Completed Sample IEP

Eileen Bailey Health Guide October 27, 2009
  •  Do you wonder what type of information should be included in an IEP? The following provides a basic IEP, filled out for you to review. You can print out a blank sample IEP as well, and complete information specific to your child.


    For more information:


    Documentation and Reports to Bring to an IEP Meeting

    The Difference Between Accommodations and Modifications

    When Parents Feel Their Child Needs Special Accommodations

    Suggestions for IEPs and Section 504s

    How IDEA Applies to Children with ADHD


    Next week, I'll provide tips to help you write an IEP for your child.


    IEP For School Age Children

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    School: Western Middle School


    Student Name:     Jennifer McCormick                  Student ID#  123456


    Age:      12                                           Date of Birth:  June 23,1997


    Disability Classification:  Learning Disabled/ADHD


    Student Information:  


    Street: 123 Barton Road


    City: Any City


    State/Zip:            55555


    Phone:  555-555-5555                                            


    County: Any County


    Current Grade: 7th Grade


    Ethnic Group: Caucasian


    Gender: Female


    Native Language: English


    Interpreter Needed:    Yes    **No


    Medical Alerts: None




    Additional Information:


    Jennifer has been diagnosed with Learning Disabilities and ADHD.




    Parent/Guardian Information


    Parent/Guardian Name(s): Thomas and Marta McCormick 


    Street: 123 Barton Rd       


    City: Any City


    State/Zip: PA


    Phone:  555-555-5555                                                        


    County: Any County


    Ethnic Group: Caucasian


    Native Language: English


    Interpreter Needed:    Yes   ** No



    General IEP Information


    Date of Initial Referral:  09     /    15      /     2009


    Date of Initial IEP Meeting:    10      /   15        /2009


    Date IEP Initially Implemented:         /            /   


    Projected Date of Next Review:  04        /     15       /   2009



    Current Meeting


    Date: 10      /  15            / 2009


    Type of Meeting:     **Initial             Requested Review            Annual Review




    Joan Carson (School Psychologist)

    Thomas Dunn (Principal)

    Roberta Davis (Teacher

    Theresa Snyder (Teacher)

    Thomas McCormick (Parent)

    Marta McCormick (Parent)






    If Requested Review, Reason for Request:



    Current Student Needs


    Student Strengths:


    Positive responses to positive reinforcement programs

    High level in mathematics

    Desire to do well

    Gets along with other

    Enjoys drawing



    Parent Concerns:


    Below grade level in reading

  • Difficulties with spelling and writing

    Takes extended amounts of time to complete homework each night

    Forgets assignments or materials/books to complete assignments




    Teacher Concerns:


    Behavior issues within the classroom, can be disruptive

    Problems with fluency in reading

    Poor spelling and writing skills

    Misses completing or handing in assignments

    May understand work but performs poorly on tests



    Student Needs


    Specific Student Needs: (list assistive technology, use of Braille, limited English proficiency, etc.)



    Specific Ways Disability Interferes with Academic Abilities:

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    Comprehending 7th grade curriculum, especially when reading and writing required

    Reading Comprehension

    Staying organized

    Coming to class prepared

    Taking tests within allotted time



    Transitional Needs: (based on student's age)



    Not applicable



    Current Student Performance and Accommodations


    (Please attach copy of most recent evaluations, report card and state or district performance tests.)


    Current level of knowledge, level of intellectual functioning, expected rate of progress, current accommodations:


    In reading, Jennifer is currently testing on a 5.9 grade level but has been making progress

    She has decoding skills

    Fluency is hindered by word recognition

    Reading comprehension is difficult, Jennifer can read a paragraph but not retain the information as she does not grasp the concept immediately

    Jennifer does well in math, she is currently working on grade level in math



    Social Development and Current Accommodations:


    Jennifer does get along well with classmates but can be disruptive at times. She is likable and friendly but can be hyperactive and have a difficult time focusing, possibly because of her energy level.

    Because this is an initial evaluation Jennifer does not have any formal, current accommodations however, her teachers have been giving spelling tests orally rather than written and she has responded well to this.



    Physical Development and Current Accommodations:


    Not applicable


    Annual Goals



    Goal: Will be reading on a 6th grade level by 4/15/2010


    Procedures for Evaluation: Use current testing procedures to determine reading level


    Evaluation Schedule: Test between 4/1/2010 and 4/10/2010 so results will be available for follow up meeting on 4/15/2010 



    Goal: Jennifer will raise her hand during class time for attention


    Procedures for Evaluation: Teacher will provide tick mark each time Jennifer calls out and disrupts class without raising her hand


    Evaluation Schedule: Teacher will share information with parents on a daily basis on whether Jennifer succeeded in raising her hand during class that day.




    Goal: Raise spelling test scores to be above 80% each week



    Procedures for Evaluation: Spelling tests will continue to be given orally


    Evaluation Schedule: Teacher will share spelling test grade with parents weekly via email.


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    Recommendation Services and Programs


    (Include Special Education Services, Related Services, Modifications/Accommodations, Assistive Technology, Aids)


    Service: Provide spelling tests orally


    Frequency: Weekly


    Duration: Remainder of school year


    Location: Jennifer will take spelling tests in the resource room


    Start Date: 10/15/09


    End Date: Continue until end of school year 2010




    Service: Jennifer will be given extended time for completing tests


    Frequency: For all tests


    Duration:Until the end of the school year


    Location: Within the regular classroom


    Start Date:10/15/2009


    End Date: End of school year 2010




    Service: Jennifer will have an extra set of books at home


    Frequency: N/A


    Duration: Until the end of the school year 2010


    Location: N/A


    Start Date: 10/15/2009


    End Date: June 2010




    Service: Seating in the front of the classroom


    Frequency: Every day


    Duration: Until review of IEP


    Location: Within regular classroom


    Start Date: 10/15/2009


    End Date: 4/15/2010




    Service: Teachers will provide a written study guide 3-4 days prior to tests


    Frequency: Before each test


    Duration: Until IEP review


    Location: Within regular Classroom


    Start Date: 10/15/2009


    End Date: 4/15/2010






    Testing Accommodations for State and District Achievement Tests


    Is Student Eligible for Testing Accommodations:  Yes     **No


    Student Will Participate in Testing:  **Yes      No


    If No, Reason Why Student Should Not Participate:






    Student Will Participate With:            **Grade Level Peers           Chronological Peers


    Testing Accommodation: None at this time, will review needs again at follow up meeting in April 2010


    Conditions for Accommodations:




    Testing Accommodation: None at this time, will review needs again at follow up meeting in April 2010


    Conditions for Accommodations:




    Testing Accommodation: None at this time, will review needs again at follow up meeting in April 2010


    Conditions for Accommodations: