Individualized Education Program (IEP) for Grade Two

IEP Performance Template-Standard 2-4
Student’s Name
Institutional Affiliation
Course
Instructor
Date
Special Education Department
Individualized Education Program (IEP)
Student Name: Jane Doe (Pseudonym)Student Data/Cover Sheet (Form A-1)IEP Meeting Date: 30/3/2023
Student ID: 356DOB: 16/08/2015
Demographic Information

Student Number:
356

Student Name:
Jane Doe

Birthdate:
16/8/2015

Gender:
Female

Grade:
2


Student Address:
N/A

Home Phone:
N/A

City, State, Zip:

Parent 1 Name:
Eve Mendoza

Parent 1 Relationship:
Mother

Parent 1 Address:
N/A

Home Phone:
N/A

City, State, Zip:

Work Phone:

Parent 1 Email:

Parent 2 Name:
Nikolai Stonebridge

Parent 2 Relationship:
Father

Parent 2 Address:
N/A

Home Phone:
N/A

City, State, Zip:

Work Phone:

Parent 2 Email:

Primary Language of Home:
Spanish

Primary Language Survey Date: 12/2/2023
Primary Language Survey Results: 13/2/2023

Language of Instruction:
English

Home District:
Attendance District:

Service Coordinator:

Home School:

Attending School:

Vision Screened On:
13/2/2023

Results: Passed

Hearing Screened On:
13/2/2023

Results: Passed

Meeting Date: 30/3/2023

Anticipated Duration of IEP:
15/2/2023 To 29/3/2023

Re-evaluation Due:
Current Evaluation:

Special Education Primary Category #1: Language Processing Disorder

Special Education Eligibility Category #2: Speech sound disorder

Special Education Eligibility Category #3:

For Students with SLD only, the following area(s) of eligibility was/were previously determined:
The learner expressed dyslexia

Level of Services: (A) Average Participation

Type: of Meeting: Annual IEP Review Meeting

Date Meeting Notice Sent to the Parent(s): 28/3/2023

Date Procedural Safeguards given to the Parent(s): 29/3/2023


Special Education Department
Individualized Education Program (IEP)
Student Name: Jane DoeStudent Data/Cover Sheet (Form A-2)IEP Meeting Date: 30/3/2023
Student ID: 356DOB: 16/8/2015
The following persons participated in the conference and/or the development of the IEP. Additionally, parents have been given a copy of their rights regarding the student’s placement in special education and understand that they have the right to request a review of their child’s IEP at any time.
Position/Relation to Student Participant Date (MM/DD/YY)

Father Nikolai Stonebridge 30/3/2023

Mother Eve Mendoza 30/3/2023

Special Education Teacher 30/3/2023

General Education Teacher ...