Iep

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name:
INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age
Student’s Name: Johnny Smith

IEP Team Meeting Date (mm/dd/yy): 12/5/19
IEP Implementation Date (Projected Date when Services and Programs Will Begin): 12/9/2019
Anticipated Duration of Services and Programs: 12/8/2020
Date of Birth: 8/25/2001
Age: 18
Grade: 12
Anticipated Year of Graduation: 2020
Local Education Agency (LEA): Ohio Mid-Eastern Regional Education Service Agency
County of Residence: Jefferson
Name and Address of Parent/Guardian/Surrogate: Phone (Home): (555)555-5555
John Smith Phone (Work): (555)555-5555
0000 Streetname Road
Richmond, Oh 43944
Other Information: Johnny lives with his father, mother, brother, and sister
The LEA and parent have agreed to make the following changes to the IEP without convening an IEP meeting, as documented by:
N/A
Date of Revision(s) Participants/Roles IEP Section(s) Amended
Page 1 of 26 April 2014

Student’s Name:
IEP TEAM/SIGNATURES
The Individualized Education Program team makes the decisions about the student’s program and placement. The student’s parent(s), the student’s special
education teacher, and a representative from the Local Education Agency are required members of this team. Signature on this IEP documents attendance, not
agreement.
Role Printed Name Signature

Parent/Guardian/Surrogate John Smith
Parent/Guardian/Surrogate Mary Smith
Student* Johnny Smith
Regular Education Teacher** Emily Miller
Special Education Teacher Mrs. Kimberly Scarfo
Local Ed Agency Rep Sarah Elliott
Career/Tech Ed Rep*** N/A
Community Agency Rep N/A
Teacher of the Gifted**** N/A
Speech and Language Pathologist James Riley
* The IEP team must invite the student if transition services are being planned or if the parents choose to have the student participate.
** If the student is, or may be, participating in the regular education environment
*** As determined by the LEA as needed for transition services and other community services
**** A teacher of the gifted is required when writing an IEP for a student with a disability who also is gifted.
One individual listed above must be able to interpret the instructional implications of any evaluation results.
Written input received from the following members:
N/A
Transfer of Rights at Age of Majority
For purposes of education, the age of majority is reached in Pennsylvania when the individual reaches 21 years of age. Likewise, for purposes of the Individuals
with Disabilities Education Act, the age of majority is reached for students with disabilities when they reach 21 years of age.

Student’s Name:
PROCEDURAL SAFEGUARDS NOTICE
I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides information about my rights,
including the process for disagreeing with the IEP. The school has informed me whom I may contact if I need more information.
Signature of Parent/Guardian/Surrogate:
MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

(Applicable only to parents who have consented to the release of billing information to Medical Assistance programs)
I understand that the school may charge the School-Based Access Program (“SBAP”)—or any program that replaces or supplements the SBAP—the cost of certain
special education and related services described in my child’s IEP. To make these charges to the SBAP, the school will release to the administrator of that
program the name, age, and address of my child, verification of Medicaid eligibility for my child, a copy of my child’s IEP, a description of the services
provided and the times and dates during which such services were provided to my child, and the identity of the provider of such services. I understand that
such information will not be disclosed, and such charges will not be made, unless I consent to the disclosure. I acknowledge that I have provided written
consent to disclose such information.
I understand that my consent is ongoing from year-to-year unless and until I withdraw it. I can withdraw my consent in writing, or orally if I am unable to
write, at any time. My refusal to consent or my withdrawal of consent will not relieve the school of the obligation to provide, at no cost to me or my family,
any service or program to which my child is entitled under the Individuals with Disabilities Education Act (“IDEA”) or that is necessary to enable my child to
receive a free appropriate public education as described in my child’s IEP.
I understand that the school cannot—
Require me or my family to sign up for or enroll in any public benefits or insurance program, such as Medicaid, as a condition of receiving a free appropriate
public education for my child;
Require me or my family to incur any expense for the provision of a free appropriate public education to my child, including co-payments and deductibles,
unless it agrees to pay such expenses on my or my family’s behalf;
Cause a decrease in available lifetime coverage or any other insured benefit;
Cause me or my family to pay for services that would otherwise be covered by a public benefits or insurance program and that are required for my child
outside the time that he or she is in school;
Risk the loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.

Student’s Name:
I. SPECIAL CONSIDERATIONS THE IEP TEAM MUST CONSIDER BEFORE DEVELOPING THE IEP. ANY FACTORS CHECKED AS “YES” MUST BE ADDRESSED IN THE IEP.
Is the student blind or visually impaired?

Yes The IEP must include a description of the instruction in Braille and the use of Braille unless the IEP team determines, after an
evaluation of the student’s reading and writing skills, needs, and appropriate reading and writing media (including an
evaluation of the student’s future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use of
Braille is not appropriate for the student.
X No
Is the student deaf or hard of hearing?

Yes The IEP must include a communication plan to address the following: language and communication needs; opportunities for
direct communications with peers and professional personnel in the student’s language and communication mode; academic
level; full range of needs, including opportunities for direct instruction in the student’s language and communication mode;
and assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The
Communication Plan must be completed and is available at www.pattan.net
X No
Does the student have communication needs?

X Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)
No
Does the student need assistive technology devices and/or services?

Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)
X No
Does the student have limited English proficiency?

Yes The IEP team must address the student’s language needs and how those needs relate to the IEP.
X No

Student’s Name:
Does the student exhibit behaviors that impede his/her learning or that of others?
Yes The IEP team must develop a Positive Behavior Support Plan that is based on a functional assessment of behavior and that
utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in the Present Levels
section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially Designed Instruction
sections of the IEP or in the Positive Behavior Support Plan if this is a separate document that is attached to the IEP. A
Positive Behavior Support Plan and a Functional Behavioral Assessment form are available at www.pattan.net
X No
Other (specify):
N/A
II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Include the following information related to the student:

 Present levels of academic achievement (e.g., most recent evaluation of the student, results of formative assessments, curriculum-based
assessments, transition assessments, progress toward current goals)
 Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress
toward current goals)
 Present levels related to current postsecondary transition goals if the student’s age is 14 or younger if determined appropriate by the IEP team
(e.g., results of formative assessments, curriculum-based assessments, progress toward current goals)
 Parental concerns for enhancing the education of the student
 How the student’s disability affects involvement and progress in the general education curriculum
 Strengths
 Academic, developmental, and functional needs related to student’s disability
Johnny is a senior in high school. He is a happy young man who has Down syndrome. Johnny loves
being around his classmates and he works hard when instructed to do so by his teachers. He thrives on
one-on-one teaching attention. When he does something in which he feels pride, he smiles a huge
smile and gives a big thumbs up. Johnny’s present levels of academic achievement and functional
performance were determined using the Brigance CBS III (hereafter called the Brigance), teacher
interviews, a review of his current records, and direct observation.
Present levels of academic achievement

Reading:
Johnny was assessed using the Brigance, and according to this assessment he is currently performing
at a kindergarten level of five years and five months in reading. He can read the most basic words, and
Student’s Name:
he knows 20/26 letters of the alphabet when shown the lower-case letters. While he can recognize the
letters, he can not recite the alphabet when asked to do so. He can read some basic words that appear
on signs. He is currently reading out of the first-grade Success for All (SFA) reader. He also learns sight
words and vocabulary words from this reader. He is good at remembering the words her learns. He has
difficulty reading without assistance, but when he reads with some prompting from a teacher, he can
read short passages.
Math:
In math he also scored at a kindergarten level according to the Brigance, with a cognitive
functioning level of five years and four months. In class he is able to solve basic math problems with a
calculator. On the Brigance assessment he was unable to complete any of the problems because he was
not using a calculator. When asked to count starting at one, he does not know which number comes
next. When counting objects, he can count up to ten. He can also read numerals up to ten, though he
sometimes confuses the numbers “eight” and “six.” In class when using a calculator, he can complete
single-digit addition and subtraction problems.
Behavior:
Johnny is well behaved in most areas. Sometimes Johnny will lift his shirt up over his head. He pulls
his shirt back down when a teacher or another student asks him to do so. One thing that he really
struggles with is self-stimulation of the genitals. This behavior occurs most often when he is not
engaged in a task that takes cognitive effort. He seems to engage in this behavior as a self-soothing
mechanism. This behavior happens frequently. During data collection, he participated in this behavior
eight times in a fifteen-minute observation period. This behavior may prevent him from getting a job
because it is not appropriate for the work place.
Communication:
Johnny struggles with speech. His tongue is thick due to his Down syndrome, so it makes it difficult
for him to speak clearly. He communicates using one-word responses. His receptive communication
skills are more developed, and he understand most questions and responds with the appropriate actions
or with one-word responses. He can answer yes or no questions. He can not answer where, why, who,
or how questions. It is unclear at this point whether this is due to a lack of understanding the questions
or an inability to communicate his answers. He has a great deal of difficulty forming words, and his
handwriting is very poor, so it is hard to tell whether he is not answering the questions because he does
not know the answer or if he knows the answer but is unable to communicate it.
Social Skills:
Johnny has very good social skills and gets along well with the other kids in his class. Because he
has limited verbal skills, most of his interactions with the other students do not include talking. Usually
he conveys his point with grunts and one-word phrases. This does not, however, limit his ability to have
friends. His best friend is in the class with him, and they sometimes walk together in gym. He friend
looks out for him and sometimes reminds him to pull up his pants or follow the rest of the class on the
way to gym.
Student’s Name:
Gross and Fine Motor Skills:

Johnny’s gross motor skills are at a cognitive level of five years and four months. He can run and
gallop easily; however, his running form needs improvement. He cannot skip with alternating feet. He
is able to balance on each foot for five seconds, and on each foot for one second with his eyes closed.
His fine motor skills are at a cognitive level of five years and five months. He is able to hold a pencil
and write, but his writing is often illegible. He is able to draw simple shapes such as a circle, a cross,
and an “X,” but not more difficult shapes like a triangle or a rectangle. He is able to write 20 out of 26
letters and the numbers one through ten, but he does not form the letters correctly while he is writing.
Adaptive Skills:
Johnny is able to take care of all of his toileting needs. He needs assistance with dressing and tying
his shoes. He is currently learning cooking and cleaning skills. He can eat independently and wash his
hands without assistance. He Knows his first name and his age. His general knowledge and Language
skills are at a cognitive level of five years and five months.
Present levels of functional performance

Johnny knows his first name and his age when asked. He can not say his last name when asked, but
he does respond to it if he is called. He does not know his middle name. Johnny needs assistance with
dressing and tying his shoes, but he does know which shoe goes on which foot. He was able to
recognize and say 9/11 colors when asked. His is able to take care of toileting needs independently.
Present levels related to current postsecondary transition goals

Johnny is currently enrolled in the life skills program at his school where he is learning basic cooking
and laundry skills. Johnny and his parents would like him to be able to live independently and get a job
after he graduates. Johnny’s parents would like him to continue working on life skills. He is good at
simple cleaning tasks. He can clean exercise equipment and wipe tables and stair rails. Sometimes he
will spray too much cleaning spray and does not realize when to stop.
Parental concerns for enhancing the education of the student

Johnny’s parents want him to be able to live independently and have a job. They would like him to
continue his involvement with the school work program so that he can continue to lean the skills he
needs to get a job upon graduation. They also want him to learn the daily living skills that he needs for
independent functioning. They would like him to be independent in a variety of settings including
home, vocational, and community settings. They would also like his participation in community events
to reach a point where he needs only minimal guidance and supports.
How the student’s disability affects involvement and progress in the general education curriculum
Johnny has been diagnosed with Down syndrome. His Down syndrome has given him some difficulty
with speech. His tongue often gets in the way of his speech and makes it very difficult to understand
him. His disability has also caused a cognitive delay and he is functioning at the level of a five-year-old
in both academic and functional realms.
Student’s Name:
Strengths
Johnny is very good at one-on-one work with a teacher.
Johnny is good at reading his sight words in his Success for All reading program.
Johnny is kind to his teachers and his classmates.
Johnny is very helpful when asked to do things to help in the classroom.
Johnny is good at completing cleaning tasks.
Johnny is a good friend to his classmates.
Johnny is empathetic.
Academic, developmental, and functional needs related to student’s disability

Because Johnny has Down syndrome, he has difficulty with his speech. He has difficulty forming
words and sentences. He understands most directions and can complete simple tasks, but his limited
speech makes it difficult for him to ask questions or express when he does not understand. Johnny will
need to continue with speech therapy to help him improve his speech. Johnny should continue to
receive life skills training to help him learn life skills and job skills. Johnny is performing at a cognitive
level significantly below that which is typical at his age. He will need accommodations and
modifications to help him in the classroom.
III. TRANSITION SERVICES – This is required for students age 14 or younger if determined appropriate by the IEP team. If the student does not attend the
IEP meeting, the school must take other steps to ensure that the student’s preferences and interests are considered. Transition services are a coordinated
set of activities for a student with a disability that is designed to be within a results oriented process, that is focused on improving the academic and
functional achievement of the student with a disability to facilitate the student’s movement from school to post school activities, including postsecondary
education, vocational education, integrated employment (including supported employment), continuing and adult education, adult services, independent
living, or community participation that is based on the individual student’s needs taking into account the student’s strengths, preferences, and interests.
POST SCHOOL GOALS – Based on age appropriate assessment, define and project the appropriate measurable postsecondary goals that address education
and training, employment, and as needed, independent living. Under each area, list the services/activities and courses of study that support that goal.
Include for each service/activity the location, frequency, projected beginning date, anticipated duration, and person/agency responsible.
For students in Career and Technology Centers, CIP Code:
N/A
Postsecondary Education and Training Goal: Measurable Annual Goal

Student’s Name:
N/A Yes/No
(Document in Section V)
Courses of Study:
N/A
Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible
Employment Goal:
Measurable Annual Goal
N/A Yes/No
Courses of Study:
N/A


Student’s Name:
Independent Living Goal, if appropriate:

Measurable Annual Goal
N/A Yes/No
Courses of Study:

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Instructions for IEP Teams:
Please select the appropriate assessment option. Information on available testing accommodations may be found in the Accommodations Guidelines
available on www.education.state.pa.us.
State Assessments
Not Assessed
No statewide assessment is administered at this student’s grade level.
X No English proficiency assessment administered because the student is not an English Language Learner.
PSSA (Math administered in grades 3-8; Science administered in grades 4 and 8; Reading administered in grades 3-8; Writing administered in grades 5
and 8; and ELA*)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Math
Science
Reading
Writing
ELA*
*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.

Student’s Name:
Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11th grade)
Without With
Algebra 1
Literature
Biology
Keystone Project Based Assessment (Available when student is unable to demonstrate proficiency on a Keystone Exam or Keystone Exam module.)
Without With
Algebra 1
Literature
Biology
Validated Local Assessment (Available when selected as option by LEA)

Without With
Algebra 1
Literature
Biology
PASA (Administered in grades 3-8, 11 for Reading and Math; Grades 4, 8, 11 for Science)
X Student will participate in the PASA.
Explain why the student cannot participate in the PSSA or the Keystone Exam for Reading/Literature, Math/Algebra 1,
Science/Biology, and Composition (The Composition exam will be available for the 2016-17 school year):
Johnny is currently performing at a cognitive level of five years five months, which is greatly different from his
chronological age of eighteen years four months. Because of this great difference in cognitive level and chronological age, it
would not be appropriate for Johnny to take the PSSA as it would not be an accurate reflection of his abilities.
Explain why the PASA is appropriate:

The PASA is appropriate for Johnny because it is based on the modified curriculum which Johnny is learning.
Choose how the student’s performance on the PASA will be documented.

X Videotape (preferred method)
Written narrative notes (requires prior approval in accordance with PDE

guidance)

Student’s Name:
ACCESS for ELLs (Administered in grades K-12)

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to
Accommodations Accommodations Participate Participate in Selected Domains
Listening N/A
Reading
Writing
Speaking
Alternate ACCESS for ELLs (Administered in grades 1-12)

Student will participate in the Alternate ACCESS for ELLs.
Explain why the student cannot participate in the ACCESS for ELLs:
Explain why the Alternate ACCESS for ELLs is appropriate:
Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to

Accommodations Accommodations Participate Participate in Selected Domains
Listening
Reading
Writing
Speaking
Local Assessments
Local assessment is not administered at this student’s grade level; OR
Student will participate in local assessments without accommodations; OR
Student will participate in local assessments with the following accommodations; OR

Student’s Name:
X The student will take a local alternate assessment.
Explain why the student cannot participate in the local regular assessment:
Because Johnny is performing at a cognitive level of five years five months, he is not learning from the curriculum that is used
in his district. Johnny is learning a modified curriculum, so an alternate assessment would be a more accurate measure of his
abilities.
Explain why the local alternate assessment is appropriate:

The local alternate assessment is appropriate because it is based off the modified curriculum which Johnny is being taught.
Therefore, it will be a more accurate measure of his abilities.

Student’s Name:
V. GOALS AND OBJECTIVES – Include, as appropriate, academic and functional goals. Use as many copies of this page as needed to plan appropriately.
Specially designed instruction may be listed with each goal/objective or listed in Section VI.
Short term learning outcomes are required for students who are gifted. The short term learning outcomes related to the student’s gifted program may be
listed under Goals or Short Term Objectives.
MEASURABLE ANNUAL GOAL Describe HOW the

Describe WHEN periodic
Include: Condition, Name, Behavior, and Criteria student’s progress toward
reports on progress will be Report of Progress
(Refer to Annotated IEP for description of these meeting this goal will be
provided to parents
components) measured
When asked to say the alphabet, Johnny will say Progress will be Progress will be reported to
each letter in order with 100% accuracy over monitored weekly by the Johnny’s parents quarterly.
seven consecutive progress monitoring periods. special education teacher.
The special education
teacher will ask Johnny to
say the alphabet and
record which letters he
knows and which letters
he does not know. The
number of correct
answers will be scored out
of 26. The data will be
recorded and graphed.
When asked to count to twenty, Johnny will say Progress will be Progress will be reported to
the numbers one through twenty with 100% monitored weekly by the Johnny’s parents quarterly.
accuracy over seven consecutive progress special education teacher.
monitoring periods. The special education
teacher will ask Johnny to
count to twenty and
record which numbers he
says correctly. The
number of correct
numbers will be scored
out of twenty. The data
will be recorded and
graphed.

Student’s Name:
While at school, Johnny will keep his hands off of Once a week the Progress will be reported to
his genital area for 95% of the time during a paraeducator will monitor Johnny’s parents quarterly.
thirty-minute observation period for five Johnny’s progress. The
consecutive progress monitoring periods. paraeducator will record
how many seconds Johnny
spends touching his
genitals during a thirty-
minute observation
period. This observation
will take place during
math class. The special
education teacher will
then record how many
seconds out of 1,800
Johnny was engaged in
the behavior. The data
will be graphed on a
chart.
SHORT TERM OBJECTIVES – Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).
Short term objectives / Benchmarks
N/A

Student’s Name:
VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS – Include, as appropriate, for nonacademic
and extracurricular services and activities.
A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)

 SDI may be listed with each goal or as part of the table below.
 Include supplementary aids and services as appropriate.
 For a student who has a disability and is gifted, SDI also should include adaptations, accommodations, or modifications to the general
education curriculum, as appropriate for a student with a disability.
Modifications and SDI Location Frequency Projected Beginning Date Anticipated Duration
SDI for Goal 1:
teacher or paraeducator
will spend time each day
working one-on-one with
Johnny reciting the
alphabet. The special
education teacher will sing The special education
Three times per week 12/9/19 12/9/19 – 12/8/20
the alphabet song with classroom
Johnny each day. The
special education teacher
will have a piece of paper
with the letters of the
alphabet written on it to
point to as they sing the
song.
SDI for Goal 1:
will explicitly teach Johnny
each letter of the alphabet Three times per week 12/9/19 12/9/19 – 12/8/20
classroom
using a chaining procedure.
The letter “A” will be
taught to mastery, then the
letter “B” will be added.
SDI for Goal 2:
teacher or paraeducator The special education
Three times per week 12/9/19 12/9/19 – 12/8/20
will help Johnny to practice classroom
counting each day. First,
the special education
Student’s Name:
teacher will show Johnny a

sheet of paper with the
numbers one through
twenty written on it.
Johnny will read the
numbers, and the teacher
will prompt as needed.
Then the special education
teacher will show Johnny
twenty objects printed on a
page. Johnny will be
instructed to count the
objects, and the teacher
will prompt as needed.
Finally, Johnny will be
asked to count to twenty
from memory, and the
teacher will prompt as
needed.
SDI for goal 2:
will ask Johnny to do
twenty of something and
count out loud as he does.
For example, the teacher
may ask Johnny to take
twenty steps and count Three times per week 12/9/19 12/9/19 – 12/8/20
classroom
each step as he walks.
Alternatively, the teacher
may ask Johnny to take out
twenty paper clips. It may
be any task as long as it
requires twenty repetitions
and can be counted out
loud.
SDI for goal 3:
Two times per week, the
special education teacher The special education
Two times per week 12/9/19 12/9/19 – 12/8/20
or paraeducator will read classroom
Johnny a Social Story about
places on our bodies that
Student’s Name:
we can not touch when we

are at school or work.
SDI for goal 3:
teacher will give Johnny a
squishy ball to hold when
he feels like he wants to
touch his genitals. If the The special education
12/9/19 12/9/19 – 12/8/20
teacher or paraeducator classroom Four days per week
see Johnny touching his
genitals, they will remind
him that he should be
touching his squishy ball
instead.
B. RELATED SERVICES – List the services that the student needs in order to benefit from his/her special education program.
Service Location Frequency Projected Beginning Date Anticipated Duration

Speech and Language Speech and Language 4 times per week for one-
12/9/19 12/9/19 – 12/8/20
Therapy pathologist’s room hour sessions
C. SUPPORTS FOR SCHOOL PERSONNEL – List the staff to receive the supports and the supports needed to implement the student’s IEP.
School Personnel to Projected Beginning

Support Location Frequency Anticipated Duration
Receive Support Date
Training on how to Parent-teacher One time one-hour 12/9/19
Paraeducator 12/9/19
use Social Stories conference room training (One hour)
Training on chaining Parent-teacher Three times one hour 12/16/19 – 1/6/20
Paraeducator 12/16/19
procedures conference room each (Three hours total)

Student’s Name:
D. GIFTED SUPPORT SERVICES FOR A STUDENT IDENTIFIED AS GIFTED WHO ALSO IS IDENTIFIED AS A STUDENT WITH A DISABILITY – Support services are
required to assist a gifted student to benefit from gifted education (e.g., psychological services, parent counseling and education, counseling services,
transportation to and from gifted programs to classrooms in buildings operated by the school district).
Support Service N/A

Support Service N/A
Support Service N/A
E. EXTENDED SCHOOL YEAR (ESY) – The IEP team has considered and discussed ESY services, and determined that:
Student IS eligible for ESY based on the following information or data reviewed by the IEP team:
OR
X As of the date of this IEP, student is NOT eligible for ESY based on the following information or data reviewed by the IEP team:
Johnny is graduating in May of 2020 and will begin receiving weekly training with the Bridges to Transitions Program which will help
him to work toward his goal of achieving employment.
The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the student’s ESY Program are:
N/A
If the IEP team has determined ESY is appropriate, complete the following:
ESY Service to be Provided Location Frequency Projected Beginning Date Anticipated Duration
N/A
N/A
N/A

Student’s Name:
VII. EDUCATIONAL PLACEMENT
A. QUESTIONS FOR IEP TEAM – The following questions must be reviewed and discussed by the IEP team prior to providing the explanations regarding
participation with students without disabilities.
It is the responsibility of each public agency to ensure that, to the maximum extent appropriate, students with disabilities, including those in public
or private institutions or other care facilities, are educated with students who are not disabled. Special classes, separate schooling or other removal
of students with disabilities from the general educational environment occurs only when the nature or severity of the disability is such that education
in general education classes, EVEN WITH the use of supplementary aids and services, cannot be achieved satisfactorily.
 What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the supplementary
aids and services will or will not enable the student to make progress on the goals and objectives (if applicable) in this IEP in the general
education class.
 What benefits are provided in the general education class with supplementary aids and services versus the benefits provided in the special
education class?
 What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the other students in the
class, even with supplementary aids and services?
 To what extent, if any, will the student participate with nondisabled peers in extracurricular activities or other nonacademic activities?
Explanation of the extent, if any, to which the student will not participate with students without disabilities in the regular education class:
Johnny is performing both academically and functionally at a level of five years and four months to five
years and five months. Because there is such a big gap between his cognitive level of function and his
chronological age, he will spend 18.75% of the school day with his general education peers for breakfast
and lunch. He will spend the remainder of the day with the special education class.
Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
Because Johnny is performing both academically and functionally at a level of five years and four
months to five years and five months, he would not be able to benefit from learning the general
education curriculum for twelfth grade. A Modified curriculum will allow Johnny to work on his
academic, behavioral, and job-related skills.

Student’s Name:
B. Type of Support
1. Amount of special education supports
Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day
Supplemental: Special education supports and services provided by special education personnel for more than 20% of the day but less than
80% of the school day
X Full-Time: Special education supports and services provided by special education personnel for 80% or more of the school day
2. Type of special education supports
Autistic Support
Blind-Visually Impaired Support
Deaf and Hard of Hearing Support
Emotional Support
Learning Support
X Life Skills Support
Multiple Disabilities Support
Physical Support
X Speech and Language Support

Student’s Name:
C. Location of student’s program
Name of School District where the IEP will be implemented: Steubenville City School District
Name of School Building where the IEP will be implemented: Steubenville City High School
Is this school the student’s neighborhood school (i.e., the school the student would attend if he/she did not have an IEP)?
Yes
X No. If the answer is “no,” select the reason why not.

X Special education supports and services required in the student’s IEP cannot be provided in the neighborhood school
Other. Please explain:

Student’s Name:
VIII. PENNDATA REPORTING: Educational Environment (Complete either Section A or B; Select only one Educational Environment)
To calculate the percentage of time inside the regular classroom, divide the number of hours the student spends inside the regular classroom by the total number of hours in the school day (including
lunch, recess, study periods). The result is then multiplied by 100.
SECTION A: For Students Educated in Regular School Buildings with Non Disabled Peers – Indicate the Percentage of time INSIDE the regular classroom for this student:
Time spent outside the regular classroom receiving services unrelated to the student’s disability (e.g., time receiving ESL services) should be considered time inside the regular classroom.
Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as college campuses or vocational sites, should be counted as time
spent inside the regular classroom.
Calculation for this Student:
Column 1 Column 2 Calculation Indicate Percentage Percentage Category

Total hours the student Total hours in a typical (Hours inside regular Section A: The percentage of
school day classroom ÷ hours in
spends in the regular time student spends inside the
school day) x 100 = %
classroom per day regular classroom: Using the calculation result – select the appropriate percentage category
(including lunch, recess
& study periods) (Column 1 ÷ Column 2) x
100 = %
1 1/2 8 (1.5 ÷ 8) X 100 = 18.75 __18.75___% of the day INSIDE the Regular Classroom 80% or More of the Day
INSIDE the Regular Classroom 79-40% of the Day
INSIDE the Regular Classroom Less Than 40% of the Day
SECTION B: This section required only for Students Educated OUTSIDE Regular School Buildings for more than 50% of the day – select and indicate the Name of School or
Facility on the line corresponding with the appropriate selection: (If a student spends less than 50% of the day in one of these locations, the IEP team must do the calculation
in Section A)
Approved Private School (Non Residential) _________________________ Other Public Facility (Non Residential) _________________________
Approved Private School (Residential) _________________________ Hospital/Homebound _________________________
Other Private Facility (Non Residential) _________________________ Correctional Facility _________________________
Other Private Facility (Residential) ________________________ Out of State Facility _________________________
Other Public Facility (Residential) ________________________ Instruction Conducted in the Home _________________________
EXAMPLES for Section A: How to Calculate PennData–Educational Environment Percentages

Column 1 Column 2 Calculation Indicate Percentage
Total hours the student spends in the Total hours in a typical school day (Hours inside regular classroom ÷ hours in school day) Section A: The percentage of time student
(including lunch, recess & study x 100 = % spends inside the regular classroom:
regular classroom per day
periods)
(Column 1 ÷ Column 2) x 100 = %
Example 1 5.5 6.5 (5.5  6.5) x 100 = 85% 85% of the day
(Inside 80% or More of Day)
Example 2 3 5 (3 5) x 100 = 60% 60% of the day
(Inside 79-40% of Day)
Example 3 1 5 (1 5) x 100 = 20% 20% of the day
(Inside less than 40% of Day)
For help in understanding this form, an annotated IEP is available on the PaTTAN website at www.pattan.net Type “Annotated Forms” in the Search feature on the website. If you do not have access
to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.

Student’s Name:
Data Collection form for Goal 1:
When Johnny is asked to recite the alphabet, record which letters he says correctly.
Letter Correct Correct Correct Correct Correct Correct Correct Correct Correct Correct Correct Correct
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
Date:
#/26
correct

Student’s Name:
Data Collection Sheet for Goal 2:
When Johnny is asked to count to twenty, record which numbers he says correctly.
Number Correct Correct Correct Correct Correct Correct Correct Correct Correct
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Date:
#/20
correct

Student’s Name:
Date Collection Sheet for Goal 3:
Using a stopwatch, record the number of seconds Johnny participates in self-stimulation of his genitals during a thirty-minute
observation period.
Date: Number of Seconds Number of seconds Percentage of 30

out of 1,800 minute period

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)

INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age

Student’s Name: Johnny Smith

Date of Revision(s) Participants/Roles IEP Section(s) Amended

Page 1 of 26 April 2014

Role Printed Name Signature

Written input received from the following members:

Transfer of Rights at Age of Majority

Page 2 of 26 April 2014

PROCEDURAL SAFEGUARDS NOTICE

MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

I understand that the school cannot—

Cause a decrease in available lifetime coverage or any other insured benefit;

Page 3 of 26 April 2014

Is the student blind or visually impaired?

Is the student deaf or hard of hearing?

Does the student have communication needs?

Does the student need assistive technology devices and/or services?

Does the student have limited English proficiency?

Page 4 of 26 April 2014

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Include the following information related to the student:

Present levels of academic achievement

Gross and Fine Motor Skills:

Present levels of functional performance

Present levels related to current postsecondary transition goals

Parental concerns for enhancing the education of the student

Academic, developmental, and functional needs related to student’s disability

For students in Career and Technology Centers, CIP Code:

Postsecondary Education and Training Goal: Measurable Annual Goal

Projected Anticipated Person(s)/Agency

Projected Anticipated Person(s)/Agency

Page 9 of 26 April 2014

Independent Living Goal, if appropriate:

Projected Anticipated Person(s)/Agency

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Page 10 of 26 April 2014

Validated Local Assessment (Available when selected as option by LEA)

Explain why the PASA is appropriate:

Choose how the student’s performance on the PASA will be documented.

Written narrative notes (requires prior approval in accordance with PDE

Page 11 of 26 April 2014

ACCESS for ELLs (Administered in grades K-12)

Alternate ACCESS for ELLs (Administered in grades 1-12)

Explain why the Alternate ACCESS for ELLs is appropriate:

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to

Local assessment is not administered at this student’s grade level; OR

Student will participate in local assessments without accommodations; OR

Student will participate in local assessments with the following accommodations; OR

Page 12 of 26 April 2014

X The student will take a local alternate assessment.

Explain why the local alternate assessment is appropriate:

Page 13 of 26 April 2014

MEASURABLE ANNUAL GOAL Describe HOW the

Page 14 of 26 April 2014

Short term objectives / Benchmarks

Page 15 of 26 April 2014

A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)

teacher will show Johnny a

we can not touch when we

Service Location Frequency Projected Beginning Date Anticipated Duration

School Personnel to Projected Beginning

Page 18 of 26 April 2014