Individualized Education Program (IEP) Grade K - 7 State of Delaware School District 302-

Student Information Student Name: Student ID#: Address: District of Residence: #arent$ %: Address &if different': )ele*hone &+ome': #arent$ 2: Address &if different': )ele*hone &+ome': IEP Status .eetin Date
.ost Recent (/aluation Summ ar" Re*ort Date I(# Re/ision Date I(# Re/ision Date

Date of Birth: Current Grade: Attendin Buildin :

Disa!ilit" Classification:

&,or-'

(-mail: &Cell' (-mail: &Cell' Temporar Placement A enc" Re*resentati/e: #arent: Date:
Within 60 days, an IEP meeting must be held

&,or-'

I(# Initiation Date I(# (nd date !eeting Participants

"ole

#ame

Signature

#arent$ % #arent$ 2 Student General (d0 )eacher S*ecial (d0 )eacher Administrator 1 Desi nee

$ #arent includes le al uardian2 educational surro ate *arent and relati/e care i/er0

Grade 3-4 I(#

Student Information

5120%0

Name:

$ata %onsiderations

Date:

%0 20 30 90 50 ;0

,hat are the student6s stren ths7

,hat are the educational concerns of the *arent &or student2 if a**ro*riate'7

,hat multi*le data sources &includin district or state8ide assessments' are !ein used to create this I(#7

+o8 does the child6s disa!ilit" affect the child6s in/ol/ement and *ro ress in the eneral education curriculum7 ,hat are the child6s other educational needs that result from the child6s disa!ilit" &e0 02 or ani:ational s-ills2 self care2 fine1 ross motor'7

,ill the student *artici*ate 8ith non-disa!led students in e<tracurricular and non-academic areas7 If "es2 identif" su**orts and ser/ices on the =Needs2 Ser/ices and Annual Goals> *a e0 If no2 e<*lain 8h" !elo80

&t'er (actors to %onsider) I(# team must consider each of the factors0 If there is a need identified2 chec- ="es> and address in the I(#0 *es #o Communication needs of the student Braille instruction for students 8ho are !lind or /isuall" im*aired Communication and lan ua e needs for students 8ho are deaf1hard of hearin ?an ua e needs for students 8ith limited (n lish *roficienc" #ositi/e !eha/ior inter/entions2 su**orts2 and strate ies for students 8hose !eha/ior im*edes learnin Need for assisti/e technolo " de/ices and ser/ices Inter/ention su**orts and strate ies for students 8ho ha/e difficult" accessin and1or usin le/el te<t!oo-s and other core materials in standard *rint formats rade-

Grade 3-4 I(#

Data Considerations

5120%0

Name:

Date:

+ni,ue Educational #eeds and %'aracteristics

Services- 4ids 5 !odifications

Provide a statement of t'e special education and related services and supplementar aids and services- .ased on peer-revie/ed researc' to t'e e0tent practica.le- to .e provided to t'e c'ild- or on .e'alf of t'e c'ild- and a statement of t'e program modifications or supports for sc'ool personnel t'at /ill ena.le t'e c'ild) to advance appropriatel to/ard attaining t'e annual goals1 to .e involved in and ma2e progress in t'e general education curriculum- and to participate in e0tracurricular and ot'er nonacademic activities1 and to .e educated and participate /it' ot'er c'ildren /it' disa.ilities and non disa.led c'ildren3 Start6End $ate (re,uenc $uration 7ocation

P7EP (Present 7evel of Education Performance)) 8enc'mar2 9: %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "# . S N &ptional #arrative)

8enc'mar2 9; %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "$ . S N &ptional #arrative)

8enc'mar2 9< %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "% . S N &ptional #arrative)

8enc'mar2 9= %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "& .

&ptional #arrative)

4nnual Goal)

. @ .astered 4nnual Goal S @ Sufficient *ro ress to meet 4nnual Goal N @ Not sufficient *ro ress to meet 4nnual Goal

)hera*ist Si nature

Date:

&Aor .edicaid Cost Reco/er"'

Grade 3-4 I(#

Needs2 Ser/ices and Annual Goals

5120%0

Name:

Date:

+ni,ue Educational #eeds and %'aracteristics

Services- 4ids 5 !odifications

Provide a statement of t'e special education and related services and supplementar aids and services- .ased on peer-revie/ed researc' to t'e e0tent practica.le- to .e provided to t'e c'ild- or on .e'alf of t'e c'ild- and a statement of t'e program modifications or supports for sc'ool personnel t'at /ill ena.le t'e c'ild) to advance appropriatel to/ard attaining t'e annual goals1 to .e involved in and ma2e progress in t'e general education curriculum- and to participate in e0tracurricular and ot'er nonacademic activities1 and to .e educated and participate /it' ot'er c'ildren /it' disa.ilities and non disa.led c'ildren3 Start6End $ate (re,uenc $uration 7ocation

P7EP (Present 7evel of Education Performance)) 8enc'mar2 9: %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "# . S N &ptional #arrative)

8enc'mar2 9; %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "$ . S N &ptional #arrative)

8enc'mar2 9< %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "% . S N &ptional #arrative)

8enc'mar2 9= %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "& .

&ptional #arrative)

4nnual Goal)

. @ .astered 4nnual Goal S @ Sufficient *ro ress to meet 4nnual Goal N @ Not sufficient *ro ress to meet 4nnual Goal

)hera*ist Si nature

Date:

&Aor .edicaid Cost Reco/er"'

Grade 3-4 I(#

Needs2 Ser/ices and Annual Goals

5120%0

Name:

Date:

+ni,ue Educational #eeds and %'aracteristics

Services- 4ids 5 !odifications

Provide a statement of t'e special education and related services and supplementar aids and services- .ased on peer-revie/ed researc' to t'e e0tent practica.le- to .e provided to t'e c'ild- or on .e'alf of t'e c'ild- and a statement of t'e program modifications or supports for sc'ool personnel t'at /ill ena.le t'e c'ild) to advance appropriatel to/ard attaining t'e annual goals1 to .e involved in and ma2e progress in t'e general education curriculum- and to participate in e0tracurricular and ot'er nonacademic activities1 and to .e educated and participate /it' ot'er c'ildren /it' disa.ilities and non disa.led c'ildren3 Start6End $ate (re,uenc $uration 7ocation

P7EP (Present 7evel of Education Performance)) 8enc'mar2 9: %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "# . S N &ptional #arrative)

8enc'mar2 9; %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "$ . S N &ptional #arrative)

8enc'mar2 9< %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "% . S N &ptional #arrative)

8enc'mar2 9= %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "& .

&ptional #arrative)

4nnual Goal)

. @ .astered 4nnual Goal S @ Sufficient *ro ress to meet 4nnual Goal N @ Not sufficient *ro ress to meet 4nnual Goal

)hera*ist Si nature

Date:

&Aor .edicaid Cost Reco/er"'

Grade 3-4 I(#

Needs2 Ser/ices and Annual Goals

5120%0

Name:

Date:

+ni,ue Educational #eeds and %'aracteristics

Provide a statement of t'e special education and related services and supplementar aids and services- .ased on peer-revie/ed researc' to t'e e0tent practica.le- to .e provided to t'e c'ild- or on .e'alf of t'e c'ild- and a statement of t'e program modifications or supports for sc'ool personnel t'at /ill ena.le t'e c'ild) to advance appropriatel to/ard attaining t'e annual goals1 to .e involved in and ma2e progress in t'e general education curriculum- and to participate in e0tracurricular and ot'er nonacademic activities1 and to .e educated and participate /it' ot'er c'ildren /it' disa.ilities and non disa.led c'ildren3

Services- 4ids 5 !odifications

Start6End $ate

(re,uenc

$uration

7ocation

P7EP (Present 7evel of Education Performance)) 8enc'mar2 9: %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "# . S N &ptional #arrative)

8enc'mar2 9; %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "$ . S N &ptional #arrative)

8enc'mar2 9< %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "% . S N &ptional #arrative)

8enc'mar2 9= %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "& .

&ptional #arrative)

4nnual Goal)

. @ .astered 4nnual Goal S @ Sufficient *ro ress to meet 4nnual Goal N @ Not sufficient *ro ress to meet 4nnual Goal

)hera*ist Si nature

Date:

&Aor .edicaid Cost Reco/er"'

Grade 3-4 I(#

Needs2 Ser/ices and Annual Goals

5120%0

Name:

Date:

+ni,ue Educational #eeds and %'aracteristics

Services- 4ids 5 !odifications

Provide a statement of t'e special education and related services and supplementar aids and services- .ased on peer-revie/ed researc' to t'e e0tent practica.le- to .e provided to t'e c'ild- or on .e'alf of t'e c'ild- and a statement of t'e program modifications or supports for sc'ool personnel t'at /ill ena.le t'e c'ild) to advance appropriatel to/ard attaining t'e annual goals1 to .e involved in and ma2e progress in t'e general education curriculum- and to participate in e0tracurricular and ot'er nonacademic activities1 and to .e educated and participate /it' ot'er c'ildren /it' disa.ilities and non disa.led c'ildren3 Start6End $ate (re,uenc $uration 7ocation

P7EP (Present 7evel of Education Performance)) 8enc'mar2 9: %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "# . S N &ptional #arrative)

8enc'mar2 9; %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "$ . S N &ptional #arrative)

8enc'mar2 9< %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "% . S N &ptional #arrative)

8enc'mar2 9= %st .ar-in #eriod

Progress $ate) Report progress here for Ben hmar! "& .

&ptional #arrative)

4nnual Goal)

. @ .astered 4nnual Goal S @ Sufficient *ro ress to meet 4nnual Goal N @ Not sufficient *ro ress to meet 4nnual Goal

)hera*ist Si nature

Date:

&Aor .edicaid Cost Reco/er"'

Grade 3-4 I(#

Needs2 Ser/ices and Annual Goals

5120%0

Name:

Date:

Related Ser/ices
Services T pe of $eliver
Indi/idual Indi/idual Indi/idual Indi/idual Indi/idual Indi/idual Indi/idual Indi/idual Indi/idual Indi/idual

Start6End $ate

(re,uenc

$uration

7ocation

Grade 3-4 I(#

Needs2 Ser/ices and Annual Goals

5120%0

Name:

4dditional %onsiderations

Date:

Transportation S*ecial trans*ortation needs7 If "es2 s*ecif": B(S NC

Is it necessar" to *lace this student2 8ho is trans*orted from the school B(S NC !" !us into the char e of a *arent or other authori:ed res*onsi!le *erson7 If "es2 )rans*ortation De*artment 8ill !e notified !": Participation in State/ide 4ssessment Student 8ill *artici*ate in re ular testin conditions 8ithout accommodations unless one of the !elo8 is chec-ed0 Student *artici*ates 8ith accommodations as documented on the attached Student Accommodation Chec-list0 Student is included in Alternate Assessment0 )he #artici*ation Guidelines form is attached and #500 is filled in on the Student Accommodation Chec-list0 Student is not in a rade that is assessed0 $iscipline )he student 8ill adhere to School Code of Conduct0 &Chec- !elo8 if an" of the follo8in are needed': Inter/entions and su**orts are descri!ed under ser/ices1su**orts and1or in oals0 Beha/ior inter/ention and su**ort *lan &see attached'0 Cther: Participation in T/elve-!ont' Program Bes No Not A**lica!le B" State ?a8 D%9 Del0C0 E%403F2 *arents of students 8ith certain disa!ilit" classifications ma" choose a %2month *ro ram 8hich does not e<ceed 2%4 school da"s &Se/ere .ental Disa!ilit"G )raina!le .ental Disa!ilit"G Crtho*edic Im*airmentG )raumatic Brain InHur"G Deaf-Blind' or 29% school da"s &Autism'0 As a *arent of a Iualif"in student2 I choose a %2-month *ro ram0 %onsideration of Eligi.ilit for E0tended Sc'ool *ear Services (ES*) I(# team must consider each of the follo8in factors: Re ression 1 Recou*ment Jocational S-ills De ree of Im*airment Brea-throu h S-ills (<tenuatin Circumstances Is ES* needed> Bes No )o Be Determined (SB offered2 !ut declined !" *arent Rationale for decision:

S*ecif" oals and ser/ices: See attached *a e &if needed' Services T pe

Start6End $ate

(re,uenc

$uration

7ocation

Grade 3-4 I(#

Additional Considerations

5120%0

Name:

Date:

7east "estrictive Environment6Placement A student 8ith a disa!ilit" shall not !e remo/ed from education in a e a**ro*riate re ular classes solel" !ecause of needed modifications in eneral education curriculum0 S*ecial classes2 se*arate schoolin 2 or other remo/al of children 8ith disa!ilities from the re ular educational en/ironment occurs onl" if the nature or se/erit" of the disa!ilit" is such that education in re ular classes 8ith the use of su**lementar" aids and ser/ices cannot !e achie/ed satisfactoril"0 Kse the o*tion !elo8 to determine the a**ro*riate settin 0 "egular Setting Includes *ull-out related ser/ices and team classrooms0 Student ser/ed inside the A0 re ular classroom reater than or eIual to L0M of the da"0 Services Provided 8ot' in Separate Special Education %lasses and "egular Setting Student B0 ser/ed inside the re ular classroom reater than or eIual to 90M of the da" and no more than 4NM of the da"0 Separate Special Education in an Integrated Setting Student ser/ed inside the re ular classroom C0 less than 90M of the da"0 Separate Sc'ool Student ser/ed in *u!lic or *ri/ate se*arate da" school facilit" for reater than D0 50M of the school da" or a residential facilit" if student does not li/e at the facilit"0 (0 "esidential (acilit 8here student resides durin the school 8ee-0 A0 G0 ?ome.ound or ?ospital %orrectional (acilities &onl" used !" DSCBA and #rison (ducation' Students *laced in short-term detention or correctional facilities0 An e<*lanation must !e *ro/ided a!out the e<tent2 if an"2 to 8hich the child 8ill not *artici*ate 8ith nondisa!led children in the re ular class0

Signatures Bes Bes Bes No No No I ac-no8led e that I ha/e recei/ed a co*" of the #rocedural Safe uards0 ." due *rocess ri hts under those #rocedural Safe uards ha/e !een e<*lained to me0 I a ree 8ith the *ro ram descri!ed in this document0 I a ree 8ith the *lacement decision as noted a!o/e and discussed at this meetin 0

#arent1Student Si nature #arent1Student Si nature

Date Date

If Parent $oes #ot 4ttend Staff mem!er !elo8 is res*onsi!le for for8ardin a co*" of the I(# and #rocedural Safe uards and e<*lainin content2 if necessar" to the #arent0 Name #osition .ethod of Contact

Grade 3-4 I(#

?R(

5120%0