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
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 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.
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.