name: date of birth: / / school system: iep meeting date: · student is pursuing a: maryland h. s....

INDIVIDUALIZED EDUCATION PROGRAMMSDE DIVISION OF SPECIAL EDUCATION AND EARLY INTERVENTION SERVICES (Last Updated 11/7/05)

Name: Date of Birth: / / School System: IEP Meeting Date: / /

VI. Placement Data Page 6.0

V. Services Pages 5.0–5.2

IV. Goals Pages 4.0–4.3

VII. IEP Approval Page 7.0

TABLE OF CONTENTS

I. Identifying & Meeting Information Pages

Child and School Information __________________________________________________________________________________ 1.0 Participation Data____________________________________________________________________________________________ 1.0 IEP Meeting and Team Members ________________________________________________________________________________ 1.1 Eligibility ___________________________________________________________________________________________________ 1.1 Parent/Guardian_____________________________________________________________________________________________ 1.2 Medical Assistance ___________________________________________________________________________________________ 1.3 Exit Information & Disciplinary Removal _________________________________________________________________________ 1.3 State Agency Information______________________________________________________________________________________ 1.3

II. Present Level of Academic Achievement and Functional Performance Pages 2.0–2.2

III. Special Considerations and Accommodations Pages

Blind or Visually Impaired _____________________________________________________________________________________ 3.0 Communication ______________________________________________________________________________________________ 3.0 Deaf or Hearing Impairment ___________________________________________________________________________________ 3.0 Behavioral Intervention _______________________________________________________________________________________ 3.0 Limited English Proficiency ____________________________________________________________________________________ 3.0 Assistive Technology __________________________________________________________________________________________ 3.0 Supplementary Aids, Services, and Support for School Personnel_____________________________________________________ 3.1 Instructional and Testing Accommodations ____________________________________________________________________3.2–3.4 Extended School Year _________________________________________________________________________________________ 3.5 Transition___________________________________________________________________________________________________ 3.6 Transition Activities __________________________________________________________________________________________ 3.7 Anticipated Services for Transition ______________________________________________________________________________ 3.8



CHILD AND SCHOOL INFORMATION PARTICIPATION DATA (continued)

First Name:______________________ MI: ___ Last Name: ______________________

Address: ________________________________________________________________

City: _________________________________State: _____ Zip Code:______________

Home Phone: ( ) - Cell: ( ) -

Email: __________________________________________________________________

Residence County: ________________________________________________________

Residence School: ________________________________________________________

Service County: __________________________________________________________

Service School:___________________________________________________________

Which county is financially responsible? ______________________________________

Grade:__________

Social Security Number: • •

Student ID #: ____________________________________________________________

Date of Birth: • • (MM•DD•YYYY)

Age:________ Gender: MALE FEMALE

Race: □ American Indian or Alaskan Native □ Hispanic or Latino □ Asian or Pacific Islander □ White (not Hispanic) □ Black or African American (not Hispanic) □ Other

Child’s native language: ___________________________________________________

Does the child require a parent surrogate? YES NO

Parent Surrogate Name: ___________________________________________________

Is the child currently under the care and custody of a state agency? YES NO

Is the student to participate in the Maryland School Assessment aligned with grade level academic achievement standards? (MSA) Reading YES NO Math YES NOIs the student to participate in the modified Maryland School Assessment aligned with modified academic achievement standards? (Mod-MSA) Reading YES NO Math YES NOIs the student to participate in alternative Maryland School Assessment aligned with alternative academic achievement standards? (Alt-MSA) Reading YES NO Math YES NO

Student is participating in the: Alt-MSA IPT HSA MSA MMSR Mod-MSA Mod-HSA N/A Student is in grade 1 or 2

Last year student participated in the: Alt-MSA IPT HSA MSA MMSR Mod-MSA Mod-HSA N/A Student was in grade 1 or 2

Documentation to support decision: __________________________________________

_________________________________________________________________________

_________________________________________________________________________What was the student’s performance on the Maryland Model for School Readiness (MMSR)? • • (MM•DD•YYYY) FULL APPROACHING DEVELOPINGWhat was the student’s performance on IPT? Assessment Date • • (MM•DD•YYYY) Score ______________ FULLY PROFICIENT LIMITED PROFICIENCY NOT PROFICIENTWhat was the student’s performance on ALT-MSA? • • (MM•DD•YYYY)

Alt-MSAAssessments

% of Mastery Objectives

Reading BASIC PROFICIENT ADVANCED

Math BASIC PROFICIENT ADVANCEDWhat was the student’s performance on MSA? • • (MM•DD•YYYY)

MSA Assessments Scale Score (Check Mod, if appropriate.)

Reading Mod BASIC PROFICIENT ADVANCED

Math Mod BASIC PROFICIENT ADVANCEDWhat was the student’s performance on HSA? • • (MM•DD•YYYY)

HSA Assessments(Check Mod, if appropriate.) Passing Score (2009) Student’s Score

English I Mod 407 PASS FAIL

Algebra/Data Analysis Mod 412 PASS FAIL

Government 394 PASS FAIL

Biology 400 PASS FAIL

Composite Score PASS FAIL

I. MEETING AND IDENTIFYING INFORMATIONPAGE 1.0

PARTICIPATION DATA

Student is pursuing a: Maryland H. S. Diploma Maryland H. S. Certificate

State graduation requirements can be found at www.MarylandPublicSchools.org.

Also record any additional local school system graduation requirements:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Graduation requirements explained to parents? YES NO




IEP MEETING ELIGIBILITY

TEAM MEMBERS PRESENT

IEP Case Manager: _________________________

IEP Chair: ________________________________

Parent/Guardian:__________________________

Parent/Guardian:__________________________

Principal/Designee: ________________________

General Educator: _________________________

Special Educator:__________________________

Guidance Counselor: _______________________

School Psychologist: _______________________

Social Worker: ____________________________

Speech/Language Pathologist: _______________

Student: _________________________________

Agency Representative: ____________________

Others in attendance:______________________



Meeting Purpose: Review written referral, existing data, assessment results, instruc-tional interventions, information from parents, and, if appropriate, determine the need for additional data

Review to determine eligibility

Develop the IEP

Review and, if appropriate, revise the IEP

Re-evaluation

Manifestation Determination

Review disciplinary removals to plan a functional behavioral assessment

Review disciplinary removals to develop a behavioral intervention plan

Consider Extended School Year services

Consider secondary transition services

Other _______________________________________________

____________________________________________________

IEP Team meeting date: • • (MM•DD•YYYY)Most Recent Annual Review date: • • (MM•DD•YYYY)Projected Annual Review date: • • (MM•DD•YYYY)Time:______ : _______ AM PM

Location:_______________________________________________________________

Did parent receive a copy of the “Procedural Safeguards Parental Rights”? YES NO

INITIAL ELIGIBILITY DATA

Date of parent consent for initial evaluation: • • (MM•DD•YYYY)Date of initial evaluation: • • (MM•DD•YYYY)Date of initial IEP development: • • (MM•DD•YYYY)Date of parent consent for initiation of services: • • (MM•DD•YYYY)Date of implementation of initial IEP: • • (MM•DD•YYYY)Is this student transitioning from Infants and Toddlers (Part C) to Pre-School (Part B) and will be receiving services? YES NO

CURRENT ELIGIBILITY DATA

Is the student making expected progress in school? YES NO

Is the lack of progress a result of the student’s disability? YES NO

Is a determinant factor for the child’s lack of academic progress the result of:a) a lack of an appropriate instruction in reading, including essential components of

reading instruction? YES NOb) lack of instruction in math? YES NOc) limited English proficiency? YES NODocumentation to support decision: _____________________________________________

____________________________________________________________________________

Does the student require specially designed instruction in order to make expected progress in school? YES NO

Does the student have one or more disabilities? YES NO

Mark primary disability as 1; secondary as 2; and tertiary as 3.__MENTAL RETARDATION __EMOTIONAL DISTURBANCE __TRAUMATIC BRAIN INJURY__HEARING IMPAIRMENT __ORTHOPEDIC IMPAIRMENTS __AUTISM__DEAF __OTHER HEALTH IMPAIRMENTS __DEVELOPMENTAL DELAY__SPEECH OR LANGUAGE IMPAIRMENT __SPECIFIC LEARNING DISABILITIES __MULTIPLE DISABILITIES__VISUAL IMPAIRMENT __DEAF - BLINDNESS List: ____________________________ ________________________________

Eligible as a student with a disability? Yes No, student is exiting from special education No, student is not eligible for special education

Evaluation Date: • • (MM•DD•YYYY)

(This is the most recent date on which the IEP team completed a full and comprehensive review of all assessment materials.)

Parent consent for evaluation is on file (required for initial IEP): • • (MM•DD•YYYY)Documentation to support decision: _____________________________________________

____________________________________________________________________________




PARENT/GUARDIAN 1

First Name:___________________________________________________MI: ____________

Last Name: __________________________________________________________________

Address: ____________________________________________________________________

City: ___________________________________ State:________ Zip Code:_____________

Home #: ( ) - Cell #: ( ) -

Work #: ( ) -

Email: ______________________________________________________________________

Relationship: ________________________________________________________________

Parent native language, if not English:___________________________________________

Interpreter needed? YES NO

PARENT/GUARDIAN 2

First Name:___________________________________________________MI: ____________

Last Name: __________________________________________________________________

Address: ____________________________________________________________________


Home #: ( ) - Cell #: ( ) -

Work #: ( ) -

Email: ______________________________________________________________________

Relationship: ________________________________________________________________



PARENT/GUARDIAN 3

First Name:___________________________________________________MI: ____________

Last Name: __________________________________________________________________

Address: ____________________________________________________________________


Home #: ( ) - Cell #: ( ) -

Work #: ( ) -

Email: ______________________________________________________________________

Relationship: ________________________________________________________________



PARENT/GUARDIAN 4

First Name:___________________________________________________MI: ____________

Last Name: __________________________________________________________________

Address: ____________________________________________________________________


Home #: ( ) - Cell #: ( ) -

Work #: ( ) -

Email: ______________________________________________________________________

Relationship: ________________________________________________________________






MEDICAL ASSISTANCE

Is the student receiving Medical Assistance? YES NO

I choose to accept Service Coordination for Children with Disabilities Case Management. I understand that the purpose of this service is to assist in gaining access to needed medical, social, educational, and other services. I understand that continuation of this service depends on meeting the eligibility requirements for Service Coordination for Children with Dis-abilities, COMAR 10.09.52.

I understand that this service does not restrict or otherwise affect a participant’s eligibility for other Medical Assistance benefits. I understand that I am free to choose a case manager for my child. At this time, I accept the following case manager(s):

Case Manager Name:__________________________________________________________________________________________________________________________________________

Case Manager Name:__________________________________________________________________________________________________________________________________________

I understand that if I wish to change the case manager in the future, I can call the school system to make a change.

Authorized Signature*: ________________________________________________________________________________________________________________________________________

Date: _______________________________________________________________________________________________________________________________________________________

* Consent must be provided by the parent or individual legally authorized to represent the participant.

EXIT INFORMATIONExit date: • • (MM•DD•YYYY)Exit category: A - Returned to general education B - Graduated with Maryland high school diploma C - Received Maryland high school certificate D - Reached 21 years of age E - Deceased F - Moved, known to be continuing H - Dropped Out

STATE AGENCY

Type of state agency: Adult Correctional Facility Department of Juvenile Service RICA — Catonsville Educational Center (Regional Institute for Children and Adolescents) Maryland School for the Blind Maryland School for the Deaf Charles H. Hickey, Jr. School

Date of entry: • • (MM•DD•YYYY)

Projected date of exit for state agency: • • (MM•DD•YYYY)

Total duration: _______________________________________________________________

Actual date of exit from state agency: • • (MM•DD•YYYY)

Division of Correction number (if appropriate): ___________________________________

DISCIPLINARY REMOVAL

Type of removal: Removed to an interim alternative education setting by school personnel Removed to an interim alternative education setting by school per-

sonnel and removals for drugs, weapons, or serious bodily injury Removed to an interim alternative educational setting based on a

hearing officer determination regarding likely injury to child or others Removed to an alternate setting by Parent Permission Suspended or expelled greater than 10 days Other _____________________________________________________ __________________________________________________________



What are the parents’ concerns, expectations, and issues for their child?

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

What are the student’s strengths, interest areas, significant personal attributes, and personal accomplishments? (Include preferences and interests for post-school outcomes, if appropriate.)

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

How does the student’s disability affect his/her involvement and progress in the general education curriculum or participation in school activities?

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

For preschool age children, how does their disability affect participation in appropriate activities?

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

II. PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE PAGE 2.0

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE



II. PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE PAGE 2.1

ACADEMIC — READING Document student’s academic achievement and functional performance levels in reading, if appropriate.

Assessment Date: • • (MM•DD•YYYY)

Source: ____________________________________________________________________

Other Assessment Date: • • (MM•DD•YYYY)

Other Source:_______________________________________________________________

Evaluator:__________________________________________________________________

Instructional Grade Level Performance: _________________________________________

(Consider private, state, local school system, and classroom based assessments, as applicable.)

Summary of Assessment Findings: _______________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Is this area affected by disability? YES NO

ACADEMIC — MATH Document student’s academic achievement and functional performance levels in math, if appropriate.


Source: ____________________________________________________________________


Other Source:_______________________________________________________________

Evaluator:__________________________________________________________________




____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________


ACADEMIC — SCIENCE Document student’s academic achievement and functional performance levels in science, if appropriate.


Source: ____________________________________________________________________


Other Source:_______________________________________________________________

Evaluator:__________________________________________________________________




____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________


ACADEMIC — WRITING Document student’s academic achievement and functional performance levels in writing, if appropriate.


Source: ____________________________________________________________________


Other Source:_______________________________________________________________

Evaluator:__________________________________________________________________




____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________




II. PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCEPAGE 2.2

HEALTH


Source: ____________________________________________________________________


Other Source:_______________________________________________________________

Evaluator:__________________________________________________________________

Level of Performance:________________________________________________________



____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________


BEHAVIORAL


Source: ____________________________________________________________________


Other Source:_______________________________________________________________

Evaluator:__________________________________________________________________




____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________


PHYSICAL


Source: ____________________________________________________________________


Other Source:_______________________________________________________________

Evaluator:__________________________________________________________________




____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________


ACADEMIC — OTHER ________________ Document student’s academic achievement and functional performance levels in other academic areas, if appropriate.


Source: ____________________________________________________________________


Other Source:_______________________________________________________________

Evaluator:__________________________________________________________________




____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________




III. SPECIAL CONSIDERATIONS AND ACCOMMODATIONSPAGE 3.0

ASSISTIVE TECHNOLOGY

Consider the assistive technology device(s) and service(s) that are needed to assist a child to access the general and/or specific curriculum related to the child’s areas of needs and IEP goals.

Was assistive technology considered? YES NO

Student needs an AT device(s)? YES NO

AT Device(s):_____________________________________________________________________

_________________________________________________________________________________

Student needs AT service(s)? YES NO (If yes, complete services page.)

Documentation to support decisions: ____________________________________________

____________________________________________________________________________

DEAF OR HEARING IMPAIRMENT

Consider language and communication needs, opportunities for direct communication, academic level, and full range of needs, including direct instruction in a child’s language and communication mode.

Student deaf or hearing impaired? YES NO

Were parents provided information regarding Maryland School for the Deaf? YES NO


____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

EXIT INFORMATIONInstruction in Braille considered? YES NOConducted by: _______________________________________________________________Evaluation date: • • (MM•DD•YYYY)Is the student blind? YES NO Is the student visually impaired? YES NOIs instruction in Braille appropriate? YES NOWere parents provided information regarding Maryland School for the Blind? YES NODocumentation to support decisions: ____________________________________________

____________________________________________________________________________

COMMUNICATION

Does the student have special communication needs? YES NODoes the student require a special communication system? YES NO(If yes, describe the specific needs.) ____________________________________________Conducted by: _______________________________________________________________Evaluation date: • • (MM•DD•YYYY)Documentation to support decisions: ____________________________________________

____________________________________________________________________________

____________________________________________________________________________

EXIT INFORMATIONConsider student’s behavior, including use of positive behavioral interventions, supports, other strengths, and the possible need for a functional behavioral assessment.

Student requires a Behavioral Intervention Plan? YES NO

Functional Behavior Assessment Evaluation date: • • Behavior Intervention Plan Evaluation date: • • Other:__________________________ Evaluation date: • •

_______________________________


____________________________________________________________________________

LIMITED ENGLISH PROFICIENCY

Consider the student’s language needs and document whether the special education and related services will be provided in a language other than English.

Does the student have Limited English proficiency? YES NO

Current IPT Score: ____________________________________________________________


____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

BLIND OR VISUALLY IMPAIRED

BEHAVIORAL INTERVENTION




SUPPLEMENTARY AIDS, SERVICES, AND SUPPORT FOR SCHOOL PERSONNEL

Check all supplementary aids to be used in the classroom

Alternative media Preferential seating Assisted note taking Provide graphic organizers/specification sheets for structuring written work Behavioral Aids Staff training Break tasks into smaller segments Use visual aids Extra processing and response time Use clear uncluttered printed materials Extra time to complete assignments Use of typewriter/word processor Give wait time prior to response Verbatim repetition of directions Physical adaptations Other, specify: _______________________________________________________________________________________

Documentation to support decision: _____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________




INSTRUCTIONAL AND TESTING ACCOMMODATIONS These are the state accommodations for testing. Any item selected for testing also must be used in the classroom.

PRESENTATION ACCOMMODATIONS:

Visual Presentation Accommodations Code

(1)Assessment:

StandardAdministration

(2)Assessment:

Non-Standard Administration

(3)

Use in Instruction

Large Print 1-A 4 N/A 4

Magnification Devices 1-B 4 N/A 4

Sign Language 1-C 4 N/A 4

Tactile Presentation Accommodations

Braille 1-D 4 N/A 4

Tactile Graphics 1-E 4 N/A 4

Auditory Presentation Accommodations

Human Reader, Audio Tape, or Compact Disk Recording for Verbatim Reading of Entire Test 1-F 4* * 4

Human Reader, Audio Tape, or Compact Disk Recording for Verbatim Reading of Selected Sections of Test 1-G 4* * 4

Audio Amplification Devices 1-H 4 N/A 4

Books on Tape 1-J N/A N/A 4

Recorded Books 1-K N/A N/A 4

Multi-Sensory Presentation Accommodations

Video Tape and Descriptive Video 1-L * N/A 4

Screen Reader for Verbatim Reading of Entire Test 1-M 4* * 4

Screen Reader for Verbatim Reading of Selected Sections of Test 1-N 4* * 4

Visual Cues 1-O 4 N/A 4

Notes, Outlines, and Instructions 1-P N/A N/A 4

Talking Materials 1-Q 4 N/A 4

Other Presentation Accommodations

Other 1-R Determined on a case-by-case basis inconsultation with MSDE

* Use of the verbatim reading accommodation is permitted on all assessments as a standard accommodation, with the exception of: (1) the Maryland School Assessment (MSA) in reading, grades 3 and 4, which assess student’s ability to decode printed language. Students in those grades receiving this ac-

commodation on the assessment will receive a score based on standards 2 and 3 (comprehension of informational and literary reading material) but will not receive a score for standard 1, general reading processes, and

(2) the Maryland Functional Reading Test.





RESPONSE ACCOMMODATIONS:

Response Accommodations Code

(1)Assessment:


(2)Assessment:


(3)

Use in Instruction

Scribe 2-A 4 N/A 4

Speech-to-Text 2-B 4 N/A 4

Large Print Response Booklet 2-C 4 N/A 4

Brailler 2-D 4 N/A 4

Electronic Note-Takers 2-E 4 N/A 4

Tape Recorder 2-F 4 N/A 4

Respond on Test Booklet 2-G 4 N/A 4

Monitor Test Response 2-H 4 N/A 4

Materials or Devices Used to Solve or Organize Responses

Calculation Devices 2-J 4 N/A 4

Spelling and Grammar Devices 2-K 4* * 4

Visual Organizers 1-L 4** ** 4

Graphic Organizers 2-M 4 N/A 4

Bilingual Dictionaries 2-N 4 N/A 4

Other Response Accommodations

Other 2-O Determined on a case-by-case basis inconsultation with MSDE

* Spelling and grammar devices are not permitted to be used on the English High School Assessment.

** Photocopying of secure test materials requires approval and must be done under the supervision of the LAC. Photocopied materials must be securely destroyed under the supervision of the LAC. Use of highlighters may be limited on certain machine-scored test forms, as highlighting may obscure test responses. Check with the LAC before al-lowing the use of highlighters on any state test.




TIMING AND SCHEDULING ACCOMMODATIONS:

Timing and Scheduling Accommodations Code

(1)Assessment:


(2)Assessment:


(3)

Use in Instruction

Extended Time 3-A 4 N/A 4

Multiple or Frequent Breaks 3-B 4 N/A 4

Change Schedule or Order of Activities — Extend over multiple days 3-C 4 N/A 4

Change Schedule or Order of Activities — Within one day 3-D 4 N/A 4

Other Timing and Scheduling Accommodations

Other 3-E Determined on a case-by-case basis inconsultation with MSDE

SETTING ACCOMMODATIONS:

Setting Accommodations Code

(1)Assessment:


(2)Assessment:


(3)

Use in Instruction

Reduce Distractions to the Student 4-A 4 N/A 4

Reduce Distractions to Other Students 4-B 4 N/A 4

Change Location to Increase Physical Access or to Use Special Equipment — Within School Building 4-C 4 N/A 4

Change Location to Increase Physical Access or to Use Special Equipment — Outside School Building 4-D 4 N/A 4

Other Setting Accommodations

Other 4-E Determined on a case-by-case basis inconsultation with MSDE





EXTENDED SCHOOL YEAR (ESY)

The IEP Team should determine if any of the factors below will significantly jeopardize the student’s ability to receive some benefit from the student’s educational program during the regular school year, if the student does not receive extended school year services. ESY services are the individualized extension of specific special education and related services that are provided beyond the normal school year of the public agency, in accordance with the IEP, at no cost to the parents.

Was ESY considered? YES NO DECISION DEFERREDDiscussion: __________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Will the benefits that the student receives from his/her education program during the regular school year be significantly jeopardized if the student is not provided ESY? YES NOAdditional questions to consider:

1. Does the student’s IEP include annual goals related to critical life skills? YES NO

Documentation to support decisions: __________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________

2. Is there a likely chance of substantial regression of critical life skills caused by the normal school break and a failure to recover those lost skills in a reasonable time? YES NO


__________________________________________________________________________________________________________________________________________________________

3. Is there a presence of emerging skills or breakthrough opportunities? YES NO


__________________________________________________________________________________________________________________________________________________________

4. Is the student demonstrating a degree of progress toward mastery of IEP goals related to critical life skills? YES NO


__________________________________________________________________________________________________________________________________________________________

5. Are there significant interfering behaviors? YES NO


__________________________________________________________________________________________________________________________________________________________

6. Does the nature and severity of the disability warrant ESY? YES NO


__________________________________________________________________________________________________________________________________________________________

7. Are there other special circumstances that require ESY? YES NO


__________________________________________________________________________________________________________________________________________________________

[NOTE: If ESY is needed, complete the services page for ESY.]




TRANSITION

Beginning at age 14, or younger if appropriate, a vision statement, based on the student’s preferences and interests, including desired outcomes in adult living, post-secondary andwork environments should be documented.

Vision Statement: ____________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Course of Study: _____________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Date of interview: • • (MM•DD•YYYY) (Attach interview form)

Name/Title of person conducting interview: ______________________________________________________________________________________________________________________Interview summary ___________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Does the student receive any Social Security Benefits? SSI SSDI CDB SCB (Surviving Child Benefit)

Functional Vocational Assessment: Vocational Interest Vocational Aptitude Availability of Community Training Availability of Employment Opportunities Actual Vocational Assessment Score

Beginning at age 16, or younger if appropriate, and updated annually, a statement of transition service needs under the applicable components of the student’s IEP that focuses on the student’s courses of study should be documented.Statement of Transition Service needs: __________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Expectations for High School graduation:_________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Continuing Special Services:____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Projected Date of Exit: • • (MM•DD•YYYY)

Projected Category of Exit (Category from which you project a student 14 years or older will exit school.) Exit with a Maryland High School Diploma Exit with a Maryland High School Certificate at age 21 Exit with a Maryland High School Certificate prior to age 21

Adult Service Agency (The agency that will provide the anticipated service.) General Services Division of Rehabilitation Services (DORS) Mental Hygiene Administration (MHA) Further Education/Training Developmental Disabilities Administration (DDA)

Post Secondary Transition Discussion: ____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________




TRANSITION ACTIVITIES

Instruction Needs: ____________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Activities: ___________________________________________________________________Agency: ________________________________________________________________________

Post Secondary education needs: _______________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________


Assistive technologies needs:___________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________


Related transportation needs: __________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________


Employment needs:___________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________


Daily living needs: ____________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________


Community experiences: ______________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________





ANTICIPATED SERVICES FOR TRANSITION Services you anticipate a student 14 years and older will need within one year of exiting special education.

General Services No Services Needed: upon exiting from the educational system. Public income maintenance: Social Security Income (SSI), Social Security Disabil-

ity Income (SSDI), welfare, Medicaid, public health insurance, etc. Transportation: specialized transportation including paratransit.

Developmental Disabilities Administration (DDA) Day Habilitation Community Residential Services Supported Employment Family and Individual Support Services Behavior/Support Services Community Supported Living Arrangements (CSLA)

Further Education/Training Continuing and Adult Education: including Adult Basic Ed (ABE), General Educa-

tion Development (GED), adult high school diploma, and adult compensatory or special education.

Higher Education Support Services: note takers, educational technology, modified testing time, mentoring and guidance, study skills, and self advocacy training.

Career School Support Services: support services in programs such as career schools, Job Training Partnership Act programs (JTPA), and Job Corps.

Mental Hygiene Administration (MHA) Mental Health Evaluation and Treatment Psychiatric Rehabilitation Programs Residential Rehabilitation Programs Supported Employment Respite Care

Division of Rehabilitation Services (DORS) Assessment and Evaluation Vocational Rehabilitation Counseling and Guidance Job Search, Placement Assistance, and Follow Up Services Medical Rehabilitation Vocational and Other Training Services Rehabilitation Technology Services Support Services



IV. GOALSPAGE 4.0

Objective 1: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________Objective 2: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________


ProgressTowards

Goal

ProgressReport 1Date_______

%

Progress Code: Achieved Making sufficient progress to meet goal Not making sufficient progress to meet the goal (IEP team needs to meet to address insufficient progress)

Description: ____________________________________________________________________________________________________________________________________


%


Description: ____________________________________________________________________________________________________________________________________


%


Description: ____________________________________________________________________________________________________________________________________


%


Description: ____________________________________________________________________________________________________________________________________

By: • • (MM•DD•YYYY) With______________% AccuracyHow will the team notify parents of progress?______________________________________________________________________________________________________________________________________________________________________________________________________

GOAL

Goal: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is this an ESY goal? YES NO DECISION DEFERREDHow often? WEEKLY Evaluation Method: INFORMAL PROCEDURES CLASSROOM-BASED ASSESSSMENT BI-WEEKLY OBSERVATION RECORD STANDARDIZED ASSESSMENT MONTHLY PORTFOLIO ASSESSMENT OTHER QUARTERLY INTERIM OTHER_____________________________



IV. GOALSPAGE 4.1



ProgressTowards

Goal


%


Description: ____________________________________________________________________________________________________________________________________


%


Description: ____________________________________________________________________________________________________________________________________


%


Description: ____________________________________________________________________________________________________________________________________


%


Description: ____________________________________________________________________________________________________________________________________


GOAL

Goal: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




IV. GOALSPAGE 4.2



ProgressTowards

Goal


%


Description: ____________________________________________________________________________________________________________________________________


%


Description: ____________________________________________________________________________________________________________________________________


%


Description: ____________________________________________________________________________________________________________________________________


%


Description: ____________________________________________________________________________________________________________________________________


GOAL

Goal: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




IV. GOALSPAGE 4.3



ProgressTowards

Goal


%


Description: ____________________________________________________________________________________________________________________________________


%


Description: ____________________________________________________________________________________________________________________________________


%


Description: ____________________________________________________________________________________________________________________________________


%


Description: ____________________________________________________________________________________________________________________________________


GOAL

Goal: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




V. SERVICESPAGE 5.0

SERVICES Complete one form for each service (25 types of Services Categories)

Service Category:

Special Education Classroom Instruction Physical Education Speech/Language Therapy Travel Training

Career and Technology Education Career and Technology Education Program w/Support Services Special Career and Technology Education Program for Disabled Vocational Evaluation Special Education Program with Pre-Vocation Objectives

Related Services Audiological Services Psychological Services Occupational Therapy Physical Therapy Recreation Early Identification and Assessment Counseling Services School Health Services Social Work Services Parent Counseling & Training Rehabilitative Counseling Orientation and Mobility Training Services Assistive Technology Services Medical Services (Diagnostic & Evaluation) Transportation Other____________________ Other Therapies (Art/Drama/Dance)

Frequency

Select the number of sessions 1 2 3 4 5 6 Other _______________

Select a time period Weekly Recheck Periodically (Includes indirect services Monthly and periodic evaluations) Yearly Residential (24 hour special education services) Only

Select the length of time, in 15 minute increments, that the service is provided during each session

15 30 45 60 75 90 120 180 240 Other_____

Begin Date: • • (MM•DD•YYYY)

End Date: • • (MM•DD•YYYY)

Duration (The number of weeks a student is served):______________________weeks

Provider/Agency (choose only one) Special Education Classroom Teacher IEP Team Orientation & Mobility Specialist Career & Technology Teacher Audiologist Rehabilitation Services Staff Speech/Language Pathologist School Social Worker Teacher of the Hearing Impaired Recreational Therapist Teacher of the Visually Impaired Other Service Provider Occupational Therapist Teacher Aide Physical Therapist Interpreter Home-Based Teacher Department of Social Services Pupil Personnel Worker Mental Hygiene Administration Guidance Counselor Developmental Disabilities Administration Physical Education Teacher Division of Rehabilitation Services (DORS) Psychologist Other Agencies General Education Teacher

Total time in school day________hrs.__________minutes/week

Time in General Education________hrs.__________minutes/week

Time out of General Education________hrs.__________minutes/week

Is this an ESY service? YES NO DECISION DEFERRED

Explain:___________________________________________________________________

__________________________________________________________________________

If yes, complete the following: Frequency




15 30 45 60 75 90 120 180 240 Other_____






V. SERVICESPAGE 5.1


Service Category:




Frequency




15 30 45 60 75 90 120 180 240 Other_____









Explain:___________________________________________________________________

__________________________________________________________________________





15 30 45 60 75 90 120 180 240 Other_____






V. SERVICESPAGE 5.2


Service Category:




Frequency




15 30 45 60 75 90 120 180 240 Other_____









Explain:___________________________________________________________________

__________________________________________________________________________





15 30 45 60 75 90 120 180 240 Other_____






VI. PLACEMENT DATAPAGE 6.0

LRE DECISION MAKING A student with a disability is not removed from education in an age-appropriate general classroom solely because of needed modifications in the general curriculum.

Special education placement (ages 3-5) Special education placement (ages 6-21)Are the services in the student’s home school (the school the child would attend if not disabled)? YES NO If no, add documentation to support decision:___________________Is placement as close as possible to the student’s home? YES NO If no, add documentation to support decision: _____________________________________________________Is transportation needed? YES NO If Yes REGULAR SPECIALIZEDAre there any potential harmful effects of the setting on the child or quality of services he or she needs? YES NOIf yes, add documentation to support decision ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What is the extent to which the student will not participate with non-disabled peers in academic, non-academic, and extracurricular activities?____________________________________________________________________________________________________________________________________________________________

PLACEMENT SUMMARY

Total time in General Education________hrs.__________minutes/week

Total time out of General Education________hrs.__________minutes/week

Special education placement (ages 3-5): ITINERANT SETTING (NO MORE THAN 3HR/WEEK) PRIVATE SEPARATE DAY SCHOOL (100%) PUBLIC SEPARATE DAY SCHOOL (100%) EARLY CHILDHOOD SETTING PUBLIC RESIDENTIAL FACILITY (100%) HOSPITAL EARLY CHILDHOOD SPECIAL ED. SETTING PRIVATE RESIDENTIAL FACILITY (100%) HOME PART-TIME EARLY CHILDHOOD/PART-TIME EARLY CHILDHOOD SPECIAL ED.

Special education placement (ages 6-21): OUTSIDE GENERAL ED. (OUT < 21%) PRIVATE SEPARATE DAY SCHOOL (FOR > 50%) PUBLIC SEPARATE DAY SCHOOL (FOR > 50%) OUTSIDE GENERAL ED. (OUT 21% - 60%) PUBLIC RESIDENTIAL FACILITY (FOR > 50%) HOSPITAL OUTSIDE GENERAL ED. (OUT > 60%) PRIVATE RESIDENTIAL FACILITY (FOR > 50%) HOME

Add documentation to support decision __________________________________________________________________________________________________________________________

If removed from the general education environment, explain reasons why services cannot be provided in the general education environment.____________________________________________________________________________________________________________________________________________________________SSIS Resident County __________________________________________________ SSIS Resident School______________________________________________________________________

SSIS Service County ___________________________________________________ SSIS Service School_______________________________________________________________________

Eligibility Codes: Eligible student with a disability served in a public school or placed in a nonpublic school by the public agency to receive FAPE. Eligible parentally placed private school student with a disability receiving special education and/or related service through a service plan from the public agency. Eligible parentally placed private school student with a disability NOT receiving service from the public agency.

SPECIALIZED TRANSPORTATION DETAILS (Optional)

Specialized equipment needs of the student YES NO Explain: _______________________________________________________________________________________________

Personnel needed to assist the student during transportation YES NO Explain: _________________________________________________________________________________

Estimated amount of time involved in transporting the student________hrs.__________minutes DAILY WEEKLY

Distance the student will be transported________________miles DAILY WEEKLY

Notes: ______________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________



VII. IEP APPROVALPAGE 7.0

IEP APPROVAL

IEP Approved: • • (MM•DD•YYYY)

My signature on this form indicates that I have reviewed and had an opportunity to participate in the development of this IEP. My signature on this form indicates that I consent to this IEP and placement and that the IEP may be implemented as described.

I understand that my rights include the right to a copy of the complete procedural safeguards, at a minimum, upon the initial referral of my child for an evaluation; with each notice of a meeting to develop, review, or revise my child’s IEP; with each notice of reevaluation; and if I file a written request for a due process hearing.

I give my permission to submit information that will be used for the Special Services Information System. This system will be used by the Maryland State Department of Education and other state agencies, as appropriate, to enable funding of programs and to assure my child’s rights to any needed assessment.

I understand that my rights include the right to receive this and all other written notices in the language I understand (primary language) or if needed, a translation of such orally, in sign language, or in Braille, as appropriate.

I understand that my rights include the right to answers from school personnel to additional questions I may have.

I understand that my rights include the right to request more information.

If the student is eligible for Medical Assistance:

I agree to IEP service coordination for my child and that the Service Coordinator(s) identified on this IEP may be appointed as Medicaid Service Coordinator(s).

I give permission to the local school system to recover costs from Medicaid for service coordination, as well as health-related services, related to the implementation of my child’s IEP goals.

I understand that this service does not restrict or otherwise affect my child’s eligibility for other Medical Assistance benefits. I also understand that my child may not receive a similar type of case management service under Medical Assistance if he/she qualifies for more than one type.

___________________________________________________________________________________________________ _________________________________________________

Signature of Parent/Guardian Date of Signature

name: date of birth: / / school system: iep meeting date: · student is pursuing a: maryland h. s....

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