IEP Form 1 – Individualized Education Program

Items above the solid line may be completed prior to the meeting, based on information contained in the student information system.

1.       Student Name: Enter the student last name and first name.

 

2.       IEP Date: Enter date of the IEP meeting.

 

3.       Last IEP: Enter the date of the last IEP.

 

4.       Next IEP: Enter the next IEP date that will be one year form the present date in most cases.

 

5.       Original SpEd Entry Date: Enter the date the student first received special education services, including IFSP (0-3 infant services).

 

6.       Last Eval: Enter the date of the most recently completed comprehensive assessment to determine or re-determine eligibility for special education and related services (triennial or initial IEP date).

 

7.       Next Eval: Enter the date when the next triennial evaluation is due.

 

8.       Purpose of Meeting: Select purpose of meeting.

á      Initial is the IEP to determine eligibility after initial assessment.

á      Annual is the IEP meeting to be held within one year of prior IEP.

á      Triennial is the IEP meeting to be held after reassessment. This meeting may also include the Annual IEP Meeting.

á      Transition means transition from infant to preschool, preschool to kindergarten, elementary to middle, middle to high school, high school to transition placements, from public school setting to NPS or reverse, etc.

á      Pre-expulsion means an IEP meeting that is being held as part of or following a manifestation determination.

á      Interim means if the child has an IEP and transfers into a district from another district.

á      Expanded IEP means an IEP meeting which includes CMH representatives.

á      Other

 

9.      Birthdate: Enter the exact birthdate.

 

10.   Age: The studentŐs age as of the IEP meeting date. 

 

11.   Gender: Enter M or F.

 

12.   Grade: Enter the appropriate grade designation.

 

13.   Migrant: Check Yes or No to reflect the studentŐs Migrant status.

 

14.   Native Language: This field was previously known as home language. This is the studentŐs home language or birth language.

 

15.   EL: Check if the student is an English learner or has been redesignated.

 

16.   Interpreter: Check if an interpreter is needed for the IEP meeting.

 

17.   Student ID and SSID:  The student ID number is automatically assigned through CASEMIS.  The SSID formerly CSIS is assigned by the State. Each student must have a SSID.  Social Security Number is optional.

 

18.   Residency: This is the studentŐs residential status.

 

19.   Parent/Guardian Information: Enter the contact information for the parent/guardian. If the student resides in an out-of-home placement through a non-educational agency, put the parent contact information in the second contact area, if known.

 

20.   District of Residence: This is the studentŐs district of residence.

 

21.   Residence School:  Enter the childŐs neighborhood school.

 

22.   Ethnicity: Check the appropriate ethnicity(s). Note: Only four ethnicities can be listed. This should be the ethnicity designated by the parent on the student enrollment form at the school site.

 

23.   Disability: Mark primary disability with ŇPÓ and secondary disability with ÓSÓ.  The primary disability should be the one that has the most significant impact on the studentŐs ability to access the general education environment.  Note:  For funding purposes, low incidence disabilities marked as secondary will generate low incidence funding.

 

      If team determines the student has a specific learning disability, complete

      Specific Learning Disability Team Determination of Eligibility form 9. Evaluation team members sign form as appropriate.

 

24.   Severe/Non Severe: Check appropriate box.

56030.5. "Severely disabled" means individuals with exceptional needs who require intensive instruction and training in programs serving pupils with the following profound disabilities: autism, blindness, deafness, severe orthopedic impairments, serious emotional disturbances, severe mental retardation, and those individuals who would have been eligible for enrollment in a development center for handicapped pupils under Chapter 6 (commencing with Section 56800) of this part, as it read on January 1, 1980.

25.   If the student is not eligible or no longer eligible for special education:

á      IEP team members sign as appropriate on (Form 6).

      If parent(s) do not agree that the child is not eligible for special education services, note their concerns, discuss options for resolving their concerns, and review Notice of Procedural Safeguards.

 

26.   How Disability Affects Educational Performance: Write a statement which describes the disability and itŐs impact, i.e. Ňauditory processing deficits adversely impact the studentŐs ability to complete activities within the general education settingÓ, Ňsignificant speech and language deficits interfere with the studentŐs ability to interact with other students in the preschool settingÓ

 

 For Initial Placements Only (Ages 3 to 22 only – Do not include infant referral dates)

1.      Has the Student Received Pre-Referral Early Intervening Service in the Past Two Years: Pre-Referral Early Intervening Services are coordinated interventions for students not currently identified as requiring special education who need additional academic and behavior support to succeed in a general education environment. They include educational and behavioral evaluations, services and supports including scientifically based literacy instruction. If the student received pre-referral early intervening services during the past two years, check yes. Otherwise, check no.

 

2.      Date of Initial Referral for Special Education Services: Enter the date of the initial referral to assess and determine eligibility for education services (ages 3-22).

 

3.      Person Initiating the Referral: Select the person initiating the referral (Parent, Teacher, SST, Other School/District Personnel, Other).

 

4.      Date District Received Parent Consent: Enter the date the district received parent signature/consent for initial evaluation.

 

Date of Initial Meeting to Determine Eligibility: Enter the date of IEP Team meeting to review initial evaluation and determine eligibility for special education.

 

 

[Source: State SELPA IEP Manual, December, 2007]