Chelsea Beinborn

I-1 - Invitation to IEP Meeting

Student: Birth Date
Toby 1/1/2008

District of Residence District of Placement Current School Grade

Viterbo University Viterbo Viterbo 3rd

Form Date Amended

11/21/2016

Dear
Jose and Luisa

We would like to meet with you to discuss the educational needs of your child:
Toby

The meeting has been scheduled for (time) on (date)

10:00am 12/8/2016

at .
Viterbo University

The purpose(s) of this IEP team meeting is to (check all that apply):

Determine initial eligibility for special education

Develop an initial IEP / Servic e Plan

Determine initial placement

Determine continuing placement

Determine continued eligibility for special educ ation

Transfer IEP

Develop annual IEP

Review existing information & determine need for additional assessments

Manifestation determination (Review/revise IEP & Placement)

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Determine setting for services during disciplinary change in placement.

This includes all Interim Alternative Educational Settings (IAES)

Review/Revise/Update IEP:

Develop a statement of transition (post-secondary) goals and services, required for child 14 and older
or younger if appropriate. If transition planning is being considered we must invite your child to the
meeting. If applicable, we must invite a representative of any participating agency that is likely to be
responsible for providing or paying for transition services.

N/A

Agency Title/Position Consent received on

If at any point during this meeting you or other IEP team participants believe that additional time is
needed to permit your meaningful involvement, additional time will be provided. Decisions related to the
purpose(s) checked above may be made in one meeting or may require more than one meeting depending
on individual circumstances. You are a participant of the team and encouraged to attend this meeting,
which must be at a mutually agreeable time and place. You may bring a friend or advisor who, you believe,
has knowledge or special expertise about your child to the meeting with you if you wish. If your child is
transferring from a Birth to 3 Early Intervention Program we will, at your request, send to the Birth to 3
coordinator or other representative an invitation to the IEP meeting. If a purpose of this meeting is to
determine eligibility for special education, an IEP will be developed only if your child is determined to be
eligible for special education. Upon request, you may receive a copy of the IEP teams most recent
evaluation report at any meeting of the IEP team.

The following individuals have been appointed as IEP participants and will attend the meeting:
Role Name/Title
General Education Teacher Mrs. McDonald
Special Education Teacher/LD Mrs. Ridge
LEA Representative/Direct of Special Education Sally Smith
School Psychologist Mr. Zambie

The following individuals have been invited as IEP participants who may attend the meeting, but are not
required participants:
Role Name/Title
Principal Chris Mastree

Other options related to the scheduling, participants, or purpose of the meeting considered, reason(s)
these options were rejected, and other relevant factors:

You and your child have protection under the procedural safeguards (rights) of special education law. The
school district must provide you with a copy of your procedural safeguards once a year and when the
school is seeking a disciplinary change in placement and/or when responding to a request for due process
hearing or IDEA complaint. Previously you received a copy of your procedural safeguards rights in a
brochure about Special Education Rights for Parents and Children. If you would like another copy of this

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brochure, please contact the school district at the telephone number below. In addition to the district staff,
you may also contact the organizations listed on the Special Education Rights for Parents and Children
brochure if you have questions about your rights.

A copy of your procedural safeguards rights is provided with this form in a brochure about Special
Education Rights for Parents and Children.
Initials Date
AZ 12/4/2016

If you have any questions about this meeting or understanding your rights, I can be reached at
123-456-7890

Name, title, and school address of district contact person:

Contact Name
Mrs. Ridge

Contact Title
Special Education Teacher

Address
123 Oak St

City
LaCrosse

State
WI

Zip
12345

Email
abc123@gmail.com

I/We will attend the meeting for as scheduled on

1. Toby

(date) , at .
12/8/2016 Viterbo

I / We cannot attend a meeting as scheduled for as scheduled on

2
.

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(date), at .

Alternate meeting date/time I/we c an attend

Involve me on the scheduled date by phone at this number

Toby's mom 12/2/2016

(Signature of parent or legal guardian) (Date)

Parent, please check the appropriate box, sign, date, and return this page to the District Contact
Person.

For School District Use Only:

Signed By:
XX

Date Signed:
12/2/2016

Initials
AB

I-2 - IEP Meeting Participants Present Documentation - Cover Sheet

Student: Birth Date WISEid
Toby 1/1/2008 9876543210

Parent/Guardian 1

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Full Name Street Address City State Zip Code Phone(s)

Luisa 123 Oak St LaCrosse WI 12345 987-654-6544

Parent/Guardian 2
Full Name Street Address City State Zip Code Phone(s)
Jose 123 Oak St LaCrosse WI 12345 987-654-6544

District of Residence District of Placement Current School Grade

LaCrosse LaCrosse Viterbo 3rd

Meeting Date
12/8/2016

Projected beginning and ending date(s) of IEP services & modifications

(Includes only scheduled school days during the general school term, unless otherwise specified.)
Begin Date End Date
12/21/2016 12/7/2016

For children transferring between public agencies:

Date IEP adopted

Date evaluation adopted

Name and title of district representative reviewing record

Name

Title

The purpose(s) of this IEP team meeting is to (all checked apply):

Determine initial eligibility for special education

Develop an initial IEP

Determine initial placement

Determine continuing placement

Determine continued eligibility for special educ ation

Transfer IEP

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Develop annual IEP

Review existing information & determine need for additional assessments

Manifestation determination (Review/revise IEP & Placement)

Determine setting for services during disciplinary change in placement.

This includes all Interim Alternative Educational Settings (IAES)

Review/Revise/Update IEP:

Develop a statement of transition (post-secondary) goals and services, required for child 14 and older
or younger if appropriate.

If a purpose of this meeting is IEP development, review, and/or revision, related to the academic,
developmental and functional needs of the child, the IEP team considered the results of the initial or most
recent evaluation and results of statewide or district wide assessments.
Yes N/A

IEP meeting participants:

Role Name/Title
LEA Sally Smith
Special Education Teacher Mrs. McDonald
General Education Teacher Mrs. Ridge
School Psychologist Mr. Zambie
Parents Luisa/Jose

Did the parent(s)/adult student attend or did they participate in the meeting by other means?
Yes No

If parent(s)/adult student did not attend or did not participate in the meeting by other means document 3
good faith efforts to involve parent(s)/adult student:
Date Method and Input

NAME AND TITLE OF DISTRICT CONTACT

Contact Name/Title
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 Chelsea Beinborn

Beinborn/Special Education

Phone
123-456-7890

Email
abc123@gmail.com

I-3 IEP Section I - CONSIDERATION OF SPECIAL FACTORS

Student: Birth Date WISEid
Toby 1/1/2008 9876543210

District of Residence District of Placement Current School Grade

Viterbo Viterbo Viterbo 3rd

Meeting Date
12/8/2016

I. Consideration of Special Factors

A. Does the child's behavior impede his/her learning or that of others?
Yes No

If yes, list positive behavioral interventions, strategies, and supports to address that behavior
(document needed services in the Instructional Services)

B. Is the child an English Language Learner (ELL)?

Yes No

If yes, describe how this factor affects the child's needs related to the IEP.

C. Does the child have communication needs that could impede his or her learning?
Yes No

If yes, identify the communication needs including (a) the child's language; (b) opportunities for
direct communication with peers and professional personnel in the child's language and
communication mode; and, (c) academic level and full range of needs including opportunities for
direct instruction in the child's language and communicative mode.

D. Does the child need assistive technology services or devices, including any services or devices
needed to assist with reading?
Yes No

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If yes, specify characteristics of device(s) or services that were considered (document needed
services in the Instructional Services).

E. Is the child deaf or hard of hearing?

Yes No

If yes, identify the communication needs including (a) the child's language; (b) opportunities for
direct communication with peers and professional personnel in the child's language and
communication mode; and, (c) academic level and full range of needs including opportunities for
direct instruction in the child's language and communicative mode.

F. If visually impaired, does the child demonstrate a current or future need for Braille instruction or the
use of Braille? In making your determination, consider reading skills, written language skills and future
needs for Braille skills.
Yes No N/A

If no, then justify.

G. Does a 3-6 year old outcome report need to be completed?

Yes No

If yes, complete the S-22 - Child Outcome Summary Form

H. Is the child aged 14 or older, or will the child turn age 14 during the timeframe of this IEP?
Yes No

If yes, complete the I-3 Subform - Transition Summary

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I-3 IEP Section III. ASSESSMENT State Wide Assessments

Student: Birth Date WISEid
Toby 1/1/2008 9876543210

District of Residence District of Placement Current School Grade

Viterbo Viterbo Viterbo 3rd

Meeting Date
12/8/2016

III. Assessment
A. Participation in General Education Curriculum
The child participates full-time in general education curriculum aligned with the general education
standards that apply to all children, or for preschoolers, in age-appropriate activities aligned with
Wisconsin Model Early Learning Standards (WMELS).

The child participates in curriculum aligned with alternate achievement standards. See Participation
Guidelines for Alternate Assessment Form I-3-S7

B. Statewide Assessments
1. The Wisconsin Forward Exam:
In this IEP year, is the child or will the child be in grade 3-8 or 10 and taking the Wisconsin Forward
Exam during the time the assessment is given?
(Students in grades 3-8 will participate in English language arts (ELA) and mathematics. Science is
administered in grades 4 and 8. Social Studies is administered in grades 4, 8, and 10.)
Yes No

If yes, Forward Wisconsin Accommodations Necessary?

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Yes No

Embedded Universal Tools Available to All Students

Embedded Universal Tools
Calculators (see non-embedded
accommodations for students who cannot
use the embedded calculator)
Description
Basic four-function and scientific calculators are
available as required, either individually or together.
For calculator-allowed items only.

Click to Enlarge Feature allows for large graphics by using a

thumbnail image of the graphic that can be enlarged
as a popup dialog for viewing. Students
can interact with the test item and other tools
simultaneously. This feature allows all test item
content to fit within a single test item page
without introducing unnecessary scrollbars.
Cross-off Tool [Strikethrough] Cross out/eliminate multiple-choice answer
selection(s) (distractors) believed to be incorrect.
Students can be remove the cross off by
simply re-selecting the crossed off item.
Flag/Mark for Review Mark a question for review at a later point. Students
can see at a glance which items have been marked
for review by the flag icon that appears on the Go-
to-Question menu and on the Review Page.
The Help Library provides information on tool usage,
Help/What's This?
test directions, helpful hints, and other topics. Also
includes a Whats This? feature
that allows a student to access contextual help for a
specific tool or button.
Highlighter This tool can be used to highlight a portion of text or
a graphic or remove existing highlights one by one
or by using the clear all option. With the exception
of the response area itself, INSIGHTs highlighter
can be used virtually anywhere within the item to
highlight passage
text, item text, answer options, portions of graphics
and images, and text within images.
Go to Question Allows a student to jump to any item or passage set
on the test by choosing the item from a drop-down
list. Items that have been flagged by the student for
review display a flag icon in this menu.
Keyboard Navigation Move through the test, access tools, and answer
questions using the keyboard.
Line Guide Movable, straightedge line used to follow along with
each line of text. Student can drag the guide up or
down on the screen as an aid in reading an item or
passage.
Magnifier Tool [Zoom] Magnify/enlarge the entire screen, including all text,
images, and objects, by 150% or 200% for better
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viewing.
Measuring Tools [Math Tools] This tool set includes both standard and metric
rulers that can be dragged to the desired location on
the screen and pivoted, to take measurements in
both inches and centimeters. Also included is a
transparent Protractor for measuring angles that can
be moved over any object on the screen and
rotated.
Pause [Breaks] Students may be allowed to take breaks periodically
as determined by their test administrator. While
away from the test, students should select the Pause
button in the lower toolbar to ensure that their test
questions and responses are not visible to others.
Insight permits students to pause the test for up to
20 minutes without having to log
back in to the current test session. A countdown
timer is displayed to indicate the amount of time
remaining. In the event that the student
does not resume testing before the 20 minute time
expires, the system automatically exits the students
test session. To resume testing, the student will
need to re-enter the username and password
provided on the test ticket.
Review Page Selecting the Review/End Test button in the lower
toolbar allows student to see at a glance which items
have been answered or flagged and which remain
unanswered. By clicking on a particular item, the
student can return directly to incomplete or flagged
questions, and/or to change answers. This page
indicates to the student if a test is ready
to be scored.
Sticky Notes [Digital Notepad] Creates and places a note on the screen in which a
student can type a short message for later
reference. Multiple notes can be created for each
item or passage, and the notes can be moved
around the screen, minimized or completely hidden,
and re-opened. For a passage or scenario that
contains multiple parts (for example, one passage
that has several questions associated with it), the
student can use the Sticky Note tool to take notes
that are visible for all questions associated with that
passage or scenario.
Test Directions Easy-to-follow instructions are provided at the
beginning of the test to guide students on how to
use the online tools and how to navigate and submit
the test. Students can return to them at any point
during the test by selecting the Help menu in the
item page toolbar.

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Tooltips Pop-up labels that describe each tool/function within

Non-embedded Universal Tools Available to All Students
Universal Tools
Breaks
Scratch Paper
Embedded Designated Supports
Designated Supports
Color Choices
Contrasting Color
Reverse Contrast
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the testing interface. Tooltips appear when the
student hovers over a tool with the mouse pointer.
For students who use the Text-to-Speech audio
accommodation, the tooltip description will be read
aloud to the student.
Description
Students may be allowed to take breaks periodically
as determined by their test administrator. While
away from the test, students should select the Pause
button in the lower toolbar to ensure that their test
questions and responses are not visible to others.
INSIGHT permits students to pause the test for up
to 20 minutes without having to log back in to the
current test session. A countdown timer is displayed
to indicate the amount of time remaining. In the
event that the student does not resume testing
before the 20 minute time expires, the system
automatically exits the students test session. To
resume testing, the student will need to re-enter the
username and password provided on the test ticket.
Plain, lined or grid/graph paper may be provided to
allow students to take notes, make computations,
sketch or plan responses. Scratch paper used by
students is secure test material and should be
collected at the end of testing for secure destruction.
Description Guidance
The background color changes Students with attention
according to the color selected difficulties, visual impairments
without changing the color of or other print disabilities may
text, graphics or response need this support. Color choice
areas. should be informed by evidence
that color selections meet the
students needs.
Using color combinations that Students with attention
are in opposite positions on the difficulties, visual impairments
color wheel, the font and or other print disabilities may
background colors change need this support. Color choice
according the combination should be informed by evidence
selected. that color selections meet the
students needs.
All colors on the test page are Students with attention
displayed in the reverse difficulties, visual impairments
(negative) color. or other print disabilities, may
need this support. Color choice
should be informed by evidence
that color selections meet the
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Masking Allows the student to cover up
(mask) content that may be
distracting, enabling the
student to more easily focus
their attention on a specific part
of the screen. Masked areas are
resizeable and moveable on the
item page.
Text-to-Speech The Text-to-Speech (TTS)
function allows the student to
listen via headphones or
speakers to test information
displayed on the screen. Words
and numbers, including test
directions, questions, answer
choices, and other information
is read aloud and can be
repeated as necessary.
Stacked Translations are
Translations (Stac ked)
available as a language support
to designated students on all
Math, Science, and Social
Studies assessments. For ELA
assessments, only the test
directions are available in
stacked translation. Stacked
Translations present students
with a complete translation
(Spanish) of all test content
together with the full text of
the original English.
Non-embedded Designated Supports
Designated Supports Description
Bilingual Dictionary A word-to-word bilingual
dictionary may be provided as a
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Chelsea Beinborn
students needs.
Students with attention
difficulties, print disabilities, or
visual impairments may need to
mask content that may be
distracting during the
assessment.
Text-To-Speech (TTS) is allowed
as an embedded designated
support for all grades in
Mathematics, Science, Social
Studies, and English Language
Arts (ELA) items as appropriate
(not ELA reading passages). It
is provided only in English. The
designated support of TTS is for
students who are struggling
readers who may need
assistance accessing the
assessment or students with
reading-related disabilities, or
by students who are blind and
do not yet have adequate
Braille skills. This is not meant
to be used by all students. TTS
is not a universal tool. Allowing
TTS, a designated support, for
all students would not be a
proper use of this support.
For students whose primary
language is not English and
who use dual language
supports in the classroom, the
use of the translation
accommodation may be
appropriate.
Guidance
Not permitted on ELA tests.
Refer to the DPI
2015 CESA 6 I-1 -

designated language support.
Magnification The size of specific areas of the
screen (e.g., text, formulas,
tables, graphics, and navigation
buttons) may be adjusted by
the student with an assistive
technology device.
Magnification allows increasing
the size to a level not provided
for by the Zoom universal tool.
Utilizing a larger monitor is the
online equivalent to large
print.
Noise Buffers Ear mufflers, white noise,
and/or other equipment used to
block external sounds.
Read Aloud (not for reading Text is read aloud to the
passages) student by a trained and
qualified human reader. All or
portions of the content may be
read aloud except ELA reading
passages.
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Accommodations and Supports
webpage linked below for a list
of DPI-approved word-to-word
dictionaries. Note: Word-to-
word dictionaries are simply
paper or electronic forms of
words provided in two
languages. Definitions are not
included.
http://dpi.wi.gov/assessment/f
orward/accommodations
Students used to viewing
enlarged text or graphics, or
navigation buttons may need
magnification to comfortably
view content. This support also
may meet the needs of
students with visual
impairments and other print
disabilities. The use of this
designated support may result
in the student needing
additional overall time to
complete the assessment or
possibly the need for an
administration in a separate
setting if the support used
creates a Test Security concern.
Students who are struggling
readers may need assistance
accessing the assessment by
having all or portion of the
mathematics, science, and
social studies portions of the
assessment read aloud. This
support also may be needed by
students with reading-related
disabilities, or by students who
are blind and do not yet have
adequate Braille skills. This is a
support that must be used
regularly during instruction for
the student. As a general
guideline, TTS should be used
in most situations and the read
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Scribe Students dictate their
responses to a human who
records verbatim what they
dictate.
Separate Setting Test location is altered so that
the student is tested in a
setting different from that
made available for most
students.
Embedded Accommodations
Accommodations Description
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aloud should be used for the
very small number of students
who may need this accessibility
resource for accessing the test.
Read Aloud Guidelines and
confidentiality forms are
available at
http://dpi.wi.gov/assessment/f
orward/accommodations.
Students who have a significant
motor, processing difficulties, or
who have had a recent injury
(such as a broken arm) that
make it difficult to provide
responses may need to dictate
their responses to a human,
who then records the students
responses verbatim. Translators
who scribe student responses
from a native language to
English should translate word-
forword to the extent possible
for all content areas except Text
Dependent Analysis (TDAs)
items. The TDA items must be
scribed in English. The Text
Dependent Analysis (TDA)
items measure composition,
grammar, punctuation,
capitalization, spelling as well
as citing evidence and the use
of textual support. Therefore, a
student must dictate their
response exactly as it is to be
written. Scribing Guidelines are
available in the Forward Exam
Accommodations and Supports
webpage.
Students who are easily
distracted or may distract
others my need an alternate
location for their assessment.
Guidance
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Video Sign Language (VSL Signed test content is
online delivery for American presented in an embedded
Sign Language (ASL)) video format by a prerecorded
human signer. Students
activate the presentation of ASL
content by selecting start
points on the test page and can
view as often as needed using
the embedded video player
controls. ASL content will be
available to students with this
accommodation for ELA
listening items and for all Math,
Science and Social Studies
content.
All American Sign Language
Closed Captioning (for ELA
videos for ELA Listening items
Listening items)
will include Closed Captioning
(text transcription) as part of
the video presentation. Other
ASL content will not include
Closed Captioning
Text-to-Speech (TTS) Text-to-speech playback will be
available to students with this
accommodation for all test
content, including for ELA
Reading passages. (See Text-
to-Speech in Embedded
Designated Supports)
Non-embedded Accommodations
Accommodations Description
Abacus This tool may be used in place
of scratch paper for students
who typically use an abacus.
Alternate Response Options Alternate response options
include but are not limited to
adapted keyboards, large
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Some students who are deaf or
hard of hearing and who
typically use ASL may need this
accommodation when accessing
text-based content in the
assessment.
Students who are deaf or hard
of hearing who typically access
information presented via audio
by reading words that appear in
synchrony with the audio.
This accommodation refers to a
small number of students
(approximately 1-2% of
students with disabilities
participating in a general
assessment). Text-to-speech is
available as an accommodation
for students whose need is
documented in an IEP or 504
plan. Reports can be run to
indicate the percent of students
who had access to text-
tospeech on reading test
passages. Students who use
text-to-speech will need
headphones unless tested
individually in a separate
setting.
Guidance
Some students with visual
impairments use an abacus in
place of using scratch paper.
Some students with physical
disabilities may need to use the
alternate response options
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keyboards, StickyKeys,
MouseKeys, FilterKeys, adapted
mouse, touch screen, head
wand, and switches
Braille An embossed (paper) Braille
version of the test will be
available to Braille
accommodated students at his
or her grade level in each
content area. All tests will be
presented in English Braille
American Edition (EBAE) and
will follow Nemeth Code for
mathematical and scientific
notation where appropriate.
Calculator For grade 6 Mathematics
assessments, a four-function
calculator with square root and
percentage functions is
permitted. For grades 7 and 8
Mathematics assessments, a
scientific calculator with
exponents, trigonometry, and
logarithmic functionalities is
permitted
Multiplication Table A paper-based single digit (1-9)
multiplication table will be
available for reference.
Print on Demand A Print-on-Demand version of
the test at each grade level and
content area will be available
electronically in .pdf format.
The Test Administrator or other
designated person will print the
test and provide it to the
student with this
accommodation. All student
responses will be recorded in
INSIGHT by the test
administrator or other
designated person using the
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accommodation. Some
alternate response options are
external devices that must be
plugged in and be compatible
with the assessment delivery
system. It is important to test
compatibility ahead of time with
the Online Training Tools.
In addition to associating this
accommodation with a student
test ticket, DACs must request
printed Braille tests using the
Additional Materials request
page in eDirect. See the Test
Administration Manual and the
Forward Exam Accommodations
and Supports webpage.
Some students with visual
impairments who are unable to
use the embedded calculator
for calculator-allowed items will
be able to use the calculator
that they typically use, such as
a Braille calculator. Test
administrators should ensure
the calculator is only available
for calculator allowed items.
For students with a documented
and persistent calculation
disability (i.e. dyscalculia).
Table is available on the
Forward Exam Accommodations
and Supports webpage.
While most of the
accommodations can be set in
eDIRECT, there is a unique
protocol for requesting a print
on demand accommodation.
The Print on Demand
accommodation is intended for
those extremely rare instances
(e.g., photosensitive epilepsy)
where a students condition
prevents him or her from
accessing material online.
Access to printed items/stimuli
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Read Aloud (for ELA reading
passages, blind students,
and who do not yet have
adequate Braille skills)
2. Dynamic Learning Maps (DLM):
In this IEP year, is the child or will the child be in grade 3,4,5,6,7,8,9,10, or 11 and taking the DLM
during the time assessment is given?
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accommodated students login
credentials for that test. The
printed test must be treated as
secure testing materials.
Text is read aloud to the
student by a trained and
qualified human reader. With
this accommodation readers
are allowed to read all or
portions of the test content to
the student, including the text
of reading passages.
Chelsea Beinborn
should not be assigned based
solely on a preference. The
decision to allow this
accommodation must be based
on each individual students
need and documented in a
students IEP or 504 Plan. If a
student requires print on
demand, the DAC must submit
a Request for Print on Demand
Accommodation approval form
located
http://dpi.wi.gov/assessment/f
orward/forms . After receiving
the request, DPI will review and
if approved, activate the
accommodation.
Students who are struggling
readers may need assistance
accessing the assessment by
having all or portion of the
mathematics, science, social
studies, and ELA portions of the
assessment read aloud. This
support also may be needed by
students with reading-related
disabilities, or by students who
are blind and do not yet have
adequate Braille skills. This is a
support that must be used
regularly during instruction for
the student. As a general
guideline, TTS should be used
in most situations and the read
aloud should be used for the
very small number of students
who may need this accessibility
resource for accessing the test.
Read Aloud Guidelines and
confidentiality forms are
available at
http://dpi.wi.gov/assessment/f
orward/accommodations.
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`
Yes No

I-3-S7 Participation Guidelines for Alternate Assessment must be included with IEP.

Dynamic Learning Maps Accommodations Necessary?

Yes No

Supports Provided Within DLM Via PNP

Magnification

Invert Color Choice

Color Contrast

Read Aloud with highlighting Text to Speech (TTS) - Text Only

Read Aloud with highlighting Text to Speech (TTS) - Text & Graphics

Read Aloud with highlighting Text to Speech (TTS)- Graphics Only

Read Aloud with highlighting Text to Speech (TTS)- Nonvisual

Supports Requiring Additional Tools/Materials

Uncontracted Braille

Single-switch system/PNP enabled

Two-switch system

Administration via iPad

Adaptive equipment used by student

Individualized Manipulatives
Supports Provided Outside the DLM System
Human Read Aloud

Sign interpretation of text

Language translation of text

Test administrator enter responses for student

Partner-Assisted Scanning (PAS)

I-3 IEP Section II. ASSESSMENT - ACT

Student: Birth Date WISEid
July 1, 2015 2015 CESA 6 I-1 -
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Toby 1/1/2008 9876543210

District of Residence District of Placement Current School Grade

Viterbo Viterbo Viterbo 3rd

Meeting Date
12/8/2016

III. Assessment
B. Statewide Assessments (continued)
3. ACT Aspire Early High School:
In this IEP year, is the child or will the child be in grade 9, 10 and taking the ACT Aspire during the
time assessment is given?
Yes No

ACT Aspire Accommodations Necessary?

Yes No

Embedded Features are available to all students for computer administered ACT Aspire
Early High School Assessments. No advanced request or documentation is needed.
Embedded features include: QWERTY keyboard, mouse, copy and paste functions, font
size, magnifier tool, highlighting, calculator, mark item for review, scratch paper, browser
zoom, magnification.
Open Access Tools are also available for any student for whom the need has been
indicated, but must be activated through the Personal Needs Profile (PNP) in advance of
the assessment.
Accommodations must be entered into the Personal Needs Profile, in advance of the
assessment. Disability related documentation is not submitted for the ACT Aspire Early
High School.
Accessibility Feature Content Areas
Presentation Supports Support Reading English Writing Math Science
Level
Presentation supports allow an examinee to receive the information intended by the test design in a way that honors and
upholds the rigor of the construct being tested while meeting the individual needs of the examinee. ("Dir. Only" is an
abbreviation for Directions Only)
Text to Speech (English Audio) Accommodati Dir. Only Dir. Only
on

Text-to-Speech(English Audio + Accommodati Dir. Only Dir. Only

Orienting Description) on

English Audio Includes Braille & Accommodati No No

Tactile Graphics for Blind on
Spanish Text + Audio Accommodati No No
on
Spanish Text + Audio: Directions Accommodati Dir. Only Dir. Only Dir. Only Dir. Only Dir. Only

Only on

Word-to-Word Dictionary Accommodati No No

on

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English Text + ASL Full Accommodati No No

Translation on
English Text + ASL: Directions Accommodati Dir. Only Dir. Only Dir. Only Dir. Only Dir. Only

Only on

Signed Exact English (SEE): Accommodati

Directions Only(English Text) on
Signed Exact English (SEE):Test Accommodati No No
Items(English Text) on
Braille Contracted Includes Accommodati
Tactile Graphics on
Braille Un-contracted Includes Accommodati
Tactile Graphics on
Large Print Open Access

Line Reader Open Access

High Contrast Colors Open Access

Low Contrast Colors Open Access

Interaction & Navigation Support Reading English Writing Math Science

Supports Level
Interaction and Navigation supports are provided through the digital test delivery system (CBT) or by locally provided
procedures to support the examinee to actively and constructively engage with items and their solution and to move fluidly
and purposely through the test as needed to engage most effectively. At all times, such supports must honor and uphold the
rigor of the construct being tested while meeting the individual needs of the examinee.
Abacus Accommodati No No No No
on
Answer-Masking Open Access N/A
Response Supports Support Reading English Writing Math Science
Level
Response supports allow an examinee to express the information intended by the test design in a way that honors and
upholds the rigor of the construct being tested while meeting the individual needs of the examinee. (Whether provided
locally or by test provider, use of all accessibility tools must be chosen by the appropriate accommodations team to meet
individual need, AND then planned, practiced, and documented PRIOR to test.
* All student responses must be provided in English
Respond in Test Booklet or Open Access No
Separate Paper
Dictate Responses Open Access

Keyboard or AAC + Local Print Open Access

General Test Conditions: Support Reading English Writing Math Science

Setting & Timing Level
Extra Time Accommodation

150 200 250

300 400

Breaks Supervised Open Access

Special Seating/Grouping Open Access

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Location for Movement Open Access

Individual Administration Open Access

Home Administration Open Access

Other Setting Open Access

Audio Environment Open Access

Video Environment Open Access

Physical/Motor Equipment Open Access

4. The ACT Plus Writing and ACT WorkKeys:

In this IEP year, is the child or will the child be in grade 11 and taking the ACT Writing and WorkKeys
during the time assessment is given?
Yes No

ACT Accommodations Necessary?

Yes No

Locally Approved Accommodations and Supports Students Testing with Standard Time do
not require review or prior approval from ACT; however, a test irregularity report must be
submitted to ACT
ACT-Approved Accommodations
Result in scores that are fully reportable to colleges, scholarships, and other entities.
Required Documentation for ACT-Approved Accommodations
State-Allowed Accommodations
Result in scores that are not college reportable; they are used for state accountability
purposes.
If accommodations are not approved by ACT and State Allowed accommodations are
utilized the Wisconsin State-Allowed Accommodations Notification form must be signed
acknowledging that scores earned through the use of State-Allowed Accommodations on
the ACT Plus Writing are not college reportable. Similarly, scores earned through the use
of State-Allowed Accommodations on the ACT WorkKeys are not eligible for National
Career Readiness Certification (NCRC).
- Locally Approved Accommodations and Supports Students Testing with Standard Time
(Do not need review or prior approval)

Locally Approved Accommodations and Supports Students Testing with Standard Time
(Do not need review or prior approval)
Designated Support Description
Administration of the Appropriate off-site or home-bound application must be
assessment in an approved by ACT.
alternate education
setting (out of school)
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with appropriate
supervision e.g.,
Home when student is
homebound,
Care facility when it is
medically necessary,
Juvenile facility
Administration of the If setting is off-site, appropriate off-site application must be
assessment individually approved by ACT.
or in a small group
The use of preferential
seating (e.g., front of
the room, back of the
room)
Use of accommodated
seating, special lighting,
or furniture
Able to move, stand or Student must test individually.
pace during
assessment
in a manner where
others work cannot be
seen and is not
distracting to others
(e.g.,
kneeling, constant
movement).
Student reads aloud to Student must test individually
him or herself
Use of sound Provided by school or student; student must test
amplification system individually if device causes distraction
for test directions only
Directions provided Applies only to spoken instructions exactly as provided in
using sign language the administration manual. ASL for test items is not ACT
American Sign Approved
Language (ASL) or
Exact English Signing
(EES)
Qualified person All directions for test administration are read verbatim in
familiar to the student English with no clarifications in another language.
administers the Qualified person cannot be a relative and must meet the
assessment (e.g., same ACT requirements as all testing staff
Special
Education Teacher,
Bilingual/ESL staff)
ACT Approved Timing and Scheduling Accommodations
(Submit application for ACT approved accommodations)
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Designated Support Description

Time of day for testing Must be within the designated two-week window that
altered begins on initial state test day and ends on the makeup
day. Testing may be scheduled for any days during the
window, but each student must take the sections of the
ACT Plus Writing & ACT WorkKeys in prescribed order. ACT
Plus
State Allowed No No Writing must be taken before the ACT
WorkKeys
Extended Test Time Normally time-and-a-half in single self paced session using
regular or large print. For certain formats and disabilities,
ACT will assign a timing code for the ACT based on the test
format and disability, up to triple time (and testing over
multiple days, one test per day). Oral presentation (e.g.,
audio DVD, or reader), and Braille normally require triple
time.
State-Allowed accommodations materials must be
ordered.
Frequent supervised Interpreted as stop-the-clock breaks; ex. standard time
breaks for students who are diabetic or have other medical
conditions requiring frequent breaks. If requested with
extended time, must provide documentation to support
need for stop-the-clock breaks in addition to extended
time. Students must test individually.
Testing over multiple Student must complete each test section in 1 day. Tests
days-standard time must be taken in the prescribed order. ACT Plus Writing
must be taken before ACT WorkKeys.
ACT Approved Presentation Accommodations
(Submit application for ACT approved accommodations)
Designated Support Description
Use of visual aids (e.g., Provided by school or student. Depending on the device
closed circuit television, used, student may have to test individually.
magnification devices)
Large Print book ACT produces large type version 18 pt. font. Large type
may be used with standard or extended time. It is reserved
for students with visual impairments.
Braille test format ACT produces Braille formats.
Test items signed using Exact English signing (EES) of test items may be requested
Exact English signing
(EES) and approved in specific cases for college reportable
scores
Use of English audio ACT Oral Presentations (Audio DVD) include all test
(DVD) versions of the questions and answers as well as any passage associated
assessments (can NOT with those items. Must use headset if testing in a group.
be used for reading ACT produces audio (DVD) version.State-Allowed
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comprehension portion accommodations materials must be ordered. ACT produces

of test) audio (DVD) versions for the state.
Test read aloud by test ACT Oral Presentations (Reader Script) include all test
administrator using questions and answers as well as any passage associated
provided reader script with those items. ACT-produced readers script read
(can NOT be used for verbatim in English. Students must test individually
reading comprehension
portion of test)
Use of highlighters, Provided by school or student. Reading guides are
highlighter tape, page interpreted as place keepers. May require student to test
flags, individually (e.g., highlighters).
and reading guides on
test booklets

ACT Approved Response Accommodations

(Submit application for ACT approved accommodations)
Designated Support Description
Use of assistive Provided by school or student. Applies only to ACT Writing
technology device
(Computer, word Test. ACT instructions for printing and returning essay must
processor, Braillewriter, be followed precisely. The following features must be
or AlphaSmart for disabled: spell check, thesaurus, grammar check.
writing test)
Student points to If student points to answers, student must test individually.
answers or writes
directly in assessment Responses must be transcribed to scannable answer
booklet (transferred to document by testing staff while examinee observes. Refer
answer document by to manual for scribe policies.
testing staff while
examinee observes)
Student responds orally Only if tested individually, responses are in English, and
(e.g., student tells the responses marked on scannable document by testing staff.
Assessment
administrator which
answer choice they are
selecting)
Use of computers with Requests considered individually based on documentation
alternative access for submitted. Approval and reportable status depend on
an alternative response detailed information about the proposed alternative
mode e.g., Switches, access. If approved, responses must be transferred to
Alternative, keyboards, scannable answer document by testing staff. Required
Eye-gaze motion, documentation of original responses to be determined on
sensors, Voice case-by-case
recognition, software, basis for college reportable ACT scores. Refer to manual
Head or mouth, pointer, for scribe policies
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Specialized, or
trackballs or mice
Use of a scribe for Applies only to ACT Writing Test. Only if tested individually.
constructed response Refer to manual for scribe policies.
items
(student must indicate
punctuation, format
and spell all keywords)
for Writing
Use of adapted paper, Provided by school. Student must test individually and
additional paper, lined responses transferred to scannable answer document by
or grid paper for testing staff while examinee observes. All materials must
recording answers be returned to ACT.
Use of Requests considered individually based on documentation
augmentative/alternati submitted. Approval and reportable status depend on
ve detailed information about the devices proposed for use.
communication
devices, e.g.,
Picture/symbol
communication boards,
Speech generating
devices

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I-3 IEP Section II. ASSESSMENT ACCESS/ District Wide

Student: Birth Date
Toby 1/1/2008

District of Residence District of Placement Current School Grade

Viterbo Viterbo Viterbo 3rd

Meeting Date
12/8/2016

III. Assessment
B. Statewide Assessments (continued)
5. Wisconsin Statewide Language Assessment:
According to Title III of the No Child Left Behind Act of 2001 section 3113 (b)(3)(D) all Limited
English Proficient/English Learner (LEP/EL) students are required to take annually a language
assessment in all four language domains of reading, writing, speaking and listening regardless of
disability status. Individualized Education Program (IEP) teams are required to decide annually
whether students who are classified as LEP/EL and who have a disability will participate in (1) the
ACCESS for ELLs with or without accommodations, or (2) the Alternate ACCESS for ELLs with or
without accommodations.

1- In this IEP year, is the child classified as an English Learner (ELP 1-5) and will be in grade
K,1,2,3,4,5,6,7,8,9,10,11 or 12 during the time the assessment is given?
Yes No

ACCESS for ELLs Alternate ACCESS for ELLs

If Alternate Access for ELLs is selected:

I-3-S7 Participation Guidelines for Alternate Assessment must be included with IEP.
Accommodations Necessary:
Yes No

ACCESS for ELLs Accomodations

Accommodation ACCESS for ELLs 2.0 Test Domains
Code Test Directions Listening Reading Speaking Writing
TABLE 1. PRESENTATION ACCOMMODATIONS ALLOWED WITH ACCESS FOR ELLS 2.0
Presentation Accommodations Allowable changes to the context or format in which the test is presented to an ELL with a
disability, including the scripted test directions, introductory text, test items, and graphic support; and how the scripted test
directions are presented.
SD Interpreter signs test directions in ASL

MC Manual control of item audio No

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RA Repeat item audio No

LH Read aloud Listening test response options by No N/A N/A
human reader
RL Repeat Listening test item response options by No N/A N/A
human reader
IH Read aloud test items by human reader No
RI Repeat test items by human reader No
LP Large print version of test

BR Braille version of test N/A N/A

Code Test Directions Listening Reading Speaking Writing

TABLE 2. RESPONSE ACCOMMODATIONS ALLOWED WITH ACCESS FOR ELLS 2.0
Response Accommodations devices or alternate procedures used by an ELL student with a disability to facilitate
responding to test questions.
SR Scribed response N/A
WD Word processor or similar keyboarding device to N/A
respond to test items
AC Student responds orally using external N/A
augmentative and/or alternative communication
device or software
RD Student responds using a recording device, which N/A N/A
is played back and transcribed by student
BW Student responds using a braille writer or braille N/A N/A
notetaker
AT Student uses assistive technology to respond to
test items
Code Test Directions Listening Reading Speaking Writing
TABLE 3. TEST ENVIRONMENT/SETTING ACCOMMODATIONS ALLOWED WITH ACCESS FOR ELLS 2.0
Test Environment/Setting Accommodations Changes in the location and conditions in which the assessment is given to an
ELL with a disability A
NS Test may be administered by school personnel in
nonschool setting
Code Test Directions Listening Reading Speaking Writing
TABLE 4. TIMING/SCHEDULING ACCOMMODATIONS ALLOWED WITH ACCESS FOR ELLS 2.0
Timing/Scheduling Accommodations Changes in the length of time needed by an ELL with a disability to complete the test
and/or the way in which testing time is organized A
ES Extended Speaking test response time N/A N/A N/A
ET Extended testing time within the school day

EM Extended testing of a test domain over multiple

days

C. District-Wide Assessments
1 Early Literacy Screener
In this IEP year, will the child be in 4K, Kindergarten, First or Second grade?
Yes No

Accommodations Necessary?

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Yes No

2 High School Civics Exam

In this IEP year, will the child be in a grade when the Civics Exam will be given?
Yes No

Is it appropriate to administer the Civics Exam to the child?

Yes No

Accommodations Necessary?
Yes No

3 Other District-Wide Assessments:

During this IEP year will the child be in a grade where district-wide assessments are given?
Yes No

1 If yes, list the name of the assessment(s) and necessary accommodations, if any.
Toby will be assessed by taking the following assessments: STAR, MAPS, and DIBELS.
Accommodations may include testing in a small group with minimal distractions, extending
time provided to complete the exam, and having tests and/or directions read aloud, if
allowed.

2) If no, document why the child cannot participate in the general district-wide assessment and
why an alternate assessment is appropriate.

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I-3 IEP Section III

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
(PLAAFP)
Student: Birth Date WISEid
Toby 1/1/2008 9876543210

District of Residence District of Placement Current School Grade

Viterbo Viterbo Viterbo 3rd

Meeting Date
12/8/2016

III. Present Level of Academic Achievement and Functional Performance

A. State the strengths of the child (including academic skills, communication skills, social skills, and
interests):

Toby is very active and excels at any physical activity including P.E.. In the classroom, Toby loves to be a
helper and favors being a door holder. He excels at sharing with his peers and not creating conflicts over
objects. Toby enjoys all his special classes such as art, music, and P.E.. He enjoys drawing and singing
about animals, especially dinosaurs. Toby prefers hands-on in class activities and his favorite academic
subject is science. In the home, both parents state that Toby enjoys technology and is allowed to watch TV,
play video games, or on a tablet for one hour after school. Tobys mother states that she has seen a drastic
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improvement this year in his behaviors and they are not of concern in the home setting. Tobys father stated
that he has taken Toby to a dinosaur museum over the summer and now has sparked a huge interest in
science. Both parents believe Toby has close friends and his social relationships are appropriate.

B. Family Engagement
1 State the concerns of the parents/family for enhancing the education of the student. This may
include concerns about reading achievement, early language/communication or early literacy
skills, other academic areas, social-emotional needs, sensory needs, behavior, the child's future
and postsecondary transition, etc.:

Tobys mother has been concerned that Tobys previous childhood behaviors have interfered with him
being academically where he needs to be with his peers. She noted that language arts is her biggest
concern and the subject he is most behind in. Both parents are concerned about third grade being a
challenging academic year. Tobys parents both stated that his behaviors are 100% improved in the last
two years of school. He is now able to control his fidgeting and hyperactivity in an appropriate and
non-distracting way. Parents believe this is due to finding the correct medication regimen.

2 Describe the concerns (if any) of the student for enhancing his or her education:
N/A
3 How will school staff engage parents/families in the education of the student (e.g. sharing
resources, communicating with parents/families, building upon family strengths, connecting
parents/families to learning activities, etc.)?
Tobys team send frequent communication to Tobys father and mother regarding academics and
behaviors for both positive and concerns. Communication is and has been made through phone
calls, emails, and notes home. Toby also receives a weekly class newsletter along with a
classroom website. Tobys family is excellent at relaying information with home behaviors,
academic struggles or successes, and other concerns. There is a great communication line for
Toby between home and school.
Before developing annual goals, review the previous IEP goals and progress (document review on
previous IEP in IEP Team Review sections).

C. Review of Previous Goals

* Previous goals have been reviewed.
Yes No N/A

D. Current Academic Achievement and Functional Performance

1. Describe the student's present level of academic achievement (including reading achievement). For
preschool children, describe the child's acquisition and use of knowledge and skills (including early
language/communication and early literacy).
Early this year, Mrs. McDonald noticed that Tobys reading was concerning and warranted further
testing. Mrs. McDonald tried several Tier 2 interventions and documented Tobys progress. Toby

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continued to show areas of concern after the interventions such as phonic analysis, structural analysis,
comprehension, r-controlled sounds, diphthongs, word endings, and silent consonants. Testing scores
for Toby provided the raw data for his reading concerns. Toby was assessed by the school psychologist
using the Wechsler Intelligence Scale for Children (WISC-R) which provides a score that represents a
child's general intellectual ability, Wide Range Achievement Test (WRAT) which measures an
individual's ability to read words, comprehend sentences, spell, and compute solutions to math
problems, and Broad Reading and Broad Written Language subtests of the Woodcock-Johnson
Psychoeducational Battery (WJPB) which allows for a considerably detailed analysis of cognitive
abilities. Testing scores were as follows:
WISC-R:
Verbal IQ = 108
Performance IQ = 128
Full Scale IQ = 119

WRAT Scores:
Reading Standard Score = 77/grade equivalent score = 1.6
Spelling standard score = 67/grade equivalent score = 1.8
Arithmetic standard score = 90/grade equivalent score = 3.1

WJPB:
Broad reading standard score = 94/percentile rank = 34
Broad mathematics standard score = 112/percentile rank = 78
Broad written language standard score = 86/percentile rank = 17
Broad knowledge standard score = 104/percentile rank = 61

Tobys general classroom teacher administered the Silvaroli Classroom Reading Inventory and results
indicated that Tobys independent reading level (reading comprehension) was at the second grade level,
his instructional reading level (reading comprehension) was at the second grade level, and his listening
comprehension was at the fourth grade level.

2. Describe the student's present level of functional performance (including impact on reading
achievement and access to instruction). For preschool children, describe the child's positive social-
emotional skills (including social relationships) and use of appropriate behaviors to meet their needs
and the impact on early literacy.

Tobys behaviors have greatly increased in appropriateness in the last two years. Neither Tobys
parents or teachers have any behavior concerns at this time. Toby is able to control his fidgeting in an
appropriate and non-distracting manner; he is allowed two fidgets in his desk. Toby can independently
locate various areas of importance in the school as his regular and special education classrooms, locker,
office, cafeteria and restrooms. Toby is clear and concise in when communicating. Toby enjoys
working with his peers in small groups for math class. He becomes disengaged at times during whole
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group reading, but his team is aware of his reading weakness and this is the priority area to work on.

E. Effects of disability
1 Does the student's disability adversely affect his or her progress toward meeting grade-level
reading standards? For preschoolers, does the disability adversely affect progress toward the
Wisconsin Model Early Learning Standards (WMELS) for language development,
communication and/or early literacy?
Yes No

2 Describe how the student's disability affects his or her access, involvement and progress in the
general education curriculum, including how the disability affects reading. For preschool
children, describe how the disability affects participation in age-appropriate activities, including
language development, communication and/or early literacy.

Tobys reading concerns impairs his ability in reading fluently due to his inability to use phonic
analysis, word endings, and silent consonants which greatly impacts his involvement and
progress in the general education curriculum.

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I-3 IEP Section IV GOALS AND OBJECTIVES

Student: Birth Date WISEid
Toby 1/1/2008 9876543210

District of Residence District of Placement Current School Grade

Viterbo Viterbo Viterbo 3rd

Meeting Date
12/8/2016

A. MEASURABLE ANNUAL ACADEMIC OR FUNCTIONAL GOALS

Goal Number 1
Goal Title:
Reading

Disability Related Need(s):

To develop reading fluency and word recognition skills.

Measurable Annual Academic or Functional Goals:

Toby will increase his instructional reading accuracy and fluency to a third grade mid-year
level and his independent reading accuracy and fluency to a second grade mid-year level as
measured by the Hudson Education Skills Inventory Reading (HESI-R) by the end of the
2016/2017 school year.

Baseline (Student's current level of performance from which progress toward this goal will be
measured)
Toby is curently at a begining year second grade instructional reading level and an end-of-y

Level of Attainment (Must relate to the baseline measurement and reflect progress)
Mid-year, third grade instructional reading level and end-of-year second grade indepenede

Procedure for measuring the student's progress toward meeting the annual goal from baseline to level
of attainment
Hudson Education Skills Inventory Reading (HESI-R)

B. PROCEDURES AND TIMELINE FOR NOTIFYING PARENTS OF CHILD'S PROGRESS TOWARD THE
ANNUAL GOAL

Progress Monitoring

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Goal Objective

Frequency:
Bi-weekly

Key For Measuring

Progress
Frequency:

Date/Progress Progress Sufficient to Summary

Reach Annual Goals?

(Date) Yes No

Initials
Choose an item.

(Date) Yes No

Initials
Choose an item.

(Date) Yes No

Initials
Choose an item.

OR

Use other method

Frequency:

Method:

C. SHORT TERM OBJECTIVES/BENCHMARKS necessary to describe the steps the child will take to make
progress in the general curriculum and reach the annual goal and disability-related educational needs:
Toby will work on skills in using beginning and ending consonants, vowel patterns and blends to
predict unknown words, read aloud accurately (90% to 100%) material from the grade level
sample reading list, and read using a balance of phonetic, semantic, and syntactic cues.

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IEP Team Review:

Goal Met

Goal Not Met

N/A

Level of attainment and IEP revision needed if goal not met:

I-3 IEP Section V.

INSTRUCTIONAL SERVICES: A STATEMENT FOR EACH OF THE
FOLLOWING WITH AMOUNT, FREQUENCY, LOCATION, & DURATION.
Student: Birth Date WISEid
Toby 1/1/2008 9876543210

District of Residence District of Placement Current School Grade

Viterbo Viterbo Viterbo 3rd

Meeting Date
12/8/2016

V. INSTRUCTIONAL SERVICES
A Statement for each of the following with amount, frequency, location, and duration.
SPECIAL EDUCATION
Special Education/ Amount Frequency Location Duration Related
Specially Designed Goal
Instruction
Reading RTI 45 minutes Daily Elementary School Length Reading
of IEP

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Physical Education
Regular

Specially designed (must be addressed in annual goal , and in instructional services)

N/A

Related Services
Yes

None needed to benefit from special educ ation.

Service Amount Frequency Location Duration Related

Goals
Assistive Technology

Audiological"
Counseling Services
Including
Rehabilitation
Counseling
Educational
Interpreting
Medical Services
(diagnostic or
evaluation)
Occupational Therapy
Orientation and
Mobility Services
(vision only)
Other Related
Services
Physical Therapy
Psychological
Services
Recreation
School Health
Services
School Social Work
Speech and
Language
Transportation

Supplementary Aids & Services

July 1, 2015 2015 CESA 6 I-1 -
Invitation to IEP Meeting
 Chelsea Beinborn

Aids, services, and other supports provided to or on behalf of the child in regular education or other
educational settings by regular education and/or special education staff.
N/A

Describe Amount Frequency Location Duration Related

Goals
Academic Support 30 minutes Daily General Education Length of Reading
for Reading IEP

Program modifications or supports for school personnel that will be provided.

N/A

Describe Amount Frequency Location Duration Related

Goals

I-3 IEP VII. DETERMINATION AND NOTICE OF PLACEMENT

Student: Birth Date
Toby 1/1/2008

District of Residence District of Placement Current School Grade

Viterbo Viterbo Viterbo 3rd

Meeting Date
12/8/2016

VII. Determination and Notice of Placement

A The IEP developed on and/or revised/updated on 2/5/2013 will be implemented at
(school) in the
Viterbo Elementary

School District.
Viterbo

July 1, 2015 2015 CESA 6 I-1 -

Invitation to IEP Meeting
 Chelsea Beinborn

1. Projected date of implementation

12/21/2016

2. Date parents/adult child was provided with this written notice of placement
12/9/2016

B. Will the child attend the school s/he would attend if non-disabled?
Yes No

If no, explain:
C.

You previously received a copy of the evaluation report, and a copy of the IEP is enclosed or
attached.

Copies of the evaluation report and the IEP are enclosed or attached.

D. List other options considered, if any, related to the placement site (school building or school
district), frequency, location, and the duration of the special education and related services,
supplementary aids and services, program modifications and supports, and the place of those
services. List the reason(s) rejected, and the description of any other factors relevant to the proposed
action:
N/A

Parent: You and your child have protection under the procedural safeguards (rights) of special education law. The school district must
provide you with a copy of your procedural safeguards once a year. Previously you received a copy of your procedural safeguard
rights in a brochure about Special Education Rights for Parents and Children. If you would like another copy of this brochure, please
contact the school district at the telephone number below. In addition to the district staff, you may also contact the organizations
listed on the Special Education Rights for Parents and Children brochure if you have questions about your rights.

NAME AND TITLE OF DISTRICT CONTACT

Contact Name/Title
Mrs. Ridge/Special Education

Phone
456-456-6445

Email
abc123@gmail.com

July 1, 2015 2015 CESA 6 I-1 -

Invitation to IEP Meeting