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STUDENT NAME: Student Name SIMS: 000000000

PARENT/GUARDIAN NAME: Students Parents Names PHONE:
ADDRESS: WK PHONE:
SCHOOL DISTRICT: 39-1 SCHOOL: Chester Elementary
DOB: 00-00-00 AGE: 11 GRADE: 4
GENDER: Male RACE: WH: White

Meeting Date: 10-26-16 Purpose of Meeting

Date Services Begin: 10-26-16 Initial Eligibility, IEP, Placement

Annual Review Date: 10-25-17 X Annual Review of IEP

Date of Eligibility Determination: 12-10-14 Three Year Reevaluation

Dismissal from Services - Date Effective:

Three Year Reevaluation Due By: 12-9-17 Parent Request

Other:

Discussed evaluation results/progress/assessment Student is eligible for special education or special education
method X Yes and related services as determined by the IEP team

(Parent/Guardian initial) X Yes No

Copy of evaluation results received X Yes An annual copy of Parent/Guardian Rights was received and
reviewed
(Parent/Guardian initial)
________ (Date) (Parent/Guardian Initial)

Transition Planning Needed x No Yes A copy of the IEP was provided to parent/guardian X Yes
(Parent/Guardian Initial)
(*If yes, attach applicable transition pages.)

Primary Disability: Behavioral Disability

Signature Date
IEP Team Membership
Parent/Guardian

Parent/Guardian

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Student

School Representative

General Education Teacher

Special Education Teacher or Provider

Speech/Language Pathologist

Individual who can interpret evaluation results

Other:

Other:

Other:

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Present Levels of Academic Achievement and Functional Performance

In developing each students IEP, the IEP Team must consider 1) the strengths of the student; 2) the concerns of the
parents for enhancing the education of their student; 3) the results of the initial or most recent evaluation of the student;
and 4) the academic, developmental, and functional needs of the student.

Provide a statement of the students present levels of academic achievement and functional performance, including 1)
how the students disability affects the students involvement and progress in the general education curriculum (i.e., the
same curriculum as for nondisabled students); or 2) for preschool students, as appropriate, how the disability affects
the students participation in appropriate activities.

Evaluation Results:

Skills Area: Reading skills and Comprehension

Students oral reading has improved and he takes great pride in reading words correctly.
He was able to read second grade passages with no errors.
Students listening comprehension is much better than when he has to read passage
himself.
Students reading fluency has improved greatly. He now averages 74 wpm which has
improved from 45 wpm last year.
Reading comprehension- Student has improved in his reading compression due to his
fluency improving. He was able to answer comprehension questions at a second-grade
level with 90% accuracy and at a third-grade level with 60% accuracy.
Student is now able to read words with phonetic irregularities.
Student has improved in his reading with common endings from 56% accuracy and 81%
accuracy.
Student is now able to read words with vowel diagraphs and diphthongs.
Student does much better using context clues to figure out unknown words.
A review of grade average posted shows that Student has been able to maintain at least
80% average or above in general education classroom since his amendment placement
(8-31-16) into the general education classroom with para assistance; language 81.25;
math 88.46; reading 84.90; Science 100; Social Studies 85.15.
Weakness
Student has difficult describing the setting, character, plot and theme with fourth grade
text from the classroom.
Student struggles with describing details from the classroom text.
Student struggles with vowel sounds and blends when decoding large (multi-syllabic)
grade level words in the classroom.

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Student gives up easily when the text material becomes too difficult for him to read.

Skill Area: Math

Strengths:

Student is able to do one digit addition with sums to 10

Student is able to do one digit subtraction
Student recognizes which number is more or less
Student knows that 10 pennies equals one dime.
Student is now able to do two-digit addition with carrying.
Student is now able to do simple story problems at the second-grade level
Student is using a number line to improve his addition and subtraction.
Student is able to add and subtract 3 digit whole numbers and decimals.
Student is improving with accuracy in addition and subtraction by using a number line.
Student does well on problems solving if the problem is read to him.

Weakness:

Student does not participate in math discussion in the classroom.

Student has difficulty applying the appropriate concepts of mathematics to solve
problems when doing a multifunction math problem.

Skills Area: Written Expression

Strengths: Student is able to write a simple sentence correctly

Weaknesses: Student has difficulty combing two sentence to make one complete sentence
that means that same thing, using correct grammar and syntax.

How the students disability affects his/her involvement in the general curriculum
for the skill area: Students lack of participation due to his difficulty with his math and
reading skills is interfering with is ability complete assignments and activities independently in
the general classroom. Student requires a lot of 1:1 assistance from the teacher or SPED staf
within the classroom to be successful with his work.

Parent Input:

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* Remember to address:

Strengths & needs using academic achievement (skill based assessment) AND functional performance

Transition strengths and needs including the students preferences and interests (must be in the students IEP by age 16)

Consideration of Special Factors

Is the student limited English proficient? Yes X No

If the answer to this question is yes, please explain the language needs of the student as these needs relate to the
students IEP.

Are there any special communication needs? Yes X No

If the answer to this question is yes, please explain the communication needs of the student, and in the case of a
student who is deaf or hard of hearing, consider the students language and communication needs, opportunities for direct
communications with peers and professional personnel in the students language and communication mode, academic
level, and full range of needs, including opportunities for direct instruction in the students language and communication
mode.

Does the student require Braille? Yes X No

If the answer to this question is yes, what instruction in Braille and use of Braille will be provided?

Does the students behavior impede his or her learning or that of others? X Yes No
If yes, what strategies are required to appropriately address this behavior, including positive behavioral interventions and
supports?

Does the student require Assistive Technology Devices and Services? Yes X No
If yes, what device or service will be provided?

Physical Education: X Regular Not Required Adaptive:

Refer to Goals/Goals & Objectives

Hearing Aid Maintenance: X Not Applicable Yes: Personnel Responsible for Monitoring:
Describe the monitoring process/frequency necessary for maintenance:

Assessment
X Student will be taking state and district-wide assessments with or without accommodations.
Student will be taking state and district-wide alternate assessments (The alternate assessment is for students working
in the alternate achievement standards) (Annual goal and short term objectives required)
a. Does the student meet the significant cognitive disability criteria? (If no, student is not eligible to take the alternate
assessment) Yes No
b. Explain the reason why the student cannot participate in the regular assessment.

c. Explain the reason why the alternate assessment selected is appropriate for this student.

No state and/or district-wide assessments are required at this students grade level during this annual IEP.
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Educational Goals and Objectives/Benchmarks

Provide a statement of measurable annual goals, including academic and functional goals designed to 1) meet the
students needs that result from the disability, 2) enable the student to be involved in and make progress in the general
education curriculum, and 3) meet each of the students other educational needs that result from the disability.
Measurable Annual Goal #
Given a list of 20 larger (multi- Proc. Date Prog. Comments:
syllabic) grade level words in the Code/s Code
classroom, Student will correctly 2,9
read the list aloud with no more 2,9
than 4 errors on 4 out of 5 trials.
2,9
2,9
Measurable Annual Goal #
After reading a grade level passage in 2,9
the classroom, Student will summarize
the passage in his own words including 2,9
the setting, character, plot and theme to
demonstrate understanding with at least 2,9
80% accuracy in 4 out of 5 trials 2,9
Measurable Annual Goal #
When a story problem is read to Student, 2,9
he will use what he knows about
addition, subtraction, multiplication and 2,9
division to correctly solve a multi-step
problem involving whole numbers with 2,9
at least 80% accuracy on 4 out of 5 trials
2,9
Measurable Annual Goal #
When given a writing assignment in the 2
classroom, Student will use correct
grammar and syntax to combine two 2
sentences into a one with the same
meaning to expand sentence length, 2
with at least 80% accuracy in 4 out of 5
trials. 2
Procedure Codes (Complete at IEP meeting) Progress Codes Reporting Frequency to Parents
1. Teacher-made tests 6. Work Samples P= Progress being made Quarterly Reports
2. Observations 7. Portfolios I= Insufficient Progress to meet goal Trimester Reports Other:
3. Weekly tests 8. Oral Tests X= Not addressed this Reporting Period Reporting Method to Parents
4. Unit tests 9. Data Response M=Met goal Conferences Report Card
5. Student Conferences 10. Other: Goal Page Copy Other:

Accommodations and Modifications

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Accommodations/Modifications/Supplementary Aides and Frequency Location Duration

Services
1. Small Group Instruction

2. Read Aloud-ELA and Math Daily General Ed Classroom Length of IEP
General Ed Classroom Length of IEP
3. Scribe- Response Assistance- including tests Daily
General Ed Classroom Length of IEP
4. Multiplication table Daily
General Ed Classroom
Length of IEP
Daily
5. Use of a calculator General Ed Classroom
Length of IEP
Daily

Statement of the program modifications or supports for school Frequency Location Duration
personnel (as appropriate):

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State/District-wide Assessment Accommodations

Student will be taking the assessment without accommodations.

x Student will be taking the assessment with the accommodations.

*Teams must consider if the accommodations are approved for the applicable test administration.

*List the accommodations the student will be taking for each test/test area.
(Only those accommodations identified for instruction on the goal pages can be considered for state and district-wide
testing. The accommodations selected for use must relate to the students disability.)

State Assessment Accommodations

Smarter Balanced Smarter Balanced Dakota STEP

ELA (Gr 3-8 & 11): Math (Gr 3-8 & 11): Science (Gr 5, 8 & 11):
Text-to-Speech (Inc. Rdg Passages) Text-to-Speech__ 6. Read Aloud_
Scribe (incl. Writing Tasks) __ Scribe_________ 11. Scribe____
_____________ _____________ _ _____________
_____________ _ _____________ _ _____________
_____________ _ _____________ _ _____________

Test: Test: Test:

* NSCS Alt Assessment and Dakota STEP- A Science

Accommodations for both instruction and assessment must be documented.

District-wide Assessment Accommodations

Test: Test: Test:

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Special Education Services

Description of services Frequency Location Duration

Basic Reading 30 min per day (150/wk.) General Ed Classroom Length of IEP
Written Expression 10 min per day (50/wk.) General Ed Classroom Length of IEP
Math 20 min per day (100/wk.) General Ed Classroom Length of IEP
SS/SCI (Reading Comprehension) 60 minutes per day (300 wk.) General Ed Classroom
Length of IEP
A para profession will be present in the general education classroom and available for Student during the time periods and
classes indicated above.

Related Service to be Provided Frequency Location Duration

Speech/Language Therapy
Occupational Therapy
Physical Therapy
Transportation (Specify when, how
often, where, distance, costs, etc.)
Counseling Services
(Including rehabilitation counseling)
Audiological Services
Interpreting Services
Medical Services
(Diagnostic Services only)
Orientation and Mobility
Parent Counseling/Training
Psychological Services
Recreation Therapy
School Nurse/Health Services
Social Work Services (in schools)
Other

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Least Restrictive Environment

The IEP Team must ensure that, to the maximum extent appropriate, students with disabilities are educated with
nondisabled peers, including extracurricular services and activities.

Continuum of Alternative Placements Continuum of Alternative Placements (Ages 3-5)

X 0100 General Classroom with Modifications 80-100% 0310 Early Childhood Setting-10 hrs.+/week

0110 Resource Room 40-79% services in Reg EC program

0120 Self-Contained Classroom 0-39% 0315 Early Childhood Setting-10 hrs.+/week

0130 Separate Day School services in other location

0140 Residential Facility 0325 Early Childhood Setting-Less than 10hrs/wk.

0150 Home/Hospital services in Reg EC program

0330 Early Childhood Setting-Less than 10hrs/wk.

services in other location

0335 Special Education Class

0345 Separate School

0355 Residential Facility

0365 Home

0375 Service Provider Location

Participation with Non-Disabled Peers

Program Options Non-Academic Extracurricular
X Art X Counseling Athletics
Industrial Technology X Meals Clubs
X Music Employment Referrals Groups
Vocational Education X Recess Recreation
Family & Consumer Science Health Services Other
Other Other

Comments:

Justification for Placement--An explanation of the extent, if any, to which the student will not participate with non-
disabled students in regular classes and non-academic activities.
(Please use accept/reject format for each alternative placement considered.)

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General classroom with modifications: is the placement accepted for Student, because he
requires flexible instruction practices at his level, individual assistance and small group
instruction available to him in the general education classroom setting to reinforce concepts
taught.

X The team addressed the potential harmful effects of the special education placement.

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Extended School Year

Extended School Year Services: needed X not needed to be determined by (Date)

Beginning
*Type of Ending Date Minutes
Goal(s) # Date **Based on
Service mm/dd/yy Per Week
mm/dd/yy

* Instruction, related services (specify), other (list)

** Regression/Recoupment, Emerging Skills, or Maintenance of Critical Life Skills

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