INDIVIDUALIZED EDUCATION PROGRAM

Page 2 of8
Students Full Name Sammy Solo

Date August 28, 1993

PART III: EXTENDED SCHOOL YEAR (ESY) DETERMINATION

Will ESY be considered while developing this IEP?

Yes: X

N/A (Student is gifted):

The IEP Team in making its determination of a students need for ESY shall review
documentation that the student exhibits, or may exhibit:
Significant regression during an interruption in educational programming;
A limited ability to recoup, or relearn skills once programming has resumed;
Regression/recoupment problem(s) that interfere with the maintenance of identified
critical skills as described in the current IEP; and
Other factors that interfere with the maintenance of identified critical skills as described
in the current IEP, such as predictive data; degree of progress; emerging skills and
breakthrough opportunities; interfering behaviors; nature and/or severity of the disability;
and special circumstances
The lack of clear evidence of such factors may not be used to deny a student ESY services, if the
IEP Team determines the need for such services and includes ESY in the IEP.
Does the student need ESY services?
Yes

X No

Defer until: ______________

(ESY shall be determined annually)

EXTENDED SCHOOL YEAR SERVICES

ESY Services

Direct /
Indirect
(D or I)

Location of Services
* General Education
Environment = GEE
* Special Education
Environment = SEE
* Other =

Extent/Frequency
per

Initiation
Date
m/d/y

After review of the proposed extended school year services, the parent(s)/guardian(s) / adult student:
accept(s) extended school services.
reject(s) extended school services.
Initials: ______ ______

Date: _____________

Duration
m/y

INDIVIDUALIZED EDUCATION PROGRAM

Page 3 of 8
Students Full Name

Date August 28, 1993

PART IV: CONSIDERATION OF FACTORS FOR IEP DEVELOPMENT/ANNUAL REVIEWS

The IEP team considers for all students:

The strengths of the student

The concerns of the parent
Results of the initial or most recent evaluation of the student. Are additional evaluations needed?
(specify) __________________________________________________
Academic, developmental and functional needs of the student
Revisions needed to address lack of progress

Additional Considerations (if Yes, must be documented in Present Levels Narrative)

1.Is the student considered gifted?
If yes, consider whether acceleration will be provided and document its effect on graduation.
2.Does the student need assistive technology devices or services:
If yes, document the type of device and provision for home use, if any, and/or the nature and
amount of services. Word Processor for school use
3.Does the student have communication needs?
If yes, address in the IEP.
4.Does the students behavior impede his or her learning or that of others?
If yes, consider the use of positive behavioral interventions and supports and other strategies
to address that behavior.
5.Does the student have blindness or low vision?
If yes, document provision of instruction in Braille and the use of Braille, OR after an
evaluation of the students reading and writing skills, needs and appropriate reading and
writing media, including an evaluation of the students future needs for instruction in Braille
or the use of Braille, document in the Present Levels a justification that instruction in Braille
or the use of Braille is not appropriate for the student.
6.Is the student deaf or hard-of-hearing?
If yes, consider the language and communication needs of the student, opportunities for
direct communication with peers and professional personnel in the students language and
communication mode, the students academic level and full range of needs, including
opportunities for direct instruction in the students language and communication mode.
7.Does the student have limited English proficiency?
If yes, consider the language needs of the student.
8.Will the students next IEP address transition services:
If yes, permission must be obtained to invite other agency representatives to the next IEP
meeting (see Activities/Linkages section under Transition Planning).
Specify Agency(ies):

Parent/Adult Student Consent:

Date:
Parent Initial _____ Student Initial _____
INDIVIDUALIZED EDUCATION PROGRAM

Yes

No
X

X
X
X
X

X
X

Page 5 of 8

Students Full Name Sammy Solo

Date August 28, 1993

PART VIII: ANNUAL GOALS, Part A (For students who are taught the WV CSOs)
* Denotes critical skill(s) to consider for extended school year.

Critical
Skill

Timeframe

Condition

Behavior

August 2016May 2017

Given the use of

an Agenda Book

Turn in homework 75%

of the time

Evaluation
Procedure with
Criteria

Mastery/Progress
Codes (optional)
(per Grade Period)

Teacher
observation and
Data Collected
80%

August 2016May 2017

Given the use of

a word processor
And
grammar
check

Write a 3 paragraph essay

with
good
grammar
mechanics and less errors

Rubric /
Collected

Data

Progress

How and when will the students progress toward the IEP goals be reported to the parent(s)? Specify.
How? Written report
When? Report cards
Record dates on which Progress Reports have been provided to parents.

Mastery Code:
0 = Regression
1 = Maintained
Student Progress Code:
P = Progress Sufficient
IP = Insufficient Progress

2 = Recouped
A = Achieved
NA = Not Applicable

INDIVIDUALIZED EDUCATION PROGRAM

Page 6 of 8
Students Full Name Sammy Solo

Date August 28, 1993

PART IX: SERVICES

A. Supplementary Aids,
Services/Program
Modifications
Use of a word processor
Extended time on writing
assignments
Test read aloud to student

B. Special Education Services

Consultation for behavior

(homework)
Resource Room

C. Related Services
none

Location of Services
Subjects that have a written
response
Subjects that have a written
response
All tests, except math

Location of Services
* General Education
Direct /
Environment = GEE
Indirect
* Special Education
(D or I)
Environment = SEE
* Other =
I
GEE

Extent/Frequency
per
Estimate 4hrs/per week

Initiation
Date
m/d/y

50% extended time

Estimate 3hrs/per week

Extent/Frequency
per

Initiation
Date
m/d/y

Duration
m/y

Duration
m/y

15 minutes/per week

SEE

30 minutes/per day

West Virginia Department of Education

March 2009

INDIVIDUALIZED EDUCATION PROGRAM

Page 7 of 8
Students Full Name _________Sammy Solo_______________________

DATEAugust 28, 1993

PART VII: Statewide Testing: (Please check all appropriate boxes)

1) Indicate the appropriate WV Measures of Academic Progress Assessment and 2) check standard conditions or standard conditions
w/accommodations.
WESTEST 2 Grades 3-11
WESTEST 2 Online Writing Grades 3-11

Alternate Assessment (APTA) Grades 3-8 & 11(MA & RLA)

Alternate Assessment (APTA) Grades 4, 6 & 11 (Science)

A) Standard Conditions
B) Standard Conditions w/Accommodations

A) Standard Conditions
B) Standard Conditions w/Accommodations

NOTE: For APTA eligibility, the student must exhibit significant cognitive disabilities, be instructed through Alternate Academic Achievement Standards and be
pursuing a modified diploma (age 14+). APTA is large print formatted. Justification for APTA:

WVEIS
Code

Standard Conditions with Accommodations

Check all that apply
WVEIS Codes:

P Presentation

R Response

Specify the test or

the part of the test
T Timing

Have test read aloud verbatim (except WESTEST 2 R/LA)

P03
P06
P13
P15
P16
P17
P18
P19
P20
P21
P22
P23
P24
P25
P26
R02
R03
R04
R05
R11
R13
R16
R17
T03
X

Use braille or other tactile form of print

Have test presented through sign language (except WESTEST 2 R/LA)
Have test presented through text-talk converter (WESTEST 2 Online Writing; or VI if routine)
Have directions only read aloud (acceptable for WESTEST 2 R/LA)
Have directions presented through sign language (acceptable for WESTEST 2 R/LA)
Use secure electronic braille note-taker (for directions & test stimulus materials)
Have directions rephrased by trained examiner
Use large print edition (when it is typical access)
Use tactile graphics
Use screen enlarging or screen reading software to access the computer (WESTEST 2 Online Writing)
Adjust screen resolution to enlarge text (VI; acceptable for WESTEST 2 Online Writing)
Use a magnifying screen cover (when it is the typical access; WESTEST 2 Online Writing)
Use electronic translator or sign-dictionary to present test (except WESTEST 2 R/LA)
Use electronic translator or sign-dictionary to present directions only
Have directions, passage and prompt read aloud (WESTEST 2 Online Writing)
Indicate responses to a scribe (for all selected-response items and WESTEST 2)
Use braille or other tactile form of print (when it is typical response mode)
Indicate responses to a scribe, specify all elements to be scored (gridded/extended response including Online Writing*)
Use an abacus (acceptable for the blind on all parts of WESTEST 2 Math and Science)
Use computer, typewriter or other assistive technology device to respond
Provide physical support (if routine) by teacher/aide who is a trained examiner
Mark responses on large-print test booklet
Use an electronic translator or sign-dictionary to respond
Take more breaks (no studying)
Use extra time for any test

T07

Flexible scheduling, extra time within the same day (no studying)

All

All

*Online Writing refers to WESTEST 2 Online Writing

INDIVIDUALIZED EDUCATION PROGRAM
Page 8 of 8
West Virginia Department of Education

March 2009

Students Full Name Sammy Solo

Date August 28, 1993

PART XI: PLACEMENT

Explain the extent, if any, to which the student WILL NOT participate in the general education classroom and/or extracurricular and
other non-academic activities. Present levels of academic achievement and functional performance must explain why full
participation is not possible.
8th Grader writing on a 3 rd grade level, he needs intensive instruction in the resource room so he can be successful in the general
education curriculum.
Percentage of time in:
X

91.7% General Education Environment

8.3% Special Education Environment

Ages 6 21
General Education: Full-Time (FT) 80% or more
General Education: Part-Time (PT) 40% to 79%
Special Education: Separate Class (SC) (general education less than 40%)
Special Education: Special School (SS) Public or Private
Special Education: Out-of-School Environment (OSE)
Special Education: Residential Facility (RF) Public or Private
Parentally placed in private school (Service Plan only)
Correctional facility

Ages 3 5
For students in Regular Early Childhood Program (RECP) (at least 50% nondisabled)
= Hours per week in the RECP
= Hours per week of special education and related services delivered in the RECP
= Hours per week student receives special education and related services in some other location.
In a Regular Early Childhood Program at least 10 hours per week
Majority of hours of special education and related services in the RECP
Majority of hours of special education and related services in some other location.
In a Regular Early Childhood Program less than 10 hours per week
Majority of hours of special education and related services in the RECP
Majority of hours of special education and related services in some other location.
For students not in Regular Early Childhood Program
Separate special education class
Separate school
Residential facility
Home
Service provider location

WVEIS LRE Code

0
1
2
3
5
6
8
9
WVEIS LRE Code

WVEIS LRE Code

W
X
Y
Z
WVEIS LRE Code
M
N
P
R
S

Least Restrictive Environment (LRE) Considerations: The IEP Team has considered:
X
Annual Placement determination based on the IEP.
X
Only schools and classroom settings that are appropriate to the students chronological age.
X
Education in a general classroom with the use of supplementary aids and services.
X
Potentially harmful effects of the selected LRE placement on the student and the quality of the students services.
X
Education with age-appropriate non-exceptional peers.
X
Placement as close to home as possible, in the school the student would normally attend if note exceptional, unless the IEP
requires other arrangement

West Virginia Department of Education

March 2009

West Virginia Department of Education

West Virginia Department of Education