NYSED-IEP-SA 12-05

Available as a Word Template

Confidential Student Information

School-Age
Individualized Education Program (IEP)

School District
Street Address
City, State, and Zip Code
Telephone Number

 

Disability Classification: Choose one

 

Street: City: Zip: Student ID#: Current Instructional Grade/Grade Equivalent: Racial/Ethnic Group of Student: Choose One Medical Alerts:

Telephone: County of Residence: Male   [  ]   Female  [  ] Native Language of Student: Interpreter for Student Needed: Yes [  ]  No [  ] If yes, specify language:   Surrogate Parent Needed: Yes [  ]  No [  ]

 

Present Levels of Academic Achievement, Functional 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, the concerns of the parents, the results of the student’s performance on any State or districtwide assessment programs; the student’s needs related to communication, behavior, use of Braille, assistive technology, limited English proficiency; how the student’s disability affects involvement and progress in the general curriculum; and the student’s needs as they relate to transition from school to post-school activities for students beginning with the first IEP to be in effect when the student turns age 15 (and younger if deemed appropriate).

 

Transcript Information – Secondary Students Only
Diploma Credits Earned:	Expected Date of High School Completion: /  / Projected # years to graduate:
Commencement-level State Tests Passed:	Expected Diploma:

 

Academic Achievement, Functional Performance 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.

 

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.

 

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.

 

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 achievement, functional performance and learning characteristics, social development and physical development.

 

Measurable Post-Secondary Goals (Ages 15 and Older) For students beginning with the first IEP to be in effect when the student turns age 15 (and younger if deemed appropriate), identify the appropriate measurable postsecondary goals based upon age appropriate transition assessments relating to training, education, employment and, when appropriate, independent living skills.

Training: Education: Employment: Independent Living Skills (when appropriate):

 

Measurable Annual Goals * For students with severe disabilities who would meet the eligibility criteria to take the New York State Alternate Assessment, the IEP must also include short-term instructional objectives and benchmarks for each annual goal.

 

Annual Goal:  What the student will be expected to be able to do by the end of the year in which the IEP is in effect. Evaluative Criteria:  How well and over what period of time the student must demonstrate performance in order to consider the annual goal to have been met. Procedures to Evaluate Goal:  The method that will be used to measure progress and determine if the student has met the annual goal. Evaluation Schedule: The dates or intervals of time by which evaluation procedures will be used to measure the student’s progress.

 

Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal:
Evaluation Schedule:

 

Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal:
Evaluation Schedule:

 

Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal:
Evaluation Schedule:

(Add additional annual goals as appropriate) 

 

Recommended Special Education Programs and Services

 

Special Education Program/Services
	Frequency	Duration	Location	Initiation Date
.	.	.	.	/   /
.	.	.	.	/   /
.	.	.	.	/   /
.	.	.	.	/   /
.	.	..	.	/   /

 

Related Services
	Frequency	Duration	Location	Initiation Date
.	.	.	.	/   /
.	..	.	.	/   /
.	.	.	.	/   /
.	.	.	.	/   /
.	.	.	.	/   /

 

Program Modifications/Accommodations/Supplementary Aids and Services
	Frequency	Duration	Location	Initiation Date
.	.	.	.	/   /
.	.	.	.	/   /
.	.	.	.	/   /
.	.	.	.	/   /
.	.	.	.	/   /

 

Assistive Technology Devices/Services
	Frequency	Duration	Location	Initiation Date
.	.	.	.	/   /
.	.	.	.	/   /
.	.	.	..	/   /

 

Supports for School Personnel On Behalf of Student
	Frequency	Duration	Location	Initiation Date
.	.	.	.	/   /
.	.	.	.	/   /

 

Special Transportation Needs: [ ] None [ ] Student has special transportation needs as recommended below: [ ] Special seating - Specify:       [ ] Vehicle and/or equipment needs - Specify:       [ ] Adult Supervision - Specify:       Type of transportation Specify:       [ ] Other Accommodations – Specify:

 

Other:

 

Testing Accommodations: The following individual appropriate accommodations are necessary to measure the academic achievement and functional performance of the student on State and districtwide assessments.  Recommended testing accommodations will be used consistently: in the student’s education program, in the administration of districtwide assessments of student achievement, consistent with school district policy, and in the administration of State assessments of student achievement, consistent with State Education Department policy.
Testing Accommodation	Conditions	Specifications
.	.	.
.	.	.
.	.	.
Participation in State Assessments [  ] The student will participate in the same State assessments that are administered to general education students. [  ] Graded: The student will take the State assessment with his/her grade level peers. [  ] Ungraded: The student will take the State assessment based on chronological age because his/her instructional levels in English and mathematics are three or more years below the grade-level coursework of the student’s nondisabled peers. [  ] The student will participate in the New York State Alternate Assessment (NYSAA) for Students with Severe Disabilities. Explain why the State assessment(s) administered to general education students is not appropriate for the student and why the alternate assessment selected is appropriate for the student: ____________

 

Participation in Districtwide Assessments [  ] The student will participate in the same districtwide assessments that are administered to general education students. [ ]The student will participate in the following alternate assessment for districtwide assessments: _______________ Explain why the districtwide assessment(s) administered to general education students is not appropriate for the student and why the alternate assessment selected is appropriate for the student: ____________

 

Removal from the general educational environment occurs only when the nature or severity of the disability is such that, even with the use of supplementary aids and services, education cannot be satisfactorily achieved. [  ]  Explanation of the extent, if any, to which the student will not participate in general education programs, including extra curricular and other nonacademic activities: ______________________________ __________________________________________________________________________ [  ]  The student will not participate in the general education physical education program, but will participate in specially designed or adapted physical education. Language other than English exemption [  ] No [  ] Yes, the student’s disability adversely affects the ability to learn a language, and the student is excused from the language other than English requirement.

 

Coordinated Set of Transition Activities (School to Post School)
For students beginning with the first IEP to be in effect when the student turns age 15 (and younger if deemed appropriate) needed transition services/activities to facilitate the student’s movement from school to post-school activities.
Coordinated Set of Transition Activities	Activity	School District/Agency Responsible	Date
Instruction	.	.	/  /
Related Services	.	.	/  /
Development of Employment/Other Post-School Adult Living Objectives	.	.	/  /
Community Experience	.	.	/  /
Acquisition of Daily Living Skills	.	.	/  /
Functional Vocational Assessment	.	.	/  /

 

Placement Recommendation

10 Month Placement:

 

Extended School Year Eligible: [  ] Yes [  ] No If yes: Provider:_______________________

Projected dates of services:  /  /  to   /  / Site:___________________________

 

Reporting Progress to Parents

Identify when periodic reports on the progress the student is making toward meeting the annual goals will be provided to the student’s parents:

 

Recommendations Upon Declassification

Date Declassified:    /   /

 

Declassification Support Services to be provided during the first year that a student moves from a special education program to a full-time general education program.
Service	Initiation Date	Frequency	Duration	Ending Date
.	/   /	.	.	/  /
.	/  /	.	.	/  /
.	/  /	.	.	/  /

 

Parent Information
Student’s Name:
Mother’s/Guardian’s Name: Street: City: Zip:	Telephone: County of Residence: Native Language of Parent/Guardian: Interpreter Needed for Meeting: Yes [  ]  No [  ]
Father’s/Guardian’s Name: Street: City: Zip:	Telephone: County of Residence: Native Language of Parent/Guardian: Interpreter Needed for Meeting: Yes [  ] 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 [  ]

¹ If the parent or another CSE member participated (with parent and school district agreement) through alternative means, indicate the manner in which he or she participated (e.g., video or telephone conference calls).

SUPPLEMENTAL PAGE FOR ADDITIONAL ANNUAL GOALS

 

Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal:
Evaluation Schedule:

 

Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal:
Evaluation Schedule:

SUPPLEMENTAL PAGE IF INCLUDING SHORT-TERM INSTRUCTIONAL OBJECTIVES AND BENCHMARKS FOR EACH ANNUAL GOAL *

* NOTE: Federal and State law and regulations require short-term instructional objectives and benchmarks in ieps only for students with severe disabilities who would meet the eligibility criteria to take the New York State Alternate Assessment and for all preschool students with disabilities. 

***DUPLICATE AS NECESSARY***