Special Factors (3A)
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Name   IEP Date
 

 
  Does student require assistive technology devices and/or services? Does student require assistive technology devices and/or services? Does student require assistive technology devices and/or services?
      If yes, specify:
 
 
 
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  Does student require low incidence services, equipment and/or materials to meet educational goals? Does student require low incidence services, equipment and/or materials to meet educational goals? Does student require low incidence services, equipment and/or materials to meet educational goals?
    If yes, specify:
 
 
 
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  Considerations if the student is blind or visually impaired Considerations if the student is blind or visually impaired Considerations if the student is blind or visually impaired
 
 
 
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  Considerations if the student is deaf or hard of hearing Considerations if the student is deaf or hard of hearing Considerations if the student is deaf or hard of hearing
 
 
 
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  If the student is an English Learner, complete the following section:  
 
  Does the student need primary language support?
 
  If yes, who will provide?  
 
  What will be the language of instruction for the student?  
 
  Who will provide ELD program to student?    General education teacher    Special education teacher
 
  What type of ELD program will be provided?    English language mainstream    Structured English immersion    Alternative Program (primary language instruction)
 

 
  Comments Comments Comments
 
 
 
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  Does student's behavior impede learning of self or others? Does student's behavior impede learning of self or others? Does student's behavior impede learning of self or others?
    (If yes, describe)
 
 
 
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  If yes, specify positive behavior interventions, strategies, and supports If yes, specify positive behavior interventions, strategies, and supports If yes, specify positive behavior interventions, strategies, and supports
 
 
 
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  Behavior Intervention Plan (BIP) attached Behavior Goal is part of this IEP
 

 
  For student to receive educational benefit, goals will be written to address the following areas of need: For student to receive educational benefit, goals will be written to address the following areas of need: For student to receive educational benefit, goals will be written to address the following areas of need:
 
 
 
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  NOTE: The state forms committee removed the following items, and they no longer print on this form:
 
  Will student take CELDT?
 
  If No, what alternative assessment will be given?  
 
  Does the student require accommodations or modification to CELDT?
 
  If yes, list below
 
 
 
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  Behavior Support Plan attached