DEPARTMENT OF DEFENSE EDUCATION ACTIVITY
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student Information
Name: _________________________________ |
ID Number: ___________ |
DOB: ____________ |
Disability: ______________________________ |
Native Language: _____________ |
Grade: ____ |
Date of IEP Meeting: _____________________ |
IEP Implementation Date: ______________________ |
Annual Review Date: _____________________ |
Triennial Review Date: ________________________ |
Type of IEP: |
Initial |
Annual Review |
Triennial |
Modified |
Draft |
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* For initial IEP, parent signature on the IEP indicates consent for provision of services. |
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Special Education Services (Direct Services to Student) |
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Type of Service |
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Location |
Anticipated |
Time |
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Start Date |
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End Date |
Service Provider |
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Frequency |
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Related Services (Direct Services to Student)
Anticipated Time Frequency
Projected |
Start Date/ |
No. Sessions |
End Date |
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Consultation (Indirect Services to School/Community Personnel and Parent only)
Signatures: |
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____________________________________________ |
__________________________________________ |
Parent/Guardian |
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Administrator |
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__________________________________________ |
Student (as appropriate) |
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Special Education Teacher |
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__________________________________________ |
General Education Teacher |
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Privacy Act Notice: Authority to Collect Information: 20 U.S.C. 927(c) and 10 U.S.C. 2164(f), as amended; E.O 9387; the Privacy Act of 1974, as amended, 5 U.S.C.
552a. Principal Purpose: The information will be used within the DoD to determine the services to be provided to a student to assist the child to receive a free appropriate public education. Disclosure to the Agency of the information requested on this form is voluntary; but failure to provide all requested information may result in the delay or denial of student services. DoDEA may disclose information requested in this form to other DoD activities and contracted service providers who require the information to deliver educational services to the child and for valid medical, law enforcement or security purposes, or for use in litigation concerning the delivery of student. Routine Uses: Disclosure of information contained in this form is authorized outside the DoD in accordance with the “Blanket Routine Uses” described at the beginning of the Office of the Secretary of Defense’s compilation of systems of records notices, published at http://www.defenselink.mil./privacy/notice/osd.
DoDEA Form 2500.13-G-F26, September 2005 |
Page 1 of 6 |
Student’s Name: _____________________________ ID: ___________ Date: _____________________
ACCOMMODATIONS/SPECIAL CONSIDERATIONS
Physical Education:
Modifications Required:
Transportation:
Modifications Required:
Standardized Testing: Student will participate without accommodations
Student will participate with accommodations
Testing not required for this grade level (KN, 1, 2 and 12)
Student will participate in an alternate assessment
Accommodations:
Special factors the IEP team has determined the student requires. Each “Y” (yes) must be addressed on a goal page.
Braille |
__ y __ n |
Limited English Proficiency |
__ y __ n |
Behavior |
__ y __ n |
Communication Needs |
__ y __ n |
Assistive Technology __ y __ n |
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Consideration of Extended School Year
IEP team needs to collect additional data in order to make this determination and will meet again by: __________
IEP team has determined that documentation does not support the need for extended school year services.
IEP team has determined that the record shows student’s inability to recoup skills within a reasonable time following regression and recommends extended school year services (attach documentation).
COMMENT:
Accommodations/Modifications in General and Special Education
DoDEA Form 2500.13-G-F26, September 2005 |
Page 2 of 6 |
Student’s Name: _____________________________ |
ID: ___________ |
Date: _____________________ |
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VOCATIONAL EDUCATION/TRANSITION SERVICES
For Students 14 years of age and older
Identify skills, courses, and experiences the student must have to better prepare the student for post-secondary transition.
Vocational Education:
Modifications Required:
Transition Statement:
Student’s interests:
Student’s strengths/capabilities:
Desired Post-Secondary Outcomes/Anticipated Post-School Setting
Employment
Education
Adult Living
Based on the student’s interests, needs, and desired post-secondary outcomes, the IEP team has determined specialized transition services and/or supports are needed in the following area(s). Each area checked must be addressed on a goal page.
__ Academic Learning |
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__ Career Planning |
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__ Employment |
__ Daily Living Skills |
__ Financial Planning |
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__ Health/Medical |
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__ Legal Services |
__ Leisure/Recreation |
__ Living Arrangements |
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__ Self Advocacy |
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__ Transportation |
__ Social Relationships |
__ Community Participation |
__ Post-secondary Training |
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__ Other |
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Graduation Plan: |
__Regular Graduation Plan |
__IEP – graduation based on IEP goals/objectives |
Transfer of Rights at Age of Majority
Notice was given to the student and parent at least one year prior to reaching the age of majority (18) informing the student of his/her rights under IDEA that will be transferred to the student upon reaching the age of majority (18).
Date notice was given ________________ |
Date student reaches age of majority ________________ |
DoDEA Form 2500.13-G-F26, September 2005 |
Page 3 of 6 |
Student’s Name: _____________________________ ID: ___________ Date: _____________________
__________________________________________________________________________________________________
GOALS and OBJECTIVES
Area:
Need:
Present Level of Performance:
Service Provider(s):
Annual Goal:
Annual Goal:
Short Term Objectives
Annual Goal:
Short Term Objectives
DoDEA Form 2500.13-G-F26, September 2005 |
Page 4 of 6 |
Student’s Name: _____________________________ ID: ___________ Date: _____________________
__________________________________________________________________________________________________
GOALS and OBJECTIVES
Area:
Need:
Present Level of Performance:
Service Provider(s):
Annual Goal:
Annual Goal:
Short Term Objectives
Annual Goal:
Short Term Objectives
DoDEA Form 2500.13-G-F26, September 2005 |
Page 5 of 6 |
Student’s Name: _____________________________ |
ID: ___________ |
Date: _____________________ |
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LEAST RESTRICTIVE ENVIRONMENT
In making the program decision, the following factors were considered by the IEP team in selecting the least restrictive environment.
__ Placement of the student is based on his/her individual needs.
__ Student is educated, to the maximum extent appropriate, with students who do not have disabilities.
__ Removal from general education only when the nature and severity of the student’s educational needs are such that education in the general education program with supplementary support and services cannot be achieved satisfactorily.
__ Participation with general education students, to the maximum extent appropriate, in school activities.
__ Placement is as close as possible to the student’s home or in the school she/he would attend if not disabled.
Justification for Placement: Explanation of the extent, if any, to which the student will not participate with non-disabled peers. Describe how the student’s disability affects his/her involvement and progress in the general curriculum. For preschool children, indicate how the child’s disability affects his/her participation in appropriate activities.
Student Progress: Parents will be informed of their child’s progress in meeting the goals of his/her IEP on the same timeline as non-disabled students. DoDEA requires the reporting of student progress on a quarterly basis.
Method by which the student’s progress will be reported. _______________________________________
If progress will be reported more frequently, indicate schedule for reporting the student’s progress. ______________
DoDEA Form 2500.13-G-F26, September 2005 |
Page 6 of 6 |
