Page 1 of 19

Individualized Education Program (IEP) Instructions for Fillable Version

This Microsoft Word document is the model form for the Individualized Education Program (IEP). The document can be edited using Microsoft Word. The user must stop protection on editing restrictions before ma!ing edits. The user must then start enforcing protection to ma!e the fillable areas useable for completing electronicall". Microsoft Word version 2 ! #) $elect the %evie& tab at the top. ') $elect the Protect (ocument dropdo&n menu on the top right. )) $elect %estrict *ormatting and Editing from the menu. +) In the column that appears on the right, clic! on the $top Protection button at the bottom. -) Ma!e desired modifications to meet the needs of the district. .) In the column on the right, ma!e sure that under Editing %estrictions the option *illing in forms is selected and that the chec! bo/ is chec!ed. Then clic! the 0es, $tart Enforcing Protection button. Microsoft Word version 2 " #) $elect the Tools dropdo&n menu at the top. ') $elect the 1nprotect (ocument. )) Ma!e desired modifications to meet the needs of the district. +) $elect the Tools dropdo&n menu at the top. -) $elect the Protect (ocument. The model form can be found on the follo&ing pages of this document. This instruction sheet is not part of the model form.

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page 2 of 19 IEP #$%E& IEP %eam Meeting Initial IEP 2ffer of a *3PE4 Implementation4 $nnual'(evie) IEP 2ffer of a *3PE4 Implementation4 (eevaluation IEP 2ffer of a *3PE4 Implementation4

Individualized Education Program (IEP)

Section 1 #emogra*+ic Information
&tudent 5ast4 *irst4 M4 6irth (ate4 8it"4 7ender4 7rade4 $tate4 1I84 9ip4

3ddress4 Phone4 %esident (istrict4 8ount"4 Parent 5ast4 *irst4 M4

2perating (istrict4 3ttending 6uilding4 %elationship to $tudent4

:ative 5anguage or 2ther 8ommunication Mode4 3ddress (if different)4 ;ome Phone4 Email4 Parent 5ast4 *irst4 M4 %elationship to $tudent4 Wor! Phone4 8it"4 $tate4 Pager<8ell4 9ip4

:ative 5anguage or 2ther 8ommunication Mode4 3ddress (if different)4 ;ome Phone4 Email4 P,(P-&E -F MEE%I./ 8hec! one of the follo&ing4 Initial IEP 3nnual<%evie& IEP %eevaluation IEP 8hec! all others that appl"4 8hange of Placement $uspension<E/pulsion $econdar" Transition 8hange of Eligibilit" 2ther4 7raduation 2ther4 Wor! Phone4 8it"4 $tate4 Pager<8ell4 9ip4

OFFICE USE P$(E.% 0-.%$0% The parent<adult student &as contacted to e/plain the purpose of the meeting and the roles and responsibilities of each participant via (chec! all that appl")4 IEP Invitation %esults4 Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010 5etter Phone 2ther4

Page " of 19 P$(E.%$1 (I/2%& $.# $/E -F M$3-(I%4 8hec! all that appl"4 %+e student )ill be age 1! during this IEP and the student &as informed of parental rights that he or she &ill receive at age #=. %+e student +as turned age 15 and the student and parent &ere informed of parental rights that &ere transferred to the student at age #=, including the right to invite a support person such as a parent, advocate, or friend. %+e student +as turned age 15 and there is a guardian established b" court order. The guardian is4 . %+e student +as turned age 15 and a legall" designated representative has been appointed. The representative is4 as (e.g., power of attor e!, tr"#tee$. IEP MEE%I./ P$(%I0IP$.%& I. $%%E.#$.0E 8hec! the bo/ indicating the IEP participant(s) &ho can e/plain the instructional implications of evaluation results. 66666666666666666666666666666666666666666 (istrict %epresentative<(esignee 66666666666666666666666666666666666666666 7eneral Education Teacher 66666666666666666666666666666666666666666 $pecial Education Teacher 66666666666666666666666666666666666666666 2ther 66666666666666666666666666666666666666666 2ther

66666666666666666666666666666666666666666 $tudent (must invite at age #. and older) 66666666666666666666666666666666666666666 Parent 66666666666666666666666666666666666666666 Parent 66666666666666666666666666666666666666666 3genc" Providing $econdar" Transition $ervices (consent on file) 66666666666666666666666666666666666666666 2ther

Parent and #istrict $greement on $ttendance .ot .ecessar7 These members are absent> their curricular area<related services are not being modified or discussed in the meeting4 Parent and #istrict $greement on E8cusal Prior to Meeting These members are absent and have submitted &ritten input to the IEP team, including the parent, prior to the meeting4 E1I/I9I1I%4 F-( &PE0I$1 E#,0$%I-. Eligible Ineligible

3rea of disabilit"4 If the student is determined ineligible as a student &ith a specific learning disabilit" ($5(), provide a statement of the basis for the determination of ineligibilit"4 If the student is determined eligible as a student &ith an $5(, chec! all that appl"4 2ral e/pression %eading fluenc" s!ills 5istening comprehension %eading comprehension Written e/pression Mathematics calculation 6asic reading s!ill Mathematics problem solving

(etermination of eligibilit" &as made in accordance &ith I(E3 regulations at ? )@@.)@.(c)(#).

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page : of 19

Section 2-A Present 1evel of $cademic $c+ievement and Functional Performance

F$0%-(& %- 0-.&I#E( /eneral The IEP team must consider each of the follo&ing4 The strengths of the student4 The concerns of the parent for enhancing the education of the student4 The results of the most recent evaluation(s) of the student4 &*ecial Factors The IEP team must consider the follo&ing for the student (chec! bo/es to indicate consideration)4 The communication needs of the student. The need for assistive technolog" devices and services for the student. The IEP team must consider the follo&ing for the student, as appropriate (chec! all that appl")4 The use of positive behavioral interventions and supports, and other strategies, to address behavior because the student has behavior that impedes his or her learning or the learning of others. The language needs of the student because the student has limited English proficienc". 6raille instruction because the student is blind or visuall" impaired. The mode of language and communication because the student is deaf or hard of hearing.

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page ; of 19

Section 2-B: Option I Present 1evel of $cademic $c+ievement and Functional Performance
3fter revie&ing the studentAs progress in the general education curriculum and an" prior special education goals and obBectives, describe ho& the student accesses or ma!es progress in the general education curriculum based on grade level content standards for the grade in &hich the student is enrolled or &ould be enrolled based on age. %eport and describe baseline data such as curriculumCbased assessments, student &or!, teacher observations, parent input, and other relevant data for each area of need. $0$#EMI0'P(E<$0$#EMI0 $02IEVEME.% I d%&%d"al a d'or d%#tr%ct-w%de a##e##me t#. /E.E($1 E#,0$%I-. 0,((I0,1,M I &ol&eme t a d progre## % t(e ge eral ed"cat%o c"rr%c"l"m, or part%c%pat%o % age-appropr%ate act%&%t%e# for pre#c(ool #t"de t#. &E0-.#$(4 %($.&I%I-. $&&E&&ME.%& )ge-appropr%ate a##e##me t related to tra% % g, ed"cat%o , emplo!me t, a d % depe de t l%&% g #*%ll#. 0-MM,.I0$%I-.' &PEE02 = 1$./,$/E (escribe ho& the studentAs academic, developmental, and functional needs affect involvement and progress in the general education curriculum or participation in appropriate activities for preschool students.

&-0I-<EM-%I-.$1' 9E2$VI-($1

PE(0EP%I-.'M-%-(' M-9I1I%4 +ro## a d f% e motor coord% at%o , bala ce, a d l%mb'bod! mob%l%t!. I.#EPE.#E.% 1IVI./ &>I11& S*%ll# for academ%c #"cce## a d % depe de t l%&% g. ME#I0$1 ,ealt(, &%#%o , (ear% g, or ot(er p(!#%cal'med%cal %##"e#.

Section 2-B: Option II Present 1evel of $cademic $c+ievement and Functional Performance
Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page ? of 19 3fter revie&ing the studentAs progress in the general education curriculum and an" prior special education goals and obBectives, describe the studentAs present level of academic achievement and functional performance. %eport and describe baseline data such as curriculumCbased assessments, student &or!, teacher observations, parent input, and other relevant data for each area of need.

(escribe ho& the studentAs academic, developmental, and functional needs affect involvement and progress in the general education curriculum or participation in appropriate activities for preschool students.

(escribe ho& the student accesses or ma!es progress in the general education curriculum based on grade level content standards for the grade in &hich the student is enrolled or &ould be enrolled based on age.

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page ! of 19

Section 2-B: Option III Present 1evel of $cademic $c+ievement and Functional Performance
3fter revie&ing the studentAs progress in the general education curriculum and an" prior special education goals and obBectives, describe the studentAs present level of academic achievement and functional performance. What is the identified area of needD %eport and describe baseline data such as curriculumCbased assessments, student &or!, teacher observations, parent input, and other relevant data.

*or an area of academic need, &hat are the districtAs prioritized content e/pectations for the studentAs grade levelD

What predictive measure(s) does the district use to determine progress on these prioritized e/pectationsD

What do &e !no& about (grade le&el$ gradersA s!ills in (co te t e-pectat%o $D

;o& does the studentAs academic, developmental, and functional needs affect involvement and progress in the general education curriculum, specific to (co te t area$, or participation in appropriate activities for preschool studentsD

Include a graph of individual student and peer group perfor

ance over ti

e!

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page 5 of 19

Section " &econdar7 %ransition 0onsiderations

$econdar" transition services are reEuired to be in effect &hen the student turns #.. IEP teams are recommended to consider secondar" transition services at a "ounger age if appropriate. $econdar" transition considerations must be updated annuall" thereafter. &%,#E.%@& P-&%&E0-.#$(4 /-$1& (VI&I-.) #ata &ources ,sed Educational (evelopment Plan (E(P) Transition 3ssessment(s) (specif")4 If t+e student did not attend t+e IEP team meetingA describe ste*s taBen to ensure consideration of t+e student@s *references'visionC $dult 1ivingF3s an adult, &here do "ou &ant to liveD 0areer'Em*lo7mentF3s an adult, &hat !ind of &or! do "ou &ant to doD 0ommunit7 Partici*ationF3s an adult, &hat hobbies and activities do "ou &ant to do (e.g., arts, recreational activities, shopping, eating out, etc.)D Postsecondar7 Education'%raining F3fter high school, &hat additional education and training do "ou &antD

P1$..I./'0-MM,.I%4 &E0-.#$(4 %($.&I%I-. &E(VI0E& .eeded &ervice (elated to t+e &tudent@s &trengt+sA Postsecondar7 /oalsA and Present 1evel Identif" the service needed in at least one of the si/ areas belo&. Include the coordinated activit"<activities for the service. Identif" the responsible agenc"<other for each activit" for the needed service. Instruction $ervice4 3ctivit"4 3ctivit"4 3ctivit"4 8onsidered, not needed (e/plain)4 0ommunit7 E8*eriences $ervice4 %ust Consider 3ctivit"4 3ctivit"4 3ctivit"4 8onsidered, not needed (e/plain)4 #evelo*ment of Em*lo7ment $ervice4 3ctivit"4 3ctivit"4 3ctivit"4 8onsidered, not needed (e/plain)4 -t+er Post<&c+ool $dult 1iving -bDectives $ervice4 3ctivit"4 3ctivit"4 3ctivit"4 8onsidered, not needed (e/plain)4 Planning'0ommunit7 &econdar7 %ransition &ervices continues on ne8t *age Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010 %esponsible agenc"<other4 %esponsible agenc"<other4 %esponsible agenc"<other4 E/pected completion date4 %esponsible agenc"<other4 %esponsible agenc"<other4 %esponsible agenc"<other4 E/pected completion date4 %esponsible agenc"<other4 %esponsible agenc"<other4 %esponsible agenc"<other4 E/pected completion date4 %esponsible agenc"<other4 %esponsible agenc"<other4 %esponsible agenc"<other4 E/pected completion date4

IE# $ea

Page 9 of 19 P1$..I./'0-MM,.I%4 &E0-.#$(4 %($.&I%I-. &E(VI0E& continued $cEuisition of #ail7 1iving &Bills Consider &hen Appropriate $ervice4 3ctivit"4 3ctivit"4 3ctivit"4 8onsidered, not needed (e/plain)4 Functional Vocational Evaluation $ervice4 3ctivit"4 3ctivit"4 3ctivit"4 8onsidered, not needed (e/plain)4 %2E 0-,(&E -F &%,#4 %($.&I%I-. &E(VI0E Indicate ho& the studentAs course of stud" aligns &ith the postsecondar" goals (chec! one)4 Michigan Merit 8urriculum (MM8) leading to a high school diploma (effective for students &ho entered =th grade in '@@.C'@@G school "ear or later). MM8 modification using Personal 8urriculum on file4 0es :o 8urriculum leading to a high school diploma (effective for students &ho entered =th grade prior to the '@@.C'@@G school "ear). 8ourse of stud" leading to4 3nticipated graduation or completion date4 %esponsible agenc"<other4 %esponsible agenc"<other4 %esponsible agenc"<other4 E/pected completion date4 %esponsible agenc"<other4 %esponsible agenc"<other4 %esponsible agenc"<other4 E/pected completion date4

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page 1

of 19

Section ': Option I /oals and -bDectives'9enc+marBs

Instructional $reaF5ist the appropriate content area (e.g., strand<domain)4 Mic+igan 0ontent E8*ectations ,*on W+ic+ /oal Will 9e 9ased F5ist the appropriate 758E, E758E, ;$8E, E;$8E, or Earl" 8hildhood $tandards of Hualit" for PreC!indergarten4 9aseline #ata The student is currentl" (data$ on the (a##e##me t$. $nnual /oal 6" (date$, the student &ill (demo #trate #*%ll$ &hen<at (co d%t%o # cr%ter%a$ on (a##e##me t'e&al"at%o $F

$hortCTerm 2bBective<6enchmar!4 Performance 8riteria4 Evaluation Procedure4 Evaluation $chedule4 $tatus (ate4 Progress To&ard 3nnual 7oal4 8omments4 $tatus (ate4 Progress To&ard 3nnual 7oal4 8omments4 $tatus (ate4 Progress To&ard 3nnual 7oal4 8omments4 $tatus (ate4 Progress To&ard 3nnual 7oal4 8omments4

$hortCTerm 2bBective<6enchmar!4 Performance 8riteria4 Evaluation Procedure4 Evaluation $chedule4 $tatus (ate4 Progress To&ard 3nnual 7oal4 8omments4 $tatus (ate4 Progress To&ard 3nnual 7oal4 8omments4 $tatus (ate4 Progress To&ard 3nnual 7oal4 8omments4 $tatus (ate4 Progress To&ard 3nnual 7oal4 8omments4

&02E#,1E F-( (EP-(%I./ P(-/(E&& When4 Position(s) responsible for implementing goal activities (chec! all that appl")4 $pecial Education Teacher $chool $ocial Wor!er 2ther4 Position(s) responsible for reporting progress on goal4 Teacher 8onsultant 2ccupational Therapist $peech and 5anguage Provider Ph"sical Therapist

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page 11 of 19

Section ': Option II /oals and -bDectives'9enc+marBs

Instructional $reaF5ist the appropriate content area (e.g., strand<domain)4 Mic+igan 0ontent E8*ectations ,*on W+ic+ /oal Will 9e 9ased F5ist the appropriate 758E, E758E, ;$8E, E;$8E, or Earl" 8hildhood $tandards of Hualit" for PreC!indergarten4 9aseline #ata The student is currentl" (data$ on the (a##e##me t$. $nnual /oal 6" (date$, the student &ill (demo #trate #*%ll$ &hen<at (co d%t%o # cr%ter%a$ on (a##e##me t'e&al"at%o $F &2-(%<%E(M -93E0%IVE&'9E.02M$(>& 6" the end of the (.$ mar!ing period of (#c(ool !ear$ the student &ill (cr%ter%a$ on (a##e##me t'e&al"at%o $. 6" the end of the (.$ mar!ing period of (#c(ool !ear$ the student &ill (cr%ter%a$ on (a##e##me t'e&al"at%o $. 6" the end of the (.$ mar!ing period of (#c(ool !ear$ the student &ill (cr%ter%a$ on (a##e##me t'e&al"at%o $. 6" the end of the (.$ mar!ing period of (#c(ool !ear$ the student &ill (cr%ter%a$ on (a##e##me t'e&al"at%o $. &02E#,1E F-( (EP-(%I./ P(-/(E&& When4 Insert Progress Monitoring #ata

Progress (e*orting (e*ort #ateC (e*ort #ateC (e*ort #ateC (e*ort #ateC ProgressC ProgressC ProgressC ProgressC 0ommentsC 0ommentsC 0ommentsC 0ommentsC

Position(s) responsible for implementing goal activities (chec! all that appl")4 $pecial Education Teacher $chool $ocial Wor!er 2ther4 Position(s) responsible for reporting progress on goal4 Teacher 8onsultant 2ccupational Therapist $peech and 5anguage Provider Ph"sical Therapist

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page 12 of 19

Section ( &u**lementar7 $ids and &ervices

$upplementar" aids and services are provided to enable the student4 To advance appropriatel" to&ard attaining the annual goals. To be involved and progress in the general education curriculum and to participate in e/traCcurricular and other nonacademic activities. To be educated and participate in activities &ith other students &ith disabilities and nondisabled students.

$upplementar" aids and services are needed at this time. -ngoing Instruction and $ssessment $cheduling, Presentation, %esponse, etc. 0urriculum &u**orts and $dDustments (irections, 7rading, ;and&riting, 3ssignments, Tests, 6oo!s, etc. &u**orts and Modifications to t+e Environment 8lassroom Environment, ;ealthC%elated :eeds, Ph"sical :eeds, 3ssistive Technolog", 6ehavioral, Training :eeds, $ocial Interaction $upports for the $tudent, etc. -t+er &u**ortsA $ccommodationsA and Modifications %ime'FreEuenc7'0ondition 1ocation

%ime'FreEuenc7'0ondition

1ocation

%ime'FreEuenc7'0ondition

1ocation

%ime'FreEuenc7'0ondition

1ocation

3ll aids and services identified &ill begin on the implementation date of the IEP and continue for the duration of the IEP. $upplementar" aids and services are not needed at this time. E/plain the e/tent, if an", to &hich the student &ill not participate &ith nondisabled students4 .

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page 1" of 19

Section ): *rades +-, $ssessmentGPartici*ation and Provisions

6ased on 7rade 5evel, Independence 5evel, and English 5anguage Proficienc" &tate $ssessmentsC /rades "<9 Is a state assessment administered at the grade level(s) covered b" this IEPD 0es :o

If a state assessment is being administered, indicate in the 3ssessment column in &hich assessment the student &ill participate. If the IEP team determines the Michigan Educational 3ssessment Program (ME3P) is not appropriate, see the ME3PC 3ccess eligibilit" criteria at )))Fmic+iganFgov'mea*<access to determine if ME3PC3ccess is appropriate. If the IEP team determines that the student must ta!e an alternate assessment (ME3PC3ccess, MIC3ccess, or a districtCdetermined social studies assessment) instead of a particular ME3P assessment, complete the %ationale column. Identif" an" individual appropriate accommodations that are necessar" on these state assessments. $ee the /e&%#ed )##e##me t )ccommodat%o S"mmar! 0able at )))Fmic+iganFgov'mea*F $ssessment $rea (eading 7rades )C= Writing 7rades + and G ME$P ME$P<$ccess MI<$ccessC *unctional Participation ME$P Mat+ematics 7rades )C= ME$P<$ccess MI<$ccessC *unctional Participation ME$P &cience 7rades - and = MI<$ccessC *unctional Participation ME$P #istrict<#etermined $ssessment $upported $upported $upported $ssessment (ationale The ME3P is not appropriate because4 The alternate assessment is appropriate because4 $ccommodations

The ME3P is not appropriate because4 The alternate assessment is appropriate because4 The ME3P is not appropriate because4 The alternate assessment is appropriate because4 The ME3P is not appropriate because4 The alternate assessment is appropriate because4

&ocial &tudiesH 7rades . and I

J If the ME3P $ocial $tudies 3ssessment is not appropriate for the student, the IEP team M1$T identif" a districtCdetermined assessment until there is a stateCdeveloped MIC3ccess $ocial $tudies 3ssessment. I#istrict<)ide assessmentsC /rades ><9J on ne8t *age

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page 1: of 19

#istrict<)ide $ssessmentsC /rades ><9 Is a districtC&ide assessment administered at the grade level(s) covered b" this IEPD

0es

:o

If a districtC&ide assessment is being administered, indicate in the 3ssessment column in &hich assessment the student &ill participate. If the IEP team determines that districtC&ide assessment is not appropriate and that the student must ta!e an alternate assessment, identif" the alternate assessment and complete the %ationale column. Identif" an" individual appropriate accommodations that are necessar" on these assessments. $ssessment #istrict<)ide $ssessment $lternate $ssessment #istrict<)ide $ssessment $lternate $ssessment #istrict<)ide $ssessment $lternate $ssessment The districtC&ide assessment is not appropriate because4 The alternate assessment is appropriate because4 The districtC&ide assessment is not appropriate because4 The alternate assessment is appropriate because4 (ationale The districtC&ide assessment is not appropriate because4 The alternate assessment is appropriate because4 $ccommodations

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page 1; of 19

Section ): *rades 1--12 $ssessmentGPartici*ation and Provisions

6ased on 7rade 5evel, Independence 5evel, and English 5anguage Proficienc" &tate $ssessmentGMic+igan Merit E8amC /rades 11<12 For #t"de t# at grade le&el 111 In &hich assessment &ill the student participateD Michigan Merit E/am (MME) MIC3ccess

For #t"de t# at grade le&el 121 *or MME retest eligibilit", see details in the MME St"de t El%g%b%l%t! document at )))Fmic+iganFgov'mmeF Will the student participate in the MMED 0es :o If the IEP team determines the student &ill participate in the MME, identif" an" individual appropriate accommodations that are necessar" on these state assessments. $ee the MME 2(art of )ccommodat%o # Date# 3 )20-)ppro&ed a d State-)llowed at )))Fmic+iganFgov'mmeF $ssessment $rea $0% %eading 8omprehension $0% English $0% Mathematics $0% $cience $0% Writing WorB>e7s %eading for Information WorB>e7s 3pplied Math WorB>e7s 5ocating Information Mic+igan Mathematics Mic+igan $cience Mic+igan $ocial $tudies $ccommodations

&tate $ssessmentGMI<$ccessC /rade 11 For +rade 111 If the IEP team determines the MME is not appropriate, identif" the alternate assessment in &hich the student &ill participate and complete the %ationale column. Identif" an" individual appropriate accommodations that are necessar" on these state assessments. $ee the /e&%#ed )##e##me t )ccommodat%o S"mmar! 0able at )))Fmic+iganFgov'mi<accessF $ssessment $rea Englis+ 1anguage $rts 7rade ## MI<$ccess' $lternate $ssessment *unctional $upported Participation *unctional $upported Participation *unctional $upported Participation &ocial &tudiesH 7rade ## (istrictC(etermined 3ssessment (ationale The MME is not appropriate because4 The alternate assessment is appropriate because4 The MME is not appropriate because4 The alternate assessment is appropriate because4 The MME is not appropriate because4 The alternate assessment is appropriate because4 The MME is not appropriate because4 The alternate assessment is appropriate because4 $ccommodations

Mat+ematics 7rade ##

&cience 7rade ##

J If the MME $ocial $tudies 3ssessment is inappropriate for the student, the IEP team M1$T identif" a districtCdetermined assessment until there is a stateCdeveloped MIC3ccess $ocial $tudies 3ssessment. I#istrict<)ide assessmentsC /rades 1 <12J on ne8t *age

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page 1? of 19

#istrict<)ide $ssessmentsC /rades 1 <12 Is a districtC&ide assessment administered at the grade level(s) covered b" this IEPD

0es

:o

If a districtC&ide assessment is being administered, indicate in the 3ssessment column in &hich assessment the student &ill participate. If the IEP team determines that districtC&ide assessment is not appropriate and that the student must ta!e an alternate assessment, identif" the alternate assessment and complete the %ationale column. Identif" an" individual appropriate accommodations that are necessar" on these assessments. $ssessment #istrict<)ide $ssessment $lternate $ssessment #istrict<)ide $ssessment $lternate $ssessment #istrict<)ide $ssessment $lternate $ssessment The districtC&ide assessment is not appropriate because4 The alternate assessment is appropriate because4 The districtC&ide assessment is not appropriate because4 The alternate assessment is appropriate because4 (ationale The districtC&ide assessment is not appropriate because4 The alternate assessment is appropriate because4 $ccommodations

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page 1! of 19

Section ): E.#A/0AE# 1*rades +-122 $ssessmentGPartici*ation and ProvisionsC E1P$

6ased on 7rade 5evel, Independence 5evel, and English 5anguage Proficienc" &tate $ssessmentC Englis+ 1anguage Proficienc7 $ssessment (E1P$) The ;ome 5anguage $urve" (;5$), a Title KI reporting reEuirement, is given to all students at the time of enrollment. Please consider these t&o Euestions annuall"4 Is the studentAs native tongue a language other than EnglishD 0es :o Is a language other than English spo!en in the studentAs home or environmentD When either ans&er is 4es, complete the follo&ing section. $ssessment 1evel and /rade for &*ring E1P$ and E1P$ Initial &creening 1evel IG7rade L 1evel IIG7rades #C' 1evel IIIG7rades )C1evel IVG7rades .C= 1evel VG7rades IC#' Initial &creening &*ring E1P$

0es

:o

*or additional information regarding E5P3 or the E5P3 screener, or to identif" an" individual appropriate accommodations that are necessar" for each of the E5P3 domains, see the /e&%#ed )##e##me t )ccommodat%o S"mmar! 0able at )))Fmic+iganFgov'el*aF $ssessed #omains 5istening %eading Writing $pea!ing $ccommodations

$ssessmentGPartici*ation and ProvisionsC .$EP

6ased on 7rade 5evel, Independence 5evel, and English 5anguage Proficienc" .ational $ssessmentC .ational $ssessment of Educational Progress (.$EP) Is a :3EP assessment administered to the studentAs district at the grade level(s) covered b" this IEPD 0es :o 0es :o

;as the student participated in the Michigan Educational 3ssessment Program (ME3P) in the subBect being testedD

8an the student participate in the :3EP &ith allo&able accommodationsD $ee the /e&%#ed )##e##me t )ccommodat%o S"mmar! 0able at )))Fmic+iganFgov'nae*F 0es :o 8an the student participate in the :3EP &ith allo&able accommodations, even if the student did not participate in the ME3P, or needs accommodations not allo&ed b" the :3EPD 0es :o If 4E&, for each content area, indicate an" assessment accommodation(s) that the student ma" need. If .-, state the reason &h" a specific :3EP assessment is not appropriate. 0es 0es 0es :o :o :o

$ssessment

Partici*ation

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page 15 of 19

Section 3 &*ecial Education &ervices and Programs

(elated &ervice (ule .umber &*ecific $mount of %ime and FreEuenc7 1ocation 0es :o #urationH #urationH

(oes the student have needs that reEuire placement &ith a teacher &ith a particular endorsementD Program (ule .umber #e*art< mentalized 0es 0es 0es :o :o :o &*ecific $mount of %ime and FreEuenc7 1ocation

J 3ll programs and services listed above &ill begin on the implementation date of the IEP and continue for the duration of the IEP, unless other&ise indicated above in the column (uration. EK%E.#E# &02--1 4E$( (E&4) &E(VI0E& E/tended $chool 0ear (E$0) services &ere considered. It &as determined that no E$0 services are needed. 8urrent annual goals address one or more s!ills that reEuire E$0 services. &ervice &*ecific $mount of %ime and FreEuenc7 I.&%(,0%I-.$1 %IME /eneral Education Instruction (minutes<hours per &ee!) (L) &*ecial Education Instruction (minutes<hours per &ee!) L E#,0$%I-.$1 E.VI(-.ME.% The district ensures that, to the ma/imum e/tent appropriate, the student &ill be educated &ith students &ho are nondisabled> and special classes, separate schools, or other removal of the student from the general education environment occurs onl" &hen the studentAs needs cannot be met satisfactoril" in the general education setting &ith supplemental aids and services. Partici*ation in a (egular Earl7 0+ild+ood Program (students age )C-) 3t least #@ hours per &ee! and4 receives the maBorit" of special education and related services I: a regular earl" childhood program. receives the maBorit" of special education and related services 21T$I(E of a regular earl" childhood program. 5ess than #@ hours per &ee! and4 receives the maBorit" of special education and related services I: a regular earl" childhood program. receives the maBorit" of special education and related services 21T$I(E of a regular earl" childhood program. Partici*ation in /eneral Education (students age .C'.) =@M of the da" or more GIM to +@M of the da" less than +@M of the da" separate facilit" M (M) %otal (minutes<hours per &ee!) 1ocation #uration

&PE0I$1 %($.&P-(%$%I-. 0es (specif")4 :o Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010

Page 19 of 19

Michigan (epartment of Education, 2ffice of $pecial Education and Earl" Intervention $ervices OSE-EIS Model Form IEP 003 December 2010