INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Students Name:

School Age

Martina Marshall

IEP Team Meeting Date (mm/dd/yy):

10/19/2015

IEP Implementation Date (Projected Date when Services and Programs Will Begin):
Anticipated Duration of Services and Programs:
Date of Birth:

10/20/2015

10/17/2016

12/13/2002

Age:

13

Grade:

8th

Anticipated Year of Graduation:

2020

Local Education Agency (LEA):

County of Residence:

Eastern University Academy Charter School

Philadelphia

Name and Address of Parent/Guardian/Surrogate:

Phone (Home):
Phone (Work):

Other Information:

The LEA and parent have agreed to make the following changes to the IEP without convening an IEP meeting, as documented by:

Date of Revision(s)

Page 1 of 24

Participants/Roles

IEP Section(s) Amended

April 2014

IEP TEAM/SIGNATURES
The Individualized Education Program team makes the decisions about the students program and placement. The students parent(s), the students special
education teacher, and a representative from the Local Education Agency are required members of this team. Signature on this IEP documents attendance, not
agreement.
Role

Printed Name

Signature

Parent/Guardian/Surrogate

Monique Marshall

Monique Marshall

Student*

Martina Marshall

Martina Marshall

Regular Education Teacher**

Darnell Coleman

Darnell Coleman

Special Education Teacher

Alonzo Matthews Jr

Alonzo Matthews Jr

Local Ed Agency Rep

Omar Barlow

Omar Barlow

Parent/Guardian/Surrogate

Career/Tech Ed Rep***
Community Agency Rep
Teacher of the Gifted****

*
The IEP team must invite the student if transition services are being planned or if the parents choose to have the student participate.
**
If the student is, or may be, participating in the regular education environment
***
As determined by the LEA as needed for transition services and other community services
****
A teacher of the gifted is required when writing an IEP for a student with a disability who also is gifted.
One individual listed above must be able to interpret the instructional implications of any evaluation results.
Written input received from the following members:
Wagner, Brown, Coleman, Mander, Matthews, Nelson

Transfer of Rights at Age of Majority

For purposes of education, the age of majority is reached in Pennsylvania when the individual reaches 21 years of age. Likewise, for purposes of the Individuals
with Disabilities Education Act, the age of majority is reached for students with disabilities when they reach 21 years of age.

PROCEDURAL SAFEGUARDS NOTICE

I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides information about my rights,
including the process for disagreeing with the IEP. The school has informed me whom I may contact if I need more information.
Signature of Parent/Guardian/Surrogate:

Monique Marshall

MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

(Applicable only to parents who have consented to the release of billing information to Medical Assistance programs)
I understand that the school may charge the School-Based Access Program (SBAP)or any program that replaces or supplements the SBAPthe cost of certain
special education and related services described in my childs IEP. To make these charges to the SBAP, the school will release to the administrator of that
program the name, age, and address of my child, verification of Medicaid eligibility for my child, a copy of my childs IEP, a description of the services provided
and the times and dates during which such services were provided to my child, and the identity of the provider of such services. I understand that such
information will not be disclosed, and such charges will not be made, unless I consent to the disclosure. I acknowledge that I have provided written consent to
disclose such information.
I understand that my consent is ongoing from year-to-year unless and until I withdraw it. I can withdraw my consent in writing, or orally if I am unable to
write, at any time. My refusal to consent or my withdrawal of consent will not relieve the school of the obligation to provide, at no cost to me or my family,
any service or program to which my child is entitled under the Individuals with Disabilities Education Act (IDEA) or that is necessary to enable my child to
receive a free appropriate public education as described in my childs IEP.
I understand that the school cannot
Require me or my family to sign up for or enroll in any public benefits or insurance program, such as Medicaid, as a condition of receiving a free appropriate
public education for my child;
Require me or my family to incur any expense for the provision of a free appropriate public education to my child, including co-payments and deductibles,
unless it agrees to pay such expenses on my or my familys behalf;
Cause a decrease in available lifetime coverage or any other insured benefit;
Cause me or my family to pay for services that would otherwise be covered by a public benefits or insurance program and that are required for my child
outside the time that he or she is in school;
Risk the loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.

I. SPECIAL CONSIDERATIONS THE IEP TEAM MUST CONSIDER BEFORE DEVELOPING THE IEP. ANY FACTORS CHECKED AS YES MUST BE ADDRESSED IN THE IEP.
Is the student blind or visually impaired?
Yes
The IEP must include a description of the instruction in Braille and the use of Braille unless the IEP team determines, after an
evaluation of the students reading and writing skills, needs, and appropriate reading and writing media (including an
evaluation of the students future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use of
Braille is not appropriate for the student.
x No
Is the student deaf or hard of hearing?
Yes
The IEP must include a communication plan to address the following: language and communication needs; opportunities for
direct communications with peers and professional personnel in the students language and communication mode; academic
level; full range of needs, including opportunities for direct instruction in the students language and communication mode;
and assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The
Communication Plan must be completed and is available at www.pattan.net
x

No

Does the student have communication needs?

Yes
Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)
x

No

Does the student need assistive technology devices and/or services?

Yes
Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)
x

No

Does the student have limited English proficiency?

Yes
The IEP team must address the students language needs and how those needs relate to the IEP.
x

No

Does the student exhibit behaviors that impede his/her learning or that of others?
Yes
The IEP team must develop a Positive Behavior Support Plan that is based on a functional assessment of behavior and that
utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in the Present Levels
section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially Designed Instruction
sections of the IEP or in the Positive Behavior Support Plan if this is a separate document that is attached to the IEP. A Positive
Behavior Support Plan and a Functional Behavioral Assessment form are available at www.pattan.net
x

No

Other (specify):

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Include the following information related to the student:
Present levels of academic achievement (e.g., most recent evaluation of the student, results of formative assessments, curriculum-based
assessments, transition assessments, progress toward current goals)
Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress
toward current goals)
Present levels related to current postsecondary transition goals if the students age is 14 or younger if determined appropriate by the IEP team
(e.g., results of formative assessments, curriculum-based assessments, progress toward current goals)
Parental concerns for enhancing the education of the student
How the students disability affects involvement and progress in the general education curriculum
Strengths
Academic, developmental, and functional needs related to students disability
Present Levels of Academic Achievement:
Martina is a 13 year old 8th grade student at Eastern University Academy Charter School. She began
attending EUACS in the 7th grade. Upon entering, Martina was identified as a student having an
Intellectual Disability. Goals in Martinas current IEP address the following: sight words, sentence
structure, difference between fantasy and reality in stories, basic comprehension, writing process,
printing legibly, speaking in complete sentences, discussing life events, adding, subtracting, and making
purchases.
On the Reading Level Indicator (group reading test) administered in 7 th grade, Martina scored as follows:
Instructional Reading Level: 3.0 and Independent Reading Level: 2.3. On the 4Sight Benchmark

administered in March of 2015 Martina scored as follows: Math: Below Basic and Reading: Below Basic.
The Wechsler Intelligence Scale for Children-Fifth Edition was administered in September of 2015.
Martina scored a Full Scale IQ of 61, and cognitive functioning was found to be in the Extremely Low
range. The Full Scale is at the .5th percentile with a 90% chance of falling in the 58-67 range. Martina
earned the following scores: Scaled Scores: 7-13 Average/IQ 90-110 Average. Martinas most recent
report card grades were:
Empirical Reasoning: 82% (Meets Expectations)
Math: 89% (Meets Expectations)
Reading: 73% (Approaching Expectations)
Social Reasoning: 61% (Little Evidence of Work)
Art: 75% (Approaching Expectations)
Overall, Martinas academic achievement is commensurate with and in some areas below expectations
based on her cognitive ability. Her achievement scores are consistent with her identification as a
student with an Intellectual Disability. Her achievement is significantly below grade level expectations.
Martina continues to qualify for and demonstrate a need for specially designed instruction as a student
with an Intellectual Disability.
Wechsler Intelligence Scale for Children-Fifth Edition: The WISC-V Full Scale IQ is comprised of five
composite score. These composite scores are the Verbal Comprehension Index, the Visual Spatial Index,
The Working Memory Index, the Processing Speed Index, and the Fluid Reasoning Index. Martinas overall
Full Scale IQ falls within the Extremely Low Range. The verbal comprehension area is a measure of
verbal concept formation, abstract reasoning, and word knowledge. Martinas ability within this area
fall within the Extremely Low Range. The Visual Spatial area is a measure of the ability to analyze and
synthesize abstract visual stimuli and visual and spatial processing. Martinas ability in this area falls
within the Extremely Low Range. The Fluid Reasoning Area is a measure of quantitative and spatial
reasoning. Martinas ability in this area falls within the Extremely Low Range. The working memory area
is a measure of the ability to actively maintain information in conscious awareness, perform some
operation or manipulation with it and produce a result. It measures working memory capacity. Martinas
ability in this area falls within the Extremely Low Range. The Processing Speed area is a measure of the
students ability to quickly process nonverbal information (visual discrimination or nonsense symbols and
visual-motor copying) Jihads ability within this area falls within the Extremely Low Range.
Wechsler Individual Achievement Test-Third Edition: On the Reading Comprehension Subtest, Martina
was unable to read grade level selections. Therefore, a standard score was not able to be calculated.
On the Sentence Composition subtests, Martina received 0s on both of the first two items: Sentence
Combining and Sentence Building. Therefore, a standard score was not able to be calculated. On the
Listening Comprehension subtests, Martina listened to vocabulary words and pointed to a picture that
illustrated each word (Receptive Vocabulary-Low) and then listened to passages and answered questions
about each one (Oral Discourse Comprehension-Very Low).
On the Reading Comprehension subtest, Martina read passages under un-time conditions, and then
answered open- ended questions about each one. On the 2nd grade passage starting point, she answered

5 of the 6 questions correctly. One the second passage (which begins the 3 rd grade starting point) she
answered 1 out of 8 correctly. On the third passage (ending point for second grade) she was unable to
read the passage. Due to her significant difficulty with reading the Early Reading Skills subtest was
administered but not scored due to Martina following outside of the grade criteria. Martina was able to
identify letters and some sounds. She began to have difficulty when she was shown pictures and told
the names of the pictures of which he had to determine either the same beginning sound or same
ending sound.
On the Math Problem Solving subtest, Martina solved un-timed math problems related to basic skills and
everyday application. She was able to answer some problems when pictures were provided to assist her.
She was unable to answer problems with money, time, and graphs. On the Numerical Operations
subtest, Martina solved un-timed written math problems in the following domains: Basic Skills and Basic
Operations. Martina was able to answer single digit addition facts and some single digit subtraction
facts. She could not complete double digit facts. She was unable to complete multiplication problems.
On the Sentence Composition subtests, Martina was to combine the information from two or three
sentences into single sentences with the same meanings (Sentence Combining). She instead copied the
sentences. Martina was to write a meaningful sentence that used specific words (Sentence Building).
She received 0s on the first two items. Neither subtest was able to be calculated to be scored. Martina
had difficulty using correct spelling, grammar, capitalization, and punctuation. On the Word Reading
subtest, Martina read aloud a list of increasingly difficult words. On the Pseudoword Decoding subtest,
Martina was to read a list of increasingly difficult nonsense words. The Expressive Vocabulary subtest for
the Oral Expression Composite was administered. Martina was shown pictures and was asked to name
the concepts shown in each picture. On the Spelling subtest, Martina wore single words that were
dictated within the context of a sentence.

Present Level of Functional Performance:

Martina follows the classroom rules and interacts appropriately with her peers. She does not consistently
return class work on time. Martina has difficulty following oral and written directions appropriate to grade
level. She often refuses to participate in group discussions. Martina can be easily distracted. She appears
comfortable and often puts forth her best effort. She does require some redirection as tasks and topics
become more challenging for her. Martina easily engages in conversation and is very polite. She often has
trouble understanding relationships as they relate to her peers. Martina is often put into social situations
wherein she is taken advantage of for her good nature. Students have taken money and supplies from
Martina under the guise of friendship only to be unkind to her later in the day. Based on her most recent
evaluation and teacher observations, it was determined by the IEP team that although Martinas current IQ
allows her to function in the inclusive environment, she will need a travelling paraprofessional to assist her
throughout the day, and to provide one-on-one life skills training.

Present Levels Related to Current Postsecondary Transition Goals:

Martina enjoys interacting with other people, music, computers, and clerical type activities in which she has
the opportunity to complete a project. She responds well to verbal praise and is able to stay focused for 20+
minutes with occasional verbal redirection. She has developed the skills to operate a variety of switch
activated devices (e.g. button maker, blender, etc.), use a paper shredder, and collate papers with explicit
directions. She demonstrates a high level of motivation to please her teachers and her mother. Martina has
become more independent within the school. She is completing support tasks with our climate assistant, Mr.
Thompson.
Based on Martinas levels, a life skills curriculum should be implemented or introduced into the inclusionary
environment to provide her with ample opportunities to learn the skills she will need to operate as an adult
with an ID. Martina expressed on 10/15/2015 that after graduation, she will continue to live with her parents
and will participate in her daily care routines to the maximum extent possible. Immediately following
graduation, Martina should participate in 1-2 age appropriate community and individual based activities per
week related to her current interests, which are socialization, animals, and music. Martina will need to
participate in year long on-campus vocational training, each for a period of three months, with a frequency
minimum of two sessions each week, and session duration of one hour per session. Martina also expressed a
desire to do clerical work for pay on this date, which is a change from Martinas previous report that she did
not want to work. She feels that she has economic difficulties and would benefit from paid work in the area
of her interest. OVR should be contacted and efforts made to support this goal. Martinas high school years
should provide her with an opportunity to both work and participate in school activities in order to better
assess her abilities in new situations. She will also need opportunities in the community in order to develop
leisure activities.
Parental Concerns for Enhancing the Education of the Student:
Ms. Marshall has reported that she has concerns about Martinas special education program. She worries that
her teachers are not on the same page regarding her IEP, and that many of them may not know that she has
an IEP. She expressed that she requires one on one help. Ms. Marshall reported that Martina has friends both
in her age group and in other age groups. Ms. Marshall has also expressed concern verbally that Martina is
not aware of her relationship with her peers and can be taken advantage of. She is also concerned that in
previous programs, instead of delivering content, she often found that Martina was playing with blocks.
She worries that his work is often not intellectually engaging.
How the students disability affects involvement and progress in the general education curriculum:
Martinas Intellectual Disability limits her progress in the general education curriculum in varied ways.
Although Martina does have a working vocabulary, she often does not understand the words that are spoken
during class lectures. Her ID is characterized by general delays in cognitive development that influence the
acquisition of language and academic skills. Moreover, while Martina can learn much information that is part
of the general education curriculum, she learns more slowly than her peers. Deficits in specific cognitive
skills contribute to this delay. Three of the most important cognitive skill deficits Martina exhibits are
related to attention, memory, and generalization. To be academically and socially successful, Martina will
need to receive specially designed instruction with an alternate curriculum, including instruction focused

career development, functional academics, and community referenced skills that are linked to the state
standard course of study in Language Arts, Math, and Science.
Strengths
Martina always has appropriate tools needed to perform in class. She asks for help when needed and
completes her work. She can read a leveled story independently.
Academic, developmental, and functional needs related to students disability:
Martina has several needs related to her disability that will need to be addressed in order for her to succeed
in the academic setting. She will need to improve upon basic math skills (including: telling time, identifying
and counting money, adding and subtracting single and double digit numbers), improve upon reading skills
(including: increase sight vocabulary, improve decoding skills, answering simple comprehension questions),
improve upon writing skills (including: improve upon spelling frequently used words, writing a sentence with
correct spelling, punctuation, and capitalization).
Advisors working with Martina should be as concrete as possible. They need to demonstrate what they mean
rather than just giving verbal directions. Rather than just relating new information verbally, they should
provide an image. They should also provide her with hands-on materials and experiences to try things
herself. Teachers should break longer, new tasks into small steps and have Martina take the steps one at a
time. In order to keep her motivated, teachers should provide immediate feedback and positive
reinforcement. Martina will need to be taught daily life skills such as daily living, social skills, occupational
awareness, and exploration as appropriate. Martina should also be involved in group activities or clubs.
Martina will need constant supervision and oversight.
III. TRANSITION SERVICES This is required for students age 14 or younger if determined appropriate by the IEP team. If the student does not attend the
IEP meeting, the school must take other steps to ensure that the students preferences and interests are considered. Transition services are a coordinated
set of activities for a student with a disability that is designed to be within a results oriented process, that is focused on improving the academic and
functional achievement of the student with a disability to facilitate the students movement from school to post school activities, including postsecondary
education, vocational education, integrated employment (including supported employment), continuing and adult education, adult services, independent
living, or community participation that is based on the individual students needs taking into account the students strengths, preferences, and interests.
POST SCHOOL GOALS Based on age appropriate assessment, define and project the appropriate measurable postsecondary goals that address education
and training, employment, and as needed, independent living. Under each area, list the services/activities and courses of study that support that goal.
Include for each service/activity the location, frequency, projected beginning date, anticipated duration, and person/agency responsible.
For students in Career and Technology Centers, CIP Code:

Postsecondary Education and Training Goal: Upon completing high school, Martina will enroll in an alternative
certificate program that offers college options for people with Intellectual Disabilities. The IEP team supports and
educational and Life Skills program that will prepare Martina for entrance and matriculation at a school if she so
chooses.

Measurable Annual Goal

Yes/No
(Document in Section V)

Courses of Study: Communications, Quantitative Reasoning, Health, Art, Social Reasoning, Empirical Reasoning

Service/Activity

Location

Frequency

Martina will have the opportunity to

read and get to know the services
available in Pennsylvania: LifeLink
PSU, Temple Academy for Adult
EUACS
Bi-weekly
Learning, Mercyhurst UniversityOasis Program, Millersville
University-Career and Life Studies,
Arcadia University- Real Certificate
Martina will have the opportunity to
choose 2-4 of the previously
mentioned universities and practice
EUACS
Monthly
understanding and completing their
admissions applications
Employment Goal: Martina has a goal of supported clerical employment.

Projected
Beginning Date

Anticipated
Duration

Person(s)/Agency
Responsible

10/20/2015

10/17/2016

Deitch/Ford/Shelley

10/20/2015

10/17/2016

Deitch/Ford/Shelley

Measurable Annual Goal

Yes/No
(Document in Section V)

Courses of Study: Communications, Quantitative Reasoning, Health, Art, Social Reasoning, Empirical Reasoning

Service/Activity

Location

Frequency

Martina will complete

questionnaires and activities (with
assistance) to determine what skills
she will need to master to attain

EUACS

Monthly

Projected
Beginning Date
10/20/2015

Anticipated
Duration
10/17/2016

Person(s)/Agency
Responsible
Harris/Ford/Shelley

future employment.
Martina will research OVR, review
information and culminate in
meeting a representative from OVR
to ask questions about her
employment opportunities after
graduation.

EUACS

Monthly

10/20/2015

10/17/2016

Harris/Ford/Shelley

Independent Living Goal, if appropriate: Martina has a goal of living with her parent after graduation.

Measurable Annual Goal

Yes/No
(Document in Section V)

Courses of Study: Life Skills One-on-One Training, Communications, Quantitative Reasoning, Health, Art, Social Reasoning, Empirical Reasoning

Service/Activity
Martina will be given the
opportunity to decipher the
difference between am and pm
Martina will practice being given a
time on a digital clock and will
draw or move hands of analog clock
to create the correct time

Location

Frequency

Projected
Beginning Date

Anticipated
Duration

EUACS

Weekly

10/20/2015

10/17/2016

EUACS

Weekly

10/20/2015

10/17/2016

Person(s)/Agency
Responsible

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Instructions for IEP Teams:
Please select the appropriate assessment option. Information on available testing accommodations may be found in the Accommodations Guidelines
available on www.education.state.pa.us.
State Assessments
Not Assessed
No statewide assessment is administered at this students grade level.
No English proficiency assessment administered because the student is not an English Language Learner.
PSSA (Math administered in grades 3-8; Science administered in grades 4 and 8; Reading administered in grades 3-8; Writing administered in grades 5
and 8; and ELA*)
Without
With
Tested Subject Accommodations Accommodations
Accommodations to be Provided
Math
x
Small group; extended time
Science
Reading
x
Small group; extended time
Writing
ELA*
*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.

Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11 th grade)
Without
With
Tested Subject
Accommodations
Accommodations
Accommodations to be Provided
Algebra 1
Literature
Biology
Keystone Project Based Assessment (Available when student is unable to demonstrate proficiency on a Keystone Exam or Keystone Exam module.)
Without
With
Tested Subject
Accommodations
Accommodations
Accommodations to be Provided
Algebra 1
Literature
Biology
Validated Local Assessment (Available when selected as option by LEA)
Without
With

V. GOALS AND OBJECTIVES Include, as appropriate, academic and functional goals. Use as many copies of this page as needed to plan appropriately.
Specially designed instruction may be listed with each goal/objective or listed in Section VI.
Short term learning outcomes are required for students who are gifted. The short term learning outcomes related to the students gifted program may be listed
under Goals or Short Term Objectives.
MEASURABLE ANNUAL GOAL
Include: Condition, Name, Behavior, and Criteria
(Refer to Annotated IEP for description of these
components)

Describe HOW the

students progress toward
meeting this goal will be
measured

Describe WHEN periodic

reports on progress will be
provided to parents

When a story is on Martinas level, she will

demonstrate what is read by responding to
questions (who, what, where, why) with 80%
accuracy 3 out of 4 probes from a baseline of 70%
accuracy.

Class work, Homework,

Summative Assessments,
Formative Assessments,
Standardized tests, CAT
exams,
Presentations/Exhibitions,
Projects, Participation
Class work, Homework,
Summative Assessments,
Formative Assessments,
Standardized tests, CAT
exams,
Presentations/Exhibitions,
Projects, Participation

Daily MMS Parent Portal

access, Biweekly Progress
Reporting, Monthly Progress
Monitoring, Trimester
Report Cards (Approx. every
12 weeks), PBSP Weekly
Report, By Parent Request
Daily MMS Parent Portal
access, Biweekly Progress
Reporting, Monthly Progress
Monitoring, Trimester
Report Cards (Approx. every
12 weeks), PBSP Weekly
Report, By Parent Request

When given 50 Dolce common sight words, Martina

will read and spell with 80% accuracy 4 out of 5
probes from a baseleline of 65% accuracy.

Report of Progress

See Progress Monitoring Report in

File

See Progress Monitoring Report in

File

SHORT TERM OBJECTIVES Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).
Short term objectives / Benchmarks

VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS Include, as appropriate, for nonacademic
and extracurricular services and activities.
A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)
SDI may be listed with each goal or as part of the table below.
Include supplementary aids and services as appropriate.
For a student who has a disability and is gifted, SDI also should include adaptations, accommodations, or modifications to the general
education curriculum, as appropriate for a student with a disability.
Modifications and SDI
Due to Martinas need in
the area of reading, group
reading instruction with
supplementary decoding
and comprehension
materials will be provided
Due to Martinas need for
positive reinforcement,
intermittent positive
reinforcement will be
provided.
Due to Martinas need for
modifications, she will
receive adapted homework,
class work, and tests based
on instructional level and
evidence based research.

Location

Frequency

Projected Beginning Date

Anticipated Duration

Across All Environments

Daily

10/20/2015

10/17/2016

Across All Environments

Daily

10/20/2015

10/17/2016

Across All Environments

Daily

10/17/2015

10/17/2016

B. RELATED SERVICES List the services that the student needs in order to benefit from his/her special education program.
Service

Location

Frequency

Projected Beginning Date

Anticipated Duration

Counseling

EUACS

30 minutes weekly

10/20/2015

10/17/2016

Paraprofessional

EUACS

Daily

10/20/2015

10/17/2016

C. SUPPORTS FOR SCHOOL PERSONNEL List the staff to receive the supports and the supports needed to implement the students IEP.

School Personnel to
Receive Support
Special Education
Advisors

Content Area Advisors

Support
Professional
Development
Professional
Development
Specifically Designed
Instruction for a
student with an
Intellectual
Disability

Location

Frequency

Projected Beginning
Date

Anticipated Duration

EUACS

Monthly

10/20/2015

10/17/2016

EUACS

Monthly

10/20/2015

10/17/2016

D. GIFTED SUPPORT SERVICES FOR A STUDENT IDENTIFIED AS GIFTED WHO ALSO IS IDENTIFIED AS A STUDENT WITH A DISABILITY Support services are
required to assist a gifted student to benefit from gifted education (e.g., psychological services, parent counseling and education, counseling services,
transportation to and from gifted programs to classrooms in buildings operated by the school district).

Support Service
Support Service
Support Service
E. EXTENDED SCHOOL YEAR (ESY) The IEP team has considered and discussed ESY services, and determined that:

x Student IS eligible for ESY based on the following information or data reviewed by the IEP team:
The IEP Team has determined the ESY service are appropriate for the following reasons:
1. Regression: Martina reverts to a lower level of functioning as evidenced by a measurable decrease in skills or behaviors that occur
as a result of interruption in educational programming.
2. Recoupment: Martina does not always show the capacity to recover the skills or behavior patterns in which regression occurred to
a level demonstrated prior to the interruption of educational programming
3. Self-sufficiency and independence: the extent to which a skill or behavior is particularly crucial for the student to meet the IEP
goals of self-sufficiency are independence from caretakers
4. Severity of disability: whether the students disability is severe, such as autism/pervasive developmental disorder, serious
emotional disturbance, severe intellectual disabilities, degenerative impairments with mental involvement and severe multiple
disabilities
OR
As of the date of this IEP, student is NOT eligible for ESY based on the following information or data reviewed by the IEP team:

The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the students ESY Program are:
GOALS
If the IEP team has determined ESY is appropriate, complete the following:

ESY Service to be Provided

Life Skills

Location
EUACS

Frequency
Weekly

Projected Beginning Date

10/20/2015

Anticipated Duration
10/17/2016

VII. EDUCATIONAL PLACEMENT

A. QUESTIONS FOR IEP TEAM The following questions must be reviewed and discussed by the IEP team prior to providing the explanations regarding
participation with students without disabilities.
It is the responsibility of each public agency to ensure that, to the maximum extent appropriate, students with disabilities, including those in public
or private institutions or other care facilities, are educated with students who are not disabled. Special classes, separate schooling or other removal
of students with disabilities from the general educational environment occurs only when the nature or severity of the disability is such that education
in general education classes, EVEN WITH the use of supplementary aids and services, cannot be achieved satisfactorily.

What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the supplementary
aids and services will or will not enable the student to make progress on the goals and objectives (if applicable) in this IEP in the general
education class.

What benefits are provided in the general education class with supplementary aids and services versus the benefits provided in the special
education class?

What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the other students in the
class, even with supplementary aids and services?

To what extent, if any, will the student participate with nondisabled peers in extracurricular activities or other nonacademic activities?

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the regular education class:
Martina has been identified as a student with an Intellectual Disability receiving Supplemental Services.
There is no extent to which Martina will not participate with students without disabilities in the regular
education class when provided with a one on one paraprofessional in academic classes. Martina will be
provided pull out services, life skills, and resource support in addition to her general education classes.
Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
Martina has been identified as a student with an Intellectual Disability receiving Supplemental Services.
By being provided with a paraprofessional, pull out support, and inclusionary SPED support in the
regular education classroom, there is no extent to which Martina will not participate with students
without disabilities in general education curriculum.

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
B. Type of Support
1. Amount of special education supports
Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day
x

Supplemental: Special education supports and services provided by special education personnel for more than 20% of the day but less than
80% of the school day
Full-Time: Special education supports and services provided by special education personnel for 80% or more of the school day

2. Type of special education supports

Autistic Support
Blind-Visually Impaired Support
Deaf and Hard of Hearing Support
Emotional Support
Learning Support
x

Life Skills Support

Multiple Disabilities Support
Physical Support
Speech and Language Support

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
C. Location of students program
Name of School District where the IEP will be implemented:

EUACS

Name of School Building where the IEP will be implemented:

EUACS

Is this school the students neighborhood school (i.e., the school the student would attend if he/she did not have an IEP)?
Yes
No. If the answer is no, select the reason why not.
Special education supports and services required in the students IEP cannot be provided in the neighborhood school
Other. Please explain:

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
VIII. PENNDATA REPORTING: Educational Environment (Complete either Section A or B; Select only one Educational Environment)
To calculate the percentage of time inside the regular classroom, divide the number of hours the student spends inside the regular classroom by the total number of hours in the school day (including
lunch, recess, study periods). The result is then multiplied by 100.

SECTION A: For Students Educated in Regular School Buildings with Non Disabled Peers Indicate the Percentage of time INSIDE the regular classroom for this student:
Time spent outside the regular classroom receiving services unrelated to the students disability (e.g., time receiving ESL services) should be considered time inside the regular classroom.
Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as college campuses or vocational sites, should be counted as time
spent inside the regular classroom.
Calculation for this Student:

Column 1

Column 2

Calculation

Indicate Percentage

Percentage Category

Total hours the student

spends in the regular
classroom per day

Total hours in a typical

school day
(including lunch, recess
& study periods)

(Hours inside regular

classroom hours in
school day) x 100 = %
(Column 1 Column 2) x
100 = %

Section A: The percentage of

time student spends inside the
regular classroom:

5 hrs

7 hrs

5/7=71%

_71____% of the day

Using the calculation result select the appropriate percentage category

INSIDE the Regular Classroom 80% or More of the Day

INSIDE the Regular Classroom 79-40% of the Day
INSIDE the Regular Classroom Less Than 40% of the Day

SECTION B: This section required only for Students Educated OUTSIDE Regular School Buildings for more than 50% of the day select and indicate the Name of School or
Facility on the line corresponding with the appropriate selection: (If a student spends less than 50% of the day in one of these locations, the IEP team must do the calculation
in Section A)
Approved Private School (Non Residential) _________________________
Approved Private School (Residential)
_________________________
Other Private Facility (Non Residential)
_________________________
Other Private Facility (Residential)
________________________
Other Public Facility (Residential)
________________________

Other Public Facility (Non Residential) _________________________

Hospital/Homebound
_________________________
Correctional Facility
_________________________
Out of State Facility
_________________________
Instruction Conducted in the Home
_________________________

EXAMPLES for Section A: How to Calculate PennDataEducational Environment Percentages

Example 1

Column 1

Column 2

Calculation

Indicate Percentage

Total hours the student spends in the

regular classroom per day

Total hours in a typical school day

(including lunch, recess & study
periods)

(Hours inside regular classroom hours in school day)

x 100 = %
(Column 1 Column 2) x 100 = %

Section A: The percentage of time student

spends inside the regular classroom:

5.5

6.5

(5.5 6.5) x 100 = 85%

85% of the day

(Inside 80% or More of Day)
Example 2
3
5
60% of the day
(3 5) x 100 = 60%
(Inside 79-40% of Day)
Example 3
1
5
20% of the day
(1 5) x 100 = 20%
(Inside less than 40% of Day)
For help in understanding this form, an annotated IEP is available on the PaTTAN website at www.pattan.net Type Annotated Forms in the Search feature on the website. If you do not have access
to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.

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