The Individualized Education Program (IEP)

The Individualized Education Program (IEP)
Students Name
Course
Subject
Professor
Date
Special Education Department
Individualized Education Program (IEP)
Student Name:Student Data/Cover Sheet (Form A-1)IEP Meeting Date:
Student ID:DOB:
Demographic Information

Student Number:

Student Name:

Birthdate:

Gender:

Grade:


Student Address:

Home Phone:

City, State, Zip:

Parent 1 Name:

Parent 1 Relationship:

Parent 1 Address:

Home Phone:

City, State, Zip:

Work Phone:

Parent 1 Email:

Parent 2 Name:

Parent 2 Relationship:

Parent 2 Address:

Home Phone:

City, State, Zip:

Work Phone:

Parent 2 Email:

Primary Language of Home:

Primary Language Survey Date:
Primary Language Survey Results:

Language of Instruction:

Home District:
Attendance District:

Service Coordinator:

Home School:

Attending School:

Vision Screened On:

Results:

Hearing Screened On:

Results:

Meeting Date:

Anticipated Duration of IEP:
To

Re-evaluation Due:
Current Evaluation:

Special Education Primary Category #1:

Special Education Eligibility Category #2:

Special Education Eligibility Category #3:

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

Level of Services: (A)

Type: of Meeting:

Date Meeting Notice Sent to the Parent (s):

Date Procedural Safeguards given to the Parent (s):


Special Education Department
Individualized Education Program (IEP)
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)










*If during the IEP year the student turns 16, if the student is not present at the IEP meeting, the service coordinator must review the IEP with the student and obtain the student’s signature and the date of this review.
Special Education Department
Individualized Education Program (IEP)
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Section 1: Current IEP Information
Goal Number Written:
Summarize special education services the student is receiving:
Section 2: Evaluation Information
Areas of Eligibility
Special Education Primary Category:
Special Education Eligibility Category #2:
Special Education Eligibility Category #3:
For students with SLD only, the following area(s) of eligibility was previously determined:
Section 3: Present Level of Academic Achievement
READING
WRITING
MATH
Parent’s Input on Student’s Current Academic Achievement:
Current Classroom-Based Data:
State and District Assessments:
Section 4: Functional Performance
Social Emotional a...