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PIONEER CENTRAL SCHOOL DISTRICT

TELEPHONE (716) 492-9440/9434/9449


FAX (716) 492-9442
STUDENT INFORMATION SUMMARY
STUDENT NAME: A.S

DATE IEP DEVELOPED / DATE OF COMMITTEE MEETING: 03/05/15

ADDRESS:

TYPE OF MEETING: ANNUAL REVIEW

COUNTY OF RESIDENCE: Erie

INITIAL REFERRAL DATE: 04/14/09

AGE: 9 DATE OF BIRTH:

MALE

FEMALE

PROJECTED DATE OF ANNUAL REVIEW MEETING: 03/05/16

2014/15 GRADE / GRADE EQUIVALENT: 04

PROJECTED DATE OF THREE-YEAR REEVALUATION: 03/22/16

2015/16 GRADE / GRADE EQUIVALENT: 05

CREDITS EARNED:

NATIVE LANGUAGE OF STUDENT: English

EXPECTED CREDENTIAL:

RACIAL/ETHNIC GROUP OF STUDENT: White

STUDENT WITH LIMITED ENGLISH PROFICIENCY:

SURROGATE PARENT NEEDED:

Yes

No

INTERPRETER FOR STUDENT NEEDED:

Yes

Yes

No

MEDICAL ALERTS AND/OR CONCERNS: None.

IF YES, SPECIFY LANGUAGE:


TRANSPORTATION:
PER DISTRICT POLICY
SPECIAL TRANSPORTATION REQUIRED

NAME:

M.S.

MEETING PARTICIPANTS: M.S.- GRANDFATHER ERIN ALLES -

RELATIONSHIP:

GRANDFATHER

BOCES SPECIAL EDUCATION TEACHER

LANGUAGE:

ENGLISH

DENISE JENNEY - BOCES SCHOOL SOCIAL WORKER

ADDRESS:
HOME:

KATHERINE BONCZAR - BOCES COUNSELOR


MRS. ANN PAJAK - CSE CHAIRPERSON
ERIN GONSER - SCHOOL PSYCHOLOGIST
MAGGIE VOSSLER - SPECIAL EDUCATION SECRETARY
MELANIE KERNS - BOCES STAFF SPECIALIST

OTHER INFORMATION:

DEBRA PYTLAK - GENERAL EDUCATION TEACHER

No

INDIVIDUALIZED EDUCATION PROGRAM (IEP)


STUDENT NAME: A.S.
DISABILITY CLASSIFICATION: Emotional Disturbance
DATE OF BIRTH:
LOCAL ID #: 000504452
PROJECTED DATE IEP IS TO BE IMPLEMENTED: March 20, 2015
PROJECTED DATE OF ANNUAL REVIEW: March 5, 2016
PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL NEEDS
DOCUMENTATION OF STUDENT'S CURRENT PERFORMANCE AND ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS
EVALUATION RESULTS (INCLUDING FOR SCHOOL-AGE STUDENTS, PERFORMANCE ON STATE AND DISTRICT-WIDE ASSESSMENTS)
Educational
evaluation 02-26-2013
Wechsler Individual Achievement Test III (WIAT-III) - Achievement testing suggests that A.S.s overall reading, writing and math skills are within
Normal limits when compared to peers his age. Composite scores are as follows (please note that Standard Scores between 85 and 115 are
considered Average): 1) Total Reading Composite, Standard Score = 87; 2) Basic Reading Composite, Standard Score = 87; 3) Rea ding
Comprehension Composite, Standard Score = 91; 4) Written Expression Composite, Standard Score = 95; 5) Mathematics Composite,
Standard Score = 100; and 6) Math Fluency Composite, Standard Score = 106.
Occupational Therapy
Evaluation 03-05-2013
BOT-2 Subtest: Bilateral Coordination - Score(s): 23 (Point Score); above average (Range); 21 (Scaled Score).
Subtest: Fine Manual Control - Score(s): 22 (sum) (Point Score); 16 (Percentile Rank); below average (Range); 40 (Standard Score).
Subtest: Fine Motor Integration - Score(s): 21 (Point Score); below average (Range); 8 (Scaled Score).
Subtest: Fine Motor Precision - Score(s): 32 (Point Score); average (Range); 14 (Scaled Score).
Subtest: Manual Coordination - Score(s): 22 (sum) (Point Score); 18 (Percentile Rank); average (Range); 41 (Standard Score).
Subtest: Manual Dexterity - Score(s): 22 (Point Score); average (Range); 13 (Scaled Score).
Subtest: Upper-Limb Coordination - Score(s): 18 (Point Score); below average (Range); 9 (Scaled Score).
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03-05-2013
Jordan Left-Right Reversal Test 3rd Edition - A.S. identified correct directionality for 12/12 designs and 20/25 upper and lower case letters and
numbers placing at the 32nd percentile placing in the average range in comparison to same aged peers. He did not determine correct
directionality for number 4 and letters b, d, f, t, and z. A.S. placed at the 32nd percentile accuracy rate and 37% for error rate of identifying correct
directionality in comparison to same aged peers.

03-05-2013
Test of Visual Perceptual Skills-3rd Edition - A.S. achieved an overall standard score of 99, placing him at the 47th percentile, solidy in the
Average Range. For Basic Processes and for Sequencing he achieved a standard score of 100 placing at the 50th percentile. For complex
processes, A.S. achieved a standard score of 95 placing at the 35th percentile.
Subtest: Visual Closure - Score(s): 25% (Percentile Rank); average (Range); 8 (Scaled Score); 5 (Raw Score).
Subtest: Visual Discrimination - Score(s): 63% (Percentile Rank); average (Range); 11 (Scaled Score); 9 (Raw Score).
Subtest: Visual Figure Ground - Score(s): 50% (Percentile Rank); average (Range); 10 (Scaled Score); 7 (Raw Score).
Subtest: Visual Form Constancy - Score(s): 16% (Percentile Rank); average (Range); 7 (Scaled Score); 5 (Raw Score).
Subtest: Visual Memory - Score(s): 7 (Percentile Rank); average (Range); 7 (Scaled Score); 16% (Raw Score).
Subtest: Visual Sequential Memory - Score(s): 50% (Percentile Rank); average (Range); 10 (Scaled Score); 8 (Raw Score).
Subtest: Visual-Spatial Relations - Score(s): 95% (Percentile Rank); above average (Range); 15 (Scaled Score); 13 (Raw
Score).
03-04-2013
Beery-Buktenica Devel Test of Visual-Motor Integration 6th Edition Subtest: Beery VMI - Score(s): 10% (Percentile); below average (Range); 15 (Raw score); 81 (Standard Score).
Subtest: Motor Coordination - Score(s): 50% (Percentile); average (Range); 21 (Raw score); 100 (Standard
Score). Subtest: Visual Perception - Score(s): 68% (Percentile); average (Range); 23 (Raw score); 107 (Standard
Score).
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03-04-2013
Eval Tool for Children's Handwriting -

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Subtest: Manuscript Letter Legibility - Score(s): 82% (Percentile).


Subtest: Manuscript Numeral Legibility - Score(s): 76%
(Percentile). Subtest: Manuscript Word Legibility - Score(s): 78%
(Percentile).
Psychological
evaluation 02-14-2013
Neuropsychological Assessment System (NEPSY-II) - Overall results suggest that A.S. is better able to recall verbal information that contextual in
nature, rather than rote and repetitive.
Subtest: List Memory - Score(s): 37 (Percentile Rank); 9 (Scaled Score). At Expected Level
Subtest: Narrative Memory - Score(s): 91 (Percentile Rank); 14 (Scaled Score). Above Expected Level

02-11-2013
Wechsler Intelligence Scale/Children-IV - A.S.'s overall level of cognitive functioning is within the Low Average range, as measured by the Full
Scale Intelligence Quotient. His overall thinking and reasoning abilities exceed those of approximately eighteen percent of students his age.
A.S.'s verbal and nonverbal reasoning skills are comparable; there is no significant meaningful difference between his ability to reason with or
Without the use of words. His working memory is also within the Low Average range, while his processing speed skills are solidly average and are
Considered an area of cognitive strength.
Subtest: Full Scale IQ Score - Score(s): 18 (Percentile Rank); 86 (Standard Score). Low Average
Subtest: Perceptual Reasoning - Score(s): 14 (Percentile Rank); 84 (Standard Score). Low Average
Subtest: Processing Speed - Score(s): 58 (Percentile Rank); 103 (Standard Score). Average
Subtest: Verbal Comprehension - Score(s): 16 (Percentile Rank); 85 (Standard Score). Low
Average Subtest: Working Memory - Score(s): 21 (Percentile Rank); 88 (Standard Score). Low
Average
02-06-2013
BASC-II Parent Rating Scale - Parent rating scales suggest that A.S. does not demonstrate behaviors related to internalizing problems (i.e., anxiety,
depression or somatization) at this time. In contrast, Mr. S ratings endorse concerns within the Externalizing Problems Composite (T=70, Clinically
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Significant), Adaptive Skills Composite (T=24, Clinically Significant) and Behavioral Symptoms Index (T=69, At-Risk). More specifically, A.S.'s levels
of hyperactivity, aggression and conduct problems are of great concern in the home setting; all scales are elevated. Similarly, all scales within the
Adaptive Skills Composite are considered At-Risk or Clinically Significant; when compared to peers his age, A.S.'s adaptability, social skills,
leadership capabilities, daily living activities and functional communication are weak. Lastly, his inattentive behaviors and

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Atypical behaviors in the home setting are of concern. Mr. S reports that A.S. is easily distracted, has a short attention span, often shows
feelings that do not fit a situation and sometimes seems out of touch with reality.
02-06-2013
BASC-II Teacher Rating Scale - At school, A.S. demonstrates more hyperactive behaviors than peers his age (Hyperactivity Scale, T=61). In
regard to internalizing problem behaviors, A.S.'s level of anxiety is considered Clinically Significant (Anxiety Scale, T=8 2). Mrs. Wilson reports
that he is often nervous, worries about things that cannot be changed, and often says, Im afraid I will make a mistake. L astly, the Atypicality
Scale within the Behavioral Symptoms Index and the Functional Communication Scale within the Adaptive Skills Composite are considered AtRisk when compared to peers A.S.s age (T=62 and 38, respectively).
Speech Evaluation 05-182010
Pre-School Language Scale - 4 Subtest: Auditory Comprehension - Score(s): 4-2 (Age Equivalent); 19 (Percentile Rank); WNL (Standard deviation point); 87 (Standard
Score).
Subtest: Chronological Age - Score(s): 4-11 (Age Equivalent).
Subtest: Expressive Communication - Score(s): 4-8 (Age Equivalent); 47 (Percentile Rank); WNL (Standard deviation point); 99 (Standard
Score).
State Tests
04-012014
Grade 3 ELA - Score: 242. Standards Met: Level 1.
04-30-2014
Grade 3 Math - Score: 280. Standards Met: Level 1.
ACADEMIC ACHIEVEMENT, FUNCTIONAL PERFORMANCE AND LEARNING CHARACTERISTICS
LEVELS OF KNOWLEDGE AND DEVELOPMENT IN SUBJECT AND SKILL AREAS INCLUDING ACTIVITIES OF DAILY LIVING, LEVEL OF INTELLECTUAL FUNCTIONING,
ADAPTIVE BEHAVIOR, EXPECTED RATE OF PROGRESS IN ACQUIRING SKILLS AND INFORMATION, AND LEARNING STYLE:
Reading:
A.S. struggles with reading. He often refuses to complete reading assignments both independently or as group activities. At this time, he is on
Level L which is beginning second grade. He can read independently at a 2.5 grade level with a 92% accuracy rate, but his comprehension is at
the frustration level. When reading, A.S. needs reminders to "chunk" and "blend" unknown words. Usually, he can accurately sound out words
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when he takes his time. If A.S. reads without prompting or assistance he reads very quickly, therefore guessing at words instead of sounding them
out. In his reading, A.S. needs to continue to use context clues and picture clues to help him figure out words he doesn't know. A.S. has difficulty
answering comprehension questions after reading. He often refuses to go back and reread information, but does not know the answers to the

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questions. A.S. is given daily vocabulary instruction. He requires a lot of repetition to remember the meaning of most words. A.S. enjoys participating
in vocabulary lessons. He is willing to give the meaning of words, but the meaning in normally incorrect. He is encouraged to use the words he has
learned in his conversational speech and his written work. A.S. has difficulty processing information and he requires frequent opportunity to practice
what he has learned.
STAR Reading Assessment
In January 2015 A.S. scored a scale score of 105 for reading.
Writing:
A.S. struggles with written activities. He has difficulty formulating sentences and writing paragraphs. He has been working on developing his
writing skills with the 6 + 1 Traits of Writing. He requires a lot of 1:1 adult assistance and modeling. Even when given topics and examples, he
struggles to generate his own ideas. A.S.'s writing is very basic, and lacks details. A.S. continues to work on ad ding details to his writing with the
use of graphic organizers. Also, he has been working on writing paragraphs with a topic sentence, details and a conclusion. He needs practice
organizing his paragraphs using transition words, such as, first, next, then and finally.
Math:
A.S. knows how to add and subtract without difficulty. A.S. has shown to have a good understanding of multiplication. He knows his multiplication
and division facts fluently. He is able to use his facts to solve larger multiplication and division problems. A.S. continues to work on multiplication
and division of 3 digits by 1 digit, along with multiplication of 2 digits by 2 digits. He knows the steps to answer these larger problems, but often
places numbers in incorrect places, or skips steps. A.S. needs prompts and reminders to recall necessary steps. With place value, A.S. has a
good understanding of ones, tens and hundreds place. A.S. can read and write these numbers accurately. A.S. does struggles with numbers larger
than the hundreds place. A.S. has a basic understanding of rounding numbers to the ones, tens, or hundreds p lace. A.S. shows an understanding
of area and perimeter, he can solve these problems using their formulas and by counting units. A.S. is unable to do multi-step word problems.
Even with one-on-one and a lot of practice he doesn't seem to comprehend that several steps need to be done in order to find the correct answer
to a problem.
STAR Math Assessment
In January 2015 A.S. scored a scale score of 422 for mathematics.
Expected Rate of Progress:
A.S. is working below his same age peers in all academic areas.
Activities of Daily Living:
A.S. is able to complete activities of daily living on his own. He does require frequent reminders to brush his teeth.
Learning Style:
A.S. is a multi-sensory learner.

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A.S. is very quick to shut down when he is given something he feels he does not know. A.S. does not allow time for lessons or activities to be
explained. He quickly decides he does not know what to do, and therefore is no longer doing it. A.S. also often states that he has already done
activities, so he is not going to do them again, but he does not have mastery of the material. During the time when a lesson is being explained,
or

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The steps to complete a problem are being taught, is often when A.S. shuts down and starts to refuse. A.S. often refuses within the first five minutes
of a lesson. Most times, A.S. responds better to being given limited knowledge about lessons. Once A.S. starts participating in a lesson and is
engaged, it is rare for him to refuse.
STUDENT STRENGTHS, PREFERENCES, INTERESTS:
- Works well 1:1
- Answers questions and participates in activities
- Enjoys listening to stories
- Enjoys working on the computer
- A.S. also enjoys going to specials such as music and gym.
- A.S. stated that when he is at home he enjoys playing games outside, playing with his electric cars, and playing "tablet" games.
ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS OF THE STUDENT, INCLUDING CONSIDERATION OF STUDENT NEEDS THAT ARE OF CONCERN TO
THE PARENT:
- Improve reading comprehension skills
- Improve reading fluency
- Increase vocabulary recall
- Develop writing skills
- Improve his listening and attending skills
- Take his time to complete written work with regard to neatness and detail
- Adult support
- Repetition of directions
- Choices of how and when to complete work
- Praise and encouragement
- 1:1 and small group instruction
- Support with writing assignments
- Improve multiplication and division skills
Guardian concerns: When he is cooperative, he does well. The problem is with getting him to cooperate.
SOCIAL DEVELOPMENT
THE DEGREE (EXTENT) AND QUALITY OF THE STUDENT'S RELATIONSHIPS WITH PEERS AND ADULTS; FEELINGS ABOUT SELF; AND SOCIAL ADJUSTMENT TO
SCHOOL AND COMMUNITY ENVIRONMENTS:
A.S. has transitioned well into the 6:1:1 classroom environment. A.S. benefits from a structured environment with clear expectations. A.S. has an
awareness of others. A.S. tends to migrate towards adults within the classroom that he has formed trusting relationships with. A.S. responds well to
positive male role models and tends to want to display appropriate behaviors when working 1:1 or in a small group set ting with this specific
individual. A.S. does display fear and/or anxiety when the topic of grief or loss to discussed. A.S. will quickly want to change the topic. However,
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when A.S. first entered the 6:1:1 environment he would frequently discuss the recent loss of his Grandmother and carry his Grandmother's prayer
card with him to school. A.S. has not mentioned his grandmother's death since before Thanksgiving. A.S. does display periods of anger and
frustration, typically during academics. As A.S.'s frustration level rises he will lose control of rational decision making. When offered a calming

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choice/sensory break he is unable to independently choose an activity. When A.S.'s anger does rise, the behaviors that he displays includes;
crawling around on the floor on all fours, hissing at anyone in his proximity, making clawing motions to other individuals, passing gas, burping,
laughing hysterically, frowning, throwing his glasses off. A.S. does display impulsive behaviors that are increased when he is angry/frustrated. At
these times, A.S. can be physically aggressive towards staff when they are blocking him from crawling around on the floor. A.S. has not focused
this aggressive towards his peers in recent months. A.S. does not display self-injurious behaviors. A.S. does display perseverance when he is
confident in a specific skill. A.S. will be very willing to complete a task that he perceives himself doing well at. When A.S. lacks confidence in a skill
or task he will quickly shut down and refuse to complete the work. When frustrated/angry, the team typically sees the hyperactivity as evidenced
by the crawling around on the floor. When A.S. is attempting to avoid a task or feels uncomfortable in a situation he will complain of his throat or
stomach bothering him or being tired. A.S. is fully capable of monitoring his own distress level and body control level on a rating scale of 1-10. A.S.
is able to connect to higher ratings related to a recent event that was upsetting to him. A.S. struggles with in dependently choosing a calming
strategy to reduce his levels of frustration/anxiety. A.S. responds very well to lying inside a big blue mat with light pressure applied. A.S. is able to
quickly reduce the negative feelings he is experiencing and does choose to stay in the mat to continue to calm. A.S. will at times, independently
ask to work while in the mat. The strategy of "LET GO" has proven to be an effective counseling tool to walk A.S. through emotionally upsetting
moments during the day. LET GO helps A.S. determine L- why he is losing it, E- the emotions that he is feeling, T- any thoughts that he is having,
G- what are his goals at the moment and O- options (ways that are going to help him achieve his goal.) At times, A.S. does not like to visually see
this process written out. During those moments, the counselor will verbally walk A.S. through the LET GO process. Counseling will continue to
focus utilizing this strategy to assist with handling stressful/upsetting situations.
Since entering the 6:1:1 classroom, A.S. has established himself as a positive role model for the younger students. In particular, A.S. has formed a
"Big brother, Little brother" relationship with a kindergarten student in the room. A.S. will help walk him in from the bus, run errands with him around
the school, hold hands with him in the hallway and encourage him to make positive choices. Other than the kindergarten student in the classroom,
A.S. does not have any true friendships at school. A.S. has mentioned other boys who ride the bus with him in a positive way but then in the same
breath shares that they were physically aggressive towards each other. A.S. does get along with another fourth grade student within the classroom.
A.S. has never had a negative interaction with this student. A.S. has not shown aggression towards peers since first being placed in the 6:1:1
classroom.
A.S. is capable of accepting direction throughout the day when it is independent of an academic task. A.S. has a difficult time responding to
academic corrections or discipline. A.S. will shut down and be unresponsive or begin crawling around the room. A.S. is very attention seeking. He
is constantly wanting to have conversations with adults or ask them questions. He will also repeatedly ask if he can "fix" something or do
something "helpful" for adults. A.S. does have a tendency to seek out adult attention while they are involved with instruct ion or with other
students. The classroom team has implemented a notebook for A.S. to write down thoughts that he wants to share with adults if they are busy at
the time. A.S. thrives on positive reinforcement. A.S. is capable of earning "Hoot Loot" which is the classroom economy s system for positive
behaviors. A.S.'s favorite thing to earn "Hoot Loot" for is lunch with another teacher that he previously had in summer school.

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A.S. has adjusted well to Arcade Elementary and the 6:1:1 classroom. A.S. has developed a leadership role within the classroom. A.S. has
adapted well to new students entering the classroom as well as new staff members. There does not seem to be a correlation between visits with
Mother/Father over the weekend and transitioning back to school on Mondays. There is not significant behavioral regression after extended breaks
from school. A.S. takes responsibility for his personal belongings and does show respect for classmates behaviors as well. A.S. is responsible
with school technology devices and takes great pride in his ability to utilize them. A.S. has responded very positively towards dimmed lighting
within the classroom and relaxing music playing. A.S. will independently turn on relaxing music to help himself stay calm and focused during work
periods. He will also take the initiative to turn it on if another student is having a difficult moment. A.S. has responded to mindfulness

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Activities that involve completing a task. A.S. Is very conscious of his daily schedule and can become agitated if it changes due to an assembly or
presentation. Staff have noted, A.S. struggles with allowing himself to relax and have fun in activities. A.S. does not like to attend assemblies or
activities such as playing out in the snow for gym class or participating in a classroom game.
STUDENT STRENGTHS:
- Positive leadership relationships with other students
- Ability to rate personal distress levels and control levels
- Has allowed for the development of positive relationships with staff members
- Responds well to dimmed lights and relaxation music
SOCIAL DEVELOPMENT NEEDS OF THE STUDENT, INCLUDING CONSIDERATION OF STUDENT NEEDS THAT ARE OF CONCERN TO THE PARENT:
- Continue to work on developing his abilities to recognize his bodies indicators of frustration/anger to then be able to proactively seek out a calming
choice/sensory break
- Access to counselor
Guardian concerns: He wants to be around adults more than his peers.
PHYSICAL DEVELOPMENT
THE DEGREE (EXTENT) AND QUALITY OF THE STUDENTS MOTOR AND SENSORY DEVELOPMENT, HEALTH, VITALITY AND PHYSICAL SKILLS OR LIMITATIONS
WHICH PERTAIN TO THE LEARNING PROCESS:
A.S. is developing at an age appropriate rate. He wears glasses. He attends regular physical education class. A.S. does frequently comp lain
about his legs, shoulders, or arms hurting. He will frequently fall down, even on a flat surface. He constantly blows on his fingertips and shakes
his hands. He has difficulty sitting still and attending. He benefits from short movement breaks between activities. His attendance at school is
good.
STUDENT STRENGTHS:
- Enjoys physical activities
- A.S. physical status is well maintained and his attendance has been good.
PHYSICAL DEVELOPMENT NEEDS OF THE STUDENT, INCLUDING CONSIDERATION OF STUDENT NEEDS THAT ARE OF CONCERN TO THE PARENT:
- Movement breaks throughout the day
Guardian concerns: A.S. grandpa said that he has difficulty attending and focusing at home. A.S. Frequently washes the dishes after dinner
and even when there are only a few dishes it takes him 45 minutes to an hour to complete the task.
MANAGEMENT NEEDS
THE NATURE (TYPE) AND DEGREE (EXTENT) TO WHICH ENVIRONMENTAL AND HUMAN OR MATERIAL RESOURCES ARE NEEDED TO ADDRESS NEEDS
IDENTIFIED ABOVE:
-1:1 or small group instruction
-Repetition of directions, skills and activities
-Support for all written activities
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-Movement breaks
-Choices of how and where to complete his work
-Access to a counselor
-Praise and encouragement
-1:1 adult assistance
EFFECT OF STUDENT NEEDS ON INVOLVEMENT AND PROGRESS IN THE GENERAL EDUCATION CURRICULUM OR, FOR A
PRESCHOOL STUDENT, EFFECT OF STUDENT NEEDS ON PARTICIPATION IN APPROPRIATE ACTIVITIES
A.S. requires small group instruction to be successful. He is easily distracted and needs verbal cues to attend and focus. He needs frequent
repetition and practice to master skills. He needs adult support for most of his assignments. He requires short movement breaks between
assignments and activities.
A.S. benefits from naturally occurring sensory movement breaks throughout his school day such as trips to the bathroom and/or water fountain,
passing out supplies, running errands and participating in academic activities while sitting or lying on the floor on his stomach.
STUDENT NEEDS RELATING TO SPECIAL FACTORS
BASED ON THE IDENTIFICATION OF THE STUDENT'S NEEDS, THE COMMITTEE MUST CONSIDER WHETHER THE STUDENT NEEDS A PARTICULAR DEVICE OR
SERVICE TO ADDRESS THE SPECIAL FACTORS AS INDICATED BELOW, AND IF SO, THE APPROPRIATE SECTION OF THE IEP MUST IDENTIFY THE PARTICULAR
DEVICE OR SERVICE(S) NEEDED.
Does the student need strategies, including positive behavioral interventions, supports and other strategies to address behaviors that impede the
student's learning or that of others?
Yes
No
Does the student need a behavioral intervention plan?
No
Yes:
For a student with limited English proficiency, does he/she need a special education service to address his/her language needs as they relate to the
IEP?
Yes
No
Not Applicable
For a student who is blind or visually impaired, does he/she need instruction in Braille and the use of Braille?
Yes
No
Not Applicable
Does the student need a particular device or service to address his/her communication needs?
Yes
No
In the case of a student who is deaf or hard of hearing, does the student need a particular device or service in consideration of the student's
language and communication needs, opportunities for direct communications with peers and professional personnel in the student's language
and communication mode, academic level, and full range of needs, including opportunities for direct instruction in the student's language and
communication mode?
Yes
No
Not Applicable
Does the student need an assistive technology device and/or service?
Yes
No
If yes, does the Committee recommend that the device(s) be used in the student's home?
Yes
No
BEGINNING NOT LATER THAN THE FIRST IEP TO BE IN EFFECT WHEN THE STUDENT IS AGE 15 (AND AT A YOUNGER AGE IF DETERMINED APPROPRIATE)

MEASURABLE POSTSECONDARY GOALS


LONG-TERM GOALS FOR LIVING, WORKING AND LEARNING AS AN ADULT

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TRANSITION NEEDS
In consideration of present levels of performance, transition service needs of the student that focus on the student's course s of study, taking
into account the students strengths, preferences and interests as they relate to transition from school to post-school activities:
Needs
Courses of study

MEASURABLE ANNUAL GOALS


THE FOLLOWING GOALS ARE RECOMMENDED TO ENABLE THE STUDENT TO BE INVOLVED IN AND PROGRESS IN THE GENERAL
EDUCATION CURRICULUM, ADDRESS OTHER EDUCATIONAL NEEDS THAT RESULT FROM THE STUDENT'S DISABILITY, AND PREPARE
THE STUDENT TO MEET HIS/HER POSTSECONDARY GOALS.
ANNUAL GOALS
CRITERIA
METHOD
SCHEDULE
W HAT THE STUDENT WILL BE EXPECTED TO ACHIEVE BY THE MEASURE TO DETERMINE IF
HOW PROGRESS WILL BE
WHEN PROGRESS WILL
GOAL HAS BEEN ACHIEVED
MEASURED
BE MEASURED
END OF THE YEAR IN WHICH THE IEP IS IN EFFECT
A.S. will independently read a 3.0 or greater grade
80% accuracy
Teacher observation
Monthly
level reading selection and correctly answer questions
Worksheets/Tests
4 out of 5 times
about the reading.
A.S. will independently write a paragraph with a topic
sentence, at least 2 details and a conclusion.

3 out of 4 times with 2 or


less prompts

Teacher observation

Monthly

A.S. will read 90 words per minute at a 3.0 grade level.

4 out of 5 times

Running record

Monthly

A.S. will multiple and divide a three digit number by a


single digit number.

80 percent accuracy 3 out


of 4 times

Teacher observation
Worksheets/Tests

Monthly

With assistance from counselor/staff, A.S. Will utilize


the counseling technique "LET GO" to identify his
triggers (why he is losing it), emotions, thoughts, what
his goal is at the moment, and to determine options that
will help calm him when feeling frustrated/upset.

8 out of 10 situations

Behavior tracking
Direct observation

Monthly

A.S. will correctly define 10 or more vocabulary words.

4 out of 5 times correctly


80% accuracy

Observed through teacher


observations
Worksheets/test

Monthly

New York State Education Department IEP Form for A . S .

Page 11 of 16

REPORTING PROGRESS TO PARENTS


Identify when periodic reports on the student's progress toward meeting the annual goals will be provided to the student's pa rents: Quarterly at
the same time regular report cards are issued.
Identify when periodic reports on the student's progress toward meeting the annual goals will be provided to the student's pa rents: Beginning
September 2013 Students in K-4 will be reported on a trimester basis (at the same time regular report cards are issued). Students in 5-12 will
be reported quarterly (at the same time regular report cards are issued).
RECOMMENDED SPECIAL EDUCATION PROGRAMS AND SERVICES

SPECIAL EDUCATION PROGRAM/SERVICES


Special Education Program:
Special Class - 6:1:1

SERVICE DELIVERY
RECOMMENDATIONS*

FREQUENCY

DURATION

LOCATION

HOW OFTEN

LENGTH OF

W HERE SERVICE WILL

PROVIDED

SESSION

BE PROVIDED

PROJECTED
BEGINNING/
SERVICE
DATE(S)

Spec Class 6 Pupils


1 Teacher 1
Paraprofessional
Spec Class 6 Pupils
1 Teacher 1
Paraprofessional

5 times /
Weekly

300
minutes

6:1:1 Special Education


Classroom

03/20/15 06/25/15

5 times /
Weekly

300
minutes

6:1:1 Special Education


Classroom

09/03/15 03/04/16

Related Services:
Counseling Services

Group

30 minutes

Counselor's Office

Counseling Services

Individual

30 minutes

Counselor's Office

Parent Counseling and Training

Individual

20 minutes

All appropriate settings

Counseling Services

Group

30 minutes

Counselor's Office

Counseling Services

Individual

30 minutes

Counselor's Office

Parent Counseling and Training

Individual

5 times /
Weekly
2 times /
Weekly
1 time /
Quarterly
5 times /
Weekly
2 times /
Weekly
1 time /
Quarterly

20 minutes

All appropriate settings

03/20/15 06/25/15
03/20/15 06/25/15
03/20/15 06/25/15
09/03/15 03/04/16
09/03/15 03/04/16
09/03/15 03/04/16

Special Class - 6:1:1

New York State Education Department IEP Form for A . S .

Page 12 of 16

Supplementary Aids and Services/ Program Modifications/ Accommodations:


Praise
and encouragement
Daily
1:1 Aide - summer school

Daily for
300 minutes
per session
Daily

Access to counselor
Movement breaks

sensory breaks

Repeat Directions

Daily
Daily

Small Group

instruction 1:1

Daily

Support

with writing activities

Daily

Choices of how and when to complete work

Daily

1:1 Aide

Daily for
300 minutes
per session

Duration of
IEP
Duration of
summer
school
Duration of
IEP
Duration of
IEP
Duration of
IEP
Duration of
IEP
Duration of
IEP
Duration of
IEP
Duration of
IEP

All classes

03/20/15

6:1:1 Special Education


Classroom

03/20/15

All classes

03/20/15

All classes

03/20/15

All classes

03/20/15

All classes

03/20/15

All classes

03/20/15

All classes

03/20/15

All appropriate settings

03/20/15

Assistive Technology Devices and/or Services:


None Recommended
Supports for School Personnel on Behalf of the Student:
None Recommended
*
Identify, if applicable, class size (maximum student-to-staff ratio), language if other than English, group or individual services, direct and/or
indirect consultant teacher services or other service delivery recommendations.
12-MONTH SERVICE AND/OR PROGRAM Student is eligible to receive special education services and/or program during July/August:
Yes
If yes:
Student will receive the same special education program/services as recommended
above. OR
Student will receive the following special education program/services:
New York State Education Department IEP Form for A . S .

No

Page 13 of 16

SPECIAL EDUCATION PROGRAM/SERVICES


Special Education Program:
Special Class - 6:1:1

Related Services:
Counseling Services

SERVICE DELIVERY
RECOMMENDATIONS

Spec Class 6 Pupils


1 Teacher 1
Paraprofessional

FREQUENCY

5 times /
Weekly

DURATION

300
minutes

Group

5 times /
30 minutes
Weekly
Counseling Services
Individual
30 minutes
2 times /
Weekly
Name of school/agency provider of services during July and August: Delevan (BOCES)
For a preschool student, reason(s) the child requires services during July and August:

LOCATION

PROJECTED
BEGINNING/
SERVICE DATE(S)

6:1:1 Special Education


Classroom

07/06/15 08/14/15

Counselor's Office

07/06/15 08/14/15
07/06/15 08/14/15

Counselor's Office

TESTING ACCOMMODATIONS (TO BE COMPLETED FOR PRESCHOOL CHILDREN ONLY IF THERE IS AN ASSESSMENT PROGRAM FOR NONDISABLED PRESCHOOL CHILDREN):
INDIVIDUAL TESTING ACCOMMODATIONS, SPECIFIC TO THE STUDENTS DISABILITY AND NEEDS, TO BE USED CONSISTENTLY BY THE STUDENT IN THE
RECOMMENDED EDUCATIONAL PROGRAM AND IN THE ADMINISTRATION OF DISTRICT-WIDE ASSESSMENTS OF STUDENT ACHIEVEMENT AND, IN ACCORDANCE
WITH DEPARTMENT POLICY, STATE ASSESSMENTS OF STUDENT ACHIEVEMENT
TESTING ACCOMMODATION
None.

CONDITIONS*

IMPLEMENTATION RECOMMENDATIONS**

Directions Read
On-task focusing prompts

All tests
All tests

and clarified

Flexible Setting

All tests

Location with minimal distractions

Tests read that do not measure reading


comprehension.

Tests that do not measure reading


comprehension as per SED guidelines

Test passages, questions, items and multiple choice


responses read to the student

Extended Time

All tests

1.5

Breaks

All tests

2 minutes after 20 minutes of testing

*Conditions Test Characteristics: Describe the type, length, purpose of the test upon which the use of testing accommodations is conditioned, if
applicable.
**Implementation Recommendations: Identify the amount of extended time, type of setting, etc., specific to the testing accommodations,
if applicable.
New York State Education Department IEP Form for A . S .

Page 14 of 16

BEGINNING NOT LATER THAN THE FIRST IEP TO BE IN EFFECT WHEN THE STUDENT IS AGE 15 (AND AT A YOUNGER AGE, IF DETERMINED APPROPRIATE).

COORDINATED SET OF TRANSITION ACTIVITIES


NEEDED ACTIVITIES TO FACILITATE THE
STUDENTS MOVEMENT FROM SCHOOL TO
POST-SCHOOL ACTIVITIES

SERVICE/ACTIVITY

SCHOOL DISTRICT/
AGENCY RESPONSIBLE

PARTICIPATION IN STATE AND DISTRICT-WIDE


ASSESSMENTS
(TO BE COMPLETED FOR PRESCHOOL STUDENTS ONLY IF THERE IS AN ASSESSMENT PROGRAM FOR NONDISABLED PRESCHOOL STUDENTS)

The student will participate in the same State and district-wide assessments of student achievement that are administered to general education
students.
The student will participate in an alternate assessment on a particular State or district-wide assessment of student
achievement. Identify the alternate assessment:
Statement of why the student cannot participate in the regular assessment and why the particular alternate assessment selected is
Appropriate for the student:
PARTICIPATION WITH STUDENTS WITHOUT DISABILITIES
REMOVAL FROM THE GENERAL EDUCATION ENVIRONMENT OCCURS ONLY WHEN THE NATURE OR SEVERITY OF THE DISABILITY IS SUCH THAT, EVEN WITH THE
USE OF SUPPLEMENTARY AIDS AND SERVICES, EDUCATION CANNOT BE SATISFACTORILY ACHIEVED.
FOR THE SCHOOL-AGE STUDENT:
Explain the extent, if any, to which the student will not participate in regular class, extracurricular and other nonacademic activities (e.g., percent
of the school day and/or specify particular activities):
A.S. will be removed from general education to participate in a 6:1:1 special education classroom for all core academic classes 5 times a week for
300 minutes per day, group counseling 5 times a week for 30 minutes per session, and individual counseling 2 times a week for 30 minutes per
session.
To prevent substantial regression, the CSE recommended A.S. attend extended school year program of 6:1:1 special education classroom 5 times
a week for 300 minutes per day, group counseling 5 times a week for 30 minutes per session, and individual counseling 2 times a week f or 30
minutes per session.
If the student is not participating in a regular physical education program, identify the extent to which the student will participate in
specially- designed instruction in physical education, including adapted physical education:
EXEMPTION FROM LANGUAGE OTHER THAN ENGLISH DIPLOMA REQUIREMENT: No
Yes - The Committee has determined that the student's
disability adversely affects his/her ability to learn a language and recommends the student be exempt from the language other than English
requirement.
New York State Education Department IEP Form for A . S .
Page 15 of 16

SPECIAL TRANSPORTATION
TRANSPORTATION RECOMMENDATION TO ADDRESS NEEDS OF THE STUDENT RELATING TO HIS/HER DISABILITY
None.
Student needs special transportation accommodations/services as follows:
Vehicle and/or equipment needs: Student requires a small bus.
Adult Supervision:

Student requires a bus aide.

Student needs transportation to and from special classes or programs at another site: Student requires transportation to/from Delevan to Arcade
PLACEMENT RECOMMENDATION
BOCES program in Public
School

New York State Education Department IEP Form for A . S .

Page 16 of 16