Special Factors
Name   IEP Date

 
Did the IEP team determine that the student requires assistive technology devices and/or services? Did the IEP team determine that the student requires assistive technology devices and/or services?
    If yes, specify:
 
Does the student have a low incidence disability and require low incidence services, equipment, and/or materials to meet educational goals? Does the student have a low incidence disability and require low incidence services, equipment, and/or materials to meet educational goals?
    If yes, specify:
 
Considerations if the student is blind or visually impaired Student not visually impaired
 
 
Considerations if the student is deaf or hard of hearing Student not hearing impaired
 
 
If the child is an English Language 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
 
 
 
Behavior Goals Behavior Support Plan (BSP) attached Behavior Intervention Plan (BIP) attached
 

 
Participation in State/Districtwide Assessments (STAR)
(California Standards Test/CAT-6, California Modified Achievement Test, California Alternate Performance Assessment)
 
Grade Exempt (before grade 2 and after grade 11)
 
(CASEMIS)   
 
  Participation status Accommodations/modifications
ELA
    (Other:) 
 
MATH
    (Other:) 
 
SCIENCE
    (Other:) 
 
History
    (Other:) 
 
Writing
    (Other:) 
 
California Alternative Performance Assessment (CAPA) - Level   
 
The student will not participate in the CST/CAT-6 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)
 
 
Promotion Criteria
 
 
Parents will be informed of progress
 
How?
 
 

 
Other Agency Services
 
California Children's Services (CCS) Regional Center
Probation Department of Rehabilitation
Department of Social Services (DSS)
  Other (specify):
County Mental Health (CMH)  
  Student Eligible for Mental Health Services under Chapter 26.5?  
  Mental Health Services Language included on the IEP?  
 

 
Legacy items (these items no longer appear on the printed form)
 
CAT-6/California Standards Tests CAT-6/California Standards Tests
 
 
Other State-Wide/ District-Wide Assessments Alternate Assessment(s) appropriate because