INDIVIDUALIZED EDUCATION PROGRAM (IEP) TEAM REPORT

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1 Van Buren ISD 490 S Paw Paw St Lawrence, MI Phone: INDIVIDUALIZED EDUCATION PROGRAM (IEP) TEAM REPORT Date of IEP Team Meeting: 09/20/2014 Date of Last Evaluation IEP: 09/15/2013 Student Name: Pam Sample Home Phone: Student's Address: 123 Love Lane, Hartford State: Michigan Zip Code: County: Van Buren County Resident District: (Van Buren ISD) Student Primary Language: English Language in the Home: English Birthdate: 10/23/2000 Age: Grade: Seventh grade district liaison. PURPOSE Purpose of IEP Team Meeting: Annual Review Additional Purpose: PARTICIPANTS Student Parent/Guardian Check all boxes for General Ed Teacher * Parent/Guardian participants who attended. Special Ed Provider * School District Rep * Participants with * by title are mandatory. Eval Team Rep * Other/Title (the individual who can interpret the instructional implications of evaluation results) NOTE: New language, Eval Team Rep is a required participant at every IEP. Other/Title * Ancillary staff are only mandatory if providing direct/consultative services. Other/Title Other/Title Other/Title These IEP Team members were absent, but submitted their input to the Team in writing: Input must be submitted prior to the IEP Team Meeting. General Ed Teacher: School District Rep: Special Ed Provider: Special Ed Provider: Other/Title: Other/Title: STUDENT PROFILE AND ELIGIBILITY In determining both eligibility and need for special education programs/services, the IEP Team must consider each of the following: Student Strengths Identify 1-2 strengths prior to the IEP as a conversation starter. Parent Concerns List any previously identified parent concerns prior to meeting. Confirm and ask parent if they have any additional concerns. Current Evaluations (Include state and district assessments) Provide a brief summary of any recent assessment(s) or evaluation information within past 12 months. Classroom assessments, state or district assessments, achievement testing, and summary of data from current evaluations can be listed in this section. Please do not copy entire ER information into this section. If dismissing a service, this information may also be included here and must also be incorporated into the Notice section of the IEP. Based on 1) Pam's current functioning, 2) the most recent evaluation findings and 3) any additional assessment information, does the IEP Team determine that this student has a disability that requires special education programs/services? If student is not eligible, deselect all pages (Set Yes, Pam is eligible for special education (Define below) Document > Sections) except the first and last pg. Primary Disability Qualifying Criteria Qualifying Criteria Specific Learning Disability Listening Comprehension Secondary Disability Qualifying Criteria Qualifying Criteria Changes to student profile information need to be made in the SIS or by the Check to ensure accuracy of Disability with most recent ER. Areas cannot be added or removed without a REED.

2 Secondary Transition Considerations Transition Assessments Completed: Assessments Student/Parent Input School Observation Data Date of Educational Plan: Will a Student Transition Visions survey be completed? Yes No Student Transition Visions survey is not required if the ESTR is given. Complete the last 2 pages of the ESTR. If student did not attend IEP, describe steps taken to ensure consideration of student's preferences/vision: Student s Post-Secondary Vision and Transition Activities Career/Employment: As an adult, what kind of work do you want to do? Career/Employment Assessment: Present level assessment related to this vision statement. Is there a need for activities or services for Career/Employment? Yes No Explanation of Responsible Type of Activity activity/service Agency/Persons Expected Completion Date Activity needs to be observable and measurable. At least one activity must be created and aligned with the PLAAFP and a goal Post-Secondary Education/Training: After leaving school, what additional education and training do you want? Post-Secondary Education/Training: Present level assessment related to this vision statement. Is there a need for activities or services for Post-Secondary Education/Training? Yes No Explanation of Responsible Type of Activity Expected Completion Date activity/service Agency/Persons Adult Living: As an adult, what kind of living arrangements would you like to have? Yes No Explanation of Responsible Type of Activity Expected Completion Date activity/service Agency/Persons Adult Living Assessment: Present level assessment related to this vision statement. Is there a need for activities or services for Adult Living? Yes No Explanation of Responsible Type of Activity activity/service Agency/Persons Community Participation: As an adult, how do you want to be involved in your community? Community Participation: Present level assessment related to this vision statement. Is there a need for activities or services for Community Participation? Yes No Type of Activity Explanation of activity/service Responsible Agency/Persons Expected Completion Date Expected Completion Date Course of Study Describe how the student's course of study aligns with the postsecondary vision: How does the students daily schedule impact their post-secondary goal? For example, if they re interested in becoming a vet, are they enrolled in extra science classes? If they want to be a cosmetologist, is the student visiting/attending the Tech Center? Check Only One: Michigan Merit Curriculum leading to a high school diploma Is a Personal Curriculum on file? (beginning with class of 2011). Yes No Course of Study leading to:

3 Is Pam expected to graduate with a Regular Diploma during this IEP year? Yes No NOTE: If box is checked yes include graduation information on Notice section of IEP using Options Considered.. Will Pam complete age eligibility for Special Education services? Yes No Will the student turn 26 yrs old this year? If box is checked yes include information on Notice section of IEP. Anticipated graduation or completion date: Community Agency Involvement Was there a need to invite a community agency representative likely to provide current or future services? Yes No If a need is present, agency rep must be listed on IEP invite. At age 16 and beyond, an agency rep should be invited unless parents refuse consent to invite, or if the student truly needs no outside agency support. If Yes, did agency representative attend? Yes No Please list any additional steps taken to ensure that the student has made connections with any appropriate outside programs and services: If there is no need for agency involvement, explain why and include how you ll connect student to agencies if/when need changes. If there is a need, yet agency did not attend, explain how you ll connect the two. Parental Rights and Age of Majority Check all that apply: The student will be age 17 during this IEP and the student was informed of parental rights that he or she will receive at age 18. The student has turned age 18 and the student and parent were informed of parental rights that were transferred to the student at age 18, including the right to invite a support person such as a parent, advocate, or friend. The student has turned age 18 and there is a guardian established by court order. The student has turned age 18 and a legally designated representative has been appointed. Remember the Age of Majority packet and signature pages for students turning 17 AND 18 years old during this IEP year.

4 PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE Progress on most recent goals and objectives? Refer back to last progress report and add statement of progress toward goals. Area of Need Subarea of Need Data Sources and Description of Need Adverse Impact Goal? List and explain how the student is progressing in the area Explain how this Reading Comprehension (reading) and subarea of need (reading comprehension). student s disability Check if How does this student compare with grade-level peers? impacts performance goal is Include data sources such as: curriculum based measures, in the general needed. If Date Modified: universal screening, district assessments and routinely education curriculum. goal box is collected classroom data. Tell the story and explain why What specifically not this student needs special education through specialized about this student s checked instruction, programming and/or services. disability impedes then need participation? must be addressed with an accommodation The PLAAFP should clearly describe the need for special education programs/services and/or accommodations contain complete sentences with grammar and professional language correspond to either a goal or an accommodation; otherwise it should not be included include a supporting statement regarding a state assessment if student is taking one The PLAAFP should not contain lengthy test report information include dismissal of services provide information about a skill area that is not also targeted by a goal or accommodation

5 SPECIAL FACTORS, SUPPLEMENTARY AIDS AND ASSESSMENTS Supports and Modifications to the Environment, Behavior Training Needs, Social Interaction Supports for the Student, Health-Related Needs, Physical Needs, Transition aids and supports are provided to enable the student: To advance appropriately toward attaining the annual goals. To be involved and progress in the general education curriculum and to participate in extra-curricular and other nonacademic activities. To be educated and participate in activities with other students with disabilities and nondisabled students. Explain the extent, if any, to which the student will not participate with nondisabled students: Simply describing how many special education classes the student has satisfies this requirement. Does Pam require supplementary aids and supports based on the following special factors? A need for positive behavioral interventions, supports and other strategies due to behavior that impedes the learning of self/others? Yes No The language needs if this student is of limited English proficiency? Yes No A need for Braille instruction? Yes No The communication needs of this student? Yes No The language/communication mode if this student is deaf or hard of hearing? Yes No The requirement for assistive technology? Yes No A need for accommodations on district assessments? This is a new statement. If box is checked yes the accommodation table below will appear. Yes No Does Pam require supplementary aids/program modifications/supports for any additional reasons? Yes No Select yes for any monitoring services Supplementary Aids/Program Modifications/Support for School Personnel List accommodation Frequency/Timeline When? How often? Be specific. When or As Needed should never be used. Location Where? (examples located in insert statements) Use a new box for each accommodation. After entering first accommodation, select Save, Continue Editing to add another box. These supplementary aids should align with assessment accommodations. Documentation of each accommodation provided is required. STATE ASSESSMENTS Are state assessments required for the grade level(s) covered by this IEP? If box is checked yes the Accommodations and Alternate Assessment page will be added to the IEP. Yes No To participate in the state assessment(s), will Pam require accommodations and/or alternative assessments? If the student needs accommodations on standardized assessments, Yes No these accommodations should align with those needed daily in the classroom. Does Pam need to take an alternate assessment instead of a particular state assessment? Yes No Rationale: Be sure to explain why an alternate is needed.

6 Personal Care Services Does the student have a chronic condition(s) that requires Personal Care Services (identified below) to enable her to accomplish Activities of Daily Living (ADL) in the area(s) checked here: Yes No Eating/Feeding/Meal Preparation Time, Frequency, Conditions, Circumstances Location/Setting Respiratory Assistance Toileting/Maintenance Continence Mobility/Positioning, Ambulation, Transferring Bathing/Dressing/Grooming/Skin-Care/Personal Hygiene Assistance with Self-Administered Medications Redirection & Intervention for Behavior Health-Related Functions (via hands-on Assistance, Supervision, Cueing) Intervention for Seizure Disorder If selecting yes, must be medically necessary due to student s disability. This page must be completed if student is receiving personal care services and a personal care log sheet is being completed. If selecting no this page may be deleted from IEP. If page is not needed Select Set Document > Sections and uncheck this page.

7 Student Name: Pam Sample IEP Date: 5/29/2013 ACCOMMODATIONS AND ALTERNATE ASSESSMENT For the listed state and district assessments, the IEP Team has determined that the following accommodations and/or alternative assessments are needed for Pam to participate: Assessment Subtest Test Type Time/Schedule Setting Presentation Response HINTS: The new Assessment drop down only includes available state assessment options. District assessments should be included on the Special Factors/Supplementary Aids/Assessments section of the IEP. Since Michigan is still determining what alternate assessment will be used long-term, a bank of insert statements have been provided that correspond with guidance from the MDE. Accommodations should match daily supplementary aids and services. For example, if a student needs extended time on standardized assessments, they should also be receiving extended time on tests during the school day.

8 GOALS AND OBJECTIVES Area of Need: Reading Subarea: Phonemic Awareness Curriculum Reference: Select Curriculum Reference from drop down and then choose Select from Curriculum tool bar. Each curriculum populates a corresponding template, which changes and populates once the specific grade level and curriculum are selected. If no curriculum aligns with goal, please select none. Annual Goal: Must be observable and measurable What will it look like? Could you graph this goal to display progress? How will you know the student has made progress? Goals must be stand alone measurable and could be calculated even if objectives/benchmarks were removed. Will a graph be used to report progress toward the annual goal and associated objectives/benchmarks? Yes No Short-Term Instructional Objectives/Benchmarks: Objectives/Benchmarks Criteria Evaluations Schedule 1 2 Must have a least 2 short term objectives/ benchmarks for each goal. Staff Responsible for Goal: List all staff who will be monitoring the goal Comments: When will progress on goals and objectives be reported? Every Grading Period Progress reports must be developed at each grading period. Other: Hints: Goals must align with the student s specific eligibility area of need and be fully supported and connected to the PLAAFP. Students who are eligible as OHI and EI should have at least 1 goal that addresses the behaviors or skills the student needs to be successful. Goals need not directly correlate to specific special education classrooms/programs.

9 PARENT NOTIFICATION AND CONSENT For billing the State for Medicaid School-Based Services Student Name: Pam Sample Birth Date: 10/23/2000 Attending District: Van Buren NOTIFICATION If any of the services listed below are included on your child s IEP (Individualized Education Program), and if your child was eligible for Medicaid at any time during the school year, we request your permission to bill the state Medicaid program to receive funding to help support the services your child received. Supported services include: Speech/ Language Therapy, Occupational Therapy, Physical Therapy, Social Work Services, Psychological Services, Nursing Services, Orientation and Mobility, Assistive Technology Services, Case Management, Personal Care, Evaluations and Transportation. Billing the state Medicaid program for your child s School-Based Services does NOT affect your family s Medicaid insurance benefits, and is at NO cost to your family, now or in the future. We are simply asking your permission to claim funds reserved by the state to help schools provide the services listed on your child s Special Education plan. Billing the state s Medicaid program requires that we release information to the state about your child. The information released could include date of birth, disability, gender, school, date of therapy, type of therapy, and progress reports. You will receive annual notification about information released in the Parent Handbook with Procedural Safeguards. Schools have released this information to the state program since 1993, but now need your permission because of changes in federal law. You have the right to refuse consent to bill the state Medicaid system, and you have the right to revoke this consent at any time. If you check No below, the district will still provide the services but the district will not receive funding from the state Medicaid system for these services. CONSENT Yes, I understand, agree, and consent that the ISD and its local school districts may: a. release Personally Identifiable Information (PII) about my child (including date of birth, disability, gender, school, date of therapy, type of therapy, progress reports to Michigan Medicaid and its billing agencies for Medicaid reimbursement of School-Based Services; and b. bill my child s Medicaid insurance for reimbursement of School-Based Services as described in my child s plan. I understand I may revoke this consent in writing at any time. No, I do not give permission for the ISD and its local school districts to bill the state Medicaid system for reimbursement of School-Based Services provided to my child. Parent/Guardian/Student Signature: Date: This page should only be included if this is an initial IEP and the student is going to receive related services of OT, PT, Speech, Social Work, Audiological, Orientation and Mobility or personal care services. If this is an annual IEP and the student is receiving one of the related services listed above, you must check if Medicaid consent is already on file before including in the IEP. If consent is already on file DO NOT include this section.

10 PROGRAMS AND SERVICES Related Services with General Education and/or Special Education Programs Direct Service: the primary mode of service is directly working with the student. There may be occasional consultation with others. Consultative Service: the primary mode of service is working with the teacher(s) and others having daily contact with the student. Direct work with the student is occasional Current IEP Year: From Date 09/20/2014 School Year: select from dropdown Grade: Sixth grade Related Services Start Date End Date Service Mode To Date: 09/19/2015 School Year: select Grade: Seventh grade Minutes Sessions Frequency Setting Low Min. High Min. Low Number High Number within Location enter date enter date Direct Consultative check year Ancillary services and/or Teacher Consultant services written here. To include TC time, use the option that matches your endorsement area, not the student s eligibility area. If student has no programs, TC time must be Direct. TC time may be Consultative if the student also has program time and a goal for the student was developed in collaboration with another service provider. For OT, PT, SW, SPL & O&M services if direct or consultative is selected there must be a goal. Programs Depart- Start Date End Date SE GE Total Frequency Bldg/Location mentalized Low Min High Min Low Min High Min Min Y N If you enter the SE Low Min and then select the lookup link for Bldg/Location, select the bldg and then select Save, Continue Editing and the GE High Min will auto calculate. Use separate lines to describe changes in program time due to trimester schedule changes or use a range if the span is not too broad. Never use zero for the SE Low Min. Regardless of your endorsement, the student s program is Elementary or Secondary Resource Room (exception: Self-contained Rooms). Are you sure the student has no programs? Does the student require a reduced day? Yes No If yes, then reduced day is allowed for: Primary Setting Update this selection for current programming and be careful in your calculation. For questions regarding primary ed setting consult your District Liaison.

11 TRANSPORTATION PROVISIONS OTHER CONSIDERATIONS Has the IEP Team determined that Pam requires special transportation? No, transportation is not required or general education transportation is sufficient to meet Pam's needs. Yes, special transportation is required due to the following: The recommended programs/services are not available in Pam's regular attendance area. The medical, health or developmental and/or behavioral needs of this student necessitate special transportation. Vehicle Type Stop Type Start Date End Date Special Bus with Lift Curb to Curb 09/21/ /19/2015 Describe other required transportation provisions not listed in the table above: Start and End Dates for transportation are new fields. This data flows to a special transportation profile upon finalization. EXTENDED SCHOOL YEAR Assurance that ESY was considered and discussed during the IEP. The IEP Team has considered the anticipated needs of this student including the need for extended school year (ESY) services ESY services are needed ANTICIPATED NEEDS AND OTHER COMMENTS Other Comments related to this IEP: It is acceptable to indicate None for this section.

12 NOTICE REGARDING PROVISION OF SPECIAL EDUCATION STUDENT INFORMATION Student: Pam Sample Date of IEP Team Meeting: 9/20/2014 Birthdate: 10/23/2000 Resident District: Van Buren ISD Age: 12-7 Student Primary Language: English Grade: Sixth grade Language in the Home: English PURPOSE This notice is a result of the Individualized Education Program (IEP) Team meeting that was held on the date listed above for the following purpose(s): Primary Purpose: Additional Purpose: NOTICE FOR PROVISION OF PROGRAMS AND SERVICES You are receiving this notice because, based upon the most recent IEP Team meeting, Pam remains eligible for special education programs/services. Upon district signature, this notice and Pam's IEP constitute the district s offer of a Free Appropriate Public Education (FAPE). All programs/services/supplementary aids will start on: Make sure date is accurate The following person will assure implementation of this IEP: Select staff from dropdown OPTIONS CONSIDERED The IEP Team Report describes the assessment/evaluation procedures and data used during the IEP Team meeting. The following options were considered but not selected for the reason(s) indicated below: Considered Options An option considered is required. (Do not indicate None. ) List items/issues that were considered but not selected during the IEP. Reasons Not Selected Provide an evidence and data-based reason for the non-selection Other relevant factors to the district s proposal or refusal: (May list none here if there were no additional relevant factors) RESOURCES FOR PARENTS The Michigan Department of Education - OSE/EIS: (517) Michigan Alliance for Families: (800) Michigan Protection & Advocacy Service: (800) Community Advocates/The Arc: (269) Advocacy Services for Kids (ASK): (269) Parent-to-Parent: (269) Citizen Mediation Service: (269) Dispute Resolution Kalamazoo: (269) To Obtain a copy of the Procedural Safeguards for Parents/Students Kalamazoo Regional Educational Service Agency (Kalamazoo RESA): (269) Van Buren Intermediate School District: (269) Michigan Department of Education: (517) that you received describes protections under the Individuals with Disabilities Education Act (IDEA). Information is also available from: MICHIGAN ALLIANCE FOR FAMILIES, 1819 South Wagner Road, PO Box 1406, Ann Arbor, MI 49106; ; MICHIGAN DEPARTMENT OF EDUCATION, OFFICE OF SPECIAL EDUCATION AND EARLY INTERVENTION SERVICES, PO Box 30008, Lansing, MI 48909; ; MICHIGAN PROTECTION AND ADVOCACY, 4095 Legacy Parkway, Suite 500, Lansing, MI ; ;

13 SIGNATURES DISTRICT COMMITMENT The school district superintendent/designee assures that the least restrictive environment has been fully considered and assigns this student to the following: (Select one) The resident district If student is attending a local district, select this box An operating district If student is attending a VBISD program, select this box Operating District: This only appears if operating district box was checked, enter VBISD. Building/Program: Enter bldg./program student will be attending The resident district: (Select one) Authorizes the operating district to conduct subsequent IEP Team meetings. Select only if student is going to a VBISD program Will conduct subsequent IEP Team meetings. Operating District Superintendent/Designee: Date: 9/20/2014 Resident District Superintendent/Designee: Date: 9/20/2014 This section will only appear if the Purpose of the IEP was selected as an Initial. PARENT/GUARDIAN/STUDENT Parent consent is required for the initial provision of special education programs and/or services. I/We, as parent/guardian/student: (Select One) Give consent to the initial provision of special education programs/services Decline to give consent to the initial provision of special education programs/services Parent/Guardian/Student: Date: 9/20/2014 All signature pages must be scanned and uploaded to TIENET. The completed IEP must be provided (or sent) to the parent/guardian within 7 school days of the IEP meeting. If you make any changes to other pages within this IEP once you have completed this section, make sure you select this page again and select Edit This Section > Save, Done Editing. This will insure accurate data flow to the student s profile upon finalization. OFFICE USE ONLY Mode of Delivery: Select choice from dropdown Date of Delivery: 9/20/2014

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