BlankIEP 2008-09

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CSE#

Date:

THIS IEP INCLUDES: NEW YORK CITYBOARD OF EDUCATION

INDIVIDUALIZED EDUCATION PROGRAM

CONFERENCE INFORMATIONTransition CSE Case #

Home District Service DistrictInterim Service Plan Date

Type

STUDENT INFORMATION *Age as of the date of the conferenceName NYC ID# Date of Birth Gender

Address Age*

Phone English LAB Year Spanish LAB Year Grade

Language(s) Spoken/Mode of Communication

Primary Agency with whom student is involved

Name of Contact Phone Agency Case #

PARENT/GUARDIAN INFORMATION Relationship to Student

Name

Address

Phone (Home) Phone (Work) Interpreter Required Yes No

Preferred Language/Mode of Communication

SPECIAL MEDICAL/PHYSICAL ALERTS (Refer to Health & Physical Development Page for additional details.)

The student has medical and/or physical limitations which affect his/her learning behavior and/or participation in school activities.

The student requires medication and/or health care treatment(s) or procedure(s) during the school day.

Other alerts:

SUMMARY OF RECOMMENDATIONS Eligibility Yes No

Classification of Disability:

Recommended Services:

Staffing RatioStaffing Ratio

Twelve Month School Year Yes No Recommended Services for the Twelve Month School Year: Staffing Ratio

Other Recommendations (Check all that apply) *Details are provided in relevant sections of IEP.

Program Accessibility* Adaptive Phys. Ed.* Bilingual Instruction

Related Services* Assistive Technology* Monolingual Services with ESL Monolingual Services without ESL

Special Education Transportation - Comment

Students who are blind or visually impaired: Students who are deaf or hard of hearing:Braille instruction needed Yes No Language of Instruction

Mode of Communication

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Copy for CSE PARENT SCHOOL STUDENT OTHER Page 1

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CONFERENCE INFORMATION

Referral Type: Initial Annual Review Conference Type: EPC Annual Review

Triennial Requested Review CSE Review CPSE Review

Attendance at ConferencePlease note that your signature reflects your participation at the conference and does not necessarily indicate agreement with the

Individual Education Plan

Signature Title(Indicate if Bilingual)

Signature Title(Indicate if Bilingual)

Parent/Legal Guardian Parent/Legal Guardian

District RepresentativeSpecial Education Teacher or Provider

General Education Teacher Parent Member (CPSE/CSE)

Student Surrogate Parent

Agency Representative Interpreter

Other Other

Other Other

Use an asterisk (*) to signify the participant who interprets the Instructional implications of evaluation results.Use the letter (T) to signify participation by teleconference.

Conference Result

Initiate Services Modify Services Change Programs/Service Category No Change

Indicate Modifications:

Initiation, Duration and Review of IEP

Projected Date of Initiation of IEP: Projected Date of Review of IEP: Duration of Services:

Contacts with Parent/Legal Guardian

Date Notice of Meeting Sent: Date IEP and Notice of Recommendation:

Date of Follow-up (if any): Given to Parent :

Type of Follow-up Letter Telephone Sent to Parent:

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SOCIAL EMOTIONAL PERFORMANCEDescribe the students strengths and weaknesses in the area of social and emotional development in English and the other than English language for LEP

students. Consider the degree and quality of the students relationships with peers and adults, feeling about self and social adjustment to school andcommunity environments. Discuss how the students disability affects his/her involvement and progress in the general curriculum or, for preschool

students, as appropriate, how the students disability affects participation in appropriate activities

PRESENT PERFORMANCE

BEHAVIOR AND THE INSTRUCTIONAL PROCESSBehavior is age appropriate

Behavior does not seriously interfere with instruction and canbe addressed by the general education and/or special educationclassroom teacher.

Behavior seriously interferes with instruction and requiresadditional adult support.

Behavior requires highly intensive supervision

Describe present levels of support including personnelresponsible for providing behavioral support.

SOCIAL/EMOTIONAL MANAGEMENT NEEDS(Environmental modifications and human/material resources)

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A behavior intervention plan has been developed. Yes No

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HEALTH AND PHYSICAL DEVELOPMENTDescribe the students health and physical development including the degree of quality of the students motor and sensory development, health, vitality and Physical skills or limitations

which pertain to the learning process, behavior and participation in physical education or other school activities. Discuss how the students disability affects his/her involvement andprogress in the general curriculum or for preschool students as appropriate, how the students disability affects participation in appropriate activities.

PRESENT HEALTH STATUS AND PHYSICAL DEVELOPMENT:

MEDICAL/HEALTH CARE NEEDS PHYSICAL NEEDS

During the school day, the student requires :Medication Yes No(If yes, functionally describe the condition for which medication is required.)

The student does does not have mobility limitations.(If yes, functionally describe the limitation(s).

Treatment(s) or other health procedure(s) Yes No(If yes, functionally describe the condition for which treatments(s) or procedure(s)are required.)

The student requires:Accessible program Yes No

Adaptive physical education Yes NoIf yes, indicate staffing ratio:

Health as a related service Yes No(If yes, specify in related service recommendations.)

Assistive technology device(s) Yes No(If assistive technology device(s) or service(s) are required, specify inmanagement needs.)

HEALTH/PHYSICAL MANAGEMENT NEEDS(Environmental modifications, human/material resources or specialized equipment)

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ANNUAL GOALS AND SHORT-TERM OBJECTIVESThere will be reports of progress per year

PROGRESS 1st 2nd 3rd 4th 5th 6th 7th 8th

ANNUAL GOALS: Method of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal



Report of Progress





Report of Progress



EXPLANATION OF CODING SYSTEM

METHODS OF MEASUREMENT REPORT OF PROGRESS PROGRESS TOWARD GOAL REASONS FOR NOT MEETING GOAL

1. Teacher Made Materials 6. Performance Assessment Task 1. Not applicable during this grading period A. Anticipate meeting goal 1. More time needed2. Standardized Tests 7. Check Lists 2. No progress made B. Do not anticipate meeting goal 2. Excessive absences or lateness

3. Class Activities 8. Verbal Explanation 3. Little progress made (Note reason) 3. Assignments not completed4. Portfolio(s) 9. Other (Specify) ___________ 4. Progress made; goal not yet made C. Goal met 4. Other (specify) ___________________5. Teacher/Provider Observations ____________________ 5. Goal met

*While a review of your childs educational program occurs every year please be advised that you have the right to request areview of your childs program at any time.

1st 2nd 3rd 4th 5th 6th 7th 8th

The students performance is approaching his/her promotional criteria as set forth on Page 9 of the IEP.

For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team bereconvened:

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Report of Progress





Report of Progress





Report of Progress











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Report of Progress





Report of Progress





Report of Progress











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SCHOOL ENVIRONMENT AND SERVICE RECOMMENDATIONS

GENERAL EDUCATION ENVIRONMENT

Area of Instruction Language of InstructionCommunication Mode

Periods perweek

Supplementary Aids and Service Program Modifications and Supportsfor School Personnel

SPECIAL CLASS ENVIRONMENT

Area o f Instruction Language of InstructionCommunication Mode

Periods perweek

Special ClassStaffing Ration

Supplementary Aids and Service Reason for Non-Part icipat ion inGeneral Education Environment

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OTHER PROGRAMS/SERVICES CONSIDERED AND REASONS FOR REJECTIONProvide an explanation of the programs/services considered and the reasons for rejection. Specify why the student can not achieve the goals

of his/her IEP within a general education program with the assistance of supplementary aids and services.

Second Language Instruction: If the student is exempt from second language instruction, explain why.

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PARTICIPATION IN SCHOOL ACTIVITIES, RELATED SERVICES RECOMMENDATIONS ANDPARTICIPATION IN ASSESSMENTS

PARTICIPATION IN SCHOOL ACTIVITIESIf the student cannot participate in lunch, assemblies, trips and/or other school activities with non-disabled students, indicate the activity and reason(s) for non-participation.

RELATED SERVICE RECOMMENDATIONSStatus* Related Services Language of Service Location** Sessions/Week Duration Group

Size

* Indicate status of recommendation:Initiate; Continue; Modify; Terminate. **Indicate whether service is provided outside the general educationclassroom.

PROMOTION

Promot ion Standard Criteria Modified Criteria*

* Describe the modified promotion criteria:

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PARTICIPATION IN ASSESSMENTSThe student WILL PARTICIPATE in State and local assessments

Without Accommodations With Accommodations

The student will participate in Alternate Assessment.

Reason for participation in Alternate Assessment:

Describe accommodations, if any, that will be used consistently throughout thestudents educational program:

In addition to Alternate Assessment, describe how the student will beassessed:

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TRANSITION

LONG TERM ADULT OUTCOMES(Beginning at age 14 or younger if appropriate, state long term outcomes based n the students preferences, needs and interests)

Community Integration:

Post=Secondary Placement:

Independent Living:

Employment:

DIPLOMA OBJECTIVE

Regents Diploma Advanced Regents Diploma Local Diploma IEP Diploma

Expected High School Completion Date Credits Earned As of Date

TRANSITION SERVICES(Required for students 15 years of age and older)

Instructional Activities:

Responsible Party: Parent School Agency Fall Spring Summer

Community Integration:


Post High School


Independent Living


Acquisition of Daily Living Skills Functional Vocational Assessment


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BEHAVIOR INTERVENTION PLAN

DESCRIBE THE BEHAVIOR(S) THAT INTERFERE(S) WITH LEARNING

WHAT BEHAVIOR CHANGES ARE EXPECTED?

WHAT STRATEGIES ARE GOING TO BE TRIED TO CHANGE THE BEHAVIOR?

WHAT SUPPORTS WILL BE EMPLOYED TO HELP THE STUDENT CHANGE THE BEHAVIOR?

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BlankIEP 2008-09

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