Sample IEP

Health Writer

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:

Social Development and Current Accommodations:

Physical Development and Current Accommodations:

Annual Goals

Goal:

Evaluation Criteria:

Procedures for Evaluation:

Evaluation Schedule:

Goal:

Evaluation Criteria:

Procedures for Evaluation:

Evaluation Schedule:

Goal:

Evaluation Criteria:

Procedures for Evaluation:

Evaluation Schedule:

Goal:

Evaluation Criteria:

Procedures for Evaluation:

Evaluation Schedule:

Recommendation Services and Programs

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

Service:

Frequency:

Duration:

Location:

Start Date:

End Date:

Service:

Frequency:

Duration:

Location:

Start Date:

End Date:

Service:

Frequency:

Duration:

Location:

Start Date:

End Date:

Service:

Frequency:

Duration:

Location:

Start Date:

End Date:

Service:

Frequency:

Duration:

Location:

Start Date:

End Date:

Service:

Frequency:

Duration:

Location:

Start Date:

End Date:

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:

Conditions for Accommodations:

Testing Accommodation:

Conditions for Accommodations:

Testing Accommodation:

Conditions for Accommodations: