FORM 1 – INDIVIDUALIZED EDUCATION
PROGRAM –
INFORMATION/ELIGIBILITY
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.
This will
be the same date as the IEP date
above.
4. Next IEP: Enter
the
next IEP date that will be one year from
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.
¥ Initial is the IEP to determine eligibility after
initial
assessment.
¥ Annual is the IEP meeting to be held within one year of prior IEP.
¥ Triennial is the IEP meeting to be held after reassessment. This meeting may also include the Annual IEP Meeting.
¥ 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.
Transition also means for students who are 16 or older, or who will
turn 16 when
this IEP is in effect, the IEP team must
address needed post-secondary transition services.
These services must include the results of age appropriate
transition assessments,
measurable post-secondary goals related to training/education,
employment and independent living skills (as appropriate) and describe the focus of the studentÕs course of study.
¥ Pre-expulsion means an IEP meeting that is being held as part of or
following a manifestation determination.
¥ Interim means if the child has an IEP and transfers into a district from another
SELPA.
¥ Expanded IEP means an IEP meeting, which includes CMH
representatives.
¥ Other
9. Birthdate: Enter the exact birthdate.
10. Age: The studentÕs 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 studentÕs Migrant
status.
14. Native Language: This field was previously known as home language. This is the studentÕs home language or
birth language.
15. EL: Check if the student is an English learner or has been re-designated.
(R-FEP)
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 studentÕs 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 studentÕs district
of
residence.
21. Residence School: Enter the childÕs neighborhood school.
22. Ethnicity: Answer the two part
question and then 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 ÒPÓ
and secondary disability withÓSÓ. The primary disability should be the one that has the most significant impact
on the studentÕs 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. Evaluation team
members
sign form as appropriate.
24. If the student is not
eligible or no longer eligible for special education:
¥ Document reason for decision and other options to address the studentÕs educational needs on IEP Team Comments Page (Form 7).
¥ 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.
25. How Disability Affects Educational
Performance: Write a statement which describes the disability and its impact, i.e. Òauditory processing deficits adversely impact the studentÕs ability to complete activities within the general education settingÓ, Òsignificant speech and
language deficits interfere with the studentÕs ability to interact with other students in the preschool
settingÓ
27. Triennial (3 Year) Re-Evaluation:
Check the appropriate box. If the triennial evaluation is due prior to the next
IEP
meeting; check one of
the
following: Summary of Progress
and Current Educational Performance, Full
Evaluation, or Other.
If other
is
check specify measurement.
For Initial Placements Only (Ages 3 to 22 only –
Do not include infant referral dates)
1. Has the Student Received Coordinated Early Intervening Services (CEIS) under the
IDEA
in the
Past Two Years: Coordinated Early
Intervening Services (CEIS) 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. NOTE:
Do not confuse this with early intervention. NOTE:
This is required for districts that have been found to be significantly disproportionate by the CDE and optional for other districts.
Districts can choose to use up to 15% of IDEA Local
Assistance
dollars
for
CEIS.
Districts that
are
found
to be
significantly disproportionate by CDE must use 15% of IDEA Local
Assistance dollars for
CEIS. Coordinated early intervening services include educational and behavioral evaluations, services and supports including scientifically based literacy instruction. If the student received coordinated early intervening services (CEIS) during the past two years, check
ÒyesÓ. If you check ÒyesÓ then it is assumed that the district has moved 15% of their
Federal Local Assistance (IDEA) funds to general education and that data is being
collected on the students who have are receiving CEIS. Coordinated early intervening services
are
only required
for districts
who
have been identified as
significantly disproportionate. 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).
Note: This date
can change if a student
is
found eligible, then exits, and then is re-assessed and found eligible again.
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.
5. Date of Initial
Meeting to Determine Eligibility: Enter
the
date of IEP Team
meeting to review initial evaluation and determine eligibility for special
education.
Educational Benefit Reminder
- Is all
of the information complete and correct?
- How will
the
manager of the school
MIS system be informed of any changes?
- Does the IEP clearly specify the childÕs disability(s)?
- Did the IEP
Team identify how
the
childÕs disability affects his or her involvement
and progress in the general curriculum or participation in appropriate activities for the
preschool child?
- Is the purpose for
the
meeting identified and clearly defined?
- Are all
dates accurate and complete?
- Is ethnicity and race properly identified and accurately completed?
[Excerpted
from the State SELPA IEP Manual, July, 2013]