INDIVIDUALIZED EDUCATION PROGRAM - BLANK TEMPLATE

STUDENT / GUARDIAN INFORMATION

Student: Patrick
Address: 55 Indian Road
Paterson, NJ 07724
Contacts: Margaret (Foster Mother)
School Year: 2015-2016

Date of Birth: 9/01/2011

Age: 4 Years 8 Months

Gender: M
Native Language:
English

Local ID: 55555

State ID: 676767
Home #:

Home/Mobile #: (555) 666Work #: (999) 183-1834 Email: Margaretthefostermom@gmail.com

7777
rd
Case Manager: Erika Dent
School: Paterson Public Schools
Grade: Preschool; 3 year

MEETING OR AGREEMENT INFORMATION

MOST RECENT ELIGIBILITY INFORMATION

INITIAL ELIGIBILITY INFORMATION

Date: 5/15/2016
Reason: Re-Evaluation Meeting

Determination: Eligible for speech-language therapy,

occupational physical therapy, behavior support
therapy, family counseling therapy, and community
supervision.
Classification: Eligible for speech-language therapy,
occupational physical therapy, behavior support
therapy, family counseling therapy, and community
supervision.
Extended School Year: Yes
Most Recent Annual Review Meeting: 1/15/2016
Most Recent Reevaluation Eligibility Meeting:
5/15/2016
Reevaluation Due by: 6/30/2016

Initial Referral: 9/15/2014

Initial Consent to Evaluate: 10/01/2014
Initial Eligibility Determination: 10/30/2014
Initial IEP Meeting: 10/30/2014
Initial Consent to Implement IEP: 10/30/2014
Initial IEP Implemented: 11/01/2014

IEP INFORMATION
Projected IEP Start Date: 9/01/2015
Projected IEP End Date: 9/01/2015
Behavior Intervention Plan: Yes
Modifications: Yes
Supplementary Aids and Services: Yes
Assistive Technology: Yes
Supports for School Personnel: Yes
Testing Accommodations: No

SUMMARY-SPECIAL EDUCATION PROGRAMS AND RELATED SERVICES

Student Name:

DOB:

PLACEMENT CATEGORY

In the presence of general education students

for at least 80% of the school day in an
inclusive setting for approximately 3 out of the
5 school days.

Meeting or Agreement Date:

Family Counseling Therapy

Community Supervision
Speech-Language Therapy
Occupational Therapy
Behavior Support Therapy
Support School Personnel

Individualized Education Program

Page 2 of 27

1x weekly 60 minutes after school

3x monthly 60 minutes after school
5x weekly 30 minutes
5x weekly 30 minutes
2x weekly 30 minutes
Daily

STATUS FOR DURATION OF IEP

9/07/2015-6/30/2016

2009 Centris Group

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

IEP PARTICIPANTS
Name and date in this section of the IEP documents participation in the meeting and does not indicate agreement with the IEP.
(Original signatures are obtained from each participant at the meeting and are maintained on file.)
Participant Name and Title

Date
5/15/2016

Student

5/15/2016
Parent/Guardian

5/15/2016
Parent/Guardian

5/15/2016
General Education Teacher

5/15/2016
Special Education Teacher or Provider

5/15/2016
Child Study Team Member

5/15/2016
Case Manager
(May be CST Member above)

Participant Name and Title

Date

Page 3 of 27

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 4 of 27

5/15/2016
School District Representative
(May be the CST member or other appropriate school
personnel)
* If a required member of the IEP team has been excused from participating in the meeting with parental consent, note the excusal in the required team member's
space.

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 5 of 27

PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE AND CONSIDERATIONS WHEN DEVELOPING
THE IEP
Initial or Most Recent Evaluations/Reports: Consider relevant data. List the sources of information used to develop the IEP.
Date
Evaluation/Report
10/05/2014 Psychological Evaluation; BASC-2

Comments
Many features associated with Fetal Alcohol Syndrome and remained apprehensive throughout testing period.

10/10/2014 Speech-Language Evaluation; CP

Communication skills were uniformly about 1 year below the expected level; nonverbal through pointing & crying.

6 week time Behavioral Evaluation; FBA

Data was compiled to form a BIP.

10/15/2014 Sociological Evaluation; Vineland II

Foster mother could benefit from assistance in teaching Patrick several developmental skills & behavior strategies.

10/17/2014 Developmental Evaluation; WPPSI-IV Significant delays in the areas of adaptive behavior, communication, and cognitive skills; some in motor skills.
10/20/2015 Medical Evaluation

th

Patrick was anemic and his weight was below the 5 percentile, as well as his height-weight ratio.

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Statewide and Districtwide Assessments Results: Consider relevant data. List the sources of information used to develop
the IEP.
Date

Test

Not Applicable

Subtest

Score/Type

Results/Outcome

Comments

Page 6 of 27

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 7 of 27

Standardized Test Results: Consider relevant data. List the sources of information used to develop
the IEP.
Date

Test

Subtest

Score/Type

Comments

Not Applicable

Strengths of the Student:

Patrick displays progress with his aggressive behavior when he is lovingly restrained through the actions of cradling and positive verbal
reinforcement.
Patrick displays progress in his aggression when completing specifically assigned tasks or activities that can not cause frustration (i.e. puzzles).

Concerns of the Parent:

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 8 of 27

None

Present Levels of Academic Achievement and Functional Performance:

Patrick is a 4 year 8 month old boy who attends an inclusive preschool classroom, that contains a general ed teacher, special ed teacher, and support
staff, within his hometown. Patrick has been evaluated at the age of 3 and has been receiving speech-language, occupational therapy, and other
specific services since his 2nd year in preschool. Patrick receives these one-on-one services everyday for most of the day, taking him away from the
curriculum. Patricks teachers have also received outside guidance from local colleges and teachers to target his emotional/behavioral needs. Patrick
has been focusing on his behavior and aggression within the classroom setting. Patrick continues to benefit from a specific behavior intervention plan
and strategies used by his teachers in order to guide him in the control of his aggression.
Patricks preschool teacher, who attempted to work with him and his foster mother in the home environment, reported that he made no progress and
was non-interactive due to interferences. The written report stated that Patrick vacillated between two emotional/behavioral styles; shy and withdrawn
or aggressive and destructive. Nearing the end of his 3rd year of preschool, Patrick displayed a saddened demeanor and more withdrawn.

How the Student's Disability Affects his or her Involvement and Progress in the General Education Curriculum : For preschool children, as appropriate, describe
how the disability affects the childs participation in appropriate activities.

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 9 of 27

Patricks emotional/behavioral problems impact his education as he now only attends preschool 3 days a week and is often led out of the classroom
filled with other students. Patrick is unable to function properly, in terms of adaptive behavior, in a classroom of other students and teachers. Due to
the fact Patrick becomes easily frustrated and aggressive, he is unable to complete foundational educative activities/tasks or display appropriate
social skills.

Special Considerations: If in considering any of the special factors listed below, the IEP team determines that the student needs a particular device or service (including an
intervention, accommodation or other program modification) to receive a free, appropriate public education, the IEP must include a statement to that effect in the appropriate section. If
a factor is not applicable, note as such.
Indicate if the student has any needs as a result of Limited English proficiency:

Indicate if the student has communication needs:

Yes

No

No

Indicate if the student's behavior impedes his or her learning or that of others:
If yes, Indicate if the student requires a behavioral intervention plan:
Yes
Has a Behavior Intervention Plan in place currently.

Yes

Yes
No

No

Student Name:

DOB:

Meeting or Agreement Date:

Indicate if the student is in need of any assistive technology devices and services

Individualized Education Program

Yes

Page 10 of 27

No

Beginning with the IEP in place for the school when the student will turn age 14 or younger, if appropriate, indicate if there is a need for consultation
from agencies that provide services for individuals with disabilities:
Yes
No

Indicate if the student is deaf or hard of hearing:

Yes
No
For a student who is deaf or hard of hearing, indicate the need for opportunities for direct communication with peers and professional personnel:
No

Indicate if the student is blind or visually impaired:

Yes
No
For a student who is blind or visually impaired, the IEP shall provide for instruction in Braille and the use of Braille :

Yes

Yes

No

Needs - Academic, Developmental, Functional and any other Needs that result from the Student's Disability and Special Considerations :

Patricks emotional/behavioral problems negatively impact his education performance throughout the day in the classroom setting. Due to Patricks
delayed speech and non-verbal communication skills, he is eligible for speech services to address his articulation skills. Patrick is also eligible for
occupational physical therapy to address his impaired motor skills. Patrick will also receive behavioral support therapy to instruct him on proper social
skills and teach him how to redirect his emotions/behaviors, in addition to an aid at all times. Patrick and his foster mother are also eligible for family
counseling therapy and community supervision after school to address the family life dynamic.

Student Name:

DOB:

Meeting or Agreement Date:

STATEMENT OF TRANSITION PLANNING

Individualized Education Program

Page 11 of 27

Beginning with the IEP in place for the school year when the student will turn age 14, or younger if appropriate, develop the long range educational plan for the student's future which
includes a statement of the student's strengths, interests and preferences; a course of study; related strategies and/or activities; a description of the need for consultation from other
agencies; and, as appropriate, identify interagency linkages and responsibilities

Statement of the Student's Strengths, Interests and Preferences:

Not Applicable

Courses of Study: Considering the student's strengths, interests, preferences, and desired postsecondary goals, list the specific courses of study for the period of time covered by
this IEP. Include both general education and special education courses. When appropriate, identify the courses of study projected for future years.

Not Applicable

Related Strategies and/or Activities: In addition to the courses listed above, list related strategies and/or activities that are consistent with the student's strengths, interests, and
preferences, and are intended to assist the student in developing or attaining postsecondary goals related to training, education, employment and, if appropriate, independent living.

Not Applicable

Statement of Consultation: Indicate the need for consultation from other agencies that provide services for individuals with disabilities including, but not limited to,
the Division of Vocational Rehabilitation Services in the Department of Labor .
List the name of any agency from which consultation is needed:
Name of school staff person who will be the liaison to postsecondary resources:

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program
Page 12 of 27
As appropriate to the anticipated needs of the student, list all agencies
Statement of Needed Interagency Linkages and Responsibilities:
to postsecondary resources in the spaces below. List the responsibility of the school district and/or student/parent(s) with respect to contacting
will be referred by the school district
information or documentation to each agency.
each agency listed and providing needed
Student/Parent Responsibilities
Agency
School District Responsibilities

STATEMENT OF APPROPRIATE MEASURABLE POSTSECONDARY GOALS AND TRANSITION SERVICES

Beginning with the IEP in place for the school year when the student will turn age 16, or younger if appropriate, indicate the student's desired postsecondary school goals and transition
services.

Measurable Postsecondary Goals: Indicate the student's desired post-school goals based upon age-appropriate transition assessments related to training,
education, employment and, if appropriate, independent living.
Postsecondary Education (Including, but not limited to, college, vocational training, and continuing and adult education)
Not Applicable

Employment/Career
Not Applicable

Independent Living Skills (if appropriate)

Not Applicable

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 13 of 27

Transition Services: Coordinated Activities/Strategies: Indicate the following multi-year plan for promoting movement from school to the student's desired post
Secondary education. Training, strengths, interests and preferences in each area must be considered, and responsibilities should be shared among participants.
Activities/Strategies Related to Measurable Postsecondary Goals
(student, parent,
school staff, Education/Training:
Instruction
- Postsecondary
The student's needs,
outside agencies, employers, etc.).

Related Services:

Community Experiences:

Employment and other -Post school Adult Living :Objectives

Daily Living Skills (if appropriate):

Functional Vocational Evaluation: (if appropriate)

Expected Date
Person or Agency Arranging
of Implementation and/or Providing Services

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

BEHAVIORAL INTERVENTIONS
If behavior impedes the students learning or the learning of others, the IEP team must consider, when appropriate, strategies,
including positive behavioral interventions and supports to address that behavior. When needed, a behavior intervention plan
must be included in the IEP.

Page 14 of 27

Student Name:

DOB:

Are Behavioral Interventions Appropriate at This Time?

Meeting or Agreement Date:

Yes

Individualized Education Program

Page 15 of 27

No

Target behavior
Student cries and/or tantrums when told to do something they do not want to do or when confronted with a challenging task.
Student cries/tantrums when interacting with peers.
Student cries and/or tantrums when they do not understand how to do something.
Student cries and/or tantrums when redirected, corrected, or disciplined.
Student frequently becomes upset, cries, tantrums, and/or destroys property.
Student has trouble compromising, sharing, taking turns, etc and cries or tantrums in response to such situations.
Documentation of prior interventions and student response
Documented FBA performed over a period of at least 6 weeks.
Documented and formulated BIP based on FBA data.
Description of the positive supports/interventions, including the conditions under which the supports/interventions will be implemented
Teacher will address and handle the student in a calm neutral tone and manner.
Teacher will use proximity control.
Teacher will have the student explain directions and directives in their own words.
Teacher will have the student complete an item of less difficulty to experience success and gain momentum before trying harder and more
challenging items- scaffolding.
Teacher and parent will reward the student for maintaining control of behavior and emotions, calming down quickly, using interventions like
taking a break appropriately, putting forth good effort, attempting assignments and tasks, and exhibiting a positive attitude.
Teacher will praise and encourage the student for good behavior, remaining calm, coping well, good effort, attempting tasks, completing work,
etc.
Teacher will give the student frequent positive feedback.
Teacher will provide positive feedback and praise discretely, whispering or leaving a note to be discovered.
Teacher will provide frequent positive praise and feedback for each small part or step of a problem or item completed without becoming upset,
remaining calm, and verbalizing needs, frustration, and feelings rather than acting them out.
When the student interacts well, shares, takes turns, and compromises with peers, they will be praised and rewarded.
Student will utilize a sticker or other similar chart for effort and word, receiving rewards for reaching goals.
Teacher will reward or praise the student for verbalizing their thoughts and feelings rather than acting them out.
The student will receive extra snack times meant to be as a break time is the student has demonstrated positive behavior.
Procedures for data collection to evaluate the effectiveness of the interventions
FBA; observation, ABC form, rubric, time interval sheet, home information, data charted.
BIP
Conditions under which the supports/interventions are changed
When the student displays no progress.
When the student is able to function within a classroom setting gradually.
When the student displays fewer acts of negative behavior or aggression throughout the period of one day.

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 16 of 27

Conditions under which the supports/interventions will be terminated

When the student is able to function properly within the general education classroom on his own for a period of time with few incidents.
Parental Involvement
Parent is to adhere to BIP and document inappropriate behaviors through observation.
Document feeding and bed times to be reviewed at community supervision meetings.
Attend all educational meetings.
Participate in family counseling therapy every week and community supervision.
Document read alouds to the child on a reading log to be reviewed at every family counseling meeting.
Participate in positive reinforcement (per BIP) rather than physical and verbal consequences.

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 17 of 27

PROGRESS REPORTING
State how the parents will be regularly informed of their student's progress toward the annual goals.
Written reports will be provided 4 times per year.

ANNUAL MEASURABLE ACADEMIC AND/OR

FUNCTIONAL GOALS
Area: Dealing with feelings/self-awareness

Goal: Patrick will identify and manage feelings (i.e. anger, anxiety, stress, frustration) on a daily basis with medium frequency as measured by the classroom
teachers and support staff.

Benchmarks or Short Term Objectives

Criteria

Evaluation Procedure

Express anger and aggression appropriately by using words to state feelings.

80% success

Structured observations of
targeted behavior.

Follow the direction to take a time out when asked by the teachers or support staff.

80% success

Structured observations of
targeted behavior.

Correctly identify emotions (happy, scared, angry, sad, etc.) from a set of pictures.

80% success

Structured observations of
targeted behavior.

Make an agreed upon symbol to display asking an adult for help when needing to move away to a separate,
secluded area (voluntary time-out)

80% success

Structured observations of
targeted behavior.

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 18 of 27

Area: Aggression
Goal: Patrick will refrain from physical aggression (kicking, throwing, hitting) across all environments in school, for 4 consecutive weeks.

Benchmarks or Short Term Objectives

Criteria

Evaluation Procedure

Student will be taught and practice self coping skills; to take deep breathes when getting frustrated.

80% success

Structured observations of
targeted behavior.

Student will adhere to a positive behavior chart, tracking the number of times he has an outburst.

80% success

Structured observations of
targeted behavior.

Student will state feelings through pictures and non-verbal cues to an adult before acting out.

80% success

Structured observations of
targeted behavior.

Student will interact and be responsive to emotional support therapy.

80% success

Structured observations of
targeted behavior.

Area: Language Arts

Goal: Student will match the written word to a picture representation correctly on 10 out of 10 trials on 5 consecutive days for 50 different words in
total.
Benchmarks or Short Term Objectives

Criteria

Evaluation Procedure

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 19 of 27

Student will be able to pronounce the beginning sounds of each word.

80% success

Structured observations of
targeted behavior.

Student will be able to read the full word out loud, using his/her phonics skills.

80% success

Structured observations of
targeted behavior.

Student will be able to apply each word to a visual representation, either through a picture or real-life object.

80% success

Structured observations of
targeted behavior.

Student will be able to point to the picture cards and describe them using the word, incorporating the use of
assistive technology.

80% success

Structured observations of
targeted behavior.

MODIFICATIONS AND SUPPLEMENTARY AIDS AND SERVICES IN THE GENERAL EDUCATION CLASSROOM AND /OR SPECIAL EDUCATION
CLASSROOM
State the modifications for the student to be involved and progress in the general education curriculum and be educated with nondisabled students. If the student will not be
participating in the general education classroom, state the modifications and supplementary aids and services to enable the student to be involved and progress in the general
education curriculum in the special education classroom. State the supplementary aids and services that will be provided to the student or on behalf of the student. Identify any
assistive technology devices and services to be provided. For preschool students, review the preschool day to determine what accommodations and modifications may be required to
allow the child to participate in the general education classroom and activities. Each modification, supplementary aid or service, and assistive technology device should be entered
separately.

Modifications:
Classroom
General education inclusive classroom
with in class support staff.

Supplementary Aids and Services:

Modifications

Positive reinforcement
Strict adherence to behavior charts
Social skills training
Behavior therapy
Consistent schedules displayed in the room
Implementation of time-outs or redirection

Student Name:

DOB:

Classroom
General education inclusive classroom
with in class support staff.

Meeting or Agreement Date:

Individualized Education Program

Page 20 of 27

Supplementary Aids and Services

One-on-one classroom support staff

Family counseling therapy
Community supervision

Assistive Technology Devices and

Services:
Classroom
General education inclusive classroom
with in class support staff.

Assistive Technology Devices and Services

Speech generating devices

Apps for prompting/communication; symwriter
Social stories; sock puppet & pictello
Visual supports; touch emotion app
Functional skills system
Data collection (teacher); tap 2 count or DIBELS

SUPPORTS FOR SCHOOL PERSONNEL

State the supports for school personnel that will be provided for the student. Supports may include, but is not limited to, training for school personnel, consultation, and access to
research-based materials and resources.

Training for school personnel on emotional/behavioral disorders.

Access to research based materials.
Training for school personnel on the implementation of assistive technology.
Consultation of social services and local university training.

STATEMENT OF SPECIAL EDUCATION PROGRAMS AND RELATED

SERVICES

Student Name:

DOB:

Special Education Programs

Meeting or Agreement Date:

Individualized Education Program

Page 21 of 27

Location

Subject

Start and End

Dates

Frequency Period

Duration

Pull Out Classroom/area

Language Arts

9/07/20156/23/2016

5/week

weekly

80 mins

Related Services

Location

Ratio

Start and End

Dates

Frequency Period

Duration

Family Counseling Therapy

Home environment

1: 1

9/07/20159/07/2016

1/week

Weekly

60 mins

Community Supervision

Home environment

1: 1

9/07/20159/07/2016

3/monthly

Monthly

60 mins

Speech Language Therapy

Service provider location

1: 1

9/07/20156/23/2016

5/week

Weekly

30 mins

Occupational Physical Therapy

Service provider location

1: 1

9/07/20156/23/2016

5/week

Weekly

30 mins

Behavioral Support Therapy

Service provider
location/classroom

1: 1

9/07/20156/23/2016

2/week

Weekly

30 mins

Support School Personnel

Classroom

1: 1

9/07/20156/23/2016

daily

Daily

Continuous

Special Transportation Related Services

Comments

Start and End

Dates

Frequency

Period

Foundation Reading Skills

Not Applicable

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 22 of 27

STATEMENT OF EXTENDED SCHOOL YEAR SPECIAL EDUCATION PROGRAMS AND RELATED SERVICES
Determine whether the student needs an extended school year (ESY) program. An extended school year program is provided in accordance with the
students IEP when an interruption in the educational programming causes the students performance to revert to a lower level of functioning and
recoupment cannot be expected in a reasonable length of time.

Does the student need an extended school year program? Yes

Extended School Placement Location: Preschool
List relevant factors considered in determining whether the student needs an ESY Program:

Social skills continuous instruction

Continuous instruction to manage behavior
Additional time to gain progressive instruction on educational foundation skills
Special Education Programs

Location

Subject

Start and End

Dates

Frequency Period

Duration

Foundational Skills Instruction

Classroom

Language Arts

7/01/20168/30/2016

5/week

Weekly

80 mins

Related Services

Location

Start and End

Dates

Frequency

Period

Duration

Family Counseling Therapy

Home environment

1:1

6/24/20169/06/2016

1/week

Weekly

60 mins

Community Supervision

Home environment

1:1

6/24/20169/06/2016

3/month

Monthly

60 mins

Speech-Language Therapy

Service provider location

1:1

6/24/20169/06/2016

5/week

Weekly

30 mins

Behavioral Support Therapy

Service provider location

1:1

6/24/20169/06/2016

5/week

Weekly

30 mins

Ratio

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 23 of 27

PLACEMENT DECISION
* NOTE: In accordance with federal data collection requirements, a student in an out-of-district segregated placement for 50% or more of the school day
must be reported as being in that setting for the entire day, regardless of whether the student is in a general education setting for the remainder of the
school day.

Placement decision category for students with disabilities ages 3-5 or 6-21: In the presence of the general education students for 80% of the school day.
RATIONALE FOR REMOVAL FROM GENERAL EDUCATION
Decisions regarding placement are based on the individual needs of students and must begin with consideration of the general education setting. The purpose of this page is to
document the discussions that have occurred with respect to accommodations, modifications, and supplementary aids and services in each academic or functional area that are
necessary to educate the student in the general education setting.
If the student will be included in the general education setting for more than 80% of the time, no rationale is required. Items 1 through 3 of this section of the IEP need not be
completed or included in the students IEP.
If a student will not be included in the general education setting for more than 80% of the time, items 1 through 3 below MUST be completed for each CONTENT/SUBJECT AREA.
* NOTE: In accordance with federal data collection requirements, a student in an out-of-district segregated placement for 50% or more of the school day must be reported as being in
that setting for the entire day, regardless of whether the student is in a general education setting for the remainder of the school day.

If a student will not be included in the general education setting for 80% or more of the time, items 1 through 3 below MUST be completed for each
content/subject area.
1. Identify the supplementary aids and services that were considered to implement the students annual goals. Explain why they are not appropriate
to meet the students needs in the general education class:

Not Applicable
2. Document the comparison of the benefits provided in the general education class and the benefits provided in the special education class:

Not Applicable

3. Document the potentially beneficial or harmful effects which a placement (in the general education class) may have on the student with disabilities or
the other students in the class: Not Applicable

TRANSITION PLANNING ACTIVITIES FOR STUDENTS IN SEPARATE SETTINGS

For students in a separate setting for all or part of a school day, set forth activities necessary to move the student to a less restrictive placement. A separate setting is defined as a
building without general education students.

PARTICIPATION IN DISTRICTWIDE AND STATEWIDE ASSESSMENT PROGRAM

Indicate any individual modifications in the administration of Statewide or districtwide assessments of student achievement needed for the student to participate. If it is determined that
the student shall not participate in a particular Statewide or districtwide assessment of student achievement (or part of such an assessment), indicate why that assessment is not
appropriate for the student and indicate how the student shall be assessed.

Student will Participate in the Following Assessments:

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 24 of 27

Not Applicable

MODIFICATIONS IN EXTRACURRICULAR AND NONACADEMIC ACTIVITIES

State the modifications that will be provided to enable the student to participate in extracurricular and nonacademic activities. Explain the extent, if any, to which the student will not
participate with nondisabled peers in extracurricular activities and nonacademic activities. In addition, for students in an out-of-district placement, delineate how the student will
participate with nondisabled peers in extracurricular and nonacademic activities including, if necessary, returning the student to the district in order to facilitate such participation.

Not Applicable

LENGTH OF SCHOOL DAY

Document the length of the school day, if different from the length of the school day for nondisabled peers.

Not Applicable

STATEMENT OF THE STUDENTS TRANSITION FROM ELEMENTARY TO SECONDARY PROGRAM

Not Applicable

Testing Modifications/Accommodations Needed for Districtwide, Statewide and Classroom Assessments:

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 25 of 27

Not Applicable

Student Will Not Participate in the Following

Assessments

Explain Why the Assessment Is Not Appropriate

State How the Student Will Be Assessed

Not Applicable

Not Applicable

Not Applicable

Not Applicable

GRADUATION REQUIREMENTS
Beginning at age 14, identify the State and local graduation requirements that the student will be expected to meet. The statement must be reviewed annually. If the student is
exempted from meeting any of the graduation requirements that all students are expected to meet or if any of the requirements are modified, provide a rationale below and list any
alternate proficiencies the student is expected to achieve.

State the Graduation Requirement

Attendance:

Not Applicable

Exemption If the student is exempt from the meeting the graduation requirement, provide a rationale for the
exemption.

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 26 of 27

Credit Hours:

Not Applicable
HSPA or SRA:

Not Applicable
Other (Local Graduation Requirements):

Not Applicable
Alternate Requirements - Provide a description of any alternate proficiencies to be achieved by the student to qualify for a State endorsed diploma:

Not Applicable

NOTICE REQUIREMENTS FOR THE IEP AND PLACEMENT

This form describes the information required in each of the components of written notice for an IEP meeting.
The written notice includes the IEP as a description of the proposed action and a description of the procedures and factors used in determining the proposed action.

Describe the proposed action and explain why the district has taken such action:
As a result of the IEP meeting, the district proposed that the students IEP should be revised and the student should be re-evaluated by being given additional
assessments. This IEP states the proposed disability and services to be provided.
It was determined the student continues to have a disability defined in NJAC 6A: 14-3.5, 3.6, and 3.7 which affects the students educational performance.
Describe any options considered and the reasons those options were rejected:
No other options at this time.
Describe the procedures, tests, records or reports and factors used in determining the proposed action:
The source of information used to develop the proposed IEP are included in the Present Level of Achievement and Functional Performance and Considerations
when Developing the IEP section of this IEP.
If applicable, describe any other factors that are relevant to the proposed action:
There were no other factors that are relevant to the proposed action.
TRANSFER OF RIGHTS AT AGE OF MAJORITY

Student Name:

DOB:

Meeting or Agreement Date:

Individualized Education Program

Page 27 of 27

On , will turn age 18 and become an adult student. The following rights will transfer to :
- The school district must receive written permission from before it conducts any assessments as part of an evaluation or reevaluation and before implementing an
IEP for the first time.
- The school must send a written notice to whenever it wishes to change or refuses to change the evaluation, eligibility, individualized education program (IEP),
placement, or the provision of a free, appropriate public education (FAPE).
- You, the parent(s), may not have access to s educational records without his/her consent, unless he/she continues to be financially dependent on you.
- The district will continue to provide you, the parent(s), with notice of meetings and of any proposed changes to your adult childs program.
- Any time disagrees with his/her special education program, he/she is the only one who can request mediation or a due process hearing to resolve any disputes
arising in those areas.
If wishes, he/she may write a letter to the school giving you, the parent(s), the right to continue to act on his/her behalf in these matters.
PROCEDURAL SAFEGUARDS STATEMENT
As the parent of a student who is, or may be determined, eligible for special education services or as an adult student who is, or may be determined, eligible for
special education, you have rights regarding identification, evaluation, classification, development of an IEP, placement and the provision of a free, appropriate
public education under the New Jersey Administrative Code for Special Education, N.J.A.C. 6A:14. A description of these rights, which are called procedural
safeguards, is contained in the document, Parental Rights in Special Education (PRISE). This document is published by the New Jersey Department of Education.
A copy of PRISE is provided to you upon referral for an initial evaluation, when a disciplinary action that constitutes a change in placement is imposed by your
school district, and the first time a due process hearing or complaint investigation is requested. In addition, a copy will be provided to you at your request.
To obtain a copy of PRISE, please contact: Bob Higgins, Director of Special Services (262) 555-6666
For help in understanding your rights, you may contact any of the following:
Bob Higgins, Director of Special Services (262) 555-6666
Statewide Parent Advocacy Network (SPAN) at (800) 654-7726
Protection and Advocacy, Inc., at (800) 922-7233