Supplemental Information

Supplemental Information

Parent information

Information about the student’s parent(s)/guardian and/or surrogate parent, if appropriate, may be documented on the supplemental page of the sample IEP form. This includes the parent(s) name(s), address and telephone number, county of residence and native language.

The native language of the parent/guardian is the language normally used by that individual. For parents with deafness or blindness, or for an individual with no written language, specify the mode of communication that is normally used by the individual (such as sign language, Braille or oral communication). There should also be documentation to indicate if the parent(s) need an interpreter (and, if so the language or mode of communication) to meaningfully participate in the meeting to develop the IEP. The Committee must ensure that the parent(s)/guardian understand the proceedings of the Committee meeting.

Student Information

For data collection purposes, the supplemental form includes a section to designate the student's race/ethnicity. The is an optional field on the IEP.

Committee participants

The Committee should have a procedure to document the participants at any meeting to develop, review or revise a student’s IEP, including:

the names,
professional titles, and
corresponding Committee membership roles of those individuals and the manner in which they participated when, for example, a member is not present at the meeting but participates through other means such as a telephone conference call.

When one member of the Committee is also fulfilling another role as allowed by State law and regulations, both roles should be indicated next to that individual’s name (e.g., the school district representative may also be the school psychologist).

There is no requirement that IEP participants sign the IEP and/or indicate their agreement with the IEP. The list of names or signatures on this form would indicate attendance at the Committee meeting at which the IEP was developed and not necessarily agreement with the recommendations on the IEP.

The required members of the Committee are indicated on the forms. Further information on Committee membership is provided in Attachment 1.

SAMPLE:

Parent Information

Student’s Name: Kevin Smith

Mother’s/Guardian’s Name: Joanne Smith

Street: 345 Ocean Street

City: Miami

Zip: 23792

Telephone: 333-425-6677

County of Residence: Seaside

Native Language of Parent/Guardian: English

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

Father’s/Guardian’s Name: Matthew Smith

Street: 345 Ocean Street

City: Miami

Zip: 23792

Telephone: 333-425-6677

County of Residence: Seaside

Native Language of Parent/Guardian: English

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

[ ] Surrogate Parent Needed Not applicable

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: White

Committee Participants
[X] CSE [ ]Subcommittee
Name	Professional Title	Committee Member Role¹
Kevin Smith	Student	Student
Joanne and Matthew Smith	Parents	Student’s parents
Sharon Strand	Special Education Director	School district representative
Drew Boswell	Special Education Teacher	Special education teacher of student
Fred Kennedy	English Teacher	General education teacher of student
Dr. Danielle Weeks	School Psychologist	School Psychologist Individual to interpret instructional implications of evaluations
Marilynn Jones	Parent of high school student	Additional parent member
Irene Sarantino	Social worker, Youth Career Support Services, Inc.	Other school or agency representative (transition) (Telephone conference participant)
Olivia Linderhart	School Nurse	Others with knowledge or expertise regarding student
Lori Argyle	Speech and Language Therapist	Others with knowledge or expertise regarding student Individual to interpret instructional implications of evaluations
Paul Qualin	VESID Counselor	Other school or agency representative
Dr. Karl Dollard	Physician	School Physician

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.

¹If the member was not present at the meeting, indicate the manner in which they participated (e.g., conference telephone calls).