Virginia Department of Education – Sample IEP Form –...

Jane Singleton/ Lisa Radtke

CRIN X83

6/20/11

TRANSITION INDIVIDUALIZED EDUCATION PROGRAM

COVER PAGE

Student Name___Susan Knowles________________________________________________________ Page _1__of ___

Student ID Number_____434809801_________________________________________________________ Grade__9___

DOB __11__/__21_/_2011_ Age* __15______ Disability(ies) (if identified) __Emotional Disturbance_____________

Parent Name____Rebecca Knowles____________________________________________________________

Home Address________1370 Landscape Circle___________ Phone # (H) (_757)_226-1030_________________

Phone # (W) (_757_)_226-1035_________________

Date of Transition IEP meeting…………………...………………………………….....……..…………..__6_/_05__/_2011

Date parent notified of Transition IEP meeting…………………………………………...………………___5_/_3__/_2011_

Date student notified of Transition IEP meeting……………..…………………...………………………___5__/_3__/2011_

This Transition IEP will be reviewed no later than ………..………………………..……….……………_6__/15_/2011__

Most recent eligibility date…………………………….…………………………………….…………….___4_/__11_/__09_

Virginia Department of Education -- Sample Transition IEP Form—Revised August 25, 2010 of 39

Next re-evaluation, including eligibility, must occur before ………....………………..…..…………….._6_/___05__/_2014_

Copy of IEP given to parent/student by _Jane Singleton_______________________ On 05__/__1___/_2011___

IEP Teacher/Manager___Jane Singleton________________ Phone Number (_757_) 222-4545__________________

PARTICIPANTS INVOLVED:

The list below indicates that the individual participated in the development of this Transition IEP and the placement decision; it does not authorize consent. Parent or student (age 18 or older) consent is indicated on the “ Prior Notice/Consent” page.

NAME OF PARTICIPANT POSITION

Susan Knowles Student

Rebecca Knowles Parent

____________Joann Grayson_____________________________ Case Manager/ Special educator__

________Lisa Smith_________________________________ _____Guidance Counselor____________

___________John Doe___________________________________ _____School Psychologist____________

__________Harry White____________________________________ _______Art Teacher____________________

______________Sam Jones____________________________ _______Principal_________________________

* The student and parent must be informed at least one year prior to turning 18 that the IDEA procedural safeguards (rights) transfer to the student at age 18 and be provided with an explanation of those procedural safeguards. Date informed _____/_____/_____ Student Initials __________ Parent Initials __________

Virginia Department of Education -- Sample Transition IEP Form—Revised August 25, 2010

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FACTORS FOR IEP TEAM CONSIDERATION

Student Name_____ Susan Knowles _________________________________ Date __6__/__15__/_11___ Page _2__ of _____

Student ID Number_____________434809801_______

1. Results of the initial or most recent evaluation of the student;

Based on testing completed for eligibility in 2006: Wechsler Intelligence Scale for Children – Fourth Edition Full Scale IQ of 100, Verbal Comprehension Index of 91, Perceptual Reasoning Index of 84, Working Memory Index of 80, and Processing Speed Index of 75. Her abilities fell within the average range, I am not a fan of including IQ SS scores in IEPs – I know that some divisions do this …

Woodcock Johnson III Test of Achievement Form A , 10/2008(reported in standard scores) Broad Reading 80 Letter Word Identification 85; Reading Fluency 77; Passage Comprehension 86; Broad Math 90; Applied Problems; 90; Calculation 95; Math Fluency 74; Broad Written Language 83; Spelling 84; Writing Fluency 82; Academic Knowledge 97.

Based on the WJR III results Susan’s academic skills for reading and written language are in the low average range. Her score for math fluency is in the low range due to tendency to work slowly. Academic knowledge is in the average range. Her writing samples included short simple sentences that included errors in spelling and sometimes problems with sequencing. It is important to not that since the test was administered some changes may have occurred in her development.

2. The strengths of the student;

Susan is very artistic and creative and has great visual spatial skills. She has adjusted well in the general education classroom, since being in a self-contained setting during her middle school years. She has improved in using her coping strategies (e.g. requesting a break) when she feels frustrated instead of acting out (e.g., verbal aggression). She works well in small groups or partners.

3. The academic, developmental, and functional needs of the student;

Susan needs assistance in comprehending content area readings, such as science and she may need some things read aloud. Hmm I’d like to know more about her reading skills – maybe I’ll see that later. Susan currently has to be reminded daily to check her work in Math as she is in a rush to get it done and makes careless errors. Additionally she needs assistance in her organization as she is often missing 2 out of 5 homework assignments in all classes. Currently a teacher has to sign her planner to make sure that she writes down homework correctly and has appropriate materials in her homework folder.

Susan’ passed all of her 9th grade SOL’s which were taken during the week of May 2-6, 2011 and her scores were as follows: English 9 (420), Algebra 1 (413), Earth Science (410).

4. The concerns of the parent(s) for enhancing the education of their child;

Mrs. Knowles would like for her daughter to learn to control her anger and further develop organizational skills. The mother is concerned about her experimenting with drugs and alcohol, and while she is happy that her daughter has some friends (because she struggled with making friends in middle school), she would like to see her daughter become involved with more positive peers and potentially join some extracurricular activities. Virginia Department of Education -- Sample Transition IEP Form—Revised August 25, 2010

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5. The communication needs of the student;

Susan does not have any difficulty with her speech and language skills. She is able to communicate with teachers and peers appropriately.

6. The student’s needs for benchmarks or short-term objectives; (see below)

7. Whether the student requires assistive technology devices and services;

Assistive Technology was considered but not found necessary at this time.

8. In the case of a student whose behavior impedes his or her learning or that of others, consider the use of positive behavioral interventions, strategies, and supports to address that behavior;

Susan is allowed to request a break when she is feeling overwhelmed and has permission to go to the guidance counselor’s office. This accommodation has been in place and used successfully to help her control her verbal aggression towards peers and/or the teacher when she starts feeling frustrated.

9. In the case of a student with limited English proficiency, consider the language needs of the student as those needs relate to the student’s IEP;

Susan does not have limited proficiency in English. Language needs were considered but not found necessary at this time.

10. In the case of a student who is blind or is visually impaired, provide for 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; When considering that Braille is not appropriate for the child the IEP team may use the Functional Vision and Learning Media Assessment for Students who are Pre-Academic or Academic and Visually Impaired in Grades K-12 (FVLMA) or similar instrument; and

It was considered but not found appropriate at this time.

11. In the case of a student who is deaf or hard of hearing, consider the student’s language and communication needs, opportunities for direct communications with peers and professional personnel in the student’s language and communication mode, academic level, and full range of needs, including opportunities for direct instruction in the student’s language and communication mode. The IEP team may use the Virginia Communication Plan when considering the student's language and communication needs and supports that may be needed.

It was considered but not found appropriate at this time.


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PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Student Name__Susan Knowles_______________________________ Date_6___/_15___/_11___ Page ___of___

Student ID Number________________________________434809801_____________________

The Present Level of Academic Achievement and Functional Performance summarize the results of assessments that identify the student’s interests, preferences, strengths and areas of need. It also describes the effect of the student’s disability on his or her involvement and progress in the general education curriculum, and for preschool children, as appropriate, how the disability affects the student’s participation in appropriate activities. This includes the student’s performance and achievement in academic areas such as writing, reading, math, science, and history/social sciences. It also includes the student’s performance in functional areas, such as self-determination, social competence, communication, behavior and personal management. Test scores, if included, should be self-explanatory or an explanation should be included, and the Present Level of Academic Achievement and Functional Performance should be written in objective measurable terms, to the extent possible. There should be a direct relationship among the desired goals, the Present Level of Academic Achievement and Functional Performance, and all other components of the IEP.

Background information:

Susan is a 15-year-old Caucasian girl, in the 9th grade who has been identified under the IDEA category of Emotional Disturbance (ED). Her medical diagnosis is Bipolar Disorder, which she was given at the age of 10 years old. Susan lives at home with her mother and grandmother. Her father passed away 3 years ago.

Student’s strengths, interests and preferences are:

Susan is a very social teenager and in non-academic settings (e.g. hallways and lunch) she seems to converse with her peers on a daily basis. Her favorite class is Art and her teacher says she takes in-class projects very seriously. Susan prefers hands –on projects as she thinks it helps her learn how concepts fit together. Given that she is a visually –oriented learner, she understands concepts and information when it is presented visually (e.g., graphic organizer). Her ability to learn is promising, as she has received passing scores on all of her SOL’s that she has taken up until the 9 th grade. However, she is not completing in-class assignments and homework, which is causing her to fail some of her classes including: Math, English and Earth Science.

Career interest

According to the Virginia Wizard Interest Inventory Assessment that Susan took on May 15, 2011, her primary interest code was artistic, which included a variety of career options including a florist, interior designer, cosmetology, and drama teacher, just to name a few. Additionally, while interviewing Susan about the different types of work environments she


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would like to work in (e.g. working alone, with other, days of week, hours) Susan prefers being able to work at her own pace and not having to interact in big groups. After conducting a career research project in cosmetology this past semester, she is interested in pursuing the study of cosmetology through the vocational services offered at the New Horizons Academy.

Parent/Student Concerns

Susan’s mother is concerned about her experimentation with drugs and alcohol, and while she is happy that her daughter has some friends (because she struggled with making friends in middle school), she would like to see her daughter become involved with more positive peers and potentially join some extracurricular activities. Susan was caught stealing jewelry from a department store a year ago and was sent to a juvenile correctional facility for 3 weeks. Since then Mrs. Knowles has required that Susan always have adult supervision. She hopes to build more trust with Susan and would like to see Susan take on more responsibilities that allow her to show that she is dependable and trustworthy, whether it be in the school or the community.

Susan’s mother did mention that she is trying to incorporate more responsibility for Susan at home (e.g. chores) and that one of Susan’s strengths is helping her grandmother with daily living tasks (e.g., getting dressed, preparing food).

Susan has a low interest in academics based on an informal interview that occurred in January 2011unless the subject allows her to use her creativity. However, she does have the desire and motivation to finish high school. She would prefer to get further education in a hands-on job, such as being a hair dresser, where she can have on-the-job training. Susan stated that she prefers to work in small groups and experiences anxiety when in the large classroom, because she feels her peers will judge her if she doesn’t say the right thing. Susan would like to get a job before she graduates high school so that she can have money of her own to go shopping or the movies. She is not interested in a four-year degree, but may be interested in enrolling in a class or two at the community college. Susan is happy to live at home following high school graduation until she becomes more financially stable, but does eventually want to share an apartment with friends or live on her own.

Academic Achievement Data:

Susan is currently enrolled in classes in an inclusive setting, in which there is a special education teacher collaborating with the general curriculum teacher. She also receives 30 minutes of a self-contained personal life skills class every day and 45 minutes of an English support.

Susan has passed all of her required SOL’s to date in the following content areas Math, Science, English, and Reading. Her spring semester 2011 grades are as follows: English: F Earth Science: D, Art: B, Algebra1 : C, Personal Life Skills: C, and Health: B, English Support: B.

Her teachers are concerned with her in-class participation as she never volunteers her opinion and, when she is called on, the most common response is “I don’t know.” In Math and English her teachers claim that she has to be prompted multiple times before she even picks up a pencil. Her Earth Science teacher claims she only stays on-task when involved in-group work that is hands-on (e.g., science experiments). Otherwise, she appears withdrawn and does not react when prompted to get to work


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TRANSITION INDIVIDUALIZED EDUCATION PROGRAM (IEP)

PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, Continued

Student Name____ Susan Knowles ___________________________ Date __6__/_15___/_11___ Page ___of___

Student ID Number_______434809801___________________________

PRESENT LEVEL OF ACADEMIC ACHEIVEMENT AND FUNCTIONAL PERFORMANCE, continued.

Communication (speech and language skills):

Susan is competent in her speech and language skills. She is able to communicate with teachers and peers appropriately.

Social/Emotional Functioning

While Susan demonstrates appropriate social functioning with her peers, she can sometimes be confrontational (e.g. verbal aggression towards other students or teachers) in her behavior when she is overwhelmed. She also does not like to be called on in-class for fear of social repercussions if she gets the answer wrong. Susan is currently allowed to request a break from class when she starts to feel overwhelmed.

Motor and Daily Living Skills:

Susan demonstrates normal developing motor and living skills for her age.

Work Habits/Work Adjustment

Susan needs to further develop her independent study skills to ensure her success on tests and quizzes in her classes. Additionally she needs help with her organization skills, as she often forgets to bring her homework home or return projects in on-time. Currently she has a folder system in place and the teacher is to double check and make sure she has her homework assignments written correctly in her planner.

Home/Independent Living

Susan currently lives with her mom (Mrs. Knowles) and is in charge of cleaning her room and packing her lunch for school.

Community Participation:

Susan owns a library card, but is not otherwise involved in the community. Her mom would like to see her more involved in the community or a school-sponsored extra-curricular activity.


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Related Information:

Susan is currently on track for a standard diploma because she is interested in attending the vocational school and obtaining a certification in cosmetology. She is not interested in foreign languages.

Additional Information:


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DIPLOMA, AND TRANSITION STATUS

Student Name__ Susan Knowles _____Date __6__/_15___/_11___ Page ___of___

Student ID Number_________434809801_________________________

DIPLOMA STATUS: Discuss at least annually, more often as appropriate. This student is a candidate for a(n):

[ ] Advanced Studies Diploma [ ] Modified Standard Diploma*

[ ] Advanced Technical Diploma [ ] Special Diploma

[X ] Standard Diploma [ ] Certificate of Program Completion

[ ] Technical Diploma [ ] GED Certificate (General Educational Development

[ ] GAD (General Achievement Diploma) (only for those who meet requirements of the GED program)

[ ] Not discussed at this time

Projected Graduation/Exit Date: __June 2014______________

Is the student projected to graduate/exit school this year? _X__No ___Yes

If yes, inform the student and parents that a Summary of Performance will be provided prior to graduating/exiting school.

* The IEP team and the student, where appropriate, may select the Modified Standard Diploma option at any point after the student’s eighth grade year. When selecting the Modified Standard Diploma, it is essential to consider the student’s need for occupational readiness upon school completion, including consideration of courses to prepare the student as a career and technical education program completer. (Use of local courses of study planning guide that includes the


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graduation requirements is recommended.)

NOTE:

Special education and related services end upon receiving an Advanced Studies Diploma, Advanced Technical Diploma, Standard Diploma, or Technical Diploma. If the student receives a Modified Standard Diploma, Special Diploma, Certificate of Program Completion, a GAD or a GED Certificate, the student remains entitled to a free appropriate public education through age 21. If the student will graduate with an advanced or standard diploma during the term of the IEP, prior written notice on page 28 must be completed.

Summary of Performance

Will the student be graduating with a Standard, Technical, or higher level diploma or exceeding the age of eligibility this year? _X__No ___Yes

If yes, a Summary of Performance must be provided to the student prior to graduating or exceeding the age of eligibility.

Interagency Release of Information Form

Is there a current signed (by parent or adult student) release of confidential information on file with the school? ___No _X__Yes

If No, discuss form for transition planning with student and family


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MIDDLE / SECONDARY TRANSITION

Student Name__ Susan Knowles ___Date__6__/_15___/_11___ Page ___of___

Student ID Number _______434809801____________________________

MEASURABLE POST SECONDARY GOALS and TRANSITION SERVICES

(To be developed no later than the IEP to be in effect at age 14, or earlier, if appropriate)

DOCUMENTATION OF TRANSITION ASSESSMENTS

Are the postsecondary goals based upon age-appropriate formal and informal transition assessments? ___No _X__Yes

If yes, identify these assessments in the Present Level of Academic Achievement and Functional Performance or indicate which age-appropriate transition assessments were conducted for the development of measurable postsecondary goals and transition activities, as well as the date they were conducted:

Formal and informal Assessments (list name of assessment and date administered):

Virginia Wizard Interest Assessment 5/15/2011

Student Interview conducted by Ms. Singleton and Ms. Radtke 5/15/2011

BRIGANCE® Transition Skills Inventory: Career Interests and Choices 5/15/2011

___________________________________________________________________________________________

MEASURABLE POSTSECONDARY EMPLOYMENT GOAL:


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Describe how the student’s courses of study support attainment of this postsecondary goal:

Susan will continue to pass her required curriculum and SOL’s (6 total) in order to obtain the credits

she needs for a Standard Diploma. The case manager will supply remediation as needed for Susan to

be successful in her classes. Susan will take a business course as an elective to learn more about

budgeting money and gaining a further understanding about customer service. In Susan’s PLS class she

will research and call local hair salons to see what opportunities are available to her to job shadow, as

well as research the job skills she will need. In addition, Susan will schedule a time to tour New

Horizons Cosmetology Department to learn more about the program. She will research required skills

of a career in cosmetology as well as give an oral presentation about it during her Personal Life Skills

class.

Transition Activities/Services (including activities that link the student to adult services)

Responsible Individual/

Describe Responsibilities

Date to be Completed

Instruction Considered, but not appropriate at this time

Teaching specific coping strategies (e.g. breathing exercises and journal writing to control emotional outbursts (e.g. verbal aggression)

Beginning 6/2011

Related Services Considered, but not appropriate at this time

Susan will continue taking counseling sessions with either Dr. Jones at CSB or Mrs. Dove the school counselor. The counselors will follow-up directly with Susan and/or her mom if she misses a session. Be sure and include in related services

Susan will sign up for summer counseling 2x a month by July 1, 2011.

Susan will check-in with school counselor by


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Susan will be employed in the Cosmetology field full time within one year of graduation from high

school.

Sept. 3 to set up a monthly schedule for visits during the 2010-2011 school year.

Community Experiences Considered, but not appropriate at this time

Susan will volunteer at SPCA with walk dogs.

Beginning

7/2011

Employment Considered, but not appropriate at this time

Susan will research jobs in customer service (e.g. receptionist, cashier) to work at part-time

Beginning 7/2011

Functional Vocational Evaluation Considered, but not appropriate at this time

Ms. White, Guidance, will arrange at New Horizons upon Susan’s enrollment.

2/2012

Daily Living Skills Considered, but not appropriate at this time

Susan will remember to take her medications without reminders from her mom and will start booking her own doctor’s appointments.

11/1/11

Adult Living Considered, but not appropriate at this time

Susan will continue to live at home with her mom and grandmother for at least a year post high school graduation, but plan to live independently in an apartment within 5 years.

Beginning 6/2014

OTHER Psychiatrist monthly to counsel and monitor medication.

On going


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MEASURABLE POSTSECONDARY EDUCATION GOAL(S) (e.g., higher education, and continuing/adult education):

Susan will enroll in additional cosmetology courses to maintain her skills in the field within two years of graduation from high school.


Susan will learn about how to fill our vocational and college applications in her PLS class, as well as learn how to balance a budget, so that she will be able to save money for the additional education she needs.






Susan will be required to complete a monthly budget based on both a hourly and salary wage in Mr. Barnes business class. Additionally Susan will be required to research scholarships for cosmetology classes.

5/3/2012







OTHER


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MEASURABLE POST SECONDARY TRAINING GOAL(S) (e.g., career and technical education, military service, on-the-job training, apprenticeship):

Susan will receive on the job training at a hair salon within one year of receiving her high school diploma.


Student will be enrolled in cosmetology courses to further gain knowledge in her preferred career field. Susan will learn how to fill out applications and will apply to take the licensure exam. Susan will also be taught how to write a cover letter and resume in Mr. Barnes business class.






Susan will develop resume and cover letter that she can submit to local hair salons.

5/5/2012


Mr. Samuels will be assigned as Susan’s job coach and provide feedback on her professionalism once she obtains a job.

7/1/11

** date dependent on job attainment






OTHER


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MEASURABLE INDEPENDENT LIVING/COMMUNITY PARTICIPATION GOAL(S): Considered, but not appropriate at this time

Susan will obtain a driver’s license within 6 months of graduation. Susan will live with mother one year after graduation in order to save money for an apartment.


Susan will enroll in a driver’s education course and learn about traffic signs while attending Woodside High school. Additionally she will learn how to read a map and learn how to use the bus system in her PLS class. Through Susan’s business and PLS class she will gain practice in balancing a budget for rent, food and transportation costs.






Guidance counselor will enroll Susan in driver’s education with Mr. Burns.

9/2011



Susan’s case manager will assist her in finding information about the local bus system.

11/2011





OTHER


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MEASURABLE ANNUAL GOALS, PROGRESS REPORT

Student Name:__Susan Knowles______________________________________ Date__6__/_15___/_11___ Page ___of___

Student ID Number_________434809801_______________ Area of Need________________________________________

# __1___ MEASURABLE ANNUAL GOAL:

By May 20, 2012 Susan will improve her English grade to at least a B average (85%) as measured by in-class assignments, homework, quizzes and tests.

Objective/Benchmark #1: Susan will turn in 8 out of 10 in-class and homework assignments on time in English 10, with 80% accuracy, by October, 1, 2012.

Objective/Benchmark #2: Susan will communicate with English 10 teacher regarding missing and/or incomplete assignments within 2 days of due date.

# __2___ MEASURABLE ANNUAL GOAL:

During the 2011-2012 school year Susan will come to school and be on-time to all classes 95% of the time as measured by her absentees and tardy slip count.

**According to the school’s attendance record, as of April 11, 2011, Susan is absent and/or tardy to class 25% of the school year.

# 3 Measurable Annual Goal:

By May 2012, Susan will improve her communication with her teachers and peers by participating in class discussion through contributing on average at least 5 relevant comments and questions per day.

**Based on teacher interviews conducted on April 11, 2011 Susan never volunteers to participate relevant comments and/or questions **

# __4__ MEASURABLE ANNUAL GOAL:


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By May 20, 2012 Susan will improve her organizations skills as measured by: (a) correctly recording homework assignments in planner (as confirmed by teacher) and (b) turning in assignments on-time 8 out of 10 times with 85% accuracy.

**Currently Susan turns in 50% of her assignments in late to all of her classes and is missing 2 out of 5 homework assignments in English and Math.

The IEP team considered the need for short-term objectives/benchmarks.

Short-term objectives/benchmarks are included for this goal. (Required for students participating in the VAAP)

Short-term objectives/benchmarks are not included for this goal.

Does this annual goal help the student make progress toward a postsecondary goal? Yes No

If YES, which postsecondary goal?

How will progress toward this annual goal be measured? (check all that apply)

__X__ Classroom Participation

____ Checklist

__X__ Class work

___X_ Homework

____ Observation

__X__ Special Projects

___X_ Tests and Quizzes

____ Written Reports

__X__ Criterion-referenced test:_________________________

__X__ Norm-referenced test: ___________________________

____ Other: _______________________________________

Progress on this goal will be reported to the parent or adult student using the following codes. Attach comments using progress report comment form located in section two.

Anticipated Date of Progress Report* 10/15/11 12/01/11 02/15/11 04/15/11 06/01/11

Actual Date of Progress Report

Progress Code


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SP -The student is making Sufficient Progress to achieve this annual goal within the duration of this IEP.

IP -The student has demonstrated Insufficient Progress to meet this annual goal and may not achieve this goal within the duration of this IEP.

ES - The student demonstrates Emerging Skill but may not achieve this goal within the duration of this IEP.

NI -The student has Not been provided Instruction on this goal.

M -The student has Mastered this annual goal.

* Progress reports will be provided at least as often as parents are informed of the progress of their children without disabilities.


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SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT

ACCOMMODATIONS/MODIFICATIONS

Student Name___ Susan Knowles ____________________________________ Date__6__/_15___/_11___ Page ___of___

Student ID Number_____434809801______________________________

This student will be provided access to general education classes, special education classes, other school services and activities including nonacademic activities and extracurricular activities, and education related settings:

___ with no accommodations/modifications

__X_ with the following accommodations/modifications

Accommodations/modifications provided as part of the instructional and testing/assessment process will allow the student equal opportunity to access the curriculum and demonstrate achievement. Accommodations/modifications also provide access to nonacademic and extracurricular activities and educationally related settings. Accommodations/modifications based solely on the potential to enhance performance beyond providing equal access are inappropriate.

Accommodations may be in, but not limited to, the areas of time, scheduling, setting, presentation and response. The impact of any modifications listed should be discussed.

ACCOMMODATIONS/MODIFICATIONS (list, as appropriate)

Accommodation(s)/Modification(s) Frequency Location

(name of school *)

Instructional Setting

Duration

m/d/y to m/d/y


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Extra Time on Tests As needed Resource Room 09/01/11-

06/30/12

Allowed to request break from class

to go to guidance when

overwhelmed

As needed Guidance Office 09/01/11-

06/30/12

Option to take tests and quizzes in

small group and have items read

aloud.

As needed Resource Room 09/01/11-

06/30/12

Student will self-monitor

organization skills by checking-in

with teacher to ensure homework is

written correctly.

Daily

Across classroom

environments in

General Ed

classes.

09/01/11-

06/30/12

* IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns about the location of the services or refuses the proposed site. A listing of more than one anticipated location is permissible, if the parents do not indicate that they will object to any particular school or state that the team should identify a single school.

Additional Supports for School Personnel: (Describe supports such as equipment, consultation, or training for school staff to meet the unique needs for the student)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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SERVICES – LEAST RESTRICTIVE ENVIRONMENT – PLACEMENT, Continued

PARTICIPATION IN THE STATE AND DIVISION-WIDE ACCOUNTABILITY/ASSESSMENT SYSTEM

Student Name Susan Knowles____________________________________ Date __6__/__15__/__11__ Page ___of___

Student ID Number______434809801____________________________

This student’s participation in state and division-wide assessments must be discussed annually. During the duration of this IEP:

Will the student be at a grade level or enrolled in a course for which the student must participate in a state and/or division-wide assessment? If yes, continue to next question.

XYes No

Based on the Present Level of Academic Achievement and Functional Performance, is this student being considered for participation in the Virginia Alternate Assessment Program (VAAP), which is based on Aligned Standards of Learning? If yes, complete the “VAAP Participation Criteria”.

Yes X No

Does the student meet the VAAP participation criteria? If yes, refer to the Aligned Standards of Learning for development of annual goals and short-term objectives or benchmarks.

Yes X No

Based on the Present Level of Academic Achievement and Functional Performance, is this student being considered for participation in the Virginia Substitute Evaluation Program (VSEP)? If yes, complete the “VSEP Participation Criteria” for each content considered.

Yes X No

Does the student meet the “VSEP participation criteria”? If yes, determine for specific content area.. Yes X No

Based on the Present Level of Academic Achievement and Functional Performance, is this student being considered for participation in the Virginia Grade Level Alternative (VGLA)? If yes, complete the “VGLA Participation Criteria” for each content considered and attach justification statement.

Yes X No

Does the student meet the VGLA participation criteria? If yes, determine for specific content area. Yes X No

Based on the Present Level of Academic Achievement and Functional Performance, is this student Yes X NoVirginia Department of Education -- Sample Transition IEP Form—Revised August 25, 2010

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being considered for participation in the Virginia Modified Achievement Standards Test (VMAST)? If yes, complete the “VMAST Participation Criteria” for each content considered.

Does the student meet the VMAST participation criteria? If yes, determine for specific content area. Note: VMAST will be available as an assessment option beginning in Spring 2012 in mathematics.

Yes X No

If “yes” to any of the above, check the assessment(s) chosen and attach (or maintain in student’s educational record) the assessment page(s), which will document how the student will participate in Virginia’s accountability system and any needed accommodations and/or modifications.

State Assessments:

__X_ SOL Assessments and retake (SOL) Reading Math Science History/Social Science Writing

___ Virginia Substitute Evaluation Program* (VSEP) Reading Math Science History/Social Science Writing

___ Virginia Grade Level Alternative* (VGLA) Reading Math Science History/Social Science Writing

___ Virginia Modified Achievement Standards Test* (VMAST) Math (beginning Spring 2012)

___ Virginia Alternate Assessment Program** (VAAP)

___ Other State Approved Substitute(s): ______________________________

Division-wide Assessment (list):

_English 10 Writing Benchmarks____November, 2011 and March, 2012_____________

_Geometry_________________March 2012_____________________________________________

__Biology___________________ March 2012_________________________________________

* Refer to Procedures for Determining Participation in the Assessment Component of Virginia’s Accountability System

and the Implementation Manuals for VGLA, VSEP and/or VMAST. Note: VGLA in math will no longer be available

as an assessment option after the Spring 2011 test administration.

** Refer to Virginia Alternate Assessment Program (VAAP) Participation Criteria and Implementation Manual.


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PARTICIPATION IN THE STATE AND DIVISION-WIDE ACCOUNTABILITY/ASSESSMENT SYSTEM (continued)

Student Name_____________Susan Knowles________________ Date __6__/__15__/_11___ Page ___of___

Student ID Number_______________434809801___________

PARTICIPATION IN STATEWIDE ASSESSMENTS

Test

Assessment Type*

(SOL, VGLA, VSEP, VMAST1, VAAP, or Board of Education Approved Substitute)

Accommodations** If yes, list accommodation(s)

Reading _________SOL_________________________________

Not Enrolled in Course w/ EOC Assessment

Yes No

Small Group, Extended time

Math ________SOL__________________________________


Yes No

Small group, extended time

Science ______________SOL____________________________


Yes No


History/SS ______SOL____________________________________


Yes No



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Writing _______SOL___________________________________


Yes No


* An IEP team may not exempt a student from participation in a content area assessment, only determine how the student will be assessed.

** Accommodation(s) must be based upon those the student generally uses during classroom instruction and assessment. For the accommodations that may be considered, refer to “Accommodations/Modifications” page of the IEP.

1 VMAST will be available in mathematics 3-8 and EOC Algebra I beginning with the Spring 2012 test administration.

Division-wide Assessment (list):

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

EXPLANATION FOR NON-PARTICIPATION IN REGULAR STATE OR DIVISION-WIDE ASSESSMENTS

If an IEP team determines that a student must take an alternate assessment instead of a regular state or division-wide assessment, explain in the space below why the student cannot participate in this regular assessment; why the particular assessment selected is appropriate for the student, including that the student meets the criteria for the alternate assessment; and how the student’s nonparticipation in the regular assessment will impact the child’s promotion, graduation with a modified standard, standard, or advanced studies diploma; or other matters. Refer to the VDOE’s Procedures for Participation of Students with Disabilities in Virginia’s Accountability System for guidance.

Alternate/Alternative Participation Criteria is attached or maintained in the student’s educational record

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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Student Name_____________________Susan Knowles________________ Date__6__/_15___/__11__ Page ___of___

Student ID Number __________434809801_______________

Least Restrictive Environment (LRE)

Service(s) Frequency Location

(name of school **)

Instructional

Setting

Duration

m/d/y to m/d/y

Personal Life Skills 150 minutes/

week; 30 minutes

daily

Somewhere H.S. Self contained 9/8/11-6/15/12

English Support 150 Minutes/

week; 30 minutes

daily

Somewhere H S Self contained 9/8/11-6/15/12

math 300 minutes/

week; 60 minutes

daily

Somewhere H. S. General education

class

9/8/11-6/30/12

“Check & Connect” services Daily Resource room 9/8/11-6/30/12


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(student will

check – in with

case manager

before and after

school.)

Extended School Year Services: (see attached summary sheet as a means to document discussion)

The IEP team determined that the student needs ESY services.

The IEP team determined that the student does not need ESY services. Describe. Need to note this

* These services are listed on the “Accommodations/Modifications” page and “Extended School Year Services” page, as needed.

** IEP teams are required to identify the specific school site (public or private) when the parent expresses concerns about the location of the services or refuses the proposed site. A listing of more than one anticipated location is permissible, if the parents do not indicate that they will object to any particular school or state that the team should identify a single school.


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Student Name___________________Susan Knowles________________ Date__6__/_15___/_11___ Page ___of___

Student ID Number_________434809801___________________

PLACEMENT

No single model for the delivery of services to any population or category of children with disabilities is acceptable for meeting the requirement for a continuum of alternative placements. All placement decisions shall be based on the individual needs of each student. The team may consider placement options in conjunction with discussing any needed supplementary aids and services, accommodations/modifications, assistive technology, and supports for school personnel. In considering the placement continuum options, check those the team discussed. Then, describe the placement selected in the PLACEMENT DECISION section below. Determination of the Least Restrictive Environment (LRE) and placement may be one or a combination of options along the continuum.

Placement Continuum Options Considered (check all that have been considered):

Services provided in:

__X_ general education class(es)

__X_ special class(es)

___ special education day school

___ state special education program / school

___ residential facility

___ home-based

___ hospital


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___ other (describe):

PLACEMENT DECISION: ____________________________________

Based upon identified services and the consideration of least restrictive environment (LRE) and placement continuum options, describe in the space below the placement. Additionally, summarize the discussions and decision around LRE and placement. This must include an explanation of why the student will not be participating with students without disabilities in the general education class(es), programs, and activities. Attach additional pages as needed.

Explanation of Placement Decision:

Susan will receive the majority of her instruction in the general education classroom with her peers. She will receive small group instruction for two of her classes (Personal Life skills and English Support) in order to provide her remedial instruction in areas in which she has weakness (e.g., writing) in order for her to improve her foundational understanding of concepts that are expected of her to know in her general curriculum classes.


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PRIOR NOTICE AND PARENT CONSENT

Student Name____________Susan Knowles______________________________ Date__6__/__15__/_11___ Page ___of___

Student ID Number______434809801______________

PRIOR NOTICE

The school division proposes to implement this IEP. This proposed IEP will allow the student to receive a free appropriate public education in the least restrictive environment. This decision is based upon a review of current records, current assessments and the student’s performance as documented in the Present Level of Academic Achievement and Functional Performance. Other options considered, if any, and the reason(s) for rejection is attached, or can be found in the Placement Decision section of this IEP. Additionally, other factors, if any that are relevant to this proposal are attached. Parent and adult student rights are explained in the Procedural Safeguards. If you, the parent(s) and adult student, need another copy of the Procedural Safeguards or need assistance in understanding this information please contact ________________________________ at (___) ____________ or e-mail ________________________________ or

________________________________ at (___) ____________ or e-mail ________________________________ .

____ Parent(s) initials here indicate that the parent(s) has read the above prior notice and attachments, if any, before giving permission to implement this IEP.

PARENT/ADULT STUDENT CONSENT: Indicate your response by checking the appropriate space and sign below.

___ I give permission to implement this IEP.

___ I do not give permission to implement this IEP.

________________________________________________________ ____/____/____


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Parent Signature or Adult Student Signature (if appropriate) Date

TRANSFER OF RIGHTS AT THE AGE OF MAJORITY (age 18):

Indicate the date that the student and parent were informed of the transfer of parental rights under IDEA to the adult student at the age of 18. This must occur at least one year prior to the age of 18.

_____________________ ___________________________________________________

Date School Official Signature

I was informed of the parental rights under IDEA and that these rights transfer to me at age 18.

_____________________ ___________________________________________________

Date Student Signature

I was informed of the parental rights under IDEA that transfer to my child at age 18.

_____________________ ___________________________________________________

Date Parent Signature


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SECTION 2

Additional Forms

To Be Used

As Needed


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PROCESS CHECKLIST

Meeting Notices sent to parent, student, and agency representatives, as appropriate

Acquire written consent from parent or age of majority student for an agency representative attend the IEP meeting

Welcome and introductions of team members

Review purpose of meeting

Review meeting agenda

Review rights and procedural safeguards pertaining to special education and the IEP meeting

Review of special factors to be considered by the IEP team

Develop Present Level of Academic Achievement and Functional Performance

Determine postsecondary goals; based upon age appropriate transition assessment

Determine if Virginia Alternate Assessment Program (VAAP) is a consideration (VAAP Participation Criteria must be completed to make this decision.)

Discuss school graduation/exit and secondary transition status

Determine postsecondary goals and transition services (beginning no later than the year student turns age 14, or younger)

Develop measurable annual goals (Discuss progress report on previous annual goals, as needed.)

Determine progress report schedule

Document that the IEP team considered the need for short-term objectives or benchmarks for students other than those who take alternate assessments aligned to alternate achievement standards

Develop short-term objectives or benchmarks for the annual goals, as needed

Determine any needed accommodations and/or modifications in instruction and assessment

Determine participation in state and division-wide assessments

Determine services and placement

Determine if student needs ESY services

Review any requests proposed and/or refused

Provide prior written notice and obtain parental (or adult student) consent

Identify how staff will be informed of their responsibilities for implementation of the IEPVirginia Department of Education -- Sample Transition IEP Form—Revised August 25, 2010

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If the student will be leaving FAPE; provide a Summary of Performance


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SAMPLE

School Division Letterhead

CONSENT TO INVITE AGENCY PERSONNEL

Date: _____________

If the division intends to invite a representative of any agency that is likely to be responsible for providing or paying for transition services to the IEP meeting, written consent from the parent or adult student is required prior to the meeting date.

_____ I give my consent for an agency representative(s) named on the meeting notice to be invited to the IEP meeting.

_____ I do not give my consent for an agency representative(s) named on the meeting notice to be invited to the IEP meeting.


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Parent/Adult Student Signature Date

________________________________________ ______________________

Parent/Adult Student Signature Date

**Please sign and return this page to your child’s IEP Case Manager.


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