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SPED 663 IEP ASSIGNMENT

Fall 2014
Directions:
Based on the Derek case study data information Complete the attached pages :
A- Cover Page of IEP (only bold italics areas)
B. Complete 2 sets of goals and objectives (the complete goals and
objectives pages) for academic skill areas and 1 set of for a functional skill
area (3 goals total). This includes PLOP, Goal, STOs or Benchmarks (you
need 3 objectives or benchmarks for each goal), and evaluation criteria and
method for each. (note across the 3 goals you must have both STOs and
Benchmark formats represented)
C. Check off the appropriate boxes and then list 4-6 modifications you
would recommend for _________ in order to help him access the general
education curriculum (be included in the general education setting. List
these modification suggestions in the grey shaded area.
D. Check off the appropriate boxes and then list 3-5 adaptations you would
recommend for ________ in order for him to participate in the testing.
E. List the number of minutes per week of special education services you
would plan for this student and then identify any related services you
think ____________________might need and include the number of minutes
per week of related services.
*Note if you do not recommend any related services explain why.
F. Complete the participation in General Education sections and the
placement recommendations sections including your reasons for not
choosing other levels of placement.

INDIVIDUALIZED EDUCATION PROGRAM (CONFERENCE SUMMARY REPORT)


DATE OF MOST RECENT EVALUATION:______/______/______DATE OF NEXT REEVALUATION:______/______/_____
PURPOSE OF CONFERENCE (Check all that apply)
Review of Existing

Reevaluation

Initial Eligibility

Initial IEP

IEP Review/Revision

Manifestation Determination

Termination of Placement

Transition

Graduation

Other (e.g. FBA/BIP)________

Data

STUDENT IDENTIFICATION INFORMATION


STUDENTS ADDRESS (Street, City, State, Zip Code)

ETHNICITY

MALE

LANGUAGE/MODE OF COMMUNICATION
USED BY STUDENT

African
American

FEMALE

STUDENTS DATE OF BIRTH

SIS ID NUMBER

CURRENT GRADE LEVEL

ANTICIPATED DATE OF HS GRADUATION

4
English

PLACEMENT(To be completed after placement determination)

DISABILITY(S)

MEDICAID NUMBER

Learning disability

YES
NO
Placement is in Resident School
RESIDENT DISTRICT

SERVING DISTRICT

RESIDENT SCHOOL

SERVING SCHOOL

PARENT/GUARDIAN INFORMATION
(1) PARENTS NAME
Parent

Educational Surrogate

(2) PARENTS NAME

Educational Surrogate Parent

(1) PARENTS ADDRESS (Street, City, State, Zip Code)

(2) PARENTS ADDRESS (Street, City, State, Zip Code)

(1) PARENTS TELEPHONE NUMBER (include Area Code)

(2) PARENTS TELEPHONE NUMBER (Include Area Code)

(1) LANGUAGE/MODE OF COMMUNICATION USED BY PARENT(S)

(2) LANGUAGE/MODE OF COMMUNICATION USED BY PARENT(S)

No Interpreter

Yes

Yes

No Interpreter

PARTICIPANTS
Signature indicates attendance. Check appropriate boxes to indicate which meetings were attended. Anyone serving in a dual role should indicate so on
the following lines. If a required participant participates through written input or is excused from all or part of the IEP meeting, the required excusal and
written report, as necessary, is attached.
ELIG.
REVIEW

IEP
Parent

Parent

Student

LEA Representative

General Education Teacher


Kate Stanley
Special Education Teacher

School Psychologist

ELIG.
REVIEW

IEP

School Social Worker

Speech-Language Pathologist

Bilingual Specialist

Interpreter

Other (specify)

Other (specify)

Other (specify)

If the parent(s) did not attend the IEP meeting, document the attempts to contact the parent(s) prior to the IEP meeting.

PROCEDURAL SAFEGUARDS
Explanation of Procedural Safeguards were provided to/reviewed with the parent(s) on _____________________________________________________
Transfer of Rights - Seventeen-year old student informed of his/her rights that will transfer to the student upon reaching age 18.

Yes

NA

Parent(s) were given a copy of the:

Evaluation report and eligibility determination

IEP

Districts behavioral intervention policies

Districts behavioral intervention procedures (initial IEP only)

GOALS AND OBJECTIVES/BENCHMARKS


Complete for initial IEPs and annual reviews.
(Anyone responsible for implementing the IEP (e.g., goals and
objectives/benchmarks, accommodations, modifications and supports) must be notified of her/his specific responsibilities.)

REPORTING ON GOALS
The progress on annual goals will be measured by the short-term objectives/benchmarks. Check the methods that will be used to
notify parents of the students progress on annual goals and if the progress is sufficient to achieve the goals by the end of the IEP year:
Report cards

Progress reports

Parent conference

Other (specify)
__________________________

CURRENT ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE


Results of the initial or most recent evaluation and results on district-wide assessments relevant to this goal; performance in
comparison to general education peers and standards.
Strengths: Derek is a 4th grade student with average ability. His favorite subjects are math and science.
Needs: Derek has a difficult time completing independent assignments and is usually missing at least 4 assignments a week and has 8+
Incomplete assignments. Derek needs to complete his assignments and turn them in to the teacher for credit.
Impact on general education: By not turning in completed assignments, Derek will fail some of his classes. He is currently failing social
studies and science.

GOALS AND OBJECTIVES/BENCHMARKS


The goals and short-term objectives or benchmarks shall meet the students educational needs that result from the students
disability, including involvement in and progress in the general curriculum, or for preschool students, participation in
appropriate activities.
Goal Statement #__1__of___3__

Given an assignment notebook for organization, Derek will have no more than 1 missing assignment and 1 incomplete
assignment each week by the end of the school year.
Indicate Goal Area:

Academic

Functional

Transition

Illinois Learning Standard:


Social emotional learning goal 1A.2b

1C.2b. Monitor progress on achieving a short- term personal goal.

Title(s) of Goal Implementer(s) : special education teacher

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

Given an assignment notebook for organization, Derek will have no more than 3 missing assignments and 6 incomplete
assignments each week by the end of the 1st quarter.

Evaluation
Criteria

% Accuracy
# of attempts

Evaluation
Procedures

Schedule for
Determining Progress

Observation Log
Data Charts

Daily
Weekly

Dates Reviewed/
Extent of Progress (Optional)

Other (specify)

Tests
Other (specify)

Quarterly
Semester
Other (specify)

No more than 3 missing/ 6


incomplete assignments
Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

Given an assignment notebook for organization, Derek will have no more than 2 missing assignments and 4 incomplete
assignments each week by the end of the 2nd quarter.

Evaluation
Criteria

Evaluation
Procedures

% Accuracy
# of attempts
Other (specify)

Observation Log
Data Charts
Tests
Other (specify)

Schedule for
Determining Progress

No more than 2 missing/ 4


incomplete assignments

Dates Reviewed/
Extent of Progress (Optional)

Daily
Weekly
Quarterly
Semester
Other (specify)

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

Given an assignment notebook for organization, Derek will have no more than 1 missing assignment and 2 incomplete
assignments
each week by the end of 3rd quarter.

Evaluation
Criteria

Evaluation
Procedures

% Accuracy
# of attempts
Other (specify)

Observation Log
Data Charts
Tests
Other (specify)

No more than 1 missing/ 2


incomplete assignments

Schedule for
Determining Progress

Dates Reviewed/
Extent of Progress (Optional)

Daily
Weekly
Quarterly
Semester
Other (specify)

GOALS AND OBJECTIVES/BENCHMARKS


Complete for initial IEPs and annual reviews.
(Anyone responsible for implementing the IEP (e.g., goals and
objectives/benchmarks, accommodations, modifications and supports) must be notified of her/his specific responsibilities.)

REPORTING ON GOALS
The progress on annual goals will be measured by the short-term objectives/benchmarks. Check the methods that will be used to
notify parents of the students progress on annual goals and if the progress is sufficient to achieve the goals by the end of the IEP year:
Report cards

Progress reports

Parent conference

Other (specify)
__________________________

CURRENT ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE


Results of the initial or most recent evaluation and results on district-wide assessments relevant to this goal; performance in
comparison to general education peers and standards.
Strengths: On the Test of Written Language, Derek wrote fifty-three words and thirty-seven different words. Derek wrote in a cursive
style on the test.
Needs: Derek misspelled twenty-three words on the Test of Written Language Test. This adds up to about 43% of the total number of
words misspelled. Dereks written language is likely to be judged as underdeveloped for a student his age.

Impact on general education: Dereks needs in development of written language may impact his ability to write essays and written
responses in his general education classes.

GOALS AND OBJECTIVES/BENCHMARKS


The goals and short-term objectives or benchmarks shall meet the students educational needs that result from the students
disability, including involvement in and progress in the general curriculum, or for preschool students, participation in
appropriate activities.
Goal Statement #__2__of__3___

Given a graphic organizer and a topic, Derek will write 2 5-sentence paragraphs with complete sentences
that are on topic and in sequential order 4/5 attempts.

Indicate Goal Area:

Academic

Functional

Transition

Illinois Learning Standard:

CCSS.ELA
LITERACY.W.4.2.B
Developthetopicwithfacts,definitions,concretedetails,quotations,orotherinformationandexamplesrelatedtothe

Title(s) of Goal Implementer(s): special education teacher

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

Given a list of nouns, verbs, and adjectives, Derek will write 6-8 complete sentences using the parts of speech correctly
8 out of 10 attempts.

Evaluation
Criteria

8/
10

% Accuracy
# of attempts
Other (specify)

Evaluation
Procedures

Schedule for
Determining Progress

Observation Log
Data Charts

Tests
Other (specify)

Dates Reviewed/
Extent of Progress (Optional)

Daily
Weekly
Quarterly
Semester
Other (specify)

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

Given a graphic organizer, Derek will organize sentences within a 5 sentence paragraph in sequential order, including a
topic sentence and a concluding sentence for each paragraph in 4/5 attempts.

Evaluation
Criteria

% Accuracy
# of attempts
4/
5

Evaluation
Procedures

Schedule for
Determining Progress

Observation Log
Data Charts

Dates Reviewed/
Extent of Progress (Optional)

Daily
Weekly

x
Other (specify)

Tests
Other (specify)

Quarterly
Semester
Other (specify)

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

Given a graphic organizer, Derek will write a 5-sentence paragraph that is on topic and in in sequential order
4/5 attempts.

Evaluation
Criteria

% Accuracy
# of attempts

Other (specify)

Evaluation
Procedures

Schedule for
Determining Progress

Observation Log
Data Charts

Daily
Weekly

4/
5
Tests
Other (specify)

Quarterly
Semester
Other (specify)

Dates Reviewed/
Extent of Progress (Optional)

GOALS AND OBJECTIVES/BENCHMARKS


Complete for initial IEPs and annual reviews.
(Anyone responsible for implementing the IEP (e.g., goals and
objectives/benchmarks, accommodations, modifications and supports) must be notified of her/his specific responsibilities.)

REPORTING ON GOALS
The progress on annual goals will be measured by the short-term objectives/benchmarks. Check the methods that will be used to
notify parents of the students progress on annual goals and if the progress is sufficient to achieve the goals by the end of the IEP year:
Report cards

Progress reports

Parent conference

Other (specify)
__________________________

CURRENT ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE


Results of the initial or most recent evaluation and results on district-wide assessments relevant to this goal; performance in
comparison to general education peers and standards.
Strengths: Dereks Word Identification (95) and Word Attack (87) scores on the Woodcock Reading Mastery Test were average. Dereks
strengths in reading skills include decoding, sight word reading, and word identification skills.
Needs: Dereks Word Comprehension score was well below the expected performance for his age. His needs include identifying
synonyms and antonyms as well as finishing analogies. Comprehension and vocabulary skills appear to be his weakest reading skills.
Impact on general education: Although Derek is in the average range with decoding skills, struggling with vocabulary and
comprehension can impact the comprehension of reading materials in general education classes.

GOALS AND OBJECTIVES/BENCHMARKS


The goals and short-term objectives or benchmarks shall meet the students educational needs that result from the students
disability, including involvement in and progress in the general curriculum, or for preschool students, participation in
appropriate activities.
Goal Statement #_3___of___3__

Given a list of 10 grade level words, Derek will be able to state the meaning of the words with 90% accuracy by the end of
the school year.

Indicate Goal Area:

Academic

Functional

Transition

Illinois Learning Standard:

CCSS.ELALITERACY.L.4.4
Determineorclarifythemeaningofunknownandmultiplemeaningwordsandphrasesbasedongrade4readingand
content,choosingflexiblyfromarangeofstrategies
Title(s) of Goal Implementer(s) special education teacher

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal


Given a list of grade level words with prefixes and suffixes, Derek will identify prefixed and suffixes and state the meaning of
the word with 90% accuracy.

Evaluation
Criteria

90
/

% Accuracy
# of attempts
Other (specify)

Evaluation
Procedures

x
x

Observation Log
Data Charts
Tests
Other (specify)

Schedule for
Determining Progress

Dates Reviewed/
Extent of Progress (Optional)

Daily
Weekly
Quarterly
Semester
Other (specify)

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

Given a list of words with Latin and Greek roots, Derek will identify the root the correct meaning of the word with
90% accuracy.

Evaluation
Criteria

90
/

% Accuracy
# of attempts
Other (specify)

Evaluation
Procedures

x
x

Observation Log
Data Charts
Tests
Other (specify)

Schedule for
Determining Progress

Dates Reviewed/
Extent of Progress (Optional)

Daily
Weekly
Quarterly
Semester
Other (specify)

Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal

Given a word, Derek will correctly complete a word relationship chart for the word, identifying synonyms, antonyms, and
homonyms of the given word 4/5 attempts.

Evaluation
Criteria

% Accuracy
# of attempts

Evaluation
Procedures

Schedule for
Determining Progress

Observation Log
Data Charts

Daily
Weekly

4/
5
Other (specify)

Tests
Other (specify)

Quarterly
Semester
Other (specify)

Dates Reviewed/
Extent of Progress (Optional)

EDUCATIONAL ACCOMMODATIONS AND SUPPORTS


Complete for initial IEPs and annual reviews. (Anyone responsible for implementing the educational accommodations must
be notified of her/his specific responsibilities).
TRANSITION
NA

Consideration of service needs, goals, and support/services is required (by age 14 , the team must address transition
service needs). If yes, complete the Transition Services section of the IEP.

NA

Consideration of Home-Based Support Services Program for Mentally Disabled Adults for eighteen-year-old student is
required. If yes, complete the Home-Based Support Services Program section of the IEP.

No
Yes
No
Yes

CONSIDERATION OF SPECIAL FACTORS


Check the boxes to indicate if the student requires any supplementary aids and/or services due to the following factors. For any box
checked yes, specify the special factors in the Supplementary Aids, Accommodations and Modifications section listed
below.
assistive technology devices and services
communication needs
deaf/hard of hearing languages and communication needs
limited English proficiency language needs
blind/visually impaired provision of Braille instruction
behavior impedes students learning or that of others. If yes, the team must consider strategies, including positive
behavioral interventions and supports to address behavior. This may include a Functional Behavioral Assessment
and/or a Behavioral Intervention Plan. If, so attach any completed forms.

No
No
No
No
No
No
Yes

LINGUISTIC AND CULTURAL ACCOMMODATIONS


Yes

No

The student requires accommodations for the IEP to meet her/his linguistic and cultural needs.
If yes, specify any needed accommodations:

No

Special education and related services will be provided in a language or mode of communication other
than or in addition to English. If yes, specify any needed accommodations:

Yes

SUPPLEMENTARY AIDS, ACCOMMODATIONS, AND MODIFICATIONS


Specify what aids, accommodations, and modifications are needed for the child to make progress toward annual goals, to progress in the general
education curriculum, participate in extracurricular and other non-academic activities, and to be educated and participate with other children with
disabilities and/or nondisabled children (e.g., accommodations for daily work, environmental accommodations, moving from class to class, etc.).
Supplementary aids, accommodations, and modifications must be based upon peer-review research to the extent practicable.

Aids: Allow Derek the use of, agendas, organizational tools, and assignment notebooks in class.
Provide graphic organizers for paragraph development in reports and essays.
Accommodations: Allow legitimate movement during class and breaks.
Allow extended time (time and a half) for assignments and testing.
Modifications:
Reduce the list of vocabulary words by 3 when having him write sentences.
Allow word problems on the math test read to Derek orally.
SUPPORTS FOR SCHOOL PERSONNEL
Yes

No

Program trainings and/or supports for school personnel are needed for the student to advance appropriately toward attaining
the annual goals, participate in the general curriculum, and be educated and participate with other students in educational
activities. If yes, specify what trainings and/or supports are needed, including when appropriate, the information that
clarifies when the trainings and/or supports will be provided, by whom, in what location, etc.

ASSESSMENT
CLASSROOM-BASED ASSESSMENTS
Yes

No

Student requires accommodations to participate in classroom-based assessments.

Yes

No

Student requires alternate assessment/methods to participate in classroom-based assessments

DISTRICT-WIDE ASSESSMENTS
District does not administer district-wide assessments
District does not administer district-wide assessments at this grade level: _________

Student will:
Participate in the entire district-wide assessment with no accommodations
Participate in the entire district-wide assessment with accommodations
Participate in part(s) of the district wide assessment (specify)
Participate in the district-wide alternate assessment

STATE ACADEMIC ASSESSMENTS


The State academic assessments are the Illinois Standards Achievement Test (ISAT) at grades 3-8 and the Prairie State Achievement Exam
(PSAE) at grade 11, Illinois Measure of Annual Growth in English (IMAGE) in grades 3-8 and 11 (for English Language Learner (ELL)
students), and Illinois alternate Assessment (IAA) in grades 3-8 and 11.
State academic assessments are not administered at this grade level __________

Student will:
Participate in the ISAT/PSAE/IMAGE with no accommodations
Participate in the ISAT/PSAE/IMAGE with accommodations
Participate in the IAA

If the student will participate in the IAA, the following were met:
The ISAT/PSAE/IMAGE is not appropriate (specify)
The IAA participation guidelines were met
The alternate assessment selected is appropriate for the student (explain)

STATE ASSESSMENT OF LANGUAGE PROFICIENCY


The State assessment of language proficiency is Assessing Comprehension and Communication in English State to State (ACCESS) in
grades K-12
Yes

No

ENGLISH LANGUAGE LEARNER (ELL). If NO, skip to next section

Student will:
participate in the ACCESS with no accommodations
participate in the ACCESS with accommodations

ASSESSMENT ACCOMMODATIONS
If the student is participating in any of the above assessment(s) with accommodations, specify the needed accommodations (e.g., extended
time, alternate setting, auditory testing) necessary to measure the students academic achievement and functional performance. The
accommodations should be appropriate for that particular assessment and reflective of those already identified for the student in the
Supplementary Aids, Accommodations, and Modifications section.

Accommodations for Derek on district and state testing include small group testing, extended time, and orally reading
math problems/tests to Derek.

EDUCATIONAL SERVICES AND PLACEMENT


PARTICIPATION IN SPECIAL EDUCATION CLASSES/SERVICES
The IEP must address all special education and related services.
Special Education Services Outside General Education
Resource- Work on writing sentences, writing paragraphs, and building vocabulary

Minutes Per Week


and Setting
250 min/week

Resource- Work on math reasoning and math concepts


250 min/week

Related Services Outside General Education


Social work

Minutes Per Week


and Setting
50 min/week

PARTICIPATION IN GENERAL EDUCATION CLASSES


The IEP must address all content areas, classes, and specify if the student will participate in general physical education.
General Education with No Supplementary Aids
(Specify content areas, classes, whether or not the child will participate in general physical education, and extracurricular
and other nonacademic activities.)

Minutes Per Week


in Setting
(Optional)
XXXXXXXXXXXXX
X

After school sports: golf, soccer, football, lacrosse, and baseball.


XXXXXXXXXXXXX
X
General Education with Supplementary Aids (as specified in the Supplementary Aids section)
(Specify content areas, classes, whether or not the child will participate in general physical education, and extracurricular
and other nonacademic activities with supports, if applicable.)

Derek will receive supplementary aids in all general and special education classes/settings such as art, PE/health, music,
science, social studies, and math.

Special Education and Related Services within the General Education Classroom
(Specify content areas and classes in which the child will participate with the provision of special education and related
services. List each special education and related service that will be provided during each class. )

What subjects do you identify as being taught fully by the special education teacher ?
Reading and writing
What subjects will be addressed (supplemental to regular education instruction in classroom in this
subject area) In the pull out setting?
Math/math concepts, writing, and reading

Minutes Per Week


in Setting
(Optional)
XXXXXXXXXXXXX
X
XXXXXXXXXXXXX
X
Minutes Per Week
in Setting

EDUCATIONAL SERVICES AND PLACEMENT


PLACEMENT CONSIDERATIONS
When determining the placement, consider any potentially harmful effect either on the student or the quality of services that he/she needs. After
determining the students placement, complete the Placement section on this cover sheet.
Yes

NA

For a child who is deaf, hard or hearing, blind or visually impaired, parents have been informed of existence of the Illinois School
for the Deaf or the Illinois School for the Visually Impaired, and other local schools that provide similar services.

PLACEMENT OPTIONS CONSIDERED

Reason Rejected
POTENTIALLY
HARMFUL EFFECT/ or
REASON
Needed/Chosen

TEAM ACCEPTS PLACEMENT

Full time general education with


accommodations and modifications. No
pull out.

Pull out 1:1 or small group instruction for


reading, writing, and math concepts
General education with accommodations
and modifications for other subjects
Derek will continue to attend math in
general education with some pull out time
to work on math concepts.

Dereks need for 1:1 instruction in


reading, writing, and math
concepts.

Yes

No

Yes

No

Yes

No

Derek has average ability with


some discrepancies in
achievement with math concepts
and reading/writing. He will be
able to function in a general
education setting with
accommodations and
modifications, as well as
instruction in the areas of
discrepancy.

Self-contained special education-full time

Derek has average ability and


should not be self-contained for
the entire day. This is not the least
restrictive environment for Derek.
He would benefit more from being
placed in general education with
pull out sessions for his specific
discrepancies.

IEP
Components
Conference
Notification
& Sign-in
PLOP,
general
curriculum
statement,
strengths &
needs

Expectations

Filled out completely & accurately with all


required sections complete

Filled out completely & accurately w/


information from the case study (test
scores)/2
Includes both strengths and needs /2
General curriculum statement clearly
explains how disability affects students
ability to participate in the general
education curriculum/2

Goals,

objectives/b
enchmarks

Goals Follow from PLOPs. /1


Annual goals clearly specify expected &
reasonable growth for 1 year period /1
specify only observable, measurable
behaviors /1
specify condition(s) under which behavior
will be performed /1
specify objective assessment criteria /1
Specify time for goal achievement /1 or for
benchmark represents the desired end of
year outcome
Appropriate Connection to ILS for each
goal. /1
Name of student, date of IEP meeting, goal
implementers and means of progress
reporting listed for each goal /1

AT least 3/4 O/B for each goal /1


G/O/B specify condition(s) under which
behavior will be performed /3
specify only observable, measurable
behaviors /3
specify objective assessment criteria that
is reasonable and appropriate for the task
and student /3
Boxes specifying appropriate frequency of
assessment (e.g., daily, weekly, monthly)
and appropriate types (probe, tests, work
samples) are completed for each
STO/Benchmark /6
--------------------------------------------------------STOs break goal into appropriate,

Obtained Points

Max.
Pts.
4
18
(6pts
each)

STO

STO

24
(8pts
each)

STO

STO

22 pts
each

STO

STO

66
total

Special
Education &
Related
Servicestimes, dates,
locations,
provider
Program
Modification
s, Assistive
Technology,.
Accommoda
tions &
Grading

State &
Local
Assessment
s
General
Education
participation
& placement

sequenced (if applicable) steps or


simultaneous components (pie), as
appropriate. /6
Or
For Benchmark Objectives the objectives
represent appropriate growth steps from
starting point to end of year goal with and
are written with the parallel structure of the
goal./6
--------------------------------------------------------Service minutes and dates of service listed
Minutes and services are appropriate to
goals.
Location of service & service provider titles
(sp.ed. teacher, social worker, etc.) listed

10

Consideration of special factors completed


Supplementary Aids section Filled out to reflect
needed supports
Supports for school personnel completed or
N/A written in if appropriate
Supports are clearly appropriate for student
(grade level, subjects etc.) and reflect given
student strengths and areas of need.

10

Appropriate assessment boxes completed


accommodations indicated
Accommodations reflect those needed for
the classroom
General ed classes in which child will
participate with and without supplementary
services are listed in accordance with the
goals and modifications written /2
Classes student for which student will not
attend general education classes are listed
(or none specified in box)
/1

10

Placement selected indicated in one of


three boxes and rationale clearly stated in
box /3
At least one less restrictive placement
considered listed and rational for rejection
of this placement clearly provided in box.
/3