IEP Team Amendment(s) Page
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Name
Birthdate
IEP date
Parents/Guardians/Surrogates have agreed that a meeting is not needed for this amendment.
Purpose of Meeting
Purpose of Meeting
Amendment(s) to the IEP dated
Amendment(s) to the IEP dated
:
Amendment(s)
Type of Service
Frequency/Duration
(e.g., days pwer week/minutes)
Location and Provider
Goals
Effective date:
Effective date:
(see attached goals)
(see attached goals)
_____ I agree to all parts of this amendment to the IEP dated
_____ I agree to this amendment to the IEP dated , with the exception of
_____ I do not agree with this amendment to the IEP dated
_____ I have been advised of and given a copy of the Notice of Procedural Safeguards, as required once per year.
Parent/Guardian/Surrogate
Date
Parent/Guardian/Surrogate
Date
LEA Rep./Admin. Designee
Date
General Education Teacher
Date
Student
Date
Special Education Specialist
Date
Additional Participant / Title
Date
Additional Participant / Title
Date
Additional Participant / Title
Date
Additional Participant / Title
Date