New York State Education Department IEP Form
MIDWEST RSE-TASC
INDICATOR 13 TIPS
SAMPLE LANGUAGE
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
STUDENT NAME:
DATE OF BIRTH: LOCAL ID #:
DISABILITY CLASSIFICATION:
PROJECTED DATE IEP IS TO BE IMPLEMENTED:
PROJECTED DATE OF ANNUAL REVIEW:
PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL NEEDS
DOCUMENTATION OF STUDENT'S CURRENT PERFORMANCE AND ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS
EVALUATION RESULTS (INCLUDING FOR SCHOOL-AGE STUDENTS, PERFORMANCE ON STATE AND DISTRICT-WIDE ASSESSMENTS)
Refer to General Directions Document http://www.p12.nysed.gov/specialed/formsnotice/IEP/home.html
In this section evaluation information will be added and described; may need to coordinate with psychologists and/or secretaries. It
CANNOT be left blank. Include title of assessment (this is not required, but is best practice and usually included), date and results. A
summary of the interpretation of the scores, including the instructionally relevant information understandable to the parent and
educational team should be included in this section. Instructional implications of an assessment can then be further summarized or
included in the appropriate section of the PLPs
Psychological Assessment
Educational Assessment
Speech & Language, PT, OT & other related service assessments
Physical Examination, Medical assessment
Classroom Observation
Functional Behavior Assessment (FBA)
Level 1/Transition Assessment
LAB-R, NYSESLAT (for LEP/ELLs)
State & District-wide Assessments; Transcript Information, Credits earned
CITATION Ia: Under the student’s present levels of performance, the IEP includes a statement of the student’s needs, taking into account the
student’s strengths, preferences and interests, as they relate to transition from school to post-school activities.
CITATION IIIa: If the purpose of a CSE meeting is to consider the post-secondary goals for the student and the transition service needed to
assist the student in reaching those goals, the school district invites the student. If the student does not attend, the district takes steps to ensure that
the student’s preferences and interests are considered.
- “According to an age appropriate transition assessment (Level One Assessment/Age Appropriate Transition Assessment), (student’s name)
New York State Education Department IEP Form
states that s/he is interested in becoming a _____________________ upon completion of high school. In order to be successful, s/he will need
______________________ (identify skills needed, high school degree requirement, experiences needed, etc.).”
- “While completing an age appropriate transition assessment (Student’s name) had stated that s/he is unaware of what s/he wants to do in the
future but has shown an interest in ____________________. In order to plan for the future, (student’s name) will need to explore various
options that match his/her interests and strengths. In order to accomplish this, s/he will need to complete an interest inventory. (NOTE: This
can then be an activity listed in the Coordinated Set of Activities under the Development of Employment).”
- “In completing an age appropriate transition assessment (Level One Assessment), (student’s name) identified, expressed interest, discussed,
said…”
ACADEMIC ACHIEVEMENT, FUNCTIONAL PERFORMANCE AND LEARNING CHARACTERISTICS
LEVELS OF KNOWLEDGE AND DEVELOPMENT IN SUBJECT AND SKILL AREAS INCLUDING ACTIVITIES OF DAILY LIVING, LEVEL OF INTELLECTUAL FUNCTIONING,
ADAPTIVE BEHAVIOR, EXPECTED RATE OF PROGRESS IN ACQUIRING SKILLS AND INFORMATION, AND LEARNING STYLE:
Refer to NYSED Guide to Quality Individualized Education Program (IEP) Development and Implementation
www.p12.nysed.gov/specialed/formsnotices/iepguidance/IEPguideFeb2010.pdf
Provide description of Student’s Current Level of Performance, This is BASELINE DATA – the “CAN DO” in the “CAN’T DO” Areas; Include
Progress toward meeting Annual Goals; “WHAT WORKS” – (Specific Strategies, Supports and Instructional Methodologies that Support
Progress made); Describe the Impact of the Disability; Manifestations or Characteristics of the Disability that have been Observed.
Expected rate of progress: (Includes current grades, effort, motivation, assessment implications, etc.)
Functional performance
Activities of daily living
Communication/language
Reading/writing
Math
Organization/attention
Transition between/among activities
Learning style
- “Currently, (student’s name) is able to do ____________________ (fill in what s/he can do in relation to the skills needed for his/her future goal
as specifically as possible) but will need to work on ___________________ (fill in what s/he needs to work on in detail) in order to be
successful as a _______________________.”
STUDENT STRENGTHS, PREFERENCES, INTERESTS:
Identify the student’s strengths, social skills, consider recreation and community experiences.
- “According to an age appropriate transition assessment (Level One Assessment/Age Appropriate Transition Assessment), (student’s name)
states that s/he is interested in becoming a ____________________ upon completion of high school. He/she exhibits strengths in the area of
_____________________ that will assist him/her in achieving this goal.”
ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS OF THE STUDENT, INCLUDING CONSIDERATION OF STUDENT NEEDS THAT ARE OF CONCERN TO THE
PARENT:
New York State Education Department IEP Form
Identify student’s SPECIFIC skill deficits as noted in the current performance areas;
Do NOT include recommendations for services or management needs.
Parent’s/student’s voice regarding student’s needs/skill deficits is clearly stated; provide parents with multiple opportunities to provide
input; document (in student file) multiple attempts to contact parent (parent/teacher conferences, phone contact, e-mail, parent
survey/questionnaire).
Best practice is to include a null statement (e.g. “Parent does not identify any concerns at this time”) if no parent concerns are
indicated.
- “The student will need to develop skills in the area of __________________ in order to be successful in a training program or workplace.”
- “As an employee in any career field, the student will need to develop skills in ____________________ (identify skills student needs to continue
to develop as it relates to the disability) in order to be successful in achieving post secondary goals.”
- Family members state that organization is a skill that (student’s name) need to develop to be successful at school and in the future for work.”
SOCIAL DEVELOPMENT
THE DEGREE (EXTENT) AND QUALITY OF THE STUDENT'S RELATIONSHIPS WITH PEERS AND ADULTS; FEELINGS ABOUT SELF; AND SOCIAL ADJUSTMENT TO
SCHOOL AND COMMUNITY ENVIRONMENTS:
*Give examples of what specific behaviors look like (include data) and possible strategies that work.*
Student’s relationship with adults and peers, social skills,
Ability to accept guidance or assistance from others:
Student’s feelings of self, level of maturity:
Self-determination, self-advocacy skills:
Play skills, taking turns, sharing (for preschoolers, early elementary)
Ability to work cooperatively with peers
Adjustment to School and Community
(Refer to SCANS and CDOS Skills for post-secondary training)
- “Student’s name) has stated that s/he is unaware of what s/he wants to do in the future but has shown an interest in ____________________.”
STUDENT STRENGTHS:
Identify the student’s strengths, social skills, consider recreation and community experiences.
- “Socially, (student’s name) has many peers. This will help the student be successful in the field of _______________________ as it requires
social interaction.”
SOCIAL DEVELOPMENT NEEDS OF THE STUDENT, INCLUDING CONSIDERATION OF STUDENT NEEDS THAT ARE OF CONCERN TO THE PARENT:
Identify the skills deficits as noted in the current level of ability.
Include the parent’s voice relating to concerns noted.
- “In order to plan for the future, (student’s name) will need to explore various career options that match his/her interests and strengths. In order
to accomplish this, s/he will need to complete an interest inventory. (NOTE: This can then be an activity listed in the Coordinated Set of
2.
New York State Education Department IEP Form
Activities under the Development of Employment).”
PHYSICAL DEVELOPMENT
THE DEGREE (EXTENT) AND QUALITY OF THE STUDENT’S MOTOR AND SENSORY DEVELOPMENT, HEALTH, VITALITY AND PHYSICAL SKILLS OR LIMITATIONS
WHICH PERTAIN TO THE LEARNING PROCESS:
Include information related to gross, fine, & grapho-motor skills, sensory needs, medical conditions and/or medications as they impact
educational performance, physical limitations or endurance. Can describe medical equipment (wheelchair, crutches, braces, AFO’s
splints, etc.) if applicable in this section.
- “(Student’s name) has good physical and motor skills and identified an interest in the field of ____________________ that will require
adequate physical development.”
STUDENT STRENGTHS:
Consider student’s health, fitness and nutritional status; attendance, recreational interests, participation in physical education,
sports or extracurricular activities.
- “(Student’s name) enjoys physical activity and is likely to be successful in the area of ____________________ as it requires hands-on
involvement to complete work tasks.”
PHYSICAL DEVELOPMENT NEEDS OF THE STUDENT, INCLUDING CONSIDERATION OF STUDENT NEEDS THAT ARE OF CONCERN TO THE PARENT:
Include skill deficits impacted by the student’s disability; If disability does not impact this (or any other) area—include null statement:
There are no disability related needs at this time.
Parent/student concerns
- “Student and parent indicate a need for (student’s name) to organize his/her medications so he/she can be independent in taking medications
in the future.”
MANAGEMENT NEEDS
THE NATURE (TYPE) AND DEGREE (EXTENT) TO WHICH ENVIRONMENTAL AND HUMAN OR MATERIAL RESOURCES ARE NEEDED TO ADDRESS NEEDS IDENTIFIED ABOVE:
ONLY needs are included in this section. Include supports, strategies to be provided by the teachers, related services and support staff.
Needs should relate to the information (what works) and needs identified in the previous PLP sections. Do NOT include programs and
services (1:1 aide) but WHAT that service is needed for (e.g. adult prompting and redirection).
Environmental Resources—adapted routine or schedule, preferential seating (describe), size of group during instruction, additional
transition time
Human Resources—adult supervision, guidance or assistance to provide support, strategies, accommodations noted in PLP
Material Resources—adaptive equipment/furniture, alternate instructional materials, assistive technology (high and low tech), graphic
organizer, study guide, copy of notes, health care plan, etc.
EFFECT OF STUDENT NEEDS ON INVOLVEMENT AND PROGRESS IN THE GENERAL EDUCATION CURRICULUM OR, FOR A PRESCHOOL STUDENT, EFFECT OF
STUDENT NEEDS ON PARTICIPATION IN APPROPRIATE ACTIVITIES
Manifestation of disability in GEN ED SETTING (“appropriate activities” ONLY refer to preschoolers). Describe the characteristics of the
disability observed consistently that impacts the student’s ability to participate and show progress in the general education curriculum.
3.
New York State Education Department IEP Form
This provides support for the least restrictive environment (LRE). Consider issues related to the environment, instructional
methodologies, content, materials and the student’s ability to demonstrate what he/she has learned.
STUDENT NEEDS RELATING TO SPECIAL FACTORS
BASED ON THE IDENTIFICATION OF THE STUDENT'S NEEDS, THE COMMITTEE MUST CONSIDER WHETHER THE STUDENT NEEDS A PARTICULAR DEVICE OR
SERVICE TO ADDRESS THE SPECIAL FACTORS AS INDICATED BELOW, AND IF SO, THE APPROPRIATE SECTION OF THE IEP MUST IDENTIFY THE PARTICULAR
DEVICE OR SERVICE(S) NEEDED.
MUST ADDRESS ALL AREAS WITH EITHER YES/NO/NA see attachment 2 in Guide to Quality IEP Development and Implementation
DOES THE STUDENT NEED STRATEGIES, INCLUDING POSITIVE BEHAVIORAL INTERVENTIONS, SUPPORTS AND OTHER STRATEGIES TO ADDRESS BEHAVIORS THAT IMPEDE THE
STUDENT'S LEARNING OR THAT OF OTHERS? YES NO
DOES THE STUDENT NEED A BEHAVIORAL INTERVENTION PLAN? NO YES: IF YES, LIST BEHAVIORS ADDRESSED ON BIP
FOR A STUDENT WITH LIMITED ENGLISH PROFICIENCY, DOES HE/SHE NEED A SPECIAL EDUCATION SERVICE TO ADDRESS HIS/HER LANGUAGE NEEDS AS THEY RELATE TO THE
IEP?
YES NO NOT APPLICABLE
FOR A STUDENT WHO IS BLIND OR VISUALLY IMPAIRED, DOES HE/SHE NEED INSTRUCTION IN BRAILLE AND THE USE OF BRAILLE? YES NO NOT APPLICABLE
DOES THE STUDENT NEED A PARTICULAR DEVICE OR SERVICE TO ADDRESS HIS/HER COMMUNICATION NEEDS? YES NO
IN THE CASE OF A STUDENT WHO IS DEAF OR HARD OF HEARING, DOES THE STUDENT NEED A PARTICULAR DEVICE OR SERVICE IN CONSIDERATION OF THE STUDENT'S
LANGUAGE AND COMMUNICATION NEEDS, OPPORTUNITIES FOR DIRECT COMMUNICATIONS WITH PEERS AND PROFESSIONAL PERSONNEL IN THE STUDENT'S LANGUAGE AND
COMMUNICATION MODE, ACADEMIC LEVEL, AND FULL RANGE OF NEEDS, INCLUDING OPPORTUNITIES FOR DIRECT INSTRUCTION IN THE STUDENT'S LANGUAGE AND
COMMUNICATION MODE?
YES NO NOT APPLICABLE
DOES THE STUDENT NEED AN ASSISTIVE TECHNOLOGY DEVICE AND/OR SERVICE? YES NO
IF YES, DOES THE COMMITTEE RECOMMEND THAT THE DEVICE(S) BE USED IN THE STUDENT'S HOME? YES NO
Consider any devices/equipment identified in management section
BEGINNING NOT LATER THAN THE FIRST IEP TO BE IN EFFECT WHEN THE STUDENT IS AGE 15 (AND AT A YOUNGER AGE IF DETERMINED APPROPRIATE)
MEASURABLE POSTSECONDARY GOALS
LONG-TERM GOALS FOR LIVING, WORKING AND LEARNING AS AN ADULT
EDUCATION/TRAINING: Write: “The student’s “goal is to”, shall or will”. (Keep in mind…These are POST high school goals).
2 OR 4 YEAR DIPLOMA OUTCOME/TRAINING: (ON THE JOB TRAINING, COMMUNITY/ADULT EDUCATION, CERTIFICATE PROGRAM)
CITATION Ib: The IEP includes appropriate measurable post-secondary goals based upon age appropriate transition assessments relating to
training, education, employment and, where appropriate, independent living skills.
- “(Student’s name) will enroll at ABC University in order to study __________________________.”
- “Upon completion of high school, (student’s name) will enroll in a certification program in ___________________________.”
- “Upon exiting from high school, (student’s name) will participate in training within a community setting and develop skills in
______________________.”
New York State Education Department IEP Form
- “(Student’s name) will receive on-the-job training with job coach support in the field of _________________________.”
EMPLOYMENT:
(COMPETITIVE, SUPPORTED)
- “After college, (student’s name) will be competitively employed as a _________________________ OR in the field of ___________________.”
- “(Student’s name) will be employed as a ___________________________.”
- “After graduation from high school, (student’s name) will be employed with support in the area of ________________________.”
- “Upon exiting from high school, (student’s name) will pursue employment within a community setting with significant support in the area of
____________________________.”
INDEPENDENT LIVING SKILLS (WHEN APPROPRIATE):
(LIVE INDEPENDENTLY IN COMMUNITY, COLLEGE DORM, SUPPORTED APARTMENT, GROUP HOME; OBTAIN DRIVER’S LICENSE)
- “Upon completion of high school, (student’s name) will live _________________________ (independently, in housing that provides
support/supervision, etc.).”
- “(Student’s name) will live in a community/residential setting with significant support.”
- “(Student’s name) will live independently.”
- “(Student’s name) will live with family members.”
TRANSITION NEEDS
IN CONSIDERATION OF PRESENT LEVELS OF PERFORMANCE, TRANSITION SERVICE NEEDS OF THE STUDENT THAT FOCUS ON THE STUDENT'S COURSES OF
STUDY, TAKING INTO ACCOUNT THE STUDENT’S STRENGTHS, PREFERENCES AND INTERESTS AS THEY RELATE TO TRANSITION FROM SCHOOL TO POST-
SCHOOL ACTIVITIES:
Transition Needs relate to the student’s needs to be addressed with the support of the school in order to achieve MPSGs
Barriers to post secondary goals—consider skills related to self-determination, advocacy or academic areas
Can make bulleted list of needs for this section
Course of study statement is narrative
Should contain diploma student is going to achieve (must match with transcript section & with participation in state/local
assessments)
Should list courses/instruction related to post secondary goals
This will help you to determine Coordinated Set of Activities (and Annual Goals) needed for the coming year
- “Currently, (student’s name) is able to do ________________________ (fill in what s/he can do in relation to the skills needed for his/her future
goal as specifically as possible) but will need to work on _______________________ (fill in what s/he needs to work on in detail) in order to be
successful as a ______________________.”
5.
New York State Education Department IEP Form
- “The student will need to develop skills in the area of ________________________ in order to be successful in a training program or
workplace.”
- “As an employee in any career field, the student will need to develop skills in _______________________ (identify skills the student needs to
continue to develop as it relates to the disability) in order to be successful in achieving post-secondary goals.”
CITATION IIa: The IEP includes a statement of the transition service needs of the student that focuses on the student’s courses of study such
as participation in advance placement courses or a vocational education program.
- “(Student’s name) is currently enrolled in ________________________, which will help provide the foundation skills necessary to become a
_________________________.”
- “(Student’s name) should consider courses such as __________________________ to support needs in the area of ___________________.”
- “(Student’s name) will continue to take Regent’s level classes to gain skills necessary for going to college.”
MEASURABLE ANNUAL GOALS
THE FOLLOWING GOALS ARE RECOMMENDED TO ENABLE THE STUDENT TO BE INVOLVED IN AND PROGRESS IN THE GENERAL EDUCATION CURRICULUM,
ADDRESS OTHER EDUCATIONAL NEEDS THAT RESULT FROM THE STUDENT'S DISABILITY, AND PREPARE THE STUDENT TO MEET HIS/HER POSTSECONDARY
GOALS. COLLABORATE WITH GENERAL EDUCATION TEACHERS, RELATED SERVICE PROVIDERS AND PARENTS
CRITERIA
MEASURE TO DETERMINE IF
GOAL HAS BEEN ACHIEVED
METHOD
HOW PROGRESS WILL BE
MEASURED
SCHEDULE
WHEN PROGRESS WILL
BE MEASURED
How well and over what
period of time will
student perform
skill/behavior to indicate
mastery of skill (must be
possible to achieve in
one year)
Identify the procedures
or methods used to
collect data to monitor
progress.
Must be tangible—
charts, checklists, rubric,
student work samples,
teacher made tests, etc.
(teacher observation is
not tangible)
How often methods will be
used to review the data so
progress can be
monitored.
Evaluation schedule should
be frequent enough to
allow adjustments to
instruction; it could be
different for each goal.
THIS IS NOT WHEN YOU
REPORT PROGRESS TO
New York State Education Department IEP Form
PARENTS
In 3 out of 5 trails daily
with less than 2 verbal
prompts
Student checklist and
work samples
Weekly
REPORTING PROGRESS TO PARENTS
IDENTIFY WHEN PERIODIC REPORTS ON THE STUDENT'S PROGRESS TOWARD MEETING THE ANNUAL GOALS WILL BE PROVIDED TO THE STUDENT'S PARENTS:
This is where you identify how often parents will receive progress reports on Annual Goals
ALTERNATE SECTION FOR STUDENTS WHOSE IEPS WILL INCLUDE SHORT-TERM INSTRUCTIONAL OBJECTIVES AND/OR BENCHMARKS
(REQUIRED FOR PRESCHOOL STUDENTS AND FOR SCHOOL-AGE STUDENTS WHO MEET ELIGIBILITY CRITERIA TO TAKE THE NEW YORK STATE ALTERNATE ASSESSMENT)
MEASURABLE ANNUAL GOALS
THE FOLLOWING GOALS ARE RECOMMENDED TO ENABLE THE STUDENT TO BE INVOLVED IN AND PROGRESS IN THE GENERAL EDUCATION CURRICULUM OR,
FOR A PRESCHOOL CHILD, IN APPROPRIATE ACTIVITIES, ADDRESS OTHER EDUCATIONAL NEEDS THAT RESULT FROM THE STUDENT'S DISABILITY, AND, FOR A
SCHOOL-AGE STUDENT, PREPARE THE STUDENT TO MEET HIS/HER POSTSECONDARY GOALS.
ANNUAL GOAL
WHAT THE STUDENT WILL BE EXPECTED TO ACHIEVE BY THE
END OF THE YEAR IN WHICH THE IEP IS IN EFFECT
CRITERIA
MEASURE TO DETERMINE IF
GOAL HAS BEEN ACHIEVED
METHOD
HOW PROGRESS WILL BE
MEASURED
SCHEDULE
WHEN PROGRESS WILL
BE MEASURED
SHORT-TERM INSTRUCTIONAL OBJECTIVES AND/OR BENCHMARKS (INTERMEDIATE STEPS BETWEEN THE STUDENT’S PRESENT LEVEL OF PERFORMANCE
AND THE MEASURABLE ANNUAL GOAL):
ANNUAL GOAL
CRITERIA
METHOD
SCHEDULE
SHORT-TERM INSTRUCTIONAL OBJECTIVES AND/OR BENCHMARKS (INTERMEDIATE STEPS BETWEEN THE STUDENT’S PRESENT LEVEL OF PERFORMANCE
New York State Education Department IEP Form
AND THE MEASURABLE ANNUAL GOAL):
ANNUAL GOAL
CRITERIA
METHOD
SCHEDULE
SHORT-TERM INSTRUCTIONAL OBJECTIVES AND/OR BENCHMARKS (INTERMEDIATE STEPS BETWEEN THE STUDENT’S PRESENT LEVEL OF PERFORMANCE
AND THE MEASURABLE ANNUAL GOAL):
(DUPLICATE TABLE/ROWS AS NEEDED)
REPORTING PROGRESS TO PARENTS
IDENTIFY WHEN PERIODIC REPORTS ON THE STUDENT'S PROGRESS TOWARD MEETING THE ANNUAL GOALS WILL BE PROVIDED TO THE STUDENT'S PARENTS:
RECOMMENDED SPECIAL EDUCATION PROGRAMS AND SERVICES
SPECIAL EDUCATION PROGRAM/SERVICES
SERVICE DELIVERY
RECOMMENDATIONS*
FREQUENCY
HOW OFTEN
PROVIDED
DURATION
LENGTH OF
SESSION
LOCATION
WHERE SERVICE WILL BE
PROVIDED
PROJECTED
BEGINNING/
SERVICE
DATE(S)
SPECIAL EDUCATION PROGRAM:
Should NOT be filled in prior to CSE
Drop down menu—special ed programs
identified in regs: Preschool §200.16/200.9
and school age §200.6
Identify group size,
native language,
etc.
Should NOT be filled in
prior to CSE
Drop down menu—
special ed programs
identified in regs:
Preschool
§200.16/200.9 and
school age §200.6
RELATED SERVICES:
Drop down menu—not finite list; see
definition §200.1(qq)
SUPPLEMENTARY AIDS AND SERVICES/PROGRAM
MODIFICATIONS/ACCOMMODATIONS:
Must correspond to PLP—Identify specific
8.
New York State Education Department IEP Form
supports noted in Management: (teacher
aide, preferential seating, verbal prompts,
etc.)
Transition Considerations:
- Are they increasing or decreasing
student independence?
- Are they available to student in post-
school settings?
Is the student aware of them and able
to advocate for them in all settings?
ASSISTIVE TECHNOLOGY DEVICES AND/OR
SERVICES:
Include equipment noted in PLP & Special
Factors section (do not include medical
equipment)
SUPPORTS FOR SCHOOL PERSONNEL ON BEHALF
OF THE STUDENT: services for staff
e.g. training on specific disability such as
autism, on assistive technology, behavior
interventions, etc.)
*IDENTIFY, IF APPLICABLE, CLASS SIZE (MAXIMUM STUDENT-TO-STAFF RATIO), LANGUAGE IF OTHER THAN ENGLISH, GROUP OR INDIVIDUAL SERVICES, DIRECT
AND/OR INDIRECT CONSULTANT TEACHER SERVICES OR OTHER SERVICE DELIVERY RECOMMENDATIONS.
12-MONTH SERVICE AND/OR PROGRAM – STUDENT IS ELIGIBLE TO RECEIVE SPECIAL EDUCATION SERVICES AND/OR PROGRAM DURING JULY/AUGUST: NO YES
IF YES:
STUDENT WILL RECEIVE THE SAME SPECIAL EDUCATION PROGRAM/SERVICES AS RECOMMENDED ABOVE.
OR
STUDENT WILL RECEIVE THE FOLLOWING SPECIAL EDUCATION PROGRAM/SERVICES:
Services can be provided to students with disabilities who…
Have intensive management needs
Have severe multiple disabilities
Are in home, hospital or residential programs
New York State Education Department IEP Form
Require ongoing instruction to avoid substantial regression (as defined by NYSED ESY policy 2006)
SPECIAL EDUCATION PROGRAM/SERVICES
SERVICE DELIVERY
RECOMMENDATIONS
FREQUENCY
DURATION
LOCATION
PROJECTED
BEGINNING/
SERVICE DATE(S)
Can be different from what was
provided during school year.
NAME OF SCHOOL/AGENCY PROVIDER OF SERVICES DURING JULY AND AUGUST:
FOR A PRESCHOOL STUDENT, REASON(S) THE CHILD REQUIRES SERVICES DURING JULY AND AUGUST:
TESTING ACCOMMODATIONS (TO BE COMPLETED FOR PRESCHOOL CHILDREN ONLY IF THERE IS AN ASSESSMENT PROGRAM FOR NONDISABLED PRESCHOOL
CHILDREN):
INDIVIDUAL TESTING ACCOMMODATIONS, SPECIFIC TO THE STUDENT’S DISABILITY AND NEEDS, TO BE USED CONSISTENTLY BY THE STUDENT IN THE
RECOMMENDED EDUCATIONAL PROGRAM AND IN THE ADMINISTRATION OF DISTRICT-WIDE ASSESSMENTS OF STUDENT ACHIEVEMENT AND, IN ACCORDANCE
WITH DEPARTMENT POLICY, STATE ASSESSMENTS OF STUDENT ACHIEVEMENT
TESTING ACCOMMODATION
CONDITIONS*
IMPLEMENTATION RECOMMENDATIONS**
NONE
Drop Down Menu—not a finite list
Refer to NYSED guide from May 2006
Test Access and Accommodations for
Students with Disabilities
When accommodation will be provided:
(tests requiring at least one written
paragraph)—not as needed, when
requested or for specific tests (regents).
Can indicate the type of test (e.g. all
timed tests)
www.p12.nysed.gov/specialed/policy/
testaccess/policyguide.htm
How accommodation will be provided; specific
recommendations for implementation (e.g.
amount of extended time).
*CONDITIONS – TEST CHARACTERISTICS: DESCRIBE THE TYPE, LENGTH, PURPOSE OF THE TEST UPON WHICH THE USE OF TESTING ACCOMMODATIONS IS
CONDITIONED, IF APPLICABLE.
**IMPLEMENTATION RECOMMENDATIONS: IDENTIFY THE AMOUNT OF EXTENDED TIME, TYPE OF SETTING, ETC., SPECIFIC TO THE TESTING ACCOMMODATIONS,
IF APPLICABLE.
BEGINNING NOT LATER THAN THE FIRST IEP TO BE IN EFFECT WHEN THE STUDENT IS AGE 15 (AND AT A YOUNGER AGE, IF DETERMINED APPROPRIATE).
COORDINATED SET OF TRANSITION ACTIVITIES
NEEDED ACTIVITIES TO FACILITATE THE
STUDENT’S MOVEMENT FROM SCHOOL TO
POST-SCHOOL ACTIVITIES
SERVICE/ACTIVITY
SCHOOL DISTRICT/
AGENCY RESPONSIBLE
New York State Education Department IEP Form
INSTRUCTION
Identify instruction student will be
getting THIS YEAR (the year the IEP is in
effect) to support achievement of
MPSGs
MUST list activities for this one
DO NOT USE DROP DOWN STATEMENTS
“Student will be provided the opportunity to…”
List courses as related to MPSG’s
Can be bulleted statements
CITATION IIb: The IEP includes needed
activities to facilitate the student’s movement
from school to post-school activities.
- “With special education support,
(student’s name) will learn to highlight
and define key vocabulary words in
order to improve reading
comprehension.”
- “With special education support,
(student’s name) will learn to tell time on
an analog clock.”
- “Student receives special education
services to develop organizational skills.”
- “Student attends CTE classes for auto
mechanics.”
MUST list district and role (not name) of person
responsible
CITATION IIc: The IEP includes a statement of
the responsibilities of the school district and, when
applicable, participating agencies for the provision of
such services and activities that promote movement
from school to post-school opportunities, or both,
before the student leaves the school setting.
CITATION IIIb: To the extent appropriate and
with parental consent or the consent of a student who
is 18 years of age or older, the school district must
invite a representative of any participating agency
that is likely to be responsible for providing or paying
for transition services. If an agency invited to send a
representative to a meeting does not do so, the
district should take steps to involve the other agency
in the planning of any transition services.
ABC School District, Special education teacher
ABC School District, Special education teacher
ABC School District, Special education teacher
BOCES or ABC School District,
CTE teacher
RELATED SERVICES
Identify what related services are going
to be provided THIS YEAR and how they
Can be bulleted—at least one
statement per service
Should correspond to related service
MUST list agency responsible if agency is paying
for/providing service (agency must be invited to
CSE with parent permission)
New York State Education Department IEP Form
will support the transition plan
section
Identify activity/skill that will be
addressed that relates to MPSG
If none then write…”Considered, but
not needed”
- “(Student’s name) receives counseling in
order to address behavior outbursts.”
ABC School District, School Counselor
COMMUNITY EXPERIENCES
Describe any community-based
experiences that will be provided to the
student THIS YEAR
Consider job shadow for 11
th
/12
th
graders?
Cannot be experiences that are not
supported by the district (church,
Boys/Girls Club etc.)
If none then write…”Considered, but not
needed”
- “(Student’s name) will identify community
bus routes and times in order to
transport to his/her job at ___________.”
- “(Student’s name) will explore the local
Workforce Development Office with
support from special education staff. The
student will then identify how this office
can assist in finding employment.”
- “Student has no needs at this time.”
ABC School District, Special education teacher,
Transition Specialist
ABC School District, Special education teacher,
Student
NA
DEVELOPMENT OF EMPLOYMENT AND OTHER
POST-SCHOOL ADULT LIVING OBJECTIVES
Identify activities that school will
provide student to support
college/training, employment and/or
independent living goals
MUST list activities for this one
Include ACCES-VR (formerly VESID)
application/connection for seniors only
Cannot be experiences that are not
supported by the district (volunteer
experiences, work obtained on their own)
- “(Student’s name) will have the
opportunity to meet with an ACCES-VR
counselor to determine eligibility for
services.”
ABC School District, Special education teacher,
School Counselor
ACCES-VR Counselor
New York State Education Department IEP Form
- “Due to reading comprehension
difficulties, (student’s name) will
complete an interest inventory with
support from special education staff to
identify potential interest areas.”
- “Student will review skills necessary to
be successful in an interview.”
ABC School District, Special education teacher,
School Counselor
ABC BOCES, Transition Specialist
ACQUISITION OF DAILY LIVING SKILLS (IF
APPLICABLE)
Identify activities to assist student in
functional skills (Dressing, hygiene, self-
care, health care, cooking, budgeting,
etc.)
Think about—SCANS and CDOS Standards
for skill areas
Organization?
Time management?
If none then write…”Considered, but not
needed”
- “Due to attention issues, (student’s
name) will practice selecting clothing
appropriate to the daily weather with
support from special education staff.”
- “Due to difficulties with gross/fine motor
skills, the student will learn how to
complete self-help tasks with support.”
- “No activities necessary at this time.”
ABC School District, Special education teacher
ABC School District, Special education teacher
NA
FUNCTIONAL VOCATIONAL ASSESSMENT (IF
APPLICABLE)
DO NOT list Level I Assessment—State
prefers the phrase “Considered, but not
needed” for any of these 6 areas in which
no activity is required”
- “(Student’s name) will have the
opportunity to participate in a functional
vocational assessment at BOCES in
order to identify possible career interest
areas.”
- “(Student’s name) will have the
opportunity to participate in a community
based assessment with XYZ Agency in
order to determine the level of support
ABC School District, Special education teacher,
ABC BOCES, Transition Specialist
ABC School District, Special education teacher
ABC BOCES, Transition Specialist
XYZ Agency
New York State Education Department IEP Form
the student will need for future
employment.”
- “CSE has determined there is no need
for a Functional Vocational Assessment
at this time.”
NA
PARTICIPATION IN STATE AND DISTRICT-WIDE ASSESSMENTS
(TO BE COMPLETED FOR PRESCHOOL STUDENTS ONLY IF THERE IS AN ASSESSMENT PROGRAM FOR NONDISABLED PRESCHOOL STUDENTS)
THE STUDENT WILL PARTICIPATE IN THE SAME STATE AND DISTRICT-WIDE ASSESSMENTS OF STUDENT ACHIEVEMENT THAT ARE ADMINISTERED TO
GENERAL EDUCATION STUDENTS.
THE STUDENT WILL PARTICIPATE IN AN ALTERNATE ASSESSMENT ON A PARTICULAR STATE OR DISTRICT-WIDE ASSESSMENT OF STUDENT
ACHIEVEMENT.
IDENTIFY THE ALTERNATE ASSESSMENT:
STATEMENT OF WHY THE STUDENT CANNOT PARTICIPATE IN THE REGULAR ASSESSMENT AND WHY THE PARTICULAR ALTERNATE
ASSESSMENT SELECTED IS APPROPRIATE FOR THE STUDENT:
Include information specific to the student’s needs related to eligibility criteria for the NYSAA—student’s limited cognitive abilities
combined with physical limitations. e.g. “She is nonverbal and uses a picture communication device to communicate basic needs. She
requires direct care for personal needs. Her chronological age is 12 but her instructional levels are at the Kindergarten level.”
PARTICIPATION WITH STUDENTS WITHOUT DISABILITIES
REMOVAL FROM THE GENERAL EDUCATION ENVIRONMENT OCCURS ONLY WHEN THE NATURE OR SEVERITY OF THE DISABILITY IS SUCH THAT, EVEN WITH THE
USE OF SUPPLEMENTARY AIDS AND SERVICES, EDUCATION CANNOT BE SATISFACTORILY ACHIEVED.
FOR THE PRESCHOOL STUDENT:
EXPLAIN THE EXTENT, IF ANY, TO WHICH THE STUDENT WILL NOT PARTICIPATE IN APPROPRIATE ACTIVITIES WITH AGE-APPROPRIATE NONDISABLED PEERS
(E.G., PERCENT OF THE SCHOOL DAY AND/OR SPECIFY PARTICULAR ACTIVITIES):
FOR THE SCHOOL-AGE STUDENT:
EXPLAIN THE EXTENT, IF ANY, TO WHICH THE STUDENT WILL NOT PARTICIPATE IN REGULAR CLASS, EXTRACURRICULAR AND OTHER NONACADEMIC ACTIVITIES
(E.G., PERCENT OF THE SCHOOL DAY AND/OR SPECIFY PARTICULAR ACTIVITIES):
IF THE STUDENT IS NOT PARTICIPATING IN A REGULAR PHYSICAL EDUCATION PROGRAM, IDENTIFY THE EXTENT TO WHICH THE STUDENT WILL PARTICIPATE IN
SPECIALLY-DESIGNED INSTRUCTION IN PHYSICAL EDUCATION, INCLUDING ADAPTED PHYSICAL EDUCATION:
EXEMPTION FROM LANGUAGE OTHER THAN ENGLISH DIPLOMA REQUIREMENT: NO YES - THE COMMITTEE HAS DETERMINED THAT THE STUDENT'S
DISABILITY ADVERSELY AFFECTS HIS/HER ABILITY TO LEARN A LANGUAGE AND RECOMMENDS THE STUDENT BE EXEMPT FROM THE LANGUAGE OTHER THAN
ENGLISH REQUIREMENT. NOTE: Consider student’s post secondary plans; response can limit college options
New York State Education Department IEP Form
SPECIAL TRANSPORTATION
TRANSPORTATION RECOMMENDATION TO ADDRESS NEEDS OF THE STUDENT RELATING TO HIS/HER DISABILITY
NONE.
STUDENT NEEDS SPECIAL TRANSPORTATION ACCOMMODATIONS/SERVICES AS FOLLOWS:
Consider:
Special seating—e.g., near window, individual seat
Vehicle and/or equipment needs—e.g., harness, lift
Adult supervision or training
Type of transportation—e.g., small bus, door to door, curb to curb, individual transport
Other accommodations—e.g., permission to bring personal items or to use iPod on bus
STUDENT NEEDS TRANSPORTATION TO AND FROM SPECIAL CLASSES OR PROGRAMS AT ANOTHER SITE:
Consider if student needs transportation from one site to another for services or programs to be provided.
PLACEMENT RECOMMENDATION
The identification of placement must specify where the student’s IEP will be implemented and should indicate the type of setting where
the student will receive special education services. Determined by student NEED, not disability or availability of program.
For example:
Public school district
BOCES
Approved private school or Special Act School District
Home/Community Setting