Annual Review Individualized Education Program (In Force)

Transcription

1 Name: Birth Date: Sex: Teacher/Coun: Dates Grade: Student ID: School: Annual Review Individualized Education Program (In Force) First M Last 1/1/1984 Male A Teacher 10th 1test School 1 Initial IEP Referral Consent 1/1/2002 3/1/2002 IEP Conference Participants Special Eduation Teacher First M Last Page 1 of 18 IEP Conference 4/1/2002 Your District Name Your District Address Your District City, AZ Home School: Parent: Address: Phone: Test School First Name Last Name Address City, NJ (908) Disability Category: Auditorily Impaired - Deaf IEP Next IEP Next Implementation Review Re-evaluation 4/1/2002 4/1/2003 4/1/2005 Title Participant Signature/Date Signed Jane Smith School Social Worker LDT/C Speech Language Pathologist Regular Education Teacher Parent Parent John Doe Betty White Beth Johnson Bob Jones Susan Last Sam Last Eligibility Statement The school staff listed above, in consultation with First M Last's parent/guardian(s)/adult Pupil, has determined that First is Eligible for Special Education and Related Services under the disability category of Auditorily Impaired - Deaf. Limited English Proficiency and lack of instruction in Math or Reading have been ruled out as determining factors in this decision.

2 PRESENT LEVELS OF PERFORMANCE A description of how this child's disability affects functioning and progress in the general curriculum or, for preschool children, functioning in appropriate activities. LANGUAGE AND COMMUNICATION NEEDS A description of the communication needs (required for all students), and, if the student has limited English proficiency, description of the student's language needs. For students who are deaf or hard of hearing, a description of the student's language and communication needs, opportunities for direct communication with peers and professional personnel in the student's language and communication mode, academic level and the full range of opportunities for direct instruction in the student's language and communication mode. STUDENT STRENGTHS AND PARENTAL CONCERNS A description of the strengths of the student and any concerns expressed by the parents for enhancing the education of the student. EVALUATION RESULTS A description of the restuls of the initial evaluation or most recent evaluation of the student. DESCRIPTION OF BEHAVIOR NEEDS If the student demonstrates behaviors that impede the student's learning or that of others, a description of the behaviors need to be addressed here and in the Behavioral Intervention section of this IEP. VISUAL IMPAIRMENT First M Last Page 2 of 18 Part A - Present Levels of Educational Performance and Consideration of Needs If the student is blind or visually impaired, a description of the student's need for instruction in Braille and the use of Braille, unless the IEP team determines, after an evaluation of the student's reading and writing skills, and current and projected need for instruction in Braille, such that instruction is not appropriate. TRANSITION NEEDS AND STUDENT INTERESTS AND PREFERENCES If the student is 14 years of age or older, a description of the student's transitional needs as they may be related to instruction, community experiences, adult living skills, prevocational and employment skills and skills of daily living.

3 First M Last Page 3 of 18 Part A - Goals and Objectives PRESENT LEVELS OF PERFORMANCE Mathematics Specify the child's instructional level (the level at which the child can learn new material with the teacher's help, without feeling frustrated). Goal: To develop addition skills with whole numbers PROGRESS OBJECTIVES: General Curriculum Proficiency Standard 4.8 To understand, select, and apply various methods of performing numerical operations. add a single digit and a two digit number without regrouping; on 4 of 5 trials Evaluation Procedure: write the sum of the numeral plus 1 more when given a list of numerals; on 4 of 5 trials Evaluation Procedure: perform addition problems with zero as a digit; on 4 of 5 trials Evaluation Procedure: Goal: To recognize and demonstrate accuracy in the use of the symbols of math General Curriculum Proficiency Standard 4.8 To understand, select, and apply various methods of performing numerical operations. PROGRESS OBJECTIVES: First will -- write on request the following math symbols:; on 4 of 5 trials Evaluation Procedure:...+;...-;.../ and ;

4 First M Last Page 4 of 18...x and *;...=; Progress Report Legend Key: A = Achieved, P = Partially Achieved (% Achieved), I = Introduced, Not Achieved, N = Not Introduced 1 = Verbal Prompting, 2 = Physical Prompting, 3 = Gestural Prompting, 4 = With a Model, 5 = Signed Prompting, 6 = Locational Prompting, 7 = Positional Prompting, 8 = Ongoing, 9 = Physical Assistance, a = Minimum, b = Moderate, c = Maximum, d = Intermittent

5 First M Last Page 5 of 18 Behavioral - Deficits Goal: To increase awareness of own behavior in a variety of situations and to recognize the effect that behavior has on others General Curriculum Proficiency Standard 0.4 To demonstrate self-management skills. PROGRESS OBJECTIVES: First will -- describe own behavior which has occurred in response to an emotional state; Evaluation Procedure: describe the emotional state of a peer who is observed to respond to an emotional state (e.g., "John's mad" in response to John throwing an object and crying); Evaluation Procedure: describe behavior currently being engaged in (e.g., "I'm pushing the car"); Evaluation Procedure: Progress Report Legend Key: A = Achieved, P = Partially Achieved (% Achieved), I = Introduced, Not Achieved, N = Not Introduced 1 = Verbal Prompting, 2 = Physical Prompting, 3 = Gestural Prompting, 4 = With a Model, 5 = Signed Prompting, 6 = Locational Prompting, 7 = Positional Prompting, 8 = Ongoing, 9 = Physical Assistance, a = Minimum, b = Moderate, c = Maximum, d = Intermittent

6 First M Last Page 6 of 18 Life Skills Goal: To increase social awareness during trips into the community General Curriculum Proficiency Standard 2.2 To learn health-enhancing personal, interpersonal, and life skills. PROGRESS OBJECTIVES: First will -- explain why a policeman is a friend and help; 80% accuracy Evaluation Procedure: discriminate between appropriate and inappropriate behaviors to be displayed while in the community by labeling such behaviors during role play situations; on cue from an adult, discontinue inappropriate behavior while in a community setting; 80% of the time Evaluation Procedure: Progress Report Legend Key: A = Achieved, P = Partially Achieved (% Achieved), I = Introduced, Not Achieved, N = Not Introduced 1 = Verbal Prompting, 2 = Physical Prompting, 3 = Gestural Prompting, 4 = With a Model, 5 = Signed Prompting, 6 = Locational Prompting, 7 = Positional Prompting, 8 = Ongoing, 9 = Physical Assistance, a = Minimum, b = Moderate, c = Maximum, d = Intermittent

7 First M Last Page 7 of 18 Part B - Recommended Program (Description of Special Education Program) Program School Location Prog Begin* Prog End* In-class Support Resource Program School 2 Regular Classroom 4/1/2002 6/30/2002 Subjects Math Duration/Frequency Daily Study Skills 2x's a week Program School Location Prog Begin* Prog End* Regular Education School 2 Regular Classroom 4/1/2002 6/30/2002 Subjects Reading Science Duration/Frequency Daily Daily Physical Education Daily Program School Location Prog Begin* Prog End* In-class Support Resource Program School 2 Regular Classroom 9/1/2002 4/1/2003 Subjects Duration/Frequency Program School Location Prog Begin* Prog End* Regular Education School 2 Regular Classroom 9/1/2002 4/1/2003 Subjects Duration/Frequency *Dates of services reflect the 180 day regular school year unless Extended School Year (ESY) services are recommended. Additional Program Information This field can be used for any additional information the user would like to include about the programs. This field is a text field that can have as long a text as needed by the user. Related Services Services/Form Location Freq. Duration Provider Dates* Speech Therapy Group Therapy Room 1x a week 30 mins./week Speech/Language Pathologist 4/1/2002 6/30/2002

8 First M Last Page 8 of 18 Speech Therapy Group Therapy Room 1x a week 30 mins./week Speech/Language Pathologist 9/1/2002 4/1/2003 Recreation Therapy Therapy Room 4x's a month 120 mins./month 4/1/2002 6/30/2002 *Dates of services reflect 180 day regular school year unless Extended School Year (ESY) services are recommeded. Additional Related Services Information This field can be used for any additional information the user would like to include about Related Services.

9 First M Last Page 9 of 18 Least Restrictive Environment & Rationale Explanation for Extent of Non-Participation with Non-Disabled Peers and Statement of Least Restrictive Environment The below statement was generated by the program based on a selection of check-offs the user selected that was relative to this students environment which is "Totally Mainstreamed." SAMPLE STATEMENT GENERATED BY THE DATABASE: Various options were considered when planning First's program. At this time, First's educational progress and needs can be appropriately met within a mainstream setting without special educational supports or accommodations. The Child Study Team will monitor First's academic progress to determine if future intervention is warranted. The program and services offered in this IEP provide First with use of mainstream curriculum and materials, the opportunity for close monitoring and immediate feedback and individual pacing of instruction throughout the day. Additionally, First's special needs for social skills training, reinforced instruction and structuring of work assignments can be accommodated in this setting. This placement, therefore, is reasonably designed and calculated to confer educational benefits to First.

10 Regular Education/Assessment Requirements and Exemptions Assessment Requirements TEST Modified Administration of High School Proficiency Assessment - Science RATIONALE SAMPLE - Current levels of functioning and projected progress during the next year do not include the range of proficiencies in the core curriculum areas. ALTERNATIVE STANDARDS/MODIFICATIONS SAMPLE - In a small group in a separate room Local Requirements LOCAL REQUIREMENTS EXEMPT from District Attendance Policy RATIONALE SAMPLE STATEMENT AVAILABLE IN DATABASE - The student's current emotional difficulties render the district's attendance policy ineffective as a means of improving student attendance. ALTERNATIVE STANDARDS/MODIFICATIONS SAMPLE STATEMENT AVAILABLE IN DATABASE - No more than _6_ unexcused absences will be permitted as an alternative to the districts attendance policy. State Requirements STATE REQUIREMENTS NOT EXEMPT from State Curriculum Proficiencies RATIONALE First M Last Page 10 of 18 SAMPLE STATEMENT AVAILABLE IN DATABASE - The adjustment to credit hour requirements is appropriate given the educational priorities and transition planning as described in this IEP. ALTERNATIVE STANDARDS/MODIFICATIONS SAMPLE STATEMENT AVAILABLE IN DATABASE - Credit hours required for graduation: (USER WOULD COMPLETE THE STATEMENT AS APPROPRIATE)

11 Graduation Requirements State Students must complete credit hour requirements and Core Curriculum Proficiencies in each of the following areas to receive a state endorsed diploma unless specifically exempted in this IEP below. English (one credit year for each year of enrollment - up to 4 years) Mathematics (three credit years) Natural/Physical Science (two credit years) Physical Education/Health/Safety (one credit year for each year of enrollment) Fine/Practical/Performing Arts (one credit year) Career Education (one credit year) Social Studies (three credit years) 110 Credits must be earned for graduation. Local First M Last Page 11 of 18 In ADDITION to State Requirements for Graduation stipulated below, students must meet the local credit hour and core curriculum proficiencies in each of the following subject areas: English 4 years Mathmatics 3 years Language Arts 3 years Physical Science 3 years Health 2 years 120 credits must be earned for graduation. Statement of Transition Service Needs Determination of Transition from Elementary to Secondary Program Complete this section the year the student is being transitioned from elementary to secondary program Post-Secondary Outcome/Course of Study SAMPLE - First does not require any transition services at this time. Transition service needs will be considered beginning at age 14. SAMPLE - First, upon completion of the secondary program, will enter the workforce as a productive employee in a employment setting of (his/her)_ own choice, demonstrate appropriate job attitude skills and functional literacy, evidence the behavioral controls necessary to serve as a contributing member of the workforce in a group work setting, as well as possess the necessary entry level skills for success in that employment setting and will function and live within the community independently. Based on this anticipated post-secondary outcome and the student's transition needs, preferences and interests as summarized in the Present Levels of Performance section of this IEP, the appropriate Course of Study

12 First M Last Page 12 of 18 summarized in the Present Levels of Performance section of this IEP, the appropriate Course of Study is: Grade_10 Actual Specific Courses of Study: List the students current Courses of Study Grade_11 (_x_projected) Specific Courses of Study: List the students projected Courses of Study Grade_12 (_x_projected) Specific Courses of Study: List the students projected Courses of Study Consideration of Technical Consultation Services from the Division of Vocational A review of this student's transition needs does not indicate the need for Technical Consultation services from DVR or any other agency or agencies at this time. Transition Services For Instruction Service SAMPLE - After school tutoring SAMPLE - Guidance Counselor to assist student and parents in planning academic schedule. Transition Services For Community Experiences/Living Service School staff to assist student in developing skills in the use of public transportation. SAMPLE - Community based field trips scheduled _3_ times a year. Responsible Agency SAMPLE - Public School Guidance Counselor Responsible Agency Public School Transition Services For Post School Adult Living And Employment Service SAMPLE - Job Coaching SAMPLE - Job seeking skills counseling to be provided by school staff. SAMPLE - Public School Responsible Agency SAMPLE - Public School SAMPLE - Public School Transition Services For Daily Living And Functional Vocational Evaluation Service SAMPLE - Skills of daily living are age appropriate and current levels of functioning and student interests and goals do not necessitate functional vocational evaluation or specialized transition services at this time. Responsible Agency SAMPLE - Public School Related Services Services/Form Location Freq. Duration Provider Dates* Counseling Individual Regular Classroom 1x a week 75 mins./month Guidance Counselor 4/1/2002 6/30/2002

13 Individual First M Last Page 13 of 18 *Dates of services reflect 180 day regular school year unless Extended School Year (ESY) services are recommeded. Additional Related Services Information This field can be used for any additional information the user would like to include about Related Services. Implementation Primary Language for Instruction: English Case Manager: Post-Secondary Planning Liaison: Monitoring Procedures/Schedule: Length of School Day/Year: Gordon Ott Betty White Parents will be notified 4 times per year as to their child's progress toward attainment of the annual goals of this IEP and the extent to which that progress is sufficient to enable achievement of those goals by year end. Regular school day and year Assistive Technology Devices and Services (if appropriate): MATH calculator Statement of How Progress Toward Attainment of Annual Goals will be Measured Teacher made tests and/or quizzes Written work (reports, essays) Grades on report cards Unit and Chapter tests

14 Instructional Accommodations/Supplementary Aids/Supports Recommended Modifications, Supplementary Aids, Supports and Services For Regular Education, Extra-curricular And Non-academic Activities Aids & Services in the Regular Education Classroom Statement(s) Freq/Duration Location/Provider Begin/End After school study group. 1x a week Aids & Services in the Special Education Classroom Regular Classroom Public School 4/1/2002 6/30/2002 Statement(s) Freq/Duration Location/Provider Begin/End Basic Skills Instruction. First M Last Page 14 of 18 2x's a month In Extracurricular and NonAcademic Activities Resource Program Public School 4/1/2002 6/30/2002 Statement(s) Freq/Duration Location/Provider Begin/End Let student provide the leadership model during after school activities. Supports for School Personnel Variable Regular Classroom Public School 4/1/2002 6/30/2002 Statement(s) Freq/Duration Location/Provider Begin/End The case manager will serve as a liaison between the students, parents and the school 4/1/2002 6/30/2002

15 First M Last Page 15 of 18 Strategies to Address Behaviors Impeding Learning Target Behavior Type the Target Behavior Behavioral Interventions Select The Intervention from a list provided or the user can handtype interventions. SAMPLES FROM THE PROGRAM: -Assist student in charting and evaluating his/her own progress. -Assist student to make transitions from one activity to another. -Avoid any situation which would expose child's disability or weaknesses to classmates (e.g., reading aloud in class, displaying poor work, announcing grades to class).

16 First M Last Page 16 of 18 Additional Information

17 Procedural Safeguards/Parental Acknowledgement NOTICE REQUIREMENTS First M Last Page 17 of 18 This document comprises the written notice requirements of NJAC 6A:14 and includes the IEP as a description of the proposed action, and description of the procedures and factors used in determining the proposed action. As a parent of a student with disabilities or as an adult student, you have rights regarding information, evaluation, classification, the developement of an IEP, placement and the provision of a free, appropriate public education under the New Jersey Administrative Code for Special Education (NJAC 6A:14). A description of these rights, which are called procedural safeguards, is contained in the document PARENTAL RIGHTS IN SPECIAL EDUCATION (PRISE). This document is published by the NJ Dept. of Education. A copy of PRISE is provided to you upon referral for an initial evaluation, upon each notification of an IEP meeting, upon reevaluation and when a due process hearing is requested. In addition, you may request a copy from who may be reached at. For help in understanding your rights, you may contact: Statewide Parent Advocacy Network (SPAN) at (800) Protection and Advocacy, Inc. at (800) OR School District Staff Phone # County Supervisor Phone # Description of proposed action and explanation of why the district has taken such action This attached IEP describes the proposed action and was developed as a result of an annual review. Description of procedures, tests, records, or reports and factors used in making this decision The sources of information used to develop the proposed IEP are listed in the Present Levels of Performance. The factors used in determining the proposed action are listed in the Present Levels of Performance and the Least Restrictive Environment Statement of this IEP. Description of options considered and the reasons the options were rejected. Only complete this section of a parental request was rejected. This is an optional field and will only print if the user types in information. Description of any other factors relevant to the proposed action. Complete this section if you have other relevant factors you would like listed in the IEP. This is an optional field and will only print if the user types in information.

18 First M Last Page 18 of 18 Parental Acknowledgment I(We), the Parent(s)/Guardian(s) of First M Last have met or otherwise conferred with the school staff listed on this IEP and acknowledge that we have participated in the development of this Individualized Education Program. We have been informed that we have protection under the procedural safeguards of NJAC 6A:14. We have been provided with a copy of PRISE, a statement of protections under the procedural safeguards of NJAC 6A:14 and NJAC 1:6a. We have also been informed that we may obtain additional copies of these protections from our case manager and have also been provided with information about sources of assistance in understanding the provisions of this chapter. I (We), the parents of First M Last, agree to the recommendation of program and related services described in this Individualized Education Program (IEP). I (We) agree that implementation of this IEP and the programs and services described therein may be implemented on or about. I (We), the parents of First M Last, acknowledge our participation in the preparation of this Individualized Education Plan, however, do not agree with the recommendations contained in this IEP. We recognize that our consent is not required for implementation of this IEP. However, this IEP may not be implemented for 15 days in accordance with NJAC 6A:14. We understand that we have the right to seek mediation and due process under NJAC 6A:14 within that 15 day period. X Signature of Parent Date Signature of Parent Date Notice of Rights to Adult Pupils First M Last has reached the age of 18 and has been provided with a copy of the procedural safeguards statement published by the NJ Department of Education and a copy of NJAC 6A:14 as well as NJAC 1:6a. I, First M Last participated in the development of this individualized Education Plan. I understand that if I disagree with the recommendation of programs and services in this IEP, I may request mediation or due process within 15 days. I have been provided information about sources to obtain assistance in understanding the provisions of this chapter. X X Signature of Student Date Administrative Acknowledgement I have reviewed the attached material and will arrange for the provision of appropriate educational and related services. X Administrative Signature Date