IEP For School Age Children
School:
Student Name: Student ID#
Age: / / Date of Birth:
Disability Classification:
Student Information:
Street:
City:
State/Zip:
Phone: Alternate Phone:
County:
Current Grade:
Ethnic Group:
Gender:
Native Language:
Interpreter Needed: Yes No
Medical Alerts:
Additional Information:
Parent/Guardian Information
Parent/Guardian Name(s):
Street:
City:
State/Zip:
Phone: Alternate Phone:
County:
Ethnic Group:
Gender:
Native Language:
Interpreter Needed: Yes No
General IEP Information
Date of Initial Referral: / /
Date of Initial IEP Meeting: / /
Date IEP Initially Implemented: / /
Projected Date of Next Review: / /
Current Meeting
Date: / /
Type of Meeting: Initial Requested Review Annual Review
Attendees:
If Requested Review, Reason for Request:
Current Student Needs
Student Strengths:
Parent Concerns:
Teacher Concerns:
Student Needs
Specific Student Needs: (list assistive technology, use of Braille, limited English proficiency, etc.)
Specific Ways Disability Interferes with Academic Abilities:
Transitional Needs: (based on student’s age)
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:
