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IEP Goals Data Collection System

Student:
School:
Grade: 4

IEP Date: 4/30/15

1. Did _____ initiate a verbal statement with a peer or adult during a regularly scheduled
communication opportunity? 2/5 times by 12/30/15
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N

2. Did _____ initiate a verbal statement with a peer or adult during a regularly scheduled
communication opportunity? 3/5 times by 4/30/15
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N

3. Did ______ approach an adult or peer and use a simple sentence to state a concern or
need, using a script as a support? By 12/30/15
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N

4. Did ______ approach an adult or peer and independently use a simple sentence to state a
concern or need? By 4/30/2016
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N
Date: _________ Y / N

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