INDIVIDUALIZED EDUCATION PROGRAM MSDE DIVISION OF SPECIAL EDUCATION AND EARLY INTERVENTION SERVICES (Last Updated 11/7/05)

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1 TABLE OF CONTENTS I. Identifying & Meeting Information Pages Child and School Information 1.0 Participation Data 1.0 IEP Meeting and Team Members 1.1 Eligibility 1.1 Parent/Guardian 1.2 Medical Assistance 1.3 Exit Information & Disciplinary Removal 1.3 State Agency Information 1.3 II. Present Level of Academic Achievement and Functional Performance Pages III. Special Considerations and Accommodations Pages Blind or Visually Impaired 3.0 Communication 3.0 Deaf or Hearing Impairment 3.0 Behavioral Intervention 3.0 Limited English Proficiency 3.0 Assistive Technology 3.0 Supplementary Aids, Services, and Support for School Personnel 3.1 Instructional and Testing Accommodations Extended School Year 3.5 Transition 3.6 Transition Activities 3.7 Anticipated Services for Transition 3.8 IV. Goals Pages V. Services Pages VI. Placement Data Page 6.0 VII. IEP Approval Page 7.0

2 I. MEETING AND IDENTIFYING INFORMATION PAGE 1.0 CHILD AND SCHOOL INFORMATION First Name: MI: Last Name: Address: City: State: Zip Code: Home Phone: ( ) - Cell: ( ) - Residence County: Residence School: Service County: Service School: Which county is financially responsible? Grade: Social Security Number: Student ID #: Date of Birth: (MM DD YYYY) Age: Gender: MALE FEMALE Race: American Indian or Alaskan Native Hispanic or Latino Asian or Pacific Islander White (not Hispanic) Black or African American (not Hispanic) Other Child s native language: Does the child require a parent surrogate? YES NO Parent Surrogate Name: Is the child currently under the care and custody of a state agency? YES NO PARTICIPATION DATA Student is pursuing a: Maryland H. S. Diploma Maryland H. S. Certificate State graduation requirements can be found at Also record any additional local school system graduation requirements: Graduation requirements explained to parents? YES NO PARTICIPATION DATA (continued) Is the student to participate in the Maryland School Assessment aligned with grade level academic achievement standards? (MSA) Reading YES NO Math YES NO Is the student to participate in the modified Maryland School Assessment aligned with modified academic achievement standards? (Mod-MSA) Reading YES NO Math YES NO Is the student to participate in alternative Maryland School Assessment aligned with alternative academic achievement standards? (Alt-MSA) Reading YES NO Math YES NO Student is participating in the: Alt-MSA IPT HSA MSA MMSR Mod-MSA Mod-HSA N/A Student is in grade 1 or 2 Last year student participated in the: Alt-MSA IPT HSA MSA MMSR Mod-MSA Mod-HSA N/A Student was in grade 1 or 2 Documentation to support decision: What was the student s performance on the Maryland Model for School Readiness (MMSR)? (MM DD YYYY) FULL APPROACHING DEVELOPING What was the student s performance on IPT? Assessment Date (MM DD YYYY) Score FULLY PROFICIENT LIMITED PROFICIENCY NOT PROFICIENT What was the student s performance on ALT-MSA? (MM DD YYYY) Alt-MSA Assessments of Mastery Objectives Reading BASIC PROFICIENT ADVANCED Math BASIC PROFICIENT ADVANCED What was the student s performance on MSA? (MM DD YYYY) MSA Assessments Scale Score (Check Mod, if appropriate.) Reading Mod BASIC PROFICIENT ADVANCED Math Mod BASIC PROFICIENT ADVANCED What was the student s performance on HSA? (MM DD YYYY) HSA Assessments (Check Mod, if appropriate.) Passing Score (2009) Student s Score English I Mod 407 PASS FAIL Algebra/Data Analysis Mod 412 PASS FAIL Government 394 PASS FAIL Biology 400 PASS FAIL Composite Score PASS FAIL

3 I. MEETING AND IDENTIFYING INFORMATION PAGE 1.1 IEP MEETING Meeting Purpose: TEAM MEMBERS PRESENT Review written referral, existing data, assessment results, instructional interventions, information from parents, and, if appropriate, determine the need for additional data Review to determine eligibility Develop the IEP Review and, if appropriate, revise the IEP Re-evaluation Manifestation Determination Review disciplinary removals to plan a functional behavioral assessment Review disciplinary removals to develop a behavioral intervention plan Consider Extended School Year services Consider secondary transition services Other IEP Team meeting date: (MM DD YYYY) Most Recent Annual Review date: (MM DD YYYY) Projected Annual Review date: (MM DD YYYY) Time: : AM PM Location:_ Did parent receive a copy of the Procedural Safeguards Parental Rights? YES NO IEP Case Manager: IEP Chair: Parent/Guardian: Parent/Guardian: Principal/Designee: General Educator: Special Educator: Guidance Counselor: School Psychologist: Social Worker: Speech/Language Pathologist: Student: Agency Representative: Others in attendance: Others in attendance: Others in attendance: ELIGIBILITY INITIAL ELIGIBILITY DATA Date of parent consent for initial evaluation: (MM DD YYYY) Date of initial evaluation: (MM DD YYYY) Date of initial IEP development: (MM DD YYYY) Date of parent consent for initiation of services: (MM DD YYYY) Date of implementation of initial IEP: (MM DD YYYY) Is this student transitioning from Infants and Toddlers (Part C) to Pre-School (Part B) and will be receiving services? YES NO CURRENT ELIGIBILITY DATA Is the student making expected progress in school? YES NO Is the lack of progress a result of the student s disability? YES NO Is a determinant factor for the child s lack of academic progress the result of: a) a lack of an appropriate instruction in reading, including essential components of reading instruction? YES NO b) lack of instruction in math? YES NO c) limited English proficiency? YES NO Documentation to support decision: Does the student require specially designed instruction in order to make expected progress in school? YES NO Does the student have one or more disabilities? YES NO Mark primary disability as 1; secondary as 2; and tertiary as 3. MENTAL RETARDATION EMOTIONAL DISTURBANCE TRAUMATIC BRAIN INJURY HEARING IMPAIRMENT ORTHOPEDIC IMPAIRMENTS AUTISM DEAF OTHER HEALTH IMPAIRMENTS DEVELOPMENTAL DELAY SPEECH OR LANGUAGE IMPAIRMENT SPECIFIC LEARNING DISABILITIES MULTIPLE DISABILITIES VISUAL IMPAIRMENT DEAF - BLINDNESS List: Eligible as a student with a disability? Yes No, student is exiting from special education No, student is not eligible for special education Evaluation Date: (MM DD YYYY) (This is the most recent date on which the IEP team completed a full and comprehensive review of all assessment materials.) Parent consent for evaluation is on file (required for initial IEP): (MM DD YYYY) Documentation to support decision:

4 I. MEETING AND IDENTIFYING INFORMATION PAGE 1.2 PARENT/GUARDIAN 1 First Name: MI: Last Name: Address: City: State: Zip Code: Home #: ( ) - Cell #: ( ) - Work #: ( ) - Relationship: Parent native language, if not English: Interpreter needed? YES NO PARENT/GUARDIAN 2 First Name: MI: Last Name: Address: City: State: Zip Code: Home #: ( ) - Cell #: ( ) - Work #: ( ) - Relationship: Parent native language, if not English: Interpreter needed? YES NO PARENT/GUARDIAN 3 First Name: MI: Last Name: Address: City: State: Zip Code: Home #: ( ) - Cell #: ( ) - Work #: ( ) - Relationship: Parent native language, if not English: Interpreter needed? YES NO PARENT/GUARDIAN 4 First Name: MI: Last Name: Address: City: State: Zip Code: Home #: ( ) - Cell #: ( ) - Work #: ( ) - Relationship: Parent native language, if not English: Interpreter needed? YES NO

5 I. MEETING AND IDENTIFYING INFORMATION PAGE 1.3 MEDICAL ASSISTANCE Is the student receiving Medical Assistance? YES NO I choose to accept Service Coordination for Children with Disabilities Case Management. I understand that the purpose of this service is to assist in gaining access to needed medical, social, educational, and other services. I understand that continuation of this service depends on meeting the eligibility requirements for Service Coordination for Children with Disabilities, COMAR I understand that this service does not restrict or otherwise affect a participant s eligibility for other Medical Assistance benefits. I understand that I am free to choose a case manager for my child. At this time, I accept the following case manager(s): Case Manager Name: Case Manager Name: I understand that if I wish to change the case manager in the future, I can call the school system to make a change. Authorized Signature*: Date: * Consent must be provided by the parent or individual legally authorized to represent the participant. EXIT INFORMATION Exit date: (MM DD YYYY) Exit category: A - Returned to general education B - Graduated with Maryland high school diploma C - Received Maryland high school certificate D - Reached 21 years of age E - Deceased F - Moved, known to be continuing H - Dropped Out STATE AGENCY Type of state agency: Adult Correctional Facility Department of Juvenile Service RICA Catonsville Educational Center (Regional Institute for Children and Adolescents) Maryland School for the Blind Maryland School for the Deaf Charles H. Hickey, Jr. School DISCIPLINARY REMOVAL Type of removal: Removed to an interim alternative education setting by school personnel Removed to an interim alternative education setting by school personnel and removals for drugs, weapons, or serious bodily injury Removed to an interim alternative educational setting based on a hearing officer determination regarding likely injury to child or others Removed to an alternate setting by Parent Permission Suspended or expelled greater than 10 days Other Date of entry: (MM DD YYYY) Projected date of exit for state agency: (MM DD YYYY) Total duration: _ Actual date of exit from state agency: (MM DD YYYY) Division of Correction number (if appropriate):

6 II. PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE PAGE 2.0 PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE What are the parents concerns, expectations, and issues for their child? What are the student s strengths, interest areas, significant personal attributes, and personal accomplishments? (Include preferences and interests for post-school outcomes, if appropriate.) How does the student s disability affect his/her involvement and progress in the general education curriculum or participation in school activities? For preschool age children, how does their disability affect participation in appropriate activities?

7 II. PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE PAGE 2.1 ACADEMIC READING Document student s academic achievement and functional performance levels in reading, if appropriate. Assessment Date: (MM DD YYYY) Source: Other Assessment Date: (MM DD YYYY) Other Source:_ Evaluator: Instructional Grade Level Performance: (Consider private, state, local school system, and classroom based assessments, as applicable.) Summary of Assessment Findings: Is this area affected by disability? YES NO ACADEMIC MATH Document student s academic achievement and functional performance levels in math, if appropriate. Assessment Date: (MM DD YYYY) Source: Other Assessment Date: (MM DD YYYY) Other Source:_ Evaluator: Instructional Grade Level Performance: (Consider private, state, local school system, and classroom based assessments, as applicable.) Summary of Assessment Findings: Is this area affected by disability? YES NO ACADEMIC WRITING Document student s academic achievement and functional performance levels in writing, if appropriate. Assessment Date: (MM DD YYYY) Source: Other Assessment Date: (MM DD YYYY) Other Source:_ Evaluator: Instructional Grade Level Performance: (Consider private, state, local school system, and classroom based assessments, as applicable.) Summary of Assessment Findings: Is this area affected by disability? YES NO ACADEMIC SCIENCE Document student s academic achievement and functional performance levels in science, if appropriate. Assessment Date: (MM DD YYYY) Source: Other Assessment Date: (MM DD YYYY) Other Source:_ Evaluator: Instructional Grade Level Performance: (Consider private, state, local school system, and classroom based assessments, as applicable.) Summary of Assessment Findings: Is this area affected by disability? YES NO

8 II. PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE PAGE 2.2 ACADEMIC OTHER Document student s academic achievement and functional performance levels in other academic areas, if appropriate. Assessment Date: (MM DD YYYY) Source: Other Assessment Date: (MM DD YYYY) Other Source:_ Evaluator: (Consider private, state, local school system, and classroom based assessments, as applicable.) Summary of Assessment Findings: Instructional Grade Level Performance: Is this area affected by disability? YES NO HEALTH Assessment Date: (MM DD YYYY) Source: Other Assessment Date: (MM DD YYYY) Other Source:_ Evaluator: Level of Performance: (Consider private, state, local school system, and classroom based assessments, as applicable.) Summary of Assessment Findings: Is this area affected by disability? YES NO PHYSICAL Assessment Date: (MM DD YYYY) Source: Other Assessment Date: (MM DD YYYY) Other Source:_ Evaluator: Level of Performance: (Consider private, state, local school system, and classroom based assessments, as applicable.) Summary of Assessment Findings: Is this area affected by disability? YES NO BEHAVIORAL Assessment Date: (MM DD YYYY) Source: Other Assessment Date: (MM DD YYYY) Other Source:_ Evaluator: Level of Performance: (Consider private, state, local school system, and classroom based assessments, as applicable.) Summary of Assessment Findings: Is this area affected by disability? YES NO

9 III. SPECIAL CONSIDERATIONS AND ACCOMMODATIONS PAGE 3.0 BLIND EXIT INFORMATION VISUALLY IMPAIRED Instruction in Braille considered? YES NO Conducted by: _ Evaluation date: (MM DD YYYY) Is the student blind? YES NO Is the student visually impaired? YES NO Is instruction in Braille appropriate? YES NO Were parents provided information regarding Maryland School for the Blind? YES NO Documentation to support decisions: COMMUNICATION Does the student have special communication needs? YES NO Does the student require a special communication system? YES NO (If yes, describe the specific needs.) Conducted by: _ Evaluation date: (MM DD YYYY) Documentation to support decisions: DEAF OR HEARING IMPAIRMENT Consider language and communication needs, opportunities for direct communication, academic level, and full range of needs, including direct instruction in a child s language and communication mode. Student deaf or hearing impaired? YES NO Were parents provided information regarding Maryland School for the Deaf? YES NO Documentation to support decisions: BEHAVIORAL EXIT INFORMATION INTERVENTION Consider student s behavior, including use of positive behavioral interventions, supports, other strengths, and the possible need for a functional behavioral assessment. Student requires a Behavioral Intervention Plan? YES NO Functional Behavior Assessment Evaluation date: Behavior Intervention Plan Evaluation date: Other: Evaluation date: Documentation to support decisions: LIMITED ENGLISH PROFICIENCY Consider the student s language needs and document whether the special education and related services will be provided in a language other than English. Does the student have Limited English proficiency? YES NO Current IPT Score: Documentation to support decisions: ASSISTIVE TECHNOLOGY Consider the assistive technology device(s) and service(s) that are needed to assist a child to access the general and/or specific curriculum related to the child s areas of needs and IEP goals. Was assistive technology considered? YES NO Student needs an AT device(s)? YES NO AT Device(s): Student needs AT service(s)? YES NO (If yes, complete services page.) Documentation to support decisions:

10 III. SPECIAL CONSIDERATIONS AND ACCOMMODATIONS PAGE 3.1 SUPPLEMENTARY AIDS, SERVICES, AND SUPPORT FOR SCHOOL PERSONNEL Check all supplementary aids to be used in the classroom Alternative media Assisted note taking Behavioral Aids Break tasks into smaller segments Extra processing and response time Extra time to complete assignments Give wait time prior to response Physical adaptations Preferential seating Provide graphic organizers/specification sheets for structuring written work Staff training Use visual aids Use clear uncluttered printed materials Use of typewriter/word processor Verbatim repetition of directions Other, specify: Documentation to support decision:

11 III. SPECIAL CONSIDERATIONS AND ACCOMMODATIONS PAGE 3.2 INSTRUCTIONAL AND TESTING ACCOMMODATIONS These are the state accommodations for testing. Any item selected for testing also must be used in the classroom. PRESENTATION ACCOMMODATIONS: Visual Presentation Accommodations Code (1) Assessment: Standard Administration (2) Assessment: Non-Standard Administration Large Print 1-A 4 N/A 4 Magnification Devices 1-B 4 N/A 4 Sign Language 1-C 4 N/A 4 Tactile Presentation Accommodations Braille 1-D 4 N/A 4 Tactile Graphics 1-E 4 N/A 4 Auditory Presentation Accommodations Human Reader, Audio Tape, or Compact Disk Recording for Verbatim Reading of Entire Test 1-F 4* * 4 Human Reader, Audio Tape, or Compact Disk Recording for Verbatim Reading of Selected Sections of Test 1-G 4* * 4 Audio Amplification Devices 1-H 4 N/A 4 Books on Tape 1-J N/A N/A 4 Recorded Books 1-K N/A N/A 4 Multi-Sensory Presentation Accommodations Video Tape and Descriptive Video 1-L * N/A 4 Screen Reader for Verbatim Reading of Entire Test 1-M 4* * 4 Screen Reader for Verbatim Reading of Selected Sections of Test 1-N 4* * 4 Visual Cues 1-O 4 N/A 4 Notes, Outlines, and Instructions 1-P N/A N/A 4 Talking Materials 1-Q 4 N/A 4 Other Presentation Accommodations (3) Use in Instruction Other 1-R Determined on a case-by-case basis in consultation with MSDE * Use of the verbatim reading accommodation is permitted on all assessments as a standard accommodation, with the exception of: (1) the Maryland School Assessment (MSA) in reading, grades 3 and 4, which assess student s ability to decode printed language. Students in those grades receiving this accommodation on the assessment will receive a score based on standards 2 and 3 (comprehension of informational and literary reading material) but will not receive a score for standard 1, general reading processes, and (2) the Maryland Functional Reading Test.

12 III. SPECIAL CONSIDERATIONS AND ACCOMMODATIONS PAGE 3.3 INSTRUCTIONAL AND TESTING ACCOMMODATIONS These are the state accommodations for testing. Any item selected for testing also must be used in the classroom. RESPONSE ACCOMMODATIONS: Response Accommodations Code (1) Assessment: Standard Administration (2) Assessment: Non-Standard Administration Scribe 2-A 4 N/A 4 Speech-to-Text 2-B 4 N/A 4 Large Print Response Booklet 2-C 4 N/A 4 Brailler 2-D 4 N/A 4 Electronic Note-Takers 2-E 4 N/A 4 Tape Recorder 2-F 4 N/A 4 Respond on Test Booklet 2-G 4 N/A 4 Monitor Test Response 2-H 4 N/A 4 Materials or Devices Used to Solve or Organize Responses Calculation Devices 2-J 4 N/A 4 Spelling and Grammar Devices 2-K 4* * 4 Visual Organizers 1-L 4** ** 4 Graphic Organizers 2-M 4 N/A 4 Bilingual Dictionaries 2-N 4 N/A 4 Other Response Accommodations (3) Use in Instruction Other 2-O Determined on a case-by-case basis in consultation with MSDE * Spelling and grammar devices are not permitted to be used on the English High School Assessment. ** Photocopying of secure test materials requires approval and must be done under the supervision of the LAC. Photocopied materials must be securely destroyed under the supervision of the LAC. Use of highlighters may be limited on certain machine-scored test forms, as highlighting may obscure test responses. Check with the LAC before allowing the use of highlighters on any state test.

13 III. SPECIAL CONSIDERATIONS AND ACCOMMODATIONS PAGE 3.4 INSTRUCTIONAL AND TESTING ACCOMMODATIONS These are the state accommodations for testing. Any item selected for testing also must be used in the classroom. TIMING AND SCHEDULING ACCOMMODATIONS: Timing and Scheduling Accommodations Code (1) Assessment: Standard Administration (2) Assessment: Non-Standard Administration Extended Time 3-A 4 N/A 4 Multiple or Frequent Breaks 3-B 4 N/A 4 Change Schedule or Order of Activities Extend over multiple days 3-C 4 N/A 4 Change Schedule or Order of Activities Within one day 3-D 4 N/A 4 Other Timing and Scheduling Accommodations (3) Use in Instruction Other 3-E Determined on a case-by-case basis in consultation with MSDE SETTING ACCOMMODATIONS: Setting Accommodations Code (1) Assessment: Standard Administration (2) Assessment: Non-Standard Administration Reduce Distractions to the Student 4-A 4 N/A 4 Reduce Distractions to Other Students 4-B 4 N/A 4 Change Location to Increase Physical Access or to Use Special Equipment Within School Building 4-C 4 N/A 4 Change Location to Increase Physical Access or to Use Special Equipment Outside School Building 4-D 4 N/A 4 Other Setting Accommodations (3) Use in Instruction Other 4-E Determined on a case-by-case basis in consultation with MSDE

14 III. SPECIAL CONSIDERATIONS AND ACCOMMODATIONS PAGE 3.5 EXTENDED SCHOOL YEAR (ESY) The IEP Team should determine if any of the factors below will significantly jeopardize the student s ability to receive some benefit from the student s educational program during the regular school year, if the student does not receive extended school year services. ESY services are the individualized extension of specific special education and related services that are provided beyond the normal school year of the public agency, in accordance with the IEP, at no cost to the parents. Was ESY considered? YES NO DECISION DEFERRED Discussion: Will the benefits that the student receives from his/her education program during the regular school year be significantly jeopardized if the student is not provided ESY? YES NO Additional questions to consider: 1. Does the student s IEP include annual goals related to critical life skills? YES NO Documentation to support decisions: 2. Is there a likely chance of substantial regression of critical life skills caused by the normal school break and a failure to recover those lost skills in a reasonable time? YES NO Documentation to support decisions: 3. Is there a presence of emerging skills or breakthrough opportunities? YES NO Documentation to support decisions: 4. Is the student demonstrating a degree of progress toward mastery of IEP goals related to critical life skills? YES NO Documentation to support decisions: 5. Are there significant interfering behaviors? YES NO Documentation to support decisions: 6. Does the nature and severity of the disability warrant ESY? YES NO Documentation to support decisions: 7. Are there other special circumstances that require ESY? YES NO Documentation to support decisions: [NOTE: If ESY is needed, complete the services page for ESY.]

15 III. SPECIAL CONSIDERATIONS AND ACCOMMODATIONS PAGE 3.6 TRANSITION Beginning at age 14, or younger if appropriate, a vision statement, based on the student s preferences and interests, including desired outcomes in adult living, post-secondary and work environments should be documented. Vision Statement: Course of Study: Date of interview: (MM DD YYYY) (Attach interview form) Name/Title of person conducting interview: Interview summary Does the student receive any Social Security Benefits? SSI SSDI CDB SCB (Surviving Child Benefit) Functional Vocational Assessment: Vocational Interest Vocational Aptitude Availability of Community Training Availability of Employment Opportunities Actual Vocational Assessment Score Beginning at age 16, or younger if appropriate, and updated annually, a statement of transition service needs under the applicable components of the student s IEP that focuses on the student s courses of study should be documented. Statement of Transition Service needs: Expectations for High School graduation: Continuing Special Services: Projected Date of Exit: (MM DD YYYY) Projected Category of Exit (Category from which you project a student 14 years or older will exit school.) Exit with a Maryland High School Diploma Exit with a Maryland High School Certificate at age 21 Exit with a Maryland High School Certificate prior to age 21 Adult Service Agency (The agency that will provide the anticipated service.) General Services Division of Rehabilitation Services (DORS) Mental Hygiene Administration (MHA) Further Education/Training Developmental Disabilities Administration (DDA) Post Secondary Transition Discussion:

16 III. SPECIAL CONSIDERATIONS AND ACCOMMODATIONS PAGE 3.7 TRANSITION ACTIVITIES Instruction Needs: Activities: Agency: Post Secondary education needs: Activities: Agency: Assistive technologies needs: Activities: Agency: Related transportation needs: Activities: Agency: Employment needs: Activities: Agency: Daily living needs: Activities: Agency: Community experiences: Activities: Agency:

17 III. SPECIAL CONSIDERATIONS AND ACCOMMODATIONS PAGE 3.8 ANTICIPATED SERVICES FOR TRANSITION Services you anticipate a student 14 years and older will need within one year of exiting special education. General Services No Services Needed: upon exiting from the educational system. Public income maintenance: Social Security Income (SSI), Social Security Disability Income (SSDI), welfare, Medicaid, public health insurance, etc. Transportation: specialized transportation including paratransit. Developmental Disabilities Administration (DDA) Day Habilitation Community Residential Services Supported Employment Family and Individual Support Services Behavior/Support Services Community Supported Living Arrangements (CSLA) Further Education/Training Continuing and Adult Education: including Adult Basic Ed (ABE), General Education Development (GED), adult high school diploma, and adult compensatory or special education. Higher Education Support Services: note takers, educational technology, modified testing time, mentoring and guidance, study skills, and self advocacy training. Career School Support Services: support services in programs such as career schools, Job Training Partnership Act programs (JTPA), and Job Corps. Mental Hygiene Administration (MHA) Mental Health Evaluation and Treatment Psychiatric Rehabilitation Programs Residential Rehabilitation Programs Supported Employment Respite Care Division of Rehabilitation Services (DORS) Assessment and Evaluation Vocational Rehabilitation Counseling and Guidance Job Search, Placement Assistance, and Follow Up Services Medical Rehabilitation Vocational and Other Training Services Rehabilitation Technology Services Support Services

18 IV. GOALS PAGE 4.0 GOAL Goal: By: (MM DD YYYY) With Accuracy How will the team notify parents of progress? Objective 1: Objective 2: Towards Goal Report 1 Report 2 Report 3 Report 4 Is this an ESY goal? YES NO DECISION DEFERRED How often? WEEKLY Evaluation Method: INFORMAL PROCEDURES CLASSROOM-BASED ASSESSSMENT BI-WEEKLY OBSERVATION RECORD STANDARDIZED ASSESSMENT MONTHLY PORTFOLIO ASSESSMENT OTHER QUARTERLY INTERIM OTHER Objective 3: Objective 4: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description:

19 IV. GOALS PAGE 4.1 GOAL Goal: By: (MM DD YYYY) With Accuracy How will the team notify parents of progress? Objective 1: Objective 2: Towards Goal Report 1 Report 2 Report 3 Report 4 Is this an ESY goal? YES NO DECISION DEFERRED How often? WEEKLY Evaluation Method: INFORMAL PROCEDURES CLASSROOM-BASED ASSESSSMENT BI-WEEKLY OBSERVATION RECORD STANDARDIZED ASSESSMENT MONTHLY PORTFOLIO ASSESSMENT OTHER QUARTERLY INTERIM OTHER Objective 3: Objective 4: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description:

20 IV. GOALS PAGE 4.2 GOAL Goal: By: (MM DD YYYY) With Accuracy How will the team notify parents of progress? Objective 1: Objective 2: Towards Goal Report 1 Report 2 Report 3 Report 4 Is this an ESY goal? YES NO DECISION DEFERRED How often? WEEKLY Evaluation Method: INFORMAL PROCEDURES CLASSROOM-BASED ASSESSSMENT BI-WEEKLY OBSERVATION RECORD STANDARDIZED ASSESSMENT MONTHLY PORTFOLIO ASSESSMENT OTHER QUARTERLY INTERIM OTHER Objective 3: Objective 4: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description:

21 IV. GOALS PAGE 4.3 GOAL Goal: By: (MM DD YYYY) With Accuracy How will the team notify parents of progress? Objective 1: Objective 2: Towards Goal Report 1 Report 2 Report 3 Report 4 Is this an ESY goal? YES NO DECISION DEFERRED How often? WEEKLY Evaluation Method: INFORMAL PROCEDURES CLASSROOM-BASED ASSESSSMENT BI-WEEKLY OBSERVATION RECORD STANDARDIZED ASSESSMENT MONTHLY PORTFOLIO ASSESSMENT OTHER QUARTERLY INTERIM OTHER Objective 3: Objective 4: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description: Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal Description:

22 V. SERVICES PAGE 5.0 SERVICES Complete one form for each service (25 types of Services Categories) Service Category: Special Education Classroom Instruction Physical Education Speech/Language Therapy Travel Training Career and Technology Education Career and Technology Education Program w/support Services Special Career and Technology Education Program for Disabled Vocational Evaluation Special Education Program with Pre-Vocation Objectives Related Services Audiological Services Psychological Services Occupational Therapy Physical Therapy Recreation Early Identification and Assessment Counseling Services School Health Services Social Work Services Parent Counseling & Training Rehabilitative Counseling Orientation and Mobility Training Services Assistive Technology Services Medical Services (Diagnostic & Evaluation) Transportation Other Other Therapies (Art/Drama/Dance) Frequency Select the number of sessions Other Select a time period Weekly Monthly Yearly Only Recheck Periodically (Includes indirect services and periodic evaluations) Residential (24 hour special education services) Select the length of time, in 15 minute increments, that the service is provided during each session Other Begin Date: (MM DD YYYY) End Date: (MM DD YYYY) Duration (The number of weeks a student is served): weeks Provider/Agency (choose only one) Special Education Classroom Teacher Orientation & Mobility Specialist Audiologist Speech/Language Pathologist Teacher of the Hearing Impaired Teacher of the Visually Impaired Occupational Therapist Physical Therapist Home-Based Teacher Pupil Personnel Worker Guidance Counselor Physical Education Teacher Psychologist General Education Teacher Total time in school day hrs. minutes/week Time in General Education hrs. minutes/week IEP Team Career & Technology Teacher Rehabilitation Services Staff School Social Worker Recreational Therapist Other Service Provider Teacher Aide Interpreter Department of Social Services Mental Hygiene Administration Developmental Disabilities Administration Division of Rehabilitation Services (DORS) Other Agencies Time out of General Education hrs. minutes/week Is this an ESY service? YES NO DECISION DEFERRED Explain: If yes, complete the following: Frequency Select the number of sessions Other Select a time period Weekly Monthly Yearly Only Recheck Periodically (Includes indirect services and periodic evaluations) Residential (24 hour special education services) Select the length of time, in 15 minute increments, that the service is provided during each session Other Begin Date: (MM DD YYYY) End Date: (MM DD YYYY) Duration (The number of weeks a student is served): weeks

23 V. SERVICES PAGE 5.1 SERVICES Complete one form for each service (25 types of Services Categories) Service Category: Special Education Classroom Instruction Physical Education Speech/Language Therapy Travel Training Career and Technology Education Career and Technology Education Program w/support Services Special Career and Technology Education Program for Disabled Vocational Evaluation Special Education Program with Pre-Vocation Objectives Related Services Audiological Services Psychological Services Occupational Therapy Physical Therapy Recreation Early Identification and Assessment Counseling Services School Health Services Social Work Services Parent Counseling & Training Rehabilitative Counseling Orientation and Mobility Training Services Assistive Technology Services Medical Services (Diagnostic & Evaluation) Transportation Other Other Therapies (Art/Drama/Dance) Frequency Select the number of sessions Other Select a time period Weekly Monthly Yearly Only Recheck Periodically (Includes indirect services and periodic evaluations) Residential (24 hour special education services) Select the length of time, in 15 minute increments, that the service is provided during each session Other Begin Date: (MM DD YYYY) End Date: (MM DD YYYY) Duration (The number of weeks a student is served): weeks Provider/Agency (choose only one) Special Education Classroom Teacher Orientation & Mobility Specialist Audiologist Speech/Language Pathologist Teacher of the Hearing Impaired Teacher of the Visually Impaired Occupational Therapist Physical Therapist Home-Based Teacher Pupil Personnel Worker Guidance Counselor Physical Education Teacher Psychologist General Education Teacher Total time in school day hrs. minutes/week Time in General Education hrs. minutes/week IEP Team Career & Technology Teacher Rehabilitation Services Staff School Social Worker Recreational Therapist Other Service Provider Teacher Aide Interpreter Department of Social Services Mental Hygiene Administration Developmental Disabilities Administration Division of Rehabilitation Services (DORS) Other Agencies Time out of General Education hrs. minutes/week Is this an ESY service? YES NO DECISION DEFERRED Explain: If yes, complete the following: Frequency Select the number of sessions Other Select a time period Weekly Monthly Yearly Only Recheck Periodically (Includes indirect services and periodic evaluations) Residential (24 hour special education services) Select the length of time, in 15 minute increments, that the service is provided during each session Other Begin Date: (MM DD YYYY) End Date: (MM DD YYYY) Duration (The number of weeks a student is served): weeks

24 V. SERVICES PAGE 5.2 SERVICES Complete one form for each service (25 types of Services Categories) Service Category: Special Education Classroom Instruction Physical Education Speech/Language Therapy Travel Training Career and Technology Education Career and Technology Education Program w/support Services Special Career and Technology Education Program for Disabled Vocational Evaluation Special Education Program with Pre-Vocation Objectives Related Services Audiological Services Psychological Services Occupational Therapy Physical Therapy Recreation Early Identification and Assessment Counseling Services School Health Services Social Work Services Parent Counseling & Training Rehabilitative Counseling Orientation and Mobility Training Services Assistive Technology Services Medical Services (Diagnostic & Evaluation) Transportation Other Other Therapies (Art/Drama/Dance) Frequency Select the number of sessions Other Select a time period Weekly Monthly Yearly Only Recheck Periodically (Includes indirect services and periodic evaluations) Residential (24 hour special education services) Select the length of time, in 15 minute increments, that the service is provided during each session Other Begin Date: (MM DD YYYY) End Date: (MM DD YYYY) Duration (The number of weeks a student is served): weeks Provider/Agency (choose only one) Special Education Classroom Teacher Orientation & Mobility Specialist Audiologist Speech/Language Pathologist Teacher of the Hearing Impaired Teacher of the Visually Impaired Occupational Therapist Physical Therapist Home-Based Teacher Pupil Personnel Worker Guidance Counselor Physical Education Teacher Psychologist General Education Teacher Total time in school day hrs. minutes/week Time in General Education hrs. minutes/week IEP Team Career & Technology Teacher Rehabilitation Services Staff School Social Worker Recreational Therapist Other Service Provider Teacher Aide Interpreter Department of Social Services Mental Hygiene Administration Developmental Disabilities Administration Division of Rehabilitation Services (DORS) Other Agencies Time out of General Education hrs. minutes/week Is this an ESY service? YES NO DECISION DEFERRED Explain: If yes, complete the following: Frequency Select the number of sessions Other Select a time period Weekly Monthly Yearly Only Recheck Periodically (Includes indirect services and periodic evaluations) Residential (24 hour special education services) Select the length of time, in 15 minute increments, that the service is provided during each session Other Begin Date: (MM DD YYYY) End Date: (MM DD YYYY) Duration (The number of weeks a student is served): weeks

25 VI. PLACEMENT DATA PAGE 6.0 LRE DECISION MAKING A student with a disability is not removed from education in an age-appropriate general classroom solely because of needed modifications in the general curriculum. Special education placement (ages 3-5) Special education placement (ages 6-21) Are the services in the student s home school (the school the child would attend if not disabled)? YES NO If no, add documentation to support decision: Is placement as close as possible to the student s home? YES NO If no, add documentation to support decision: Is transportation needed? YES NO If Yes REGULAR SPECIALIZED Are there any potential harmful effects of the setting on the child or quality of services he or she needs? YES NO If yes, add documentation to support decision What is the extent to which the student will not participate with non-disabled peers in academic, non-academic, and extracurricular activities? PLACEMENT SUMMARY Total time in General Education hrs. minutes/week Total time out of General Education hrs. minutes/week Special education placement (ages 3-5): ITINERANT SETTING (NO MORE THAN 3HR/WEEK) PRIVATE SEPARATE DAY SCHOOL (100) PUBLIC SEPARATE DAY SCHOOL (100) EARLY CHILDHOOD SETTING PUBLIC RESIDENTIAL FACILITY (100) HOSPITAL EARLY CHILDHOOD SPECIAL ED. SETTING PRIVATE RESIDENTIAL FACILITY (100) HOME PART-TIME EARLY CHILDHOOD/PART-TIME EARLY CHILDHOOD SPECIAL ED. Special education placement (ages 6-21): OUTSIDE GENERAL ED. (OUT < 21) PRIVATE SEPARATE DAY SCHOOL (FOR > 50) PUBLIC SEPARATE DAY SCHOOL (FOR > 50) OUTSIDE GENERAL ED. (OUT 21-60) PUBLIC RESIDENTIAL FACILITY (FOR > 50) HOSPITAL OUTSIDE GENERAL ED. (OUT > 60) PRIVATE RESIDENTIAL FACILITY (FOR > 50) HOME Add documentation to support decision If removed from the general education environment, explain reasons why services cannot be provided in the general education environment. SSIS Resident County SSIS Resident School SSIS Service County SSIS Service School Eligibility Codes: Eligible student with a disability served in a public school or placed in a nonpublic school by the public agency to receive FAPE. Eligible parentally placed private school student with a disability receiving special education and/or related service through a service plan from the public agency. Eligible parentally placed private school student with a disability NOT receiving service from the public agency. SPECIALIZED TRANSPORTATION DETAILS (Optional) Specialized equipment needs of the student YES NO Explain: Personnel needed to assist the student during transportation YES NO Explain: Estimated amount of time involved in transporting the student hrs. minutes DAILY WEEKLY Distance the student will be transported miles DAILY WEEKLY Notes:

26 VII. IEP APPROVAL PAGE 7.0 IEP APPROVAL IEP Approved: (MM DD YYYY) My signature on this form indicates that I have reviewed and had an opportunity to participate in the development of this IEP. My signature on this form indicates that I consent to this IEP and placement and that the IEP may be implemented as described. I understand that my rights include the right to a copy of the complete procedural safeguards, at a minimum, upon the initial referral of my child for an evaluation; with each notice of a meeting to develop, review, or revise my child s IEP; with each notice of reevaluation; and if I file a written request for a due process hearing. I give my permission to submit information that will be used for the Special Services Information System. This system will be used by the Maryland State Department of Education and other state agencies, as appropriate, to enable funding of programs and to assure my child s rights to any needed assessment. I understand that my rights include the right to receive this and all other written notices in the language I understand (primary language) or if needed, a translation of such orally, in sign language, or in Braille, as appropriate. I understand that my rights include the right to answers from school personnel to additional questions I may have. I understand that my rights include the right to request more information. If the student is eligible for Medical Assistance: I agree to IEP service coordination for my child and that the Service Coordinator(s) identified on this IEP may be appointed as Medicaid Service Coordinator(s). I give permission to the local school system to recover costs from Medicaid for service coordination, as well as health-related services, related to the implementation of my child s IEP goals. I understand that this service does not restrict or otherwise affect my child s eligibility for other Medical Assistance benefits. I also understand that my child may not receive a similar type of case management service under Medical Assistance if he/she qualifies for more than one type. Signature of Parent/Guardian Date of Signature