Needed

Surrogate Parent’s Name :

Street:

City:

Zip:

 

Date Appointed:  /  /

Telephone:

Native Language of Surrogate Parent:

Interpreter Needed for Meeting: Yes [ ] No [ ]

 

Student Information
For data collection purposes only:
Race/Ethnicity: Hispanic

 

CPSE Participants

Name

Professional Title

CPSE Member Role1

Joseph Martinez

Parent

Student’s parent (interpreter present)

Janice Martinez

Parent

Student’s parent

Gregory Hines

Special Education Director

School district representative

Melinda Torres

Special Education Teacher

Student’s special education teacher

Sean Flynn

Head Start Teacher

General education teacher

Esther Raulino

Parent

Additional parent member

Karen Dacshel

Speech and Language Therapist

Individual to interpret instructional implications of evaluation results; Other with knowledge and expertise (related service provider.)

Mikel Cortez

Director, Head Start Program

Other school representative

Robert Times

Supervisor, Children’s Center, Green County

Early intervention representative (phone conference participation)

The list of names or signatures above indicates attendance/participation at the Committee meeting and not necessarily agreement with the IEP recommendations developed at the meeting.

1 If the member was not present, indicate the manner in which he or she participated (e.g., Conference telephone call).