Iep Ben S

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EVALUATION REPORT
Form ER-1 (Rev. 10/06)
Horizon Elementary
School District of Bartlett, WI
Name of Student: Benjamin Shea
TYPE OF EVALUATION:
Initial
Reevaluation
DATE ON WHICH ELIGIBILITY DETERMINATION WAS MADE:
11/20/2016
(month/day/year)
THIS EVALUATION REPORT AND DETERMINATION OF ELIGIBILITY INCLUDES THE

FOLLOWING (check all that apply)
Information from review of existing data
Information from assessments and other sources
Additional documentation required when

child is evaluated for a specific learning
disability
Documentation for determining Braille
needs for a child with a visual impairment
Determination of eligibility for special

education
INFORMATION FROM REVIEW OF EXISTING DATA
A.% Summary of previous evaluations
In addition to data provided by previous and current curriculum based assessments, teacher
observations, the Phonological Awareness Skills Test (PAST), and Woodcock-Johnson 3
Normative Update Tests of Cognitive Abilities the following assessments will be used to
reevaluate Benjamin Shea:
Areas to be evaluated
Description of assessments and other

evaluation materials and titles, if known
Name of evaluator
Reading
Comprehension
Fountas & Pinnell Benchmark Literacy

Assessment
Molly Nelson
Speaking, Listening,
Writing, and Reading
Kaufmann Test of Educational Achievement
Paul Berg
Reading
Comprehension,
Reading Recognition,
and Spelling
Peabody Individual Achievement TestRevised (PIAT-R)
Martha Devine
Behavior and
Attention
Connors 3
Paul Berg
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B. Information provided by parents

Mrs. Shea provided information about her son detailing that she has had concerns about him reaching
developmental milestones later than his sister, especially in the area of language. Mrs. Shea also stated that she
had concerns about difficulties with attention, and weakness for Benjamins memory of letters and words as
discussed with Benjamins previous teacher, Mrs. Brandi Keller in May of 2015.
C. Previous interventions and the effects of those interventions
During the middle to end of the 2015 school year, Benjamin received modifications such as: reading
buddies, peer tutoring, remedial reading, small group instruction, shortened list of spelling words, and
additional time for assignment completion; however, at the end of first grade Benjamin did make
improvements, but did not reach grade level proficiency. An initial evaluation was conducted during
January 20th of the 2015 school year. Data from this evaluation suggested that Benjamin had difficulty
with phonemic awareness, frequent vowel and consonant substitutions, and inability to identify
rhyming words. It was noted that he had difficulty processing sounds (difficulty recognizing and/or
manipulating sounds), however, it was also noted that his hearing was within normal range. The
evaluation determined that Benjamin met Specific Learning Disability (SLD) criteria and evaluation
data reflected that he had average to above average deficits in reading and would be best served in a
pull out special education classroom and/or resource classroom. At the end of first grade, Benjamin
received pull out special education services for 45 minutes daily to target phonemic awareness and
reading skills. The prognosis for Benjamin was noted as good due to his interest and enjoyment in
school. A meeting was held on May 20, 2015 with Benjamins mother, Molly Shea, to discuss
concerns about Benjamins current academic progress. Benjamins special education teacher, Mrs.
Brandi Keller, briefed Mrs. Shea on her sons academic performance stating that he has exhibited
highly distractible behaviors and has difficulty following directions and classroom rules. Mrs. Keller
also stated that Benjamin has been reading primer texts at a kindergarten level and has memorized
information rather than generalizing it and applying it. Mrs. Keller stated that there have been
instances where Benjamin has made up information to answer questions about the content of texts
read in class, which has also been marked by his overreliance on background information when asked
to answer questions about reading passages. Mrs. Keller stated that Benjamins deficits fall primarily
in the areas of phonemic awareness and associative word processing/learning. In addition to academic
concerns, Mrs. Keller also suggested that Benjamin has had difficulty with fine motor control. At the
conclusion of the meeting, Mrs. Keller suggested that although Benjamin did not meet any goals as of
yet, that she would recommend Benjamin continue receiving pull out special education services in
reading for 45 minutes daily and that she would check on his progress in the next few weeks to see if
his performance warrants additional attention and requires that his current IEP be amended. Previous
interventions conducted during the 2015 school year included:
-%
-%
-%
Early Reading Intervention targeting phonological awareness

Build Up Complete targeting rhyming
Peer Assisted Learning Strategies (PALS) targeting reading skills and comprehension
The results of these interventions suggest that Benjamin receive additional one-on-one classroom
instruction focusing specifically on reading comprehension and phonemic awareness.
D. Current classroom-based, local or state assessments
Previous and current classroom-based assessments targeting letter/sound recognition proved to be difficult for
Benjamin as he exhibited trouble recognizing the sounds of letters in both upper and lower case forms.
Because this skill is typically mastered in kindergarten, Benjamin was behind his peers in the beginning to end
of first grade. Additional classroom-based assessments targeting phonological awareness showed that
Benjamin struggled to recognize sight words, had difficulty rhyming, and was unable to segment and blend
words and pronounce them correctly.
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Benjamins performance on local assessments (PALS) also indicated that he has trouble in the area of reading
and writing as he scored well below average in comparison to typically developing peers.
E. Current classroom-based observations
Classroom based assessments echo Benjamins previous classroom-based observations made by Mrs. Brandi
Keller as he continues to exhibit difficulties in completing classroom tasks in reading. Benjamin exhibits
highly distractible behaviors and has difficulty following directions and classroom rules. Benjamin also has
difficultly generalizing information and applying it. In comparison to last years classroom-based observations,
Benjamin has continued to make up information to answer questions about the content of texts read in class,
which has also been marked by his overreliance on background information when asked to answer questions
about reading passages.
F. Observations by teachers and related service providers
Benjamins general education teacher, Vivian Harrison, and special education teacher, Andrea Alvin,
have noted similar behaviors regarding Benjamins distractibility and unwillingness to cooperate when
asked to complete reading tasks. Mrs. Alvin noted that Benjamin tends to talk to other students when
asked to read and/or answer questions about reading passages. When place in a separate environment,
Benjamin is reluctant to complete assignments/reading tasks and will often times sit and kick the desk
or doodle on his assignment sheets.
INFORMATION FROM ASSESSMENTS AND OTHER SOURCES
In determining whether the student has a disability (impairment and need for special education) document
consideration of other information including individual assessments, aptitude and achievement tests,
independent and outside evaluations, teacher recommendations and information about the students
physical condition, social or cultural background and adaptive behavior.
Based on the data provided on the following assessments: Fountas & Pinnell Benchmark Literacy
Assessment, Kaufmann Test of Educational Achievement, Peabody Individual Achievement TestRevised (PIAT-R), and Connors 3 it has been determined that Benjamin meets qualification for special
education services under the following disability categoriesOHI: ADHD, Speech and Language, and
Specific Learning Disability (SLD) in reading. The following scores suggest that Benjamin score well
below his typically developing peers and is not performing at grade level.
Fountas and Pinnell:
Data from this assessment placed Benjamin in the frustrational category at a level H during his first
interval assessment, which warrants intensive intervention.
Kaufmann Test of Educational Achievement:
Benjamin receive a standard score of 79 placing him in the borderline average category which suggests
that he may have difficulty in the classroom.
Peabody Individual Achievement Test- Revised:
Benjamin scored in the 68 percentile suggesting that he performs in a lower range academically in
comparison to his typically developing peers.
Connors 3:
A clinical assessment was triangulated with teacher and parent assessments, which yielded similar data.
Overall, Benjamins scores reflected that he fell within a very elevated category for inattention (72),
hyperactivity/impulsivity (77), and learning problems (65). Benjamin scores within normal range in
executive functioning (57), and defiance/aggression (66).
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NOTE: Taken together, this data suggests that Benjamin would be best served in a special education
classroom focusing on intensive interventions in reading and comprehension. Additionally, Benjamin
should receive attention to regulating his behavior.
If assessments or other evaluation materials were not administered in accordance with the instructions
provided by the publisher or producer of the assessments describe the extent to which there were
variations in administration from standard conditions such as qualifications of the evaluator or methods
of assessment administration including the language or other mode of communication that was used in
assessing the student.
N/A
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DETERMINATION OF ELIGIBILITY FOR SPECIAL EDUCATION

A. This student meets the criteria for one or more of the following impairments:
Check all that apply:
Autism
Cognitive Disability
Emotional Behavioral Disability
Hearing Impairment
Specific Learning Disability
(complete ER-2, Additional
documentation required for
specific learning disabilities)
None found (complete C. below)
Orthopedically Impaired
Other Health Impairment
Speech or Language Impairment
Traumatic Brain Injury
Visual Impairment (complete ER-3, Determining
Braille Needs)
Significant Developmental Delay (first consider
other areas as the primary disability)
B. For each impairment identified, document how the student meets the criteria:
Specific Learning Disability (SLD) in reading. The following score suggest that Benjamin score well
below his typically developing peers and it not performing at grade level.
Connors 3:
Taken together, this data suggests that Benjamin would be best served in a special education classroom
focusing on intensive interventions in reading and comprehension. Additionally, Benjamin should receive
attention to regulating his behavior.
C. Were impairments considered and rejected? Yes
No
(If yes, document which one(s) and how the student did not meet the criteria)
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D. By reason of the impairment(s) identified, does this student need or continue to need special education?
Yes
No (In order for the IEP team to determine that the student needs special education, the
IEP team must answer yes to question 1 AND list needs under 2b and/or 3
below)
Yes
1.% Does the student have needs that cannot be met in regular education as structured?
(If yes, list the needs below. Use reverse side or attach additional pages if needed)
It has been determined that Benjamin needs specialized intensive instruction in Reading for 60
minutes daily in all school environments for the length of his IEP (11/20/2016-11/20/2017). In
addition, Benjamin also needs speech-language services for 30 minutes 3x weekly in all
school environments for the length of his IEP (11/20/2016-11/20/2017).
No
Yes
(If no, there is no need for special education).

2.% Are there modifications that can be made in the regular education program to allow the
student access to general education curriculum and to meet the educational standards
that apply to all students? (Consider adaptation of content, methodology and/or delivery
of instruction.)
If yes,
a)! List modifications that do not require special education. (Use reverse side of page
or attach additional pages if needed)
Benjamin will receive the following accommodations: preferential seating, paraprofessional
assistance, behavior charts, extended time, lists of instructions/visual schedules, highlighters,
breaks, use of place markers, and outlines/graphic organizers.
b) List modifications that require special education. (Use reverse side of page or attach
additional pages if needed)
No
Yes
No
Benjamin will receive modifications such as: reading buddies, peer tutoring, remedial reading,
small group instruction, shortened list of spelling words, and additional time for assignment
completion.
(If no, go to question 3).

3.% Are there additions or modification that the child needs which are not provided through
the general education curriculum? (Consider replacement content, expanded core
curriculum, and/or other supports.)
(If yes, list below. Use reverse side of page or attach additional pages if needed)
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B. Information provided by parents

Mrs. Shea provided information about her son detailing that she has had concerns about him reaching
developmental milestones later than his sister, especially in the area of language. Mrs. Shea also stated that she
had concerns about difficulties with attention, and weakness for Benjamins memory of letters and words as
discussed with Benjamins previous teacher, Mrs. Brandi Keller in May of 2015.
C. Previous interventions and the effects of those interventions
instances where Benjamin has made up information to answer questions about the content of texts
read in class, which has also been marked by his overreliance on background information when asked
to answer questions about reading passages. Mrs. Keller stated that Benjamins deficits fall primarily
in the areas of phonemic awareness and associative word processing/learning. In addition to academic
his performance warrants additional attention and requires that his current IEP be amended. Previous
interventions conducted during the 2015 school year included:
-%
-%
-%
Early Reading Intervention targeting phonological awareness

Build Up Complete targeting rhyming
Peer Assisted Learning Strategies (PALS) targeting reading skills and comprehension
The results of these interventions suggest that Benjamin receive additional one-on-one classroom
instruction focusing specifically on reading comprehension and phonemic awareness.
D. Current classroom-based, local or state assessments
Previous and current classroom-based assessments targeting letter/sound recognition proved to be difficult for
Benjamin as he exhibited trouble recognizing the sounds of letters in both upper and lower case forms.
Because this skill is typically mastered in kindergarten, Benjamin was behind his peers in the beginning to end
of first grade. Additional classroom-based assessments targeting phonological awareness showed that
Benjamin struggled to recognize sight words, had difficulty rhyming, and was unable to segment and blend
words and pronounce them correctly.
Form%ER.1%
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Benjamins performance on local assessments (PALS) also indicated that he has trouble in the area of reading
and writing as he scored well below average in comparison to typically developing peers.
E. Current classroom-based observations
Classroom based assessments echo Benjamins previous classroom-based observations made by Mrs. Brandi
Keller as he continues to exhibit difficulties in completing classroom tasks in reading. Benjamin exhibits
highly distractible behaviors and has difficulty following directions and classroom rules. Benjamin also has
difficultly generalizing information and applying it. In comparison to last years classroom-based observations,
Benjamin has continued to make up information to answer questions about the content of texts read in class,
which has also been marked by his overreliance on background information when asked to answer questions
about reading passages.
F. Observations by teachers and related service providers
Benjamins general education teacher, Vivian Harrison, and special education teacher, Andrea Alvin,
have noted similar behaviors regarding Benjamins distractibility and unwillingness to cooperate when
asked to complete reading tasks. Mrs. Alvin noted that Benjamin tends to talk to other students when
asked to read and/or answer questions about reading passages. When place in a separate environment,
Benjamin is reluctant to complete assignments/reading tasks and will often times sit and kick the desk
or doodle on his assignment sheets.
INFORMATION FROM ASSESSMENTS AND OTHER SOURCES
In determining whether the student has a disability (impairment and need for special education) document
consideration of other information including individual assessments, aptitude and achievement tests,
independent and outside evaluations, teacher recommendations and information about the students
physical condition, social or cultural background and adaptive behavior.
Specific Learning Disability (SLD) in reading. The following scores suggest that Benjamin score well
below his typically developing peers and is not performing at grade level.
Connors 3:
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NOTE: Taken together, this data suggests that Benjamin would be best served in a special education
classroom focusing on intensive interventions in reading and comprehension. Additionally, Benjamin
should receive attention to regulating his behavior.
If assessments or other evaluation materials were not administered in accordance with the instructions
provided by the publisher or producer of the assessments describe the extent to which there were
variations in administration from standard conditions such as qualifications of the evaluator or methods
of assessment administration including the language or other mode of communication that was used in
assessing the student.
N/A
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Form%ER.1%
DETERMINATION OF ELIGIBILITY FOR SPECIAL EDUCATION

A. This student meets the criteria for one or more of the following impairments:
Check all that apply:
Autism
Cognitive Disability
Emotional Behavioral Disability
Hearing Impairment
Specific Learning Disability
(complete ER-2, Additional
documentation required for
specific learning disabilities)
None found (complete C. below)
Orthopedically Impaired
Other Health Impairment
Speech or Language Impairment
Traumatic Brain Injury
Visual Impairment (complete ER-3, Determining
Braille Needs)
Significant Developmental Delay (first consider
other areas as the primary disability)
B. For each impairment identified, document how the student meets the criteria:
Specific Learning Disability (SLD) in reading. The following score suggest that Benjamin score well
below his typically developing peers and it not performing at grade level.
Connors 3:
Taken together, this data suggests that Benjamin would be best served in a special education classroom
focusing on intensive interventions in reading and comprehension. Additionally, Benjamin should receive
attention to regulating his behavior.
C. Were impairments considered and rejected? Yes
No
(If yes, document which one(s) and how the student did not meet the criteria)
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D. By reason of the impairment(s) identified, does this student need or continue to need special education?
Yes
No (In order for the IEP team to determine that the student needs special education, the
IEP team must answer yes to question 1 AND list needs under 2b and/or 3
below)
Yes
1.% Does the student have needs that cannot be met in regular education as structured?
(If yes, list the needs below. Use reverse side or attach additional pages if needed)
It has been determined that Benjamin needs specialized intensive instruction in Reading for 60
minutes daily in all school environments for the length of his IEP (11/20/2016-11/20/2017). In
addition, Benjamin also needs speech-language services for 30 minutes 3x weekly in all
school environments for the length of his IEP (11/20/2016-11/20/2017).
No
Yes
(If no, there is no need for special education).

2.% Are there modifications that can be made in the regular education program to allow the
student access to general education curriculum and to meet the educational standards
that apply to all students? (Consider adaptation of content, methodology and/or delivery
of instruction.)
If yes,
a)! List modifications that do not require special education. (Use reverse side of page
or attach additional pages if needed)
Benjamin will receive the following accommodations: preferential seating, paraprofessional
assistance, behavior charts, extended time, lists of instructions/visual schedules, highlighters,
breaks, use of place markers, and outlines/graphic organizers.
b) List modifications that require special education. (Use reverse side of page or attach
additional pages if needed)
No
Yes
No
Benjamin will receive modifications such as: reading buddies, peer tutoring, remedial reading,
small group instruction, shortened list of spelling words, and additional time for assignment
completion.
(If no, go to question 3).

3.% Are there additions or modification that the child needs which are not provided through
the general education curriculum? (Consider replacement content, expanded core
curriculum, and/or other supports.)
(If yes, list below. Use reverse side of page or attach additional pages if needed)
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REQUIRED'DOCUMENTATION'FOR''
SPECIFIC'LEARNING'DISABILITY'(SLD)''REEVALUATION'
Form'ER<2B''(New.'9/13)'
Student Name: Benjamin Shea

Date of Eligibility Determination: 11/20/2016
A student who met initial SLD identification criteria and continues to demonstrate a need for special education,
including specially designed instruction, is a student with a continuing disability unless the exclusionary factors now
apply. If the student no longer needs special education to address needs resulting from impairment, then the student
is no longer a student with a disability under Ch. 115, Wis. Stats., and the Individuals with Disabilities Education
Act (IDEA). A student continues to be a student with the impairment of specific learning disability (SLD) who
needs special education if all items are marked "YES." If information is addressed elsewhere in the IEP team
evaluation report, please reference where the information can be found.
CONSIDERATION OF EXIT CRITERIA AND CONTINUING NEED FOR SPECIAL EDUCATION

Yes
Yes
Yes
No The student was previously found eligible as having the impairment of SLD. If "No", the IEP team
should consider whether the student meets initial SLD criteria.
No The student does not perform to generally accepted expectations in the general education
classroom without specially designed instruction.
No The student continues to need special education to address needs resulting from the impairment of
SLD.
Reason for determination including data used (document on model forms ER-1 Evaluation Report or explain below):
CONSIDERATION OF EXCLUSIONARY FACTORS

Yes
No Exclusionary Factors DO NOT apply. Check "Yes" if none of the exclusionary factors apply
and complete the section Consideration of Exit Criteria and Continuing Need for Special
Education. Mark "NO" if one or more exclusionary factors apply and check the factor(s) below. If
one or more factors apply, the student is not a student with a specific learning disability and is not
eligible for special education.
The student does not meet general education expectations primarily because of (check all that
apply):
Environmental, cultural, or economic factors
Limited English proficiency
Lack of appropriate instruction in the identified area(s) of concern: oral expression,
listening comprehension, written expression, basic reading skill, reading fluency skills,
reading comprehension, mathematics calculation, or mathematics problem solving
Other impairment (specify):
Additional Notes (if any):
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ADDITIONAL DOCUMENTATION REQUIRED WHEN STUDENT IS EVALUATED FOR SLD

Relevant behavior noted during observation of the student in his or her learning environment, including the regular
classroom, and the relationship of that behavior to the students academic functioning.
Educationally relevant medical findings:
relevant medical findings, (specify): After receiving score reports from the Connors 3 and a
clinical consultation, it was determined that Benjamin showed elevated levels of inattention
and hyperactivity which is congruent with a diagnosis of ADHD.
Yes,
No relevant medical findings.

The IEP team assures that the decision of whether the child has a specific learning disability was based on
information from a variety of sources and not on any single measure or assessment as the sole criterion. Each IEP
team participant must sign below and indicate whether he/she agrees with the conclusions regarding whether or not
the child is a child with a specific learning disability. If this does not reflect his/her conclusions, then that IEP team
participant must also attach a statement with his/her conclusions.
Name and title
Signature
Emma Watson
LEA
Elsa Dumke
Special Education Teacher
Vicky Larson
General Education Teacher
Casey Bokingo
School Social Worker
Paul Berg
School Psychologist
Erica Levin
Diagnostician
Miriam Campbell
Special Education Director
Additional Notes (if any):
Agree or disagree
WORKSHEET FOR CONSIDERATION OF EXISTING

DATA TO DETERMINE IF ADDITIONAL ASSESSMENTS
OR EVALUATION MATERIALS ARE NEEDED
Worksheet EW-1 (Rev. 7/06)
Horizon Elementary
Name of student: Benjamin Shea
(Note: If a meeting is held to consider existing data and this form is used as documentation of that
meeting, complete I-3, Evaluation Report and IEP Cover Sheet and sections I and II below. If no
meeting is held, this form is used to document the input and decision of the IEP team participants.
Complete sections I, II, III, and IV and the name of the person completing the form).
I.!
List of information/reviewed:
Normative Update Tests of Cognitive Abilities the following assessments will be used to evaluate
Benjamin Shea:
II.!

Name of evaluator,
if known
Reading
Comprehension

Assessment
Molly Nelson
Paul Berg
Reading
Comprehension,
and Spelling
Martha Devine
Behavior and
Attention
Connors 3
Paul Berg
III.!
Action to be taken as a result of review of considering the existing information/data:

Additional assessments or other evaluation materials are needed
No additional assessments or other evaluation materials are needed
IV.!
Documentation of parent involvement (including dates and method) and their input:
Mrs. Shea was contacted via telephone on 09/20/2016 and received a written request to have her
child, Benjamin Shea, reevaluated for special education services. Mrs. Shea has participated in
two meetings on 09/28/2016 and 10/15/2016 to discuss assessments that will be used to
reevaluate Benjamin on 10/17/2016.
V.!
List of other IEP team participants involved and their input (including dates):
The following members were present at the meetings with Mrs. Shea on 09/28/2016 and
10/15/2016:
You and your child (if appropriate) are IEP team participants
In addition, the following people are being appointed to the IEP team by the school district
Role
Name, if known
Representative of local educational

agency (LEA) authorized to commit
the resources of the LEA
Special Ed. Teacher(s)
Emma Watson
Regular Ed. Teacher(s)
Vicky Larson
Related Services Personnel
Casey Bokingo
Elsa Dumke
Matthew Larson
Others
Miriam Campbell Special Education Director

Molly Shea Mother of Benjamin
For SLD evaluations using response

to intervention only*, a licensed
person who is qualified to assess data
on individual rate of progress using a
psychometrically valid and reliable
methodology.
For SLD evaluation using response
person who has implemented
scientific, research-based or evidencebased, intensive interventions with the
referred pupil.
person who is qualified to conduct
individual diagnostic evaluations of
children.
Worksheet completed by Elsa Dumke
Paul Berg
Elsa Dumke
Erica Levin
WORKSHEET FOR CONSIDERATION OF EXISTING

DATA TO DETERMINE IF ADDITIONAL ASSESSMENTS
OR EVALUATION MATERIALS ARE NEEDED
Worksheet EW-1 (Rev. 7/06)
Horizon Elementary
Name of student: Benjamin Shea
(Note: If a meeting is held to consider existing data and this form is used as documentation of that
meeting, complete I-3, Evaluation Report and IEP Cover Sheet and sections I and II below. If no
meeting is held, this form is used to document the input and decision of the IEP team participants.
Complete sections I, II, III, and IV and the name of the person completing the form).
I.!
List of information/reviewed:
Normative Update Tests of Cognitive Abilities the following assessments will be used to evaluate
Benjamin Shea:
II.!

Name of evaluator,
if known
Reading
Comprehension

Assessment
Molly Nelson
Paul Berg
Reading
Comprehension,
and Spelling
Martha Devine
Behavior and
Attention
Connors 3
Paul Berg
III.!
Action to be taken as a result of review of considering the existing information/data:

Additional assessments or other evaluation materials are needed
No additional assessments or other evaluation materials are needed
IV.!
Documentation of parent involvement (including dates and method) and their input:
Mrs. Shea was contacted via telephone on 09/20/2016 and received a written request to have her
child, Benjamin Shea, reevaluated for special education services. Mrs. Shea has participated in
two meetings on 09/28/2016 and 10/15/2016 to discuss assessments that will be used to
reevaluate Benjamin on 10/17/2016.
V.!
List of other IEP team participants involved and their input (including dates):
The following members were present at the meetings with Mrs. Shea on 09/28/2016 and
10/15/2016:
Role
Name, if known
Representative of local educational

agency (LEA) authorized to commit
the resources of the LEA
Emma Watson
Vicky Larson
Casey Bokingo
Elsa Dumke
Matthew Larson
Others

Molly Shea Mother of Benjamin
For SLD evaluations using response

person who is qualified to assess data
on individual rate of progress using a
psychometrically valid and reliable
methodology.
person who has implemented
scientific, research-based or evidencebased, intensive interventions with the
referred pupil.
person who is qualified to conduct
individual diagnostic evaluations of
children.
Worksheet completed by Elsa Dumke
Paul Berg
Elsa Dumke
Erica Levin
INVITATION TO A MEETING OF THE

INDIVIDUALIZED EDUCATION PROGRAM (IEP) TEAM
Form I-1 (Rev. 10/06)
Horizon Elementary
[If you need this invitation in a different language or communicated in a different way, or have
questions about this invitation, please contact Marya Plowman at mplow@email.com]
Dear Mrs. Shea,
Date: 11/01/2016
You are a participant on the IEP Team which will meet to address the educational needs of your child,
Benjamin Shea. IEP team meetings must be held at a mutually agreeable time and place. An IEP team
meeting has tentatively been scheduled for the following date 11/20/2016, time 6:00PM and location 123
Horizon Elementary. If these meeting arrangements are not agreeable to you, please call Elsa Dumke at
555-555-5555. You may bring other people who you believe have knowledge or special expertise about
your child to the meeting with you. If your child is transferring from a Birth to 3 Early Intervention
Program we will, at your request, send to the Birth to 3 coordinator or other representative an invitation
to the IEP meeting.
The purpose of this IEP team meeting is (check all that apply):
EVALUATION AND REEVALUATION
Determine initial eligibility for special education
Determine continuing eligibility for special education
INDIVIDUALIZED EDUCATION PROGRAM (IEP) (if student is eligible)
Develop an initial IEP
Develop an annual IEP
Review/revise IEP
Transition the consideration of postsecondary goals and transition services
(required for students beginning at age 14)
PLACEMENT (if student is eligible)
Determine initial placement
Determine continuing placement
OTHER
Review existing information to determine need for additional assessments or other
evaluation materials (meeting optional)
Conduct a manifestation determination (check appropriate boxes under IEP and
placement if changes in either are contemplated)
Determine setting for services during disciplinary change in placement (must also check
appropriate boxes under IEP & placement)
Specify: _______________________________________________________________
________________________________________________________________________
If transition is checked as one of the purposes of this meeting, your child will be invited to attend.
Because you provided your consent we are also inviting representatives from the following agencies who
may assist in the transition planning for your child:
None
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Form%I-1%
Horizon Elementary
______________________
Agency
Elsa Dumke Special Education Teacher

___________________________________________
Name (if known), and Title/Position
Horizon Elementary
_______________________
Agency

_____________________________________________
Name (if known), and Title/Position
If at any point during this meeting you or other IEP team participants believe that additional time is
needed to permit your meaningful involvement, additional time will be provided. Decisions related to the
purpose(s) checked above may be made in one meeting or may require more than one meeting, depending
on individual circumstances. In addition, and upon request you may receive a copy of the IEP teams
most recent evaluation report.
The following individuals have been appointed as IEP team participants and will attend the meeting.
Vicky Larson
____________________________________
Name/Reg. Ed. Teacher
Elsa Dumke
________________________________________
Name/Sp. Ed. Teacher
Emma Watson
_____________________________________
Name/LEA Representative
Casey Bokingo School Social Worker

________________________________________
Name &Title
Paul Berg School Psychologist

_____________________________________
Name & Title
Molly Nelson Reading Specialist

________________________________________
Name & Title
Matthew Larson Speech-Language Therapist

_____________________________________
Name & Title
Erica Levin Diagnostician

________________________________________
Name & Title

_____________________________________
Name & Title
________________________________________
Name & Title
You and your child have protection under the procedural safeguards (rights) of special education law.
The school district must provide you with a copy of your procedural safeguards once a year.
You received a copy of your procedural safeguard rights in a brochure about parent and child rights
earlier this year. If you would like another copy of this brochure, please contact the district at the
telephone number above.
A copy of the parent and child rights brochure is enclosed with this invitation.
In addition to district staff, you may also contact Marya Plowman at mplow@email.com if you have
questions about your rights.
Sincerely,
Name and Title of District Contact Person
AGREEMENT(ON(IEP(TEAM(PARTICIPANT((
ATTENDANCE(AT(IEP(MEETING(
Form(I22(((Rev(10/06)(
Horizon Elementary
[If you need this agreement in a different language or communicated in a different way, or have
questions about this agreement, please contact Marya Plowman at mplow@email.com]
Dear Mrs. Shea,
Date: 11-01-2016
An IEP team meeting for your child Benjamin Shea is scheduled for 11/20/2016 at 6:00PM at Horizon Elementary School.
On we [met or spoke on the phone or exchanged emails] and agreed the following individual(s) is/are not required to attend
all or part of the meeting (include name and title).
We agree __________________________________________________ will not attend the IEP meeting

because his/her/their area of curriculum or related service is not being changed or discussed at the meeting.
We agree Mrs. Brandi KellerPrevious special education teacher will not attend the IEP meeting during
which his/her/their area of curriculum or related service will be discussed at the meeting. However,
she/he/they will prepare and provide to you prior to the IEP meeting written information that can be used in
developing or revising your childs IEP.
We agree __________________________________________________ will be or was present for that

portion of the meeting during which his/her/their area of curriculum or related service will be or was
discussed or changed and his/her/their attendance is no longer required.
Other options, if any, related to the above action that were considered and the reason(s) they were rejected including a
description of any other relevant factors include:
None
You and your child have protection under the procedural safeguards (rights) of special education law. The school district
must provide you with a copy of your procedural safeguards once a year. Enclosed is a copy or earlier this year you
received a copy of your procedural safeguard rights in a brochure about parent and child rights. If you would like another
copy of this brochure, please contact the district at the telephone number above. In addition to district staff, you may also
contact Marya Plowman at mplow@email.com if you have questions about your rights.
Sincerely,
__________________________________________________
----------------------------------------------------------------------------------------------------------------------------------------------------Your agreement or consent to excuse the above identified IEP team participant(s) from attending the meeting must be in
writing. (Please sign, date and return one copy of this agreement to the school district)
I agree that the above named IEP team participant(s) need not attend all or part of my childs IEP meeting. I understand
that my consent is voluntary and may be revoked at any time before the excusal of the team participant(s) takes effect. I
understand that I may request to meet with the excused team participant(s) before agreeing or consenting to excusing the
participant(s) from attending the IEP team meeting.
_____________________________________________
Signature of parent or legal guardian or adult student
_________________
Date
EVALUATION REPORT AND IEP COVER SHEET

Form I-3 (Rev. 10/06)
Name of Student
Benjamin Shea
DOB
01/28/2009
Sex
M
Parent or Legal Guardian

Molly Shea
Telephone (area/number)
555-555-5555
Grade
2nd
District of Residence
Bartlett
Current District of Placement

Horizon Elementary School
Address
For students transferring between public agencies:

IEP reviewed and adopted by
________________________________________________
On _____________________________________________
123 Oak St. Bartlett, WI 54680
Race/Ethnic (if parent chooses to

identify) White
For students transferring between public agencies:

Evaluation report reviewed and adopted by
_____________________________________
On _____________________________________________
PURPOSE OF MEETING (Check all that apply):
Evaluation including determination of eligibility
Initial or annual IEP development
IEP review/revision
Placement
Develop a statement of transition goals and

services (required for students age 14 and older,
or younger if appropriate)
Manifestation determination
Alternate assessment
Other: _____________________________
Determine setting for services during

disciplinary change in placement
Other: _____________________________
If a purpose of this meeting is IEP development, review, and/or revision related to the academic, developmental and
functional needs of the child, the IEP team considered the results of:
Initial or most recent evaluation
Statewide assessments
District-wide assessments
Yes
Yes
Yes
Not applicable
Not applicable
Not applicable
Date of Meeting: 11/20/2016

(month/day/year)
IEP Team Participants Attending or Participating by Alternate Means in the Meeting:
Parent/Guardian
Molly Shea
Student (if appropriate):
Benjamin Shea
LEA Representative/Title:
Emma Watson
Regular education teacher/title:

Vicky Larson
Special education teacher/title:
Elsa Dumke
Other:
Paul Berg School Psychologist
Regular education teacher/title:

Special education teacher/title:
Other:
Matthew Larson Language
Therapist
Other:
Other:
Other:
Casey Bokingo School Social Worker
Erica Levin Diagnostician
Molly Nelson Reading Specialist
If the parent did not attend or participate in the meeting by other means and did not agree to the time and place of the IEP
team meeting, document 3 efforts to involve the parents:
Page%____%of%____%
INDIVIDUALIZED EDUCATION PROGRAM: PRESENT LEVEL

OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Form I-4 (Rev. 9/13)
Name of Student Benjamin Shea
Describe the students strengths and the concerns of the parents about the students education.
Mrs. Shea provided information about her son detailing that she has had concerns about him reaching developmental
milestones later than his sister, especially in the area of language. Mrs. Shea also stated that she had concerns about
difficulties with attention, and weakness for Benjamins memory of letters and words as discussed with Benjamins
previous teacher, Mrs. Brandi Keller in May of 2015.
Describe the students present level of academic achievement and functional performance including how the
students disability affects his or her involvement and progress in the general education curriculum. For
preschool children, describe how the disability affects involvement in age-appropriate activities. (Note: Present
level of performance must include information that corresponds with each annual goal)
Based on a review of curriculum-based measures and data collected from teacher observations, Benjamin
Shae, demonstrates difficulty in attending to auditory instruction and direction in all academic settings.
Furthermore, given one minute to read a 1st grade passage, Benjamin reads a level K Fountas and Pinnell
reading passage at 80 words per minutes with 85% accuracy. Given a 2rd grade Fountas and Pinnell level L
passage, Benjamin reads at 100 words per minute with 60% accuracy.
Benjamin is able to read basic sight words and uses picture cues to identify words in a text. He decodes
simple one-syllable words with short vowels but has great difficulty reading words with multiple syllables.
He does not use word identification strategies to read unfamiliar words in a passage.
Benjamins oral reading, segmentation, and decoding skill are below beginning 2nd grade reading level.
Therefore, he has difficulty reading 2nd grade level material independently without the use of cue or
teacher/paraprofessional assistance. Due to these reading and comprehension deficits, Benjamin has
difficulty completing assignments independently in reading and other subjects requiring text-dependent
material. His independent work is often attempted with frustration and is left incomplete and/or inaccurate.
*Source:Present Levels of Academic Achievement and Functional Performance (PLAAFP) and Measurable
Annual Goals. (2014). In The Individualized Education Program (IEP) Development Present Levels of
Academic Achievement and Functional Performance (PLAAFP) and Measurable Annual Goals. N.p.: Public
Schools of North Carolina.
Will the student be involved full-time in the general education curriculum or, for preschoolers, in ageappropriate activities? Yes
No
(If no, describe the extent to which the student will not be involved full-time in the general curriculum or,
for preschoolers, in age-appropriate activities)
Benjamin Shea will receive pull out special education services targeting reading comprehension and phonemic
awareness. Benjamin will participate in all other subjects/curriculum in general education settings with typically
developing peers.
SPECIAL FACTORS After consideration for special factors (behavior, limited English proficiency, Braille
needs, communication needs including deaf/hard of hearing, and assistive technology), is there a need in any of
the areas?
Yes
No (If yes or student has a visual impairment, attach I-5, Special Factors page)
Page%____%of%____%
INDIVIDUALIZED*EDUCATION*PROGRAM*
SPECIAL*FACTORS*
Form*I75**(Rev.*7/06)*
Note: For any need(s) identified below, there must be a statement of the service(s) to meet that need (including
amount/frequency, location, and duration) on the Program Summary page (I-9).

A. Does the students behavior impede his/her learning or that of others?
Yes No
(If yes, include the positive behavioral interventions, strategies, and supports to address that behavior)
Previous successful behavioral interventions have included the following:
% Break cards
% Teacher-student conference
% Preferential seating
% Visual schedule
% Homework buddy
% Graphic organizer
% Behavior plans with the use of token economies
More recent strategies have focused on using Zones of Regulation to help Benjamin focus on self-regulation
strategies that can be used to help him regain focus in the classroom.
B. Is the student an English Language Learner?
Yes No
(If yes, include the language needs that relate to this IEP)
C.% If visually impaired, does the student need instruction in Braille or the use of Braille?
Yes
No Cannot be determined at this time
(If yes, include Braille needs; if no or cannot be determined, attach ER-3, Determining Braille
Needs from the latest evaluation/reevaluation)
D.% Does the student have communication needs that could impede his/her learning?
(If yes, include communication needs)
Yes
No
{If yes and the student is deaf or hard of hearing, identify the communication needs including (a) the students
language; (b) opportunities for direct communication with peers and professional personnel in the students
language and communication mode; and, (c) academic level and full range of needs including opportunities for
direct instruction in the students language and communicative mode}:
E. Does the student need assistive technology services or devices?

{If yes, specify particular device(s) and service(s)}
Yes
No
Page%____%of%____%
INDIVIDUALIZED*EDUCATION*PROGRAM*
ANNUAL*GOAL*
Form*I66**(Rev.*10/06)*

Measurable annual academic or functional goal to enable the student to be involved in and progress in the
general education curriculum, and to meet other educational needs that result from the students disability.
(Note: present levels of academic achievement and functional performance must include information that
corresponds with each annual goal)
Upon review:
Goal met
Goal not met
IEP Goals:
By 03/20/2017, given 20 unfamiliar words of 3 or more syllables, Benjamin Shae, will correctly segment
17 out of 20 words and will demonstrate this ability in all settings.
By 03/20/2017, given a Fountas and Pinnell level L reading passage, Benjamin Shea will summarize the
important details/information regarding main idea, characters, plot, and conclusion in a text without the
use of materials (text) as means of answering literal and inferential questions 9 out of 10 opportunities.
By 03/20/2017, given a Fountas and Pinnell level M reading passage, Benjamin Shea, will increase his
fluency rate to 120 words per minute while maintaining 97% accuracy with fewer than 3 errors per 100
words.
By 03/20/2017, Benjamin Shae, will demonstrate an ability to attend to auditory instruction and direction
for 40 minutes in all academic settings
Common Core State Standards:
CCSS.ELA-LITERACY.CCRA.R.1
Read closely to determine what the text says explicitly and to make logical inferences from it; cite
specific textual evidence when writing or speaking to support conclusions drawn from the text.
CCSS.ELA-LITERACY.CCRA.R.2
Determine central ideas or themes of a text and analyze their development; summarize the key
supporting details and ideas.
CCSS.ELA-LITERACY.RL.2.1
Ask and answer such questions as who, what, where, when, why, and how to demonstrate understanding
of key details in a text.
Use information gained from the illustrations and words in a print or digital text to demonstrate
understanding of its characters, setting, or plot.
By the end of the year, read and comprehend literature, including stories and poetry, in the grades 2-3
text complexity band proficiently, with scaffolding as needed at the high end of the range.
Page%____%of%____%
Procedures for measuring the students progress toward meeting the annual goal.
Student progress will be measured by:
Curriculum Based Assessments
Formal Tests
Informal Tests
Anecdotal records/notes that detail progress, preferences, and use of accommodations, modifications,
and aids
Teacher Records of Observations
Data Collection Forms
Work Samples
Will the student participate in an alternate assessment aligned with alternate achievement standards for students
with disabilities in any subject area? Yes
No
(If yes, include benchmarks or short-term objectives for the student)
By 03/20/2017, given 20 unfamiliar words of 3 or more syllables, Benjamin Shae, will correctly segment
17 out of 20 words and will demonstrate this ability in all settings.
Benchmark1: Given 10 unfamiliar words of 3 or more syllables, Benjamin Shae, will correctly
segment 8 out of 10 words and will demonstrate this ability in all settings.
Benchmark 2: Given 15 unfamiliar words of 3 or more syllables, Benjamin Shae, will correctly
segment 14 out of 15 words and will demonstrate this ability in all settings.
By 03/20/2017, given a Fountas and Pinnell level L reading passage, Benjamin Shea will summarize the
important details/information regarding main idea, characters, plot, and conclusion in a text without the
use of materials (text) as means of answering literal and inferential questions 9 out of 10 opportunities.
Benchmark1: Given a Fountas and Pinnell level L reading passage, Benjamin Shea will summarize
the important details/information regarding main idea, characters, plot, and conclusion in a text
without the use of materials (text) as means of answering literal and inferential questions 7 out of 10
opportunities.
Benchmark 2: Given a Fountas and Pinnell level L reading passage, Benjamin Shea will summarize
the important details/information regarding main idea, characters, plot, and conclusion in a text
without the use of materials (text) as means of answering literal and inferential questions 8 out of 10
opportunities.
By 03/20/2017, given a Fountas and Pinnell level M reading passage, Benjamin Shea, will increase his
fluency rate to 120 words per minute while maintaining 97% accuracy with fewer than 3 errors per 100
words.
Benchmark1: Given a beginning second grade Fountas and Pinnell level L reading passage,
Benjamin Shae will increase his fluency rate to 120 words per minute while maintaining 97%
accuracy with fewer than 3 errors per 100 words.
Benchmark 2: Given an intermediate level second grade Fountas and Pinnell level N reading
passage, Benjamin Shae will increase his fluency rate to 120 words per minute while maintaining
97% accuracy with fewer than 3 errors per 100 words.
Page%____%of%____%
By 03/20/2017, Benjamin Shae, will demonstrate an ability to attend to auditory instruction and direction
for 40 minutes in all academic settings
Benchmark1: Benjamin Shae, will demonstrate an ability to attend to auditory instruction and
direction for 20 minutes in all academic settings.
*Goals and benchmarks reference: www.goalbank.com and http://learningabledkids.com
When will reports about the students progress toward meeting the annual goal be provided to parents?
Reports regarding progress toward achieving annual goals will be provided upon request of Benjamins
parents/guardians and/or at the end of each semester.
PARTICIPATION)GUIDELINES)FOR)ALTERNATE)ASSESSMENT)
Form)I575A)(Rev.)3/14))

IEP teams are responsible for deciding whether students with disabilities will participate in general education assessments
with or without testing accommodations, or in the alternate assessment with or without accommodations.1 In a given year, a
student must participate in either all general education assessments or all alternate assessments, not parts of both.
Participation Criterion
Participation Criterion Descriptors
Agree (Yes) or
Disagree (No)?
1. The student has a significant

cognitive disability
Review of student record indicates a disability (i.e. Autism,

Cognitive Disability, or Traumatic Brain Injury) that
significantly impacts intellectual functioning and adaptive
behavior. Adaptive behavior is defined as essential for
someone to live independently and to function safely in daily
life.
Yes / No
2. The student is primarily being

instructed using the Common
Core Essential Elements and
the Extended Grade Band
Standards as content
standards.
Goals listed in the IEP for this student are linked to the
enrolled grade level Common Core Essential Elements and
the Extended Grade Band Standards and address knowledge
and skills that are appropriate and challenging for this
student.
Yes / No
3. The student requires extensive The student

direct individualized
a.! requires extensive, repeated, individualized instruction
instruction and substantial
and support that is not of a temporary nature and
supports to achieve
b.! uses substantially adapted materials and individualized
measureable gains in the
methods of accessing information in alternative ways to
grade-and age-appropriate
acquire, maintain, generalize, demonstrate and transfer
curriculum.
skills across multiple settings.
Yes / No
When the IEP team concurs that all three of the criteria above accurately characterize a students current educational
situation, an alternate assessment should be used to provide a meaningful evaluation of the students current academic
achievement.
The IEP team determined the student must participate in alternate assessments.
Yes / No
Decisions for determining participation in the alternate assessment must not be based solely on any of the following:
1.! A disability category or label
9.! Low reading level/achievement level
2.! Poor attendance or extended absences
10.! Anticipated students disruptive behavior
3.! Native language/social/cultural or economic
11.! Impact of student scores on accountability
difference
system
4.! Expected poor performance on the general
12.! Administrator decision
education assessment
13.! Anticipated emotional distress
5.! Academic and other services student receives
14.! Need for accommodations (e.g., assistive
6.! Educational environment or instructional setting
technology/Augmentative and Alternative
7.! Percent of time receiving special education
Communication) to participate in assessment
8.! English Language Learner (ELL) status
process
General Education Assessments in Wisconsin refer to content reflective of the Common Core State Standards and the Wisconsin Model Academic
Standards. These assessments include Students identified as English Language Learners are required to participate annually in a language
assessment. the Wisconsin Knowledge and Concepts Examination, Smarter Balanced Assessment, ACT Aspire Early High School, ACT
WorkKeys and The ACT. Alternate assessments in Wisconsin assess content reflective of the Common Core Essential Elements and the Wisconsin
Extended Grade Band Standards. These assessments include the Wisconsin Alternate Assessment for Students with Disabilities and Dynamic
Learning Maps.
INDIVIDUALIZED*EDUCATION*PROGRAM:*
PARTICIPATION*IN*ASSESSMENTS*
To#be#completed#for#all#students##
*
Form*I878District8Wide*Assessment*(Rev.*3/14)*
PARTICIPATION IN DISTRICT-WIDE ASSESSMENTS
District-wide assessments not given

OR
!
Student will not be in the grade when a district-wide assessment is given
OR
!
District-wide assessments given

List district-wide assessment(s) student will take:
! Yes ! No The student needs testing accommodations (please list):
! Yes No The student will participate in an alternate assessment (the I-7-A Participation
Guidelines for Alternate Assessments must be included with the IEP).
!
PARTICIPATION*IN*STATEWIDE*ASSESSMENTS*
Form*I979*WAA9SwD*(New*3/14)*
To#be#completed#for#students#participating#
in#the#Wisconsin#Alternate#Assessment#for*
Students#with#Disabilities*

The student will be in (circle one) 4th, 8th, or 10th grade when the Wisconsin Alternate Assessment for Students with
Disabilities (WAA-SwD) is given in Science and Social Studies. The student will be taking the alternate assessment1
for all content areas required at this grade level (the I-7-A Participation Guidelines for Alternate Assessment must be
included with the IEP). Note: Social Studies is assessed through a Teacher Rater Form found on the Department of
Public Instruction website at http://oea.dpi.wi.gov/oea_waa/#testad. Ratings are based upon teacher observation of
classroom instruction.
Allowable test practices and accommodations for the WAA-SwD are specific to this assessment. Please refer to the
Office of Student Assessment website for the current policies.
Section A: Allowable test practices
Allowable test practices are for all students, as needed; they do not alter the content being tested. Please list allowable
test practices that may be required for the student at the time of testing:
Section B: Accommodations
Science
! Science without
accommodations.
! Science with (list) :
!
!
1Alternate
assessments in Wisconsin assess content reflective of the Common Core Essential Elements and
the Wisconsin Extended Grade Band Standards. These assessments include the Wisconsin Alternate
Assessment for Students with Disabilities and Dynamic Learning Maps. Students identified as English
Language Learners are required to participate annually in a language assessment.
Page%____%of%____%
SUMMARY*
Form*I99**(Rev.*10/06)*

Projected beginning and ending date(s) of IEP services & modifications 11/20/2016 to
11/20/2017
(month/day/year)
(month/day/year)
Physical education:
Regular
Vocational education: Regular
Specially designed
Specially designed
Include a statement for each of I, II, III and IV below to allow the student (1) to advance appropriately toward
attaining the annual goals; (2) to be involved and progress in the general education curriculum; (3) to be
educated and participate with other students with and without disabilities to the extent appropriate, and (4) to
participate in extracurricular and other nonacademic activities. Include frequency, location, & duration (if
different from IEP beginning and ending dates).
I. Special education
Frequency/
Location
Duration
Amount
Specialized Intensive Instruction in Reading
(Pertaining to SLD Diagnosis)
Speech-Language Services (Targeting ADHD

Deficits; and Acquire Appropriate Social Behaviors)
60 minutes daily
OR
as suggested by
staff
School
Environment
11/20/2016 11/20/2017
30 minutes
3x/Weekly
School
Environment
11/20/2016 11/20/2017
II. Related services needed to benefit from special education including frequency, location, and
duration (if different from IEP beginning and ending dates).
None needed to benefit from special education

Freq / Amt
Assistive Technology
Audiology
Counseling
Educational Interpreting
Medical Services for Diagnosis and Evaluation
Location
Duration
Occupational Therapy
Orientation and Mobility (VI only)
Physical Therapy
Psychological Services
Recreation
Rehabilitation Counseling Services
School Health Services
Once during School

the course of Environment
the students
evaluation
11/20/2016
11/20/2017
Page%____%of%____%
School Nurse Services

School Social Work Services
Speech / Language
Transportation
Other: specify
Form%I-9%
30 minutes
3x/Weekly
All School
Environment
11/20/2016
11/20/2017
Form%I-9%
Page%____%of%____%
III. Supplementary aids and services: aids,

services, and other supports provided to or
on behalf of the student in regular
education or other educational settings.
Yes
No (If yes, describe)
Benjamin will receive the following
accommodations: preferential seating,
paraprofessional assistance, behavior charts,
extended time, lists of instructions/visual
schedules, highlighters, breaks, use of place
markers, and outlines/graphic organizers.
Freq / Amt
Location
Duration
Daily; as
suggested
by staff
Across All
School
Environments
11/20/2016
11/20/2017
Daily; as
suggested
by staff
Across All
School
Environments
11/20/2016
11/20/2017
IV. Program modifications or supports for

school personnel that will be provided.
Yes No (If yes, describe)
Benjamin will receive modifications such as:
reading buddies, peer tutoring, remedial
reading, small group instruction, shortened list
of spelling words, and additional time for
assignment completion.
V. Participation in Regular Education Classes
The student will participate full-time with non-disabled peers in regular education
classes, or for preschoolers, in age-appropriate settings.
The student will not participate full-time with non-disabled peers in regular education
classes, or for preschoolers, in age-appropriate settings. (If you have indicated a
location other than regular education classes or age-appropriate settings in the case of a
preschooler in I, II, or III above, you must check this box and explain why full-time
participation with non-disabled peers is not appropriate.)
With the exception of specialized reading instruction, Benjamin will participate in all other
general education classes/curriculum.
VI. Participation in Extracurricular and Nonacademic Activities
Will the student be able to participate in extracurricular and nonacademic activities with
nondisabled students?
Yes
No
I-9 (2)
Revised 7/1/06
Page%____%of%____%
Form%I-9%
(If yes, include under I., II., III., and IV. any special education, related services, supplementary
aids and services, and program modifications or supports necessary to assist the student. If no,
describe the extent to which the student will not be involved in extracurricular and nonacademic
activities with nondisabled students)
DETERMINATION*AND*NOTICE*OF*PLACEMENT**
Form*P22**(Rev.*7/06)*
Horizon Elementary
[If you need this notice in a different language or communicated in a different way, or have
questions about this notice, please contact Marya Plowman at mplow@email.com].
Date of the placement determination: 11/20/2016

Date parent provided with notice of placement 11/22/2016
Name of student: Benjamin Shae
Dear Mrs. Shae,
The IEP developed on 11/20/2016 will be implemented at Horizon Elementary School in the Bartlett School
District/City, with a projected date of implementation on 11/25/2016 .
Will the child attend the school he/she would attend if nondisabled?
Yes No (If no, explain)
List other options considered, if any, related to the placement site (school building or school district), frequency,
location, and duration of the special education and related services, supplementary aids and services, program
modifications and supports, and the place of those services. List the reason(s) rejected, and description of any other
factors relevant to the proposed action:
None
You previously received a copy of your childs evaluation report and a copy of his/her IEP is enclosed.
A copy of your childs evaluation report and IEP are enclosed.
You and your child have protection under the procedural safeguards (rights) of special education law. The school
district must provide you with a copy of your procedural safeguards once a year. Enclosed is a copy or earlier this
year you received a copy of your procedural safeguard rights in a brochure about parent and child rights. If you
would like another copy of this brochure, please contact the district at the telephone number above. In addition to
district staff, you may also contact Marya Plowman at mplow@email.com if you have questions about your rights.
Sincerely,
_____________________________________________________
REFERRAL&FORM&&&
SPECIAL&EDUCATION&AND&RELATED&SERVICES&
Form&R51&&(Rev.&7/06)&
&
Horizon Elementary
Initial
Reevaluation
Name of child (Last, first, middle)
Date of birth
Shea, Benjamin J.
Name of parent or legal guardian
01/28/2009
2nd
Address (Street, city, state, zip)
Molly Shea
Telephone
area/no.
Grade
School
Horizon Elementary
123 Oak St. Bartlett, WI 54680

Person making referral/title
Date parent notified of intent to refer
555-555-5555
Elsa Dumke Special Education Teacher
Method of notifying parent of intent to refer
09/20/2016
Is an interpreter needed?
Conference
Phone call Written
Yes
No
Parents or adult students native language or other primary mode of communication if other than English
(specify):
Childs native language or other primary mode of communication if other than English (specify):
Date of receipt of referral by school district/LEA 10/03/2016 (month, day, year)

(Note: the date the district receives the referral begins the 15 business day timeline in which to complete the review
of existing information and notify the parents of whether additional assessments are needed.)
State reason you believe this child has a disability (impairment and a need for special education) - such as
academic and non-academic performance and medical information; any special programs, services,
interventions used to address this students needs and the results of those interventions, etc.
It is believed that Benjamin Shea would be a good candidate to receive special education services as he
has demonstrated a need for additional support in reading based on his previous academic history.
instances where Benjamin has made up information to answer questions about the content of texts read
in class, which has also been marked by his overreliance on background information when asked to
answer questions about reading passages. Mrs. Keller stated that Benjamins deficits fall primarily in
the areas of phonemic awareness and associative word processing/learning. In addition to academic
his performance warrants additional attention and requires that his current IEP be amended.
If the child is transitioning from a Birth to 3 Early Intervention Program, and the district was invited by the
designated lead agency to participate in the transition planning meeting, document the date of the meeting
and who attended for the LEA or explain why the LEA did not attend:
N/A
NOTICE'OF'REEVALUATION''
Form'RE11''(Rev.'7/06)'
Horizon Elementary
questions about this notice, please contact Marya Plowman at mplow@email.com]
Dear Molly Shea,
Date: 08-20-2016
This letter is to inform you that the Horizon Elementary School District intends to reevaluate your
child Benjamin Shea . The school district must reevaluate your child if the educational or related
services needs of your child warrant a reevaluation, or you or your childs teacher requests a
reevaluation. However, a child is not to be reevaluated more than once a year unless you and the
school district agree. The school district must also reevaluate your child at least once every three years
unless the school district and you agree that a reevaluation is unnecessary. The purpose for this
reevaluation is to determine whether your child continues to have a disability (impairment and need for
special education), and to identify your childs current educational needs. The reason that the school
district intends to reevaluate your child is:
The school district received a request for a reevaluation on 08/20/2016 from:
you (statement of your parental rights enclosed)
your childs teacher (name) Elsa Dumke
other (specify) ____________________________________________________
The school district determined that the educational or related services needs of your child
warrant a reevaluation (explain/describe):
Data collected by Mrs. Brandi Keller for the 2015 school year detailed Benjamins lack of
progress in reading skills and phonemic awareness. It is suggested that he be reevaluated to
better adjust academic supports to meet his needs and allow him to meet grade level
proficiency.
The last evaluation/reevaluation of your child was completed on ___________and therefore

a reevaluation is due.
The individualized education program (IEP) team is responsible for this reevaluation and will conduct
this reevaluation at no cost to you. You are a participant on the IEP team. You may include others on
the IEP team who have knowledge or special expertise about the child.
Page%2%of%3%
Form%RE/1%
Role
Name, if known
Representative of local
Emma Watson
educational agency (LEA)

authorized to commit the resources
of the LEA
Elsa Dumke; Brandi Keller
Vicky Larson
Casey Bokingo, Matthew Larson, Paul Berg, Molly

Nelson, Martha Devine, Erica Levin, and Miriam
Campbell
Others
N/A
Other options, if any, such as the selection of IEP team participants which were considered and the
reason(s) they were rejected and a description of any other factors relevant to the proposed action:
None
IEP team participants will first review existing information available on your child including
information provided by you and then determine what, if any, further evaluation or assessment is
necessary to assist in identifying the educational needs of your child and in making a determination of
whether your child continues to have a disability. You will be sent a notification of this
determination within 15 business days of: August 20, 2016 the date that the school district received
the request to reevaluate your child; ! the date of this notice (when a request did not initiate the
reevaluation). This notification will be sent by September 3, 2016.
(month/day/year)
If the IEP team determines that additional assessments or other evaluation materials are necessary, the
school district needs your written consent (permission) before it may administer any assessments or
other evaluation materials to obtain further information about your child. You will be informed about
what assessments or other evaluation materials will be given before they are administered. You will
also be informed of the names of the individuals who will conduct those evaluations, if known at the
time of the notice. Upon completion of the reevaluation, the IEP team will prepare an evaluation
report, which will include documentation of your childs eligibility for special education. You will be
provided with a copy of the evaluation report.
Within 60 calendar days of receiving your consent for this reevaluation or being provided with a
notice that no further assessment of your child is necessary, the IEP team will meet to determine
whether your child continues to be a child with a disability. If the IEP team determines that your
child continues to have a disability, the team will review and revise, as appropriate, your childs
IEP and determine a placement to carry out the IEP within 30 calendar days. You will be
provided with a notice of placement and a copy of your childs IEP. If it is determined by the
IEP team that your child no longer needs special education, you will be provided with a notice of
that finding.
If at any point during an IEP team meeting to determine your childs continued eligibility for
special education and educational needs, to review or revise your childs IEP, or to determine a
placement to carry out the IEP, you or other IEP team participants believe that additional time is
needed to permit your meaningful involvement, additional time will be provided subject to the
time limitations described above. This IEP team process may be concluded in one meeting or
may require more than one meeting depending on individual circumstances. In addition and
upon request you may receive a copy of the IEP teams most recent evaluation report.
You and your child have protection under the procedural safeguards (rights) of special education
law. The school district must provide you with a copy of your procedural safeguards once a
year.
You received a copy of your procedural safeguard rights in a brochure about parent and
child rights earlier this year. If you would like another copy of this brochure, please contact
the district at the telephone number above.
A copy of the parent and child rights brochure is enclosed with this notice.
In addition to district staff, you may also contact Marya Plowman at

mplow@email.com if you have questions about your rights.
Sincerely,
___________________________________________
RE-1 (2)
Revised 7/1/06
NOTICE'OF'AGREEMENT'TO'CONDUCT'
A'REEVALUATION'MORE'THAN'ONCE'A'YEAR'
Form'RE62''(Rev.'7/06)!
Horizon Elementary SCHOOL DISTRICT

Dear Molly Shea,
Date 08-20-2016
It has been less than a year since your child 01/20/2015 was last evaluated. Under federal special education law,
evaluations of children with disabilities do not occur more often than once a year unless the childs parent and
school district agree that an evaluation is needed.
On 09/20/2015 we [met or spoke on the phone or exchanged emails] and agreed that a reevaluation of your child
is necessary at this time for the following reason(s):
Other options, if any, related to the above action which were considered and the reason(s) they were rejected
including a description of any other relevant factors, include:
None
The individualized education program (IEP) team is responsible for this reevaluation and will conduct this
reevaluation at no cost to you. You are a participant on the IEP team. You may include others on the IEP
team who have knowledge or special expertise about the child.
Role
Representative of local
Name, if known
Emma Watson
educational agency (LEA)

authorized to commit the resources
of the LEA
Elsa Dumke; Brandi Keller
Vicky Larson
Casey Bokingo, Matthew Larson, Paul Berg, Molly

Nelson, Erica Levin, and Martha Devine
Page!2!of!2!
Others
Form!RE.2!
N/A
Page!2!of!2!
Form!RE.2!
Other
options, if any, related to the selection of IEP team participants which were considered and the
reason(s) they were rejected and a description of any other factors relevant to the proposed action: None
IEP team participants will first review existing information available on your child, including information
provided by you, and then determine what, if any, further evaluation or assessment is necessary to assist in
identifying the educational needs of your child and in making a determination of whether your child continues
to have a disability. You will be sent a notification of this determination within 15 business days of the date
you and the school district agreed that a reevaluation of your child was necessary. This notification will be
sent by: August 20, 2016.
(month/day/year)
If the IEP team determines that additional assessments or other evaluation materials are necessary, the school
district needs your written consent (permission) before it may administer any assessments or other evaluation
materials to obtain further information about your child. You will be informed about what assessments or other
evaluation materials will be given before they are administered. You will also be informed of the names of the
individuals who will conduct those evaluations, if known at the time of the notice. Upon completion of the
reevaluation, the IEP team will prepare an evaluation report, which will include documentation of your childs
eligibility for special education. You will be provided with a copy of the evaluation report.
Within 60 calendar days of receiving your consent for this reevaluation or being provided with a notice that no
further assessment of your child is necessary, the IEP team will meet to determine whether your child continues
to be a child with a disability. If the IEP team determines that your child continues to have a disability, the team
will review and revise, as appropriate, your childs IEP and determine a placement to carry out the IEP within
30 calendar days. You will be provided with a notice of placement and a copy of your childs IEP. If it is
determined by the IEP team that your child no longer needs special education, you will be provided with a
notice of that finding.
If at any point during an IEP team meeting to determine your childs continued eligibility for special education
and educational needs, to review or revise your childs IEP, or to determine a placement to carry out the IEP,
you or other IEP team participants believe that additional time is needed to permit your meaningful involvement,
additional time will be provided subject to the time limitations described above. This IEP team process may be
concluded in one meeting, or may require more than one meeting, depending on individual circumstances. In
addition and upon request, you may receive a copy of the teams most recent evaluation report.
You and your child have protection under the procedural safeguards (rights) of special education law. The
school district must provide you with a copy of your procedural safeguards once a year. Enclosed is a copy or
earlier this year you received a copy of your procedural safeguard rights in a brochure about parent and child
rights. If you would like another copy of this brochure, please contact the district at the telephone number
above. In addition to district staff, you may also contact Marya Plowman at mplow@email.com if you
have questions about your rights.

Sincerely,

_________________________________________________
REEVALUATION:,,NOTICE,AND,CONSENT,
REGARDING,NEED,TO,CONDUCT,,
ADDITIONAL,ASSESSMENTS,
Form,RE65,,(Rev.,10/06),
Horizon Elementary SCHOOL DISTRICT

Date 09-25-2016
Dear Molly Shea,
Previously, you were notified of the school districts intent to reevaluate your child. The individualized education
program (IEP) team is responsible for this reevaluation. You are a participant on the IEP team. The IEP team
considered the following existing evaluation assessments, procedures, records or reports:
The IEP team has determined that additional assessments or other evaluation materials are needed to determine
whether your child continues to have a disability (impairment and a need for special education), and to identify your
childs current educational needs.
You participated in making this decision on 09/20/2016 in the following way: Provision of verbal and written
consent.
You did not participate in making this determination and the school district made 3 attempts to involve you as
follows:
The school district needs your written consent (permission) before it can administer assessments or other evaluation
materials to your child. With your consent the following assessments or other evaluation materials will be
administered:
Areas to be
evaluated

evaluation materials and titles, if
known
Name of evaluator,
if known
Reading
Comprehension

Assessment
Molly Nelson
Paul Berg
Reading
Comprehension,
and Spelling
Martha Devine
Behavior and
Attention
Connors 3
Paul Berg
Page%2%of%3%
Form%RE/5%
Other evaluation options, if any, considered and reasons rejected, including a description of any other factors
relevant to the proposed evaluation of this child:
None
Following the administration of these assessments or other evaluation materials, the IEP team will meet to
review the results of these assessments and other evaluation materials along with other existing
information available on your child, including information provided by you. Using the results of these
assessments or other evaluation materials along with other available information, the IEP team will make
a determination of whether your child continues to have a disability. As a participant on the IEP team,
you will be involved in this determination. Upon completion of the reevaluation, the IEP team will
prepare an evaluation report which will include documentation of your childs eligibility for special
education. You will be provided with a copy of the evaluation report. If the IEP team determines that
your child continues to have a disability, the team will review and revise, as appropriate, your childs IEP
and determine a placement to carry out the IEP. You will be provided with a notice of placement and a
copy of your childs IEP. If it is determined by the IEP team that your child no longer needs special
education, you will be provided with a notice of that finding.
If at any point during an IEP team meeting to determine your childs continued eligibility for special
education or educational needs, review or revise your childs IEP, or determine a placement to carry out
the IEP, you or other IEP team participants believe that additional time is needed to permit your
meaningful involvement, additional time will be provided. This IEP team process may be concluded in
one meeting or may require more than one meeting depending on individual circumstances. In addition
and upon request you may receive a copy of the IEP teams most recent evaluation report.
You and your child have protection under the procedural safeguards (rights) of special education law.
The school district must provide you with a copy of your procedural safeguards once a year. Enclosed is
a copy or earlier this year you received a copy of your procedural safeguard rights in a brochure about
parent and child rights. If you would like another copy of this brochure, please contact the district at the
telephone number above. In addition to district staff, you may also contact Marya Plowman at
mplow@email.com if you have questions about your rights.
Sincerely,
_____________________________________________________
Form%RE/5%
Page%3%of%3%
PARENT CONSENT/PERMISSION TO ADMINISTER ASSESSMENTS AND

OTHER EVALUATION MATERIALS AS PART OF A REEVALUATION
I understand that if I do not respond to the school districts requests for my written consent (permission)
to administer these assessments or other evaluation materials, the school district is permitted to proceed
with the assessments or other evaluation materials without my written consent.
I understand the action proposed by the school district and
(please check appropriate box below, sign and date, and return one copy to the school district)
I give my consent for the school district to administer these assessments or other evaluation
materials described in this notice to my child as part of a reevaluation. I understand that my
consent is voluntary and may be revoked at any time before the administration of assessments
or other evaluation materials.
I do not give my consent for the school district to administer these assessments or other
evaluation materials described in this notice to my child as part of a reevaluation. I understand
that if I do not give my written consent for the school district to administer these assessments
or other evaluation materials, the school district may request mediation or initiate a due
process hearing regarding whether those assessments or other evaluation materials should be
administered.
_________________________________________________
Signature of parent or legal guardian or adult student
__________________
Date
For School District Use Only
Date school district received parent consent

______________________
(month/day/year)
Dumke& 1&
Case Study: Benjamin Shea
For the purpose of this assignment I chose to complete my case study on Benjamin Shea.
Benjamin is a 2nd grade student who is very creative, curious and inquisitive. He does a great
job of using his background knowledge to making meaning, however he struggles with reading
the words on the page in order to use the information from the text to help him create meaning.
Benjamin also has a great memory for facts. Benjamin demonstrates delays and/or deficits in
phonological awareness and associative word learning, which effects his ability to recognize
letters and their sounds and use such information to decode words. In the past, Benjamin has
shown a great love for learning. Recently, Benjamins frustrations towards reading have begun to
take a negative toll on not only his opinion regarding school but also on his confidence as an
individual. He also struggles to remain on task and is very easily distracted. Benjamin needs
frequent reminders and has a very difficult time following given directions.
As, Benjamin does not have a cognitive disability, I did not consider him for the DLM. I
did use the DPI guide for accommodations to decide how to best assist him during the SBA
testing once he is in third grade. I also assumed that he would take the MAP assessment and
literacy benchmark testing, as those are the assessments that are commonly administered to and
for second graders. If he were my student, I would utilize the assessments that I wrote on his I-7
DWA in addition to utilizing running records that go along with the leveled literacy intervention.
I would also utilize the phonological and word assessments provided by Fountas and Pinnell. I
wouldve like to know specifics in regards to his present level, as what was provided was general
to an extent. It was hard to write measurable goals when I didnt know specifics. For instance,
what is his exact reading level, what specific kinds of questions can he answer and to what
degree of accuracy, can he retell a story or identify characters, etc., also what letter names and
Dumke& 2&
sounds does he know, and just how many of the expected sight words does he recognize in
isolation and within a text.
Instructional models that I would use would be movement based whenever possible, for
instance, I would likely use the Phonics Dance program components as a way to teach him
phonics and word recognition. I would also utilize the Leveled Literacy Intervention program,
and the PCI program as ways to provide instruction for him. I would also a structured work
system for any independent work times that he would have, as well as providing a quiet, lessdistracting space in which he could complete his work. In addition, his desk would be place
away from windows, doors and distractions. I would provide an incentive program for him as a
way to encourage positive behaviors and following directions. Another possible strategy that I
would use with him would be to take reading out of math, etc. for him by reading the directions
and materials for him so that he is able to continue to experience greater success in other
academic areas without having his reading delays hinder him.

Iep Ben S

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DATE ON WHICH ELIGIBILITY DETERMINATION WAS MADE:

THIS EVALUATION REPORT AND DETERMINATION OF ELIGIBILITY INCLUDES THE

Information from assessments and other sources

Additional documentation required when

Determination of eligibility for special

Description of assessments and other

Fountas & Pinnell Benchmark Literacy

Kaufmann Test of Educational Achievement

Peabody Individual Achievement TestRevised (PIAT-R)

B. Information provided by parents

Early Reading Intervention targeting phonological awareness

DETERMINATION OF ELIGIBILITY FOR SPECIAL EDUCATION

(If no, there is no need for special education).

(If no, go to question 3).

B. Information provided by parents

Early Reading Intervention targeting phonological awareness

DETERMINATION OF ELIGIBILITY FOR SPECIAL EDUCATION

(If no, there is no need for special education).

(If no, go to question 3).

Student Name: Benjamin Shea

CONSIDERATION OF EXIT CRITERIA AND CONTINUING NEED FOR SPECIAL EDUCATION

CONSIDERATION OF EXCLUSIONARY FACTORS

Additional Notes (if any):

ADDITIONAL DOCUMENTATION REQUIRED WHEN STUDENT IS EVALUATED FOR SLD

No relevant medical findings.

Name and title

Special Education Teacher

General Education Teacher

School Social Worker

Special Education Director

Additional Notes (if any):

WORKSHEET FOR CONSIDERATION OF EXISTING

Description of assessments and other

Fountas & Pinnell Benchmark Literacy

Kaufmann Test of Educational Achievement

Peabody Individual Achievement TestRevised (PIAT-R)

Action to be taken as a result of review of considering the existing information/data:

Representative of local educational

Regular Ed. Teacher(s)

Related Services Personnel

Miriam Campbell Special Education Director

For SLD evaluations using response

WORKSHEET FOR CONSIDERATION OF EXISTING

Description of assessments and other

Fountas & Pinnell Benchmark Literacy

Kaufmann Test of Educational Achievement

Peabody Individual Achievement TestRevised (PIAT-R)

Action to be taken as a result of review of considering the existing information/data:

Representative of local educational

Regular Ed. Teacher(s)

Related Services Personnel

Miriam Campbell Special Education Director

For SLD evaluations using response

INVITATION TO A MEETING OF THE

Elsa Dumke Special Education Teacher

Miriam Campbell Special Education Director

Casey Bokingo School Social Worker

Paul Berg School Psychologist

Molly Nelson Reading Specialist

Matthew Larson Speech-Language Therapist

Erica Levin Diagnostician

Page%_%of%_