Individualized Education Program Template

Individualized Education Program Template
SPED/500 Version 2 / 1

University of Phoenix Material

Individualized Education Program Template

Learner Information

Name
Date of Birth
Home Address
Home Phone Number
Parent or Legal Guardian Name
Parent or Legal Guardian Home Address
Parent or Legal Guardian Home Phone Number
Eligibility
Annual Review Date
Re-evaluation Date

IEP Meeting Attendees

Learner
Parent or Legal Guardian
Special Education Teacher
General Education Teacher
Speech Therapist
Local Education Agency (LEA)
Physical Therapist
Occupational Therapist
Others (state name and title)

Present Levels of Performance

Learner’s Strengths
Health/Medical Concerns
Present Level of Academic Performance
Present Level of Functional Performance
Adverse Effects:
Describe the effect of this individual's disability on involvement and progress in the general education curriculum and on the functional implications of the learner’s skills.
*For a preschool child, describe the effect of this individual's disability on involvement in appropriate activities.
*By age 14 1/2, describe the effect of this individual's disability on the pursuit of postsecondary expectations (living, learning, and working).

Goal #1 – Annual Goal

Goal Statement
Implementer (Special Education Teacher, General Education Teacher, Speech Therapist, Social Worker, Other-Please Specify)
Type of Goal (Academic, Functional, Transition)
Objective #1
Criterion for Mastery (Number of Attempts, Accuracy)
Evaluation Procedure (Observation, Daily Class Work, Charting, Tests)
Objective #2
Criterion for Mastery (Number of Attempts, Accuracy)
Evaluation Procedure (Observation, Daily Class Work, Charting, Tests)
Objective #3
Criterion for Mastery (Number of Attempts, Accuracy)
Evaluation Procedure (Observation, Daily Class Work, Charting, Tests)

Goal #2 – Annual Goal

Goal #3 – Annual Goal

Goal #4 – Annual Goal

Goal #5 – Annual Goal

Educational Accommodations

Transition
Consideration of service needs, goals, and support/services is required (by age 14 1/2, the team must address transition service needs).
Yes, No, or N/A
Considerations of Special Factors
All learners—assistive technology and devices.
Yes or No
Considerations of Special Factors
All learners—communication needs.
Yes or No
Considerations of Special Factors
Deaf or hard of hearing learners—language and communication needs.
Yes or No
Considerations of Special Factors
Blind or visually impaired learners—provision of Braille instruction.
Yes or No
Considerations of Special Factors
Behavior—the learner’s behavior impedes his or her own learning or the learning of others. If yes, a functional behavior assessment must be completed and a behavior intervention plan must be developed.
Yes or No
Supplementary Aids, Accommodations, and Modifications
List the specific aids, accommodations, and modifications that are required for the learner to progress toward his or her annual goals and objectives.

Assessment

Classroom-Based Assessment
Learner requires accommodations to participate in classroom-based assessments.
Yes or No
Classroom-Based Assessment
Learner requires alternate assessments/methods to participate in classroom assessments.
Yes or No
District Assessment
Learner will participate in district assessments without accommodations.
Yes or No
District Assessment
Learnerwill participate in district assessments with accommodations.
Yes or No
District Assessment
Learnerwill not participate in district assessments.
Yes or No
If learner will not participate, state why.
State Assessment
Learnerwill participate in state assessments without accommodations.
Yes or No
State Assessment
Learnerwill participate in state assessments with accommodations.
Yes or No
State Assessment
Learnerwill not participate in state assessments.
Yes or No
If learner will not participate, state why.
Accommodations
Please list all of the appropriate accommodations to be used during assessments.

Educational Services and Placement

General Education: No Supports / General Education: With Supports, Accommodations, and Modifications / Special Education in the General Education Classroom (Class and Minutes) / Special Education Outside of the General Education Classroom (Class and Minutes)
Related Services / Number of Minutes Per Week
Speech
Occupational Therapy
Physical Therapy
Social Work
Other-Please Specify
Other-Please Specify