Special Factors (Form 3)
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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?
      If yes, specify:
 
 
  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:
 
 
  Considerations if the student is blind or visually impaired
 
 
  Considerations if the student is deaf or hard of hearing
 
 
  If the child is an English Learner, consider the language needs of the child as those needs relate to the IEP
 
 
  Does student's behavior impede learning of self or others? Does student's behavior impede learning of self or others?
    (If yes, describe)
 
 
  If yes, specify positive behavior interventions, strategies, and supports If yes, specify positive behavior interventions, strategies, and supports
 
  Behavior Support Plan (BSP) attached Behavior Intervention Plan (BIP) attached
 
  Areas of need to be addressed in goals for the student to receive educational benefit Areas of need to be addressed in goals for the student to receive educational benefit
 
 

 
Participation in Statewide Assessment Program, STAR
(California Standards Test/CAT-6, California Modified Achievement Test, California Alternate Performance Assessment)
 
Grade Exempt (before grade 2 and after grade 11)
 
 
 
  NOTE: The following item in blue is obsolete as of the introduction of the 10.22.2007 version of Form 3. If the box for this item is checked, AND none of the three new boxes in rose are checked (Math, Science, and English Language Arts), then the PREVIOUS Form 3 (4/07) will be printed.  
 
CAT-6/California Standards Test CAT-6/California Standards Test
 
 
 
 
  NOTE: The following items in rose are new on the 10.22.2007 version of Form 3. They do not appear on the previous (4/07) version of Form 3. If any of these boxes are checked (Math, Science, and English Language Arts), then the newer version of Form 3 will be printed.  
 
MATH MATH
 
 
SCIENCE SCIENCE
 
 
English Language Arts (ELA) English Language Arts (ELA)
 
 
 
 
California Alternative Performance Assessment (CAPA) - Level
(CASEMIS) (CASEMIS)   
 

 
The student will not participate in the CST/CAT-6 because The student will not participate in the CST/CAT-6 because
 
Participation in the CAPA is appropriate because Participation in the CAPA is appropriate because
 

 
For Preschoolers (Ages 3, 4 and 5 years) (Desired Results Developmental Profile (DRDP))
DRDP-R DRDP-Access
 
Adaptations  
 

 
  Other State-Wide/ District-Wide Assessments (Accommodations/Modifications)
 
 
  Other State-Wide/ District-Wide Assessment(s) Alternate Assessment(s) appropriate because
 
 
 
 
  NOTE: The following item is obsolete as of the introduction of the 10.22.2007 version of Form 3 (see note above).  
 
Alternate assessment(s) appropriate because