Oklahoma Form Iep – Fill Out and Use This PDF

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

NAME OF CHILD: ____________________________________________________STUDENT ID: ____________________________

FIRST MIDDLELAST

BIRTHDATE: ___________________________		GRADE: ____________________			AGE: ___________________________
MONTH/DAY/YEAR
PARENT(S):_______________________________________________________________________________________________
PHONE: (WORK) _______________________ (HOME) ________________________					(OTHER) __________________________
HOME ADDRESS: _______________________________________________________ DISTRICT/AGENCY: ________________
STREET ADDRESS/P.O. BOX		CITY	STATE	ZIP
BUILDING:________________	SITE CODE: __________		IEP TEACHER OF RECORD:______________________________

Present Levels of Academic Achievement and Functional Performance: Document current evaluation data and write objective statements, (may include most recent statewide and districtwide assessments) to demonstrate how the child’s disability affects the child’s involvement, functional performance, and progress in the general education curriculum and postsecondary transition, as appropriate. For students of transition age, document transition assessment results as they relate to the postsecondary goal(s). For preschool children, describe how the disability affects the child’s participation in age appropriate activities.

OSDE Form 7	Page __ of __
	Initial IEP Date__________ Interim IEP Date____________ Subsequent IEP Date____________

IEP – Strengths/Needs, Special Factors, and Parent Concerns Page

List strengths of the child and a statement of the anticipated	List the educational needs resulting from the child’s disability,
effects on the child’s participation in the general education	which may require special education, related services,
curriculum or appropriate activities.	supplementary aids, supports for personnel, or modifications.
Strengths:

Anticipated Effects:

Consideration of special factors: Check yes or no whether the IEP team considers each special factor to be relevant to this child. Yes No

Strategies, positive behavior interventions and supports, as appropriate, if behavior impedes learning of self or others

Language needs as related to the IEP for a child with limited English proficiency (LEP)

Instruction and use of Braille if child is blind or visually impaired, unless determined inappropriate based on evaluation.

Communication needs, and for child who is deaf or hard of hearing, the language and communication needs and opportunities for communication and instruction in the child’s native language and communication mode

Whether this child requires assistive technology devices and service

For special factors checked yes, explain determinations of the team as to whether services are required in the IEP.

Parent Concerns for Enhancing the Child’s Education:

OSDE Form 7

Page __ of __

Initial IEP Date__________ Interim IEP Date____________ Subsequent IEP Date____________

IEP – Goals Page

NAME OF CHILD:				STUDENT ID:_________________________
	FIRST	MIDDLE	LAST

Annual Goals:

Provide measurable annual goals, including academic and functional goals to enable the child to be involved in and make progress in the general education curriculum (for a preschool child in the appropriate activities), and to meet other educational needs that result from the disability.

GOAL # _______

How will the extent of progress toward annual goals be measured?

GOAL # _______

How will the extent of progress toward annual goals be measured?

GOAL # _______

How will the extent of progress toward annual goals be measured?

COMMENTS:

OSDE Form 7		Page __ of __
	Initial IEP Date__________ Interim IEP Date____________ Subsequent IEP Date____________

IEP – Goals and Short-Term Objective/Benchmark Page

NAME OF CHILD:				STUDENT ID:_________________________
	FIRST	MIDDLE	LAST

Annual Goals:

Provide measurable annual goals, including academic and functional goals to enable the child to be involved in and make progress in the general education curriculum (for a preschool child in the appropriate activities), and to meet other educational needs that result from the disability.

Short-term Objectives or Benchmarks: In addition to Annual Goals, provide at least two short-term objectives or benchmarks per goal for children who take alternate assessments aligned to alternate achievement of the standards.

GOAL # _______

SHORT-TERM OBJECTIVE/BENCHMARK #________

SHORT-TERM OBJECTIVE/BENCHMARK #________

SHORT-TERM OBJECTIVE/BENCHMARK #________

SHORT-TERM OBJECTIVE/BENCHMARK #________

How will the extent of progress toward annual goals be measured?

COMMENTS:

OSDE Form 7

Page __ of __

Initial IEP Date__________ Interim IEP Date____________ Subsequent IEP Date____________

IEP – Transition Services Plan – Goals and Activities Page

(Beginning not later than the first IEP developed during the student’s ninth grade year, or upon turning 16 years of age, whichever occurs first)

NAME OF CHILD:				STUDENT ID: ________________________
	FIRST	MIDDLE	LAST

Postsecondary Goal(s): _________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Annual Transition Goals

Provide measurable annual transition goals to assist the young adult in working toward their postsecondary goal(s). The annual transition goal(s) must include academic and functional goals to enable the young adult to be involved in and make progress in the general education curriculum and in community experiences. For a young adult beginning with the first IEP developed during the student’s ninth grade year or upon turning 16 years of age, whichever occurs first, postsecondary goal(s) based upon age appropriate transition assessments related to education/training, employment, and where appropriate, independent living skills, and to meet other educational needs that result from the disability. For young adults being taught to alternate achievement of the standards, include a minimum of two (2) short-term objectives or benchmarks for each annual goal.

Education/Training Goal(s)	Short-Term Objectives/Benchmarks (as needed)
Coordinated Activities	Responsible Party(ies)
Parents are to be informed of progress in annual goals, in addition to general	Extent of progress toward achieving the annual transition goals by
education academic performance reports. Describe how often this will occur	the end of the year (i.e., one-half, two-thirds, fifty percent, passing
and what methods will be utilized.	grades in general curriculum).
	DATE	DATE	DATE	DATE	DATE	DATE (ESY)
How will the extent of progress toward annual goals be measured?
Employment Goal(s)	Short-Term Objectives/Benchmarks (as needed)
Coordinated Activities	Responsible Party(ies)
Parents are to be informed of progress in annual goals, in addition to general	Extent of progress toward achieving the annual transition goals by
education academic performance reports. Describe how often this will occur	the end of the year (i.e., one-half, two-thirds, fifty percent, passing
and what methods will be utilized.	grades in general curriculum).
	DATE	DATE	DATE	DATE	DATE	DATE (ESY)
How will the extent of progress toward annual goals be measured?
OSDE Form 7						Page __ of __

Initial IEP Date__________ Interim IEP Date____________ Subsequent IEP Date____________

IEP – Transition Services Plan – Transition Goals/Course of Study

(Beginning not later than the first IEP developed during the student’s ninth grade year or upon turning 16 years of age, whichever occurs first.)

NAME OF CHILD:						STUDENT ID:_________________________
	FIRST	MIDDLE	LAST
Independent Living Goal(s) (if appropriate)				Short-Term Objectives/Benchmarks (as needed)
Coordinated Activities				Responsible Party(ies)
Parents are to be informed of progress in annual goals, in addition to general				Extent of progress toward achieving the annual transition goals by
education academic performance reports. Describe how often this will occur				the end of the year (i.e., one-half, two-thirds, fifty percent, passing
and what methods will be utilized.				grades in general curriculum).
				DATE	DATE		DATE	DATE	DATE	DATE (ESY)
How will the extent of progress toward annual goals be measured?

Build a course of study, to be updated annually, to assist the young adult in achieving their postsecondary goal(s):

Grade __________

Grade __________

Grade __________

Grade __________

Grade ___________

Projected date of graduation/program completion and type:

______________________________________

______________________________________

 Standard Diploma

 General Education Development (GED)  Other _____________________________

In planning the course of study, is information needed regarding opportunities for vocational education (e.g., high school vocational education courses, school-based training, work study programs, technology education, or area career technology center programs)?

Yes  No

If yes, document date(s) when information was provided to young adult and parent(s). Date: ______________________

By age 16, the young adult has been referred to the vocational rehabilitation counselor in the young adult’s school district.

Yes  No

Person responsible for the referral: __________________________________________Date:__________________________________

Name of the Vocational Rehabilitation Counselor: ____________________________________________________________________

Have the young adult and parent(s) been provided a copy of the referral form?  Yes  No

If no, explain why. _____________________________________________________________________________________________

If yes, explain how. ____________________________________________________________________________________________

By age 17, have young adult and parent(s) been informed of any transfer of rights at age of majority?  Yes  No

If no explain why: _____________________________________________________________________________________________

Comments: __________________________________________________________________________________

OSDE Form 7

Page __ of __

Initial IEP Date__________ Interim IEP Date____________ Subsequent IEP Date____________

IEP – Services Page

NAME OF CHILD:								STUDENT ID:_________________________
	FIRST			MIDDLE		LAST
Special Education Services: List each special education service.
Type of Service(s)					Amount of Services (Time		Starting Date		Ending Date	Person Responsible
						and Frequency)				(Title)
Related Services: List each related service necessary for the child to benefit from special education.
Type of Service(s)			Location of		Amount of Services (Time		Starting Date		Ending Date	Person Responsible
			Services			and Frequency)				(Title)

Provide an explanation of the extent, if any, to which the child will not participate with nondisabled children in the general education curriculum or age-appropriate activities:

The continuum of placements for the least restrictive environment (LRE) includes regular classes full-time, special classes part-time or full-time, public/private separate day school facility, public/private residential facility, home instruction/hospital environment, correctional facility, or parentally placed in private schools. For preschool children (aged 3 through 5), the continuum includes early childhood program, special education program, residential facilities, home, service provider location.

Continuum of Placement:

Amount of time in general education setting: _____ of _____ periods per day OR __________ % of instructional day.

If block schedule, describe:

Is this child’s instructional day the same length as nondisabled peers?  Yes  No

If no, describe the reason(s) for a shortened school day:

 Regular PE  Adapted PE  NA	List modifications necessary for this child to participate in regular PE
If not applicable provide justification:	(specially designed adapted PE, if needed, must be addressed on the IEP):

Supplementary aids and services, program modifications and/or supports for personnel in general education or other education-related settings not otherwise addressed as special education or related services:

Supplementary aids and services:	Location/Class/Settings
Program modifications:	Location/Class/Settings
Supports for personnel:	Location/Class/Settings
OSDE Form 7	Page __ of __

Initial IEP Date__________ Interim IEP Date____________ Subsequent IEP Date____________

IEP – Signature Page

NAME OF CHILD:					STUDENT ID:_________________________
	FIRST	MIDDLE	LAST
State and Districtwide Assessment Programs
Child will participate in:		 Oklahoma Core Curriculum Tests (OCCT)		 Alternate Assessment (OAAP or OMAAP)

If the child is participating in alternate assessment, has the IEP team considered the guidelines for participation in alternate assessment?

 Yes  No If no, explain why:
If the child is participating in an alternate assessment, how will the child be assessed?	OAAP Portfolio	OMAAP
If the child is participating in OMAAP, list each subject for which the child will participate.
Specify state approved accommodations used in each test administration.

Extended School Year (ESY) Services

ESY Services:  Requires further data; will reconvene by ___/____/___	 are necessary	 are not necessary
If necessary, describe services provided:

Documentation of LRE Placement Considerations

Describe continuum of placements considered and reasons determined not appropriate:

Is this placement in the school the child would normally attend if nondisabled?  Yes  No

If no, is the placement as close as possible to the child’s home?  Yes  No

If no, explain why the IEP requires other arrangements:

Explain considerations of potential harmful effects on the child or the quality of services needed:

When special classes, separate schools/facilities, or other removal from the general education environment occurs, describe how the nature and severity of the disability is such that education in general education classes, with the use of supplementary aids and services, cannot be achieved satisfactorily:

Date of next IEP _______________________________________________________________Date of next 3 year reevaluation ______________

FROM INITIAL	FROM INTERIM	FROM SUBSEQUENT
Team Participant Signatures:
Parent(s)________________________________________________			Date _________________	 Agree	 *Disagree
Special Education Teacher__________________________________			Date _________________	 Agree	 *Disagree
Regular Education Teacher _________________________________			Date _________________	 Agree	 *Disagree
Administrative Representative_______________________________			Date _________________	 Agree	 *Disagree
Student _________________________________________________			Date _________________	 Agree	 *Disagree
Other___________________________________________________			Date _________________	 Agree	 *Disagree

*Team members who disagree may submit separate statements presenting their conclusions. (Complete Comment Form as necessary.)

If parent(s) did not attend the IEP meeting, explain other methods to ensure parent participation (and/or child as appropriate): (e.g., conference call, videoconference, home visit)

Parent(s) have protection under the procedural safeguards.		Translation/Interpretation needed:	 Yes  No
Parent(s) received Parents Rights in Special Education:		If yes, specify how provided: ______________________
Notice of Procedural Safeguards
 Yes	 No
Parent(s) received Parent Survey form and business reply envelope:		Parent Initial: _____________________
 Yes	 No
Parent consent for initial placement (consent is voluntary and may be revoked at any time)			 Yes  No

Parent Signature: _______________________________________________________ Date: _________________________________

OSDE Form 7

Page __ of __

Initial IEP Date__________ Interim IEP Date____________ Subsequent IEP Date____________

OSDE Form 7

Page __ of __

Initial IEP Date__________ Interim IEP Date____________ Subsequent IEP Date____________