Individualized Education Program
IEP Date   Student Name

Coordination of Services Coordination of Services

(Specify if other:) 
 
Specialized/Supplemental equipment, materials, services
 
Physical Education Option (Specify if other:) 

Tests, evaluation, information relied upon:
     
 
  Other Relevant Factors: Other Relevant Factors:
 

GENERAL EDUCATION PARTICIPATION
Academic Subjects:   Assemblies, Field Trips, School Activities
 
Electives:   Extracurricular Activities
 
Lunch, Recess, Passing Periods   Community Based Instruction
 
Other:
 
Other than as indicated above, due to the student's unique needs identified in the present levels and goals, student will not participate in the general education environment. Rationale:
 
Classroom Accommodation/Modifications
 
Provision for Transition to General Education
 
BEHAVIOR:
Student's behavior   impede learning of self or others (describe)
 
PARENT COMMUNICATION/REPORTING SCHEDULE:
   Report Cards - Concurrent with issuance of General Education Report Cards
 
    Home/School Communication: Home/School Communication:
   
 
    Other: Other: