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INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student Name:_____________________________________________ Date:________________

Student #:

DOB:

Age:

Grade Level:

Gender: M F

Ethnicity:

Parent(s)/Guardian(s):

Address:

Home Phone:

Work/Message Phone:

School:

School Phone:

School Address:

Most Recent Evaluation Report Date: Next Evaluation Report Date:

IEP Purpose:___________________________________ Next Annual IEP Date: _____________

Based on assessment and evaluation information:

The primary exceptionality is:
Identified areas of need:	Math	Reading	Written Language	Behavior
Other:
The secondary exceptionality is:
Identified areas of need:	Math	Reading	Written Language	Behavior
Other:

STUDENT PROFILE

What do the parent and student envision as the student’s future?

Employment:

Community Participation:

Recreation & Leisure:

Post-Secondary Training & Learning:

Daily/Independent Living:

Student/Family Vision Statement: ________________________________________________

______________________________________________________________________________

B-IEP Page 1 of 21 IEP for ___________________________________________________ Date: ______________

______________________________________________________________________________

STUDENT PROFILE (continued)

Note: When completing this section the IEP team must consider and describe the following: the student’s strengths and concerns as identified by the parent, student, teachers, related service staff, and other team members; results from district and statewide assessments; results from initial and most recent multi-disciplinary evaluations; results from any evaluations provided by the parents or guardians; and any extracurricular and non-academic areas that may be affected.

Domain

Strengths

Concerns / Recommendations

Academic:

(input from the general and special education teachers)

Recreation & Leisure:

(extra-curricular and non-academic)

Community

Participation:

Home/

Independent Living:

Jobs and

Job Training:

Post-Secondary

Training or Learning:

B-IEP Page 2 of 21 IEP for ___________________________________________________ Date: ______________

Other Areas:

(health considerations, communications, motor, emotional or behavioral, assistive devices needs, attendance)

TRANSITION SERVICES

Course of Study (Required beginning by age 14, or sooner if appropriate)

School Year Year

Courses Selected for High School Program

Yr. 1

Yr. 2

Yr. 3

Yr. 4

B-IEP Page 3 of 21 IEP for ___________________________________________________ Date: ______________

Ages 18-21

The student’s planned program of study meets the requirements for

Standard Pathway Career Readiness Pathway Ability Pathway

For the Career Readiness Pathway:

Explain why the Standard Pathway was rejected:

Note: The team is responsible for documenting progress on all five Career Readiness Standards on the IEP goals/objectives pages.

For the Ability Pathway:

Explain why the Standard and Career Readiness Pathways were rejected:

For all Pathways:

Projected date of graduation:

Is the student on target with graduation requirements? YES NO

B-IEP Page 4 of 21 IEP for ___________________________________________________ Date: ______________

If NO, what are the concerns (credits, NMHSCE, attendance or behavior concerns) and how will they be addressed?

For a Certificate, the IEP Team must agree:

The student’s program and instruction have been appropriate

The student has maintained realistic efforts to meet IEP goals

The student has successfully completed four or more years of high school

The student can participate equitably in all graduation activities

The student has a follow-up plan of action in the form of a transition IEP

Projected date of graduation for the student:

TRANSITION SERVICES/INTERAGENCY LINKAGE

Needed to Accomplish Desired Post-School Outcomes (Required beginning at age 16, or sooner if appropriate)

Student Needs		Agency/	Provider/
	Activities/Strategies	Responsibility	Payer

Instruction:

Related Services:

Community
Experiences:

B-IEP Page 5 of 21 IEP for ___________________________________________________ Date: ______________

Employment or

Post-School

Options:

Independent

Living:

Functional

Vocational

Assessment:

Will the student need involvement from any outside agency in order to make a successful transition? YES NO If NO, explain: _________________________________________

PRESENT LEVELS OF PERFORMANCE

Educational and/or Behavioral

1) Area of Need:		Math	Reading	Written Language	Behavior
Other: