Jay's IEP

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Individualized Education Program (IEP)
Instructions for Fillable Version
This Microsoft Word document is the model form for the Individualized Education Program (IEP).
The document can be edited using Microsoft Word. The user must “stop protection” on editing
restrictions before making edits. The user must then “start enforcing protection” to make the fillable
areas useable for completing electronically.
Microsoft Word version 2007

1) Select the “Review” tab at the top.
2) Select the “Protect Document” dropdown menu on the top right.
3) Select “Restrict Formatting and Editing” from the menu.
4) In the column that appears on the right, click on the “Stop Protection” button at the bottom.
5) Make desired modifications to meet the needs of the district.
6) In the column on the right, make sure that under “Editing Restrictions” the option “Filling in
forms” is selected and that the check box is checked. Then click the “Yes, Start Enforcing Protection”
button.
Microsoft Word version 2003

1) Select the “Tools” dropdown menu at the top.
2) Select the “Unprotect Document.”
3) Make desired modifications to meet the needs of the district.
4) Select the “Tools” dropdown menu at the top.
5) Select the “Protect Document.”
The model form can be found on the following pages of this document. This instruction sheet is not part
of the model form.
Michigan Department of Education, Office of Special Education and Early Intervention Services
OSE-EIS Model Form IEP 003  December 2010
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IEP DATES
IEP Team Meeting Initial IEP Annual/Review IEP Reevaluation IEP
Offer of a FAPE: Offer of a FAPE: Offer of a FAPE:

Implementation: Implementation: Implementation:
Individualized Education Program (IEP)

Section 1
Demographic Information
Last: First: M:

Student Birth Date: Gender: Grade: UIC:

Address: City: State: Zip:
Phone:
Resident District: Operating District:
County: Attending Building:
Last: First: M:

Parent Relationship to Student:

Native Language or Other Communication Mode:
Address (if different): City: State: Zip:
Home Phone: Work Phone: Pager/Cell:
Email:
Parent Last: First: M: Relationship to Student:
Native Language or Other Communication Mode:
Address (if different): City: State: Zip:
Home Phone: Work Phone: Pager/Cell:
Email:
PURPOSE OF MEETING
Check one of the following: Check all others that apply:

Initial IEP Change of Placement
Annual/Review IEP Suspension/Expulsion Graduation Other:
Reevaluation IEP Secondary Transition
Change of Eligibility
Other:
OFFICE USE
PARENT CONTACT
The parent/adult student was contacted to explain the purpose of the meeting and the roles and responsibilities of each participant
via (check all that apply):
IEP Invitation Letter Phone Other:
Results:
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PARENTAL RIGHTS AND AGE OF MAJORITY
Check all that apply:

The student will be age 17 during this IEP and the student was informed of parental rights that he or she will receive at age 18.
The student has turned age 18 and the student and parent were informed of parental rights that were transferred to the
student at age 18, including the right to invite a support person such as a parent, advocate, or friend.
The student has turned age 18 and there is a guardian established by court order. The guardian is: .
The student has turned age 18 and a legally designated representative has been appointed. The representative is:
as (e.g., power of attorney, trustee).
IEP MEETING PARTICIPANTS IN ATTENDANCE
Check the box indicating the IEP participant(s) who can explain the instructional implications of evaluation results.

_________________________________________ _________________________________________
Student (must invite at age 16 and older) District Representative/Designee

_________________________________________ _________________________________________
Parent General Education Teacher

_________________________________________ _________________________________________
Parent Special Education Teacher

_________________________________________ _________________________________________
Agency Providing Secondary Transition Services Other
(consent on file)

_________________________________________ _________________________________________
Other Other
Parent and District Agreement on Attendance Not Necessary

These members are absent; their curricular area/related services are not being modified or discussed in the meeting:
Parent and District Agreement on Excusal Prior to Meeting

These members are absent and have submitted written input to the IEP team, including the parent, prior to the meeting:
ELIGIBILITY FOR SPECIAL EDUCATION
Eligible Ineligible
Area of disability:
If the student is determined ineligible as a student with a specific learning disability (SLD), provide a statement of the basis for the
determination of ineligibility:
If the student is determined eligible as a student with an SLD, check all that apply:
Oral expression Listening comprehension Written expression Basic reading skill

Reading fluency skills Reading comprehension Mathematics calculation Mathematics problem solving
Determination of eligibility was made in accordance with IDEA regulations at § 300.306(c)(1).
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Section 2-A
Present Level of Academic Achievement and Functional Performance
FACTORS TO CONSIDER
General
The IEP team must consider each of the following:
The strengths of the student:
The concerns of the parent for enhancing the education of the student:
The results of the most recent evaluation(s) of the student:
Special Factors
The IEP team must consider the following for the student (check boxes to indicate consideration):
The communication needs of the student.
The need for assistive technology devices and services for the student.
The IEP team must consider the following for the student, as appropriate (check all that apply):
The use of positive behavioral interventions and supports, and other strategies, to address behavior because the student
has behavior that impedes his or her learning or the learning of others.
The language needs of the student because the student has limited English proficiency.
Braille instruction because the student is blind or visually impaired.
The mode of language and communication because the student is deaf or hard of hearing.
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Section 2-B: Option I

After reviewing the student’s progress in the general education curriculum and any prior special education goals and objectives,
describe how the student accesses or makes progress in the general education curriculum based on grade level content
standards for the grade in which the student is enrolled or would be enrolled based on age.
Report and describe baseline data such as Describe how the student’s academic,
curriculum-based assessments, student work, developmental, and functional needs affect
teacher observations, parent input, and other involvement and progress in the general
relevant data for each area of need. education curriculum or participation in
appropriate activities for preschool students.
ACADEMIC/PRE-ACADEMIC

ACHIEVEMENT
Individual and/or district-wide
assessments.
GENERAL EDUCATION

CURRICULUM
Involvement and progress in
the general education
curriculum, or participation
in age-appropriate activities
for preschool students.
SECONDARY TRANSITION

ASSESSMENTS
Age-appropriate assessment
related to training, education,
employment, and independent
living skills.
COMMUNICATION/

SPEECH & LANGUAGE
SOCIO-EMOTIONAL/

BEHAVIORAL
PERCEPTION/MOTOR/

MOBILITY
Gross and fine motor
coordination, balance, and
limb/body mobility.
INDEPENDENT LIVING

SKILLS
Skills for academic success
and independent living.
MEDICAL

Health, vision, hearing, or
other physical/medical
issues.
Section 2-B: Option II

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describe the student’s present level of academic achievement and functional performance.
Report and describe baseline data such as curriculum-based assessments, student work, teacher observations, parent input, and
other relevant data for each area of need.
Sources of data used with Jay include teacher/student/parent intereviews, behavioral observations, Stanford-Binet Intelligence
Scale--Fifth Edition (SB-V), Woodcock-Johnson Tests of Achievement--Third Edition (WJ-III), Vineland Adaptive Behavior Scales
(parent interview), and Draw-a-person.
Relevant data includes the fact that Jay already has an IEP for language deficits. He was diagnosed with Attention Deficit
Hyperactivty Disorder around 5 or 6 years old and shortly after he was diagnosed with Bipolar Disorder. He currently takes several
medications throughout the day and both parent and teacher report that he acts like a completely different child when he does not
take his medication.
Academics:
The Woodcock-Johnson Tests of Achievement--Third Edition (WJ-III) indicated that Jay falls in the below average range.
Letter/Word Identification SS 73, Passage Comprehension SS 72, Calculation SS 56, Applied Problems SS 78, Spelling SS 71,
Writing Samples SS61, and Brief Writing SS 60. Standard scores between 85 to 115 are considered average.
His strength on this assessment was the "Applied Problems" subtest with a standard score of 78 (85 to 115 are condsidered
average). His weakness was the "Calculation" subtest with a standard score of 56. Jay performed significantly better on the
reasoning subtests, though he still fell below average for his age.
Behavior:
The Vineland Adaptive Behavior Scales--Second Edition was the assessment used to measure Jay's behavior with the informant
being his mother. Jay's scores includes overall Communication being a Standard Score of 70 with Expressive and Receptive Below
Average, Written Low; Overall Daily Living Skills being a Standard Score of 69 with Personal Low, Domestic and Community Below
Average; Overall Socialization being a Standard Score of 69 with Interpersonal Relationships being Below Average and Play &
Leisure Time and Coping Skills Low. The Adaptive Behavior Composite Standard Score was a 68. According to this assessment,
Jay's score fell at the Low Range.
The Draw-a Person assessment indicated that his drawing was significantly immature for a 1st grader. He seemed to change his
mind while he was drawing.
Describe how the student’s academic, developmental, and functional needs affect involvement and progress in the general
education curriculum or participation in appropriate activities for preschool students.
When it comes to academics, Jay has a relative strength of being able to identify the majority of capital and lower case letters.
However, according to the teacher interview, Jay is not reaching the 1st grade benchmarks. For instance, at the winter
benchmarking of early literacy skills, Jay can not read any sounds or words in three-letter short vowel nonsense words (>50 is
expected for 1st graders in the winter). In addition to trouble with literacy, Jay seems to be struggling to understand the concepts
behind basic addition and subtraction. For example, on a timed test with addtion sums to ten, Jay got 1 of 36 correct. His teacher
also explained that Jay needs directions not only repeated by further explained step-by-step, but consistently needs one-on-one
assistance for academic tasks.
The WJ-III further indicated that Jay falls in the below average range. Jay's relative strength on this assessment was the "Applied
Problems" subtest with a standard score of 78 (85 to 115 are condsidered average). His weakness was the "Calculation" subtest
with a standard score of 56. Jay performed significantly better on the reasoning subtests, though he still fell below average for his
age.
When it comes to behavior, Jay appears to have a relative strength in interpersonal relationships. A parent interview was
conducted using the Vineland Adaptive Behavior Scales to measure Jay's adaptive behavior. According to the assessment results,
Jay falls in the low range. As mentioned earlier his interpersonal relationships appear to be a relative strength, however his coping
skills are a relative weakness.
Jay's student interview indicated that Jay's favorite part of school is computer time while his least favorite parts of school are
science and math.
The Draw-a Person assessment indicated that his drawing was significantly immature for a 1st grader. He seemed to change his
mind while he was drawing.
According to classroom observations and testing, Jay needs more intensive school-based services to remediate his academic and
behavior difficulties.
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Describe how the student accesses or makes progress in the general education curriculum based on grade level content standards
for the grade in which the student is enrolled or would be enrolled based on age.
Academics:
As observations and testing have occurred, it has proved that Jay needs the appropriate, intensive school-based services when it
comes to all areas of academics. Even though Jay can identify the majority of capital and lower case letters, he is still below
average in the area of literacy. Because Jay ranks academically at a beginning to mid-kindergarten level, his goals and objectives
will be aligned with Kindergarten GLCEs. He also is below average in the area of mathematics indicated by answering only 1 of 36
problems correctly on a timed test of additions sums to ten. Because Jay ranks academically at a beginning to mid-kindergarten
level, his goals and objectives will be aligned with Kindergarten GLCEs.
Behavior:
According to classroom observations and testing, Jay needs support not only in academics, but with behavior as well. Even though
Jay has a relative strength in interpersonal relationships, he has weaknesses in the areas of communication (expressive,
receptive, and written), daily living skills (personal, domestic, community), and socialization (play and leisure time, coping skills).
One area of concern indicated by the parent interview is that Jay reacts strongly when there is a change in plans or when he does
not get his own way at home. Another area addressed in the interview was that Jay does not like to play alone and when playing
games he has trouble waiting his turn and likes to change the rules. Goals and objectives will be centered around these areas of
concern to decrease some of those behaviors as well as have him reach behaviors of what is expected of him for a 1st grader.
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Section 2-B: Option III

describe the student’s present level of academic achievement and functional performance.
What is the identified area of need?
Report and describe baseline data such as curriculum-based assessments, student work, teacher observations, parent input, and
other relevant data.
For an area of academic need, what are the district’s prioritized content expectations for the student’s grade level?
What predictive measure(s) does the district use to determine progress on these prioritized expectations?
What do we know about (grade level) graders’ skills in (content expectation)?

How does the student’s academic, developmental, and functional needs affect involvement and progress in the general education
curriculum, specific to (content area), or participation in appropriate activities for preschool students?

Include a graph of individual student and peer group performance over time.
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Section 3
Secondary Transition Considerations
Secondary transition services are required to be in effect when the student turns 16. IEP teams are recommended to consider
secondary transition services at a younger age if appropriate. Secondary transition considerations must be updated annually
thereafter.
STUDENT’S POSTSECONDARY GOALS (VISION)

Data Sources Used
Educational Development Plan (EDP)
Transition Assessment(s) (specify):
If the student did not attend the IEP team meeting, describe steps taken to ensure consideration of the student’s
preferences/vision:
Adult Living—As an adult, where do you want to live?
Career/Employment—As an adult, what kind of work do you want to do?
Community Participation—As an adult, what hobbies and activities do you want to do (e.g., arts, recreational activities,
shopping, eating out, etc.)?
Postsecondary Education/Training—After high school, what additional education and training do you want?
PLANNING/COMMUNITY SECONDARY TRANSITION SERVICES

Needed Service Related to the Student’s Strengths, Postsecondary Goals, and Present Level
Identify the service needed in at least one of the six areas below. Include the coordinated activity/activities for the service.
Identify the responsible agency/other for each activity for the needed service.
Instruction Expected completion date:
Service:
Activity: Responsible agency/other:
Considered, not needed (explain):
Community Experiences Expected completion date:
Service:
IEP Team Must Consider

Development of Employment Expected completion date:
Service:
Other Post-School Adult Living Objectives Expected completion date:
Service:
Planning/Community Secondary Transition Services continues on next page
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PLANNING/COMMUNITY SECONDARY TRANSITION SERVICES continued

Acquisition of Daily Living Skills Expected completion date:
Service:
Consider When Appropriate

Functional Vocational Evaluation Expected completion date:
Service:
THE COURSE OF STUDY TRANSITION SERVICE

Indicate how the student’s course of study aligns with the postsecondary goals (check one):
Michigan Merit Curriculum (MMC) leading to a high school diploma (effective for students who entered 8th grade in
2006-2007 school year or later).
MMC modification using Personal Curriculum on file: Yes No
Curriculum leading to a high school diploma (effective for students who entered 8th grade prior to the 2006-2007
school year).
Course of study leading to:
Anticipated graduation or completion date:
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Section 4: Option I
Goals and Objectives/Benchmarks
Instructional Area—List the appropriate content area (e.g., strand/domain): Literacy and Math
Michigan Content Expectations Upon Which Goal Will Be Based—List the appropriate GLCE, EGLCE, HSCE, EHSCE, or Early
Childhood Standards of Quality for Pre-kindergarten:
Baseline Data
The student is currently standard scores between 56-78 (data) on the WJ-III (assessment).
Annual Goal
By January 2012 (date), the student will identify lower and captial letters of the alpahbet, write upper and lowercase
letters, and use one-to-one correspondence in math (demonstrate skill) when/at Literacy and Math (conditions criteria) on
end of marking period (assessment/evaluation).
Short-Term Objective/Benchmark:

Performance Criteria:
Evaluation Procedure:
Evaluation Schedule:
Status Date: Status Date:

Progress Toward Annual Goal: Progress Toward Annual Goal:
Comments: Comments:

Comments: Comments:
Short-Term Objective/Benchmark:

Performance Criteria:
Evaluation Procedure:
Evaluation Schedule:

Comments: Comments:

Comments: Comments:
SCHEDULE FOR REPORTING PROGRESS
When:
Position(s) responsible for implementing goal activities (check all that apply):
Special Education Teacher Teacher Consultant Speech and Language Provider
School Social Worker Occupational Therapist Physical Therapist
Other:
Position(s) responsible for reporting progress on goal:
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Section 4: Option II
Goals and Objectives/Benchmarks
Instructional Area—List the appropriate content area (e.g., strand/domain): ELA and Math
Michigan Content Expectations Upon Which Goal Will Be Based—List the appropriate GLCE, EGLCE, HSCE, EHSCE, or Early
Childhood Standards of Quality for Pre-kindergarten: Kindergarten ELA and Math GLCEs: N.ME.00.02, W.HW.00.01,
R.WS.00.03
Baseline Data
The student is currently at the standard scores of 56 (Math), the standard score of 73 (Letter/Word Identification), and
the standard score of 60 (Writing) (data) on the WJ-III (assessment).
Annual Goal
By January 2012 (date), the student will identify lower and captial letters of the alpahbet, write upper and lowercase
letters, and use one-to-one correspondence in math (demonstrate skill) when/at Reading/Writing Workshop and Math
(conditions criteria) on end of marking period (assessment/evaluation).
SHORT-TERM OBJECTIVES/BENCHMARKS
By the end of the 1 (#) marking period of 2011 (school year) the student will
a)identify at least a quarter of the lowercase letters and at a quarter half of capital letters;
b)writing at least a quarter of the lowercase letters and at least a quarter of the uppercase letters;
c)use one-to-one correspondence (criteria) on end of the card marking assessment
a)student will be asked to identify the letters verbally with flashcards (lowercase and capital);
b)write down letters on lined sheet of paper;
c)put chips in squares and count the chips as they are put into squares (assessment/evaluation).
a)identify at least half of the lowercase letters and at least half of capital letters
b)writing at least half of the lowercase letters and at least half of the captial letters;
c) use one-to-one correspondence in math (criteria) on end of marking period assessments and through informal assessments
weekly
a)student will be asked to identify the letters verbally with flashcards (lowercase and capital)
b)write down letters on lined sheet of paper;
c)verbally describe different scenarios using manipulatives using phrases like "more than" or "less than") (assessment/evaluation).
a)identify all lowercase and captial letters
b)write all lowercase and captial letters correctly
c)use one-to-one correspondence in math (criteria) on end of card marking and through weekly informal assessments
a)identify the letters verbally with flashcards (lowercase and capital)

b)write all lowercase and capital letters on lined paper
c)Compare and order sets of objects up to 30 (assessment/evaluation).
By the end of the (#) marking period of (school year) the student will (criteria) on (assessment/evaluation).
SCHEDULE FOR REPORTING PROGRESS
When:
Insert Progress Monitoring Data
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Progress Reporting
Report Date: Progress: Comments:
Position(s) responsible for implementing goal activities (check all that apply):
Special Education Teacher Teacher Consultant Speech and Language Provider
School Social Worker Occupational Therapist Physical Therapist
Other:
Position(s) responsible for reporting progress on goal:
Section 5
Supplementary Aids and Services
Supplementary aids and services are provided to enable the student:
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• To advance appropriately toward attaining the annual goals.

• To be involved and progress in the general education curriculum and to participate in extra-curricular and other
nonacademic activities.
• To be educated and participate in activities with other students with disabilities and nondisabled students.
Supplementary aids and services are needed at this time.
Ongoing Instruction and Assessment

Time/Frequency/Condition Location
Scheduling, Presentation, Response, etc.

Curriculum Supports and Adjustments

Directions, Grading, Handwriting, Assignments, Time/Frequency/Condition Location
Tests, Books, etc.

Supports and Modifications to the Environment

Classroom Environment, Health-Related Needs,
Time/Frequency/Condition Location
Physical Needs, Assistive Technology, Behavioral, Training
Needs, Social Interaction Supports for the Student, etc.

Other Supports, Accommodations, and Modifications Time/Frequency/Condition Location

All aids and services identified will begin on the implementation date of the IEP and continue for the duration of the IEP.
Supplementary aids and services are not needed at this time.
Explain the extent, if any, to which the student will not participate with nondisabled students: .
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Section 6: Grades K-9

Assessment—Participation and Provisions
Based on Grade Level, Independence Level, and English Language Proficiency
State Assessments: Grades 3-9

Is a state assessment administered at the grade level(s) covered by this IEP? Yes No
If a state assessment is being administered, indicate in the Assessment column in which assessment the student will
participate. If the IEP team determines the Michigan Educational Assessment Program (MEAP) is not appropriate, see the MEAP-
Access eligibility criteria at www.michigan.gov/meap-access to determine if MEAP-Access is appropriate. If the IEP team
determines that the student must take an alternate assessment (MEAP-Access, MI-Access, or a district-determined social
studies assessment) instead of a particular MEAP assessment, complete the Rationale column.
Identify any individual appropriate accommodations that are necessary on these state assessments. See the Revised
Assessment Accommodation Summary Table at www.michigan.gov/meap.
Assessment
Assessment Rationale Accommodations
Area
MEAP
Reading The MEAP is not appropriate because:
Grades 3-8 MEAP-Access
Writing MI-Access: The alternate assessment is
Grades 4 and 7 Functional Supported appropriate because:
Participation
MEAP
The MEAP is not appropriate because:
MEAP-Access
Mathematics
Grades 3-8 MI-Access: The alternate assessment is
Functional Supported appropriate because:
Participation
MEAP The MEAP is not appropriate because:

Science
MI-Access:
Grades 5 and 8 Functional Supported The alternate assessment is
Participation appropriate because:
MEAP The MEAP is not appropriate because:

Social
Studies* District-Determined Assessment
Grades 6 and 9 The alternate assessment is
appropriate because:
* If the MEAP Social Studies Assessment is not appropriate for the student, the IEP team MUST identify a district-determined
assessment until there is a state-developed MI-Access Social Studies Assessment.
“District-wide assessments: Grades K-9” on next page
Page 16 of 21
District-wide Assessments: Grades K-9

Is a district-wide assessment administered at the grade level(s) covered by this IEP? Yes No
If a district-wide assessment is being administered, indicate in the Assessment column in which assessment the student will
participate. If the IEP team determines that district-wide assessment is not appropriate and that the student must take an
alternate assessment, identify the alternate assessment and complete the Rationale column.
Identify any individual appropriate accommodations that are necessary on these assessments.
District-wide Assessment

The district-wide assessment is not appropriate
because:

The alternate assessment is appropriate because:
Alternate Assessment


because:



because:


Page 17 of 21
Section 6: Grades 10-12

Assessment—Participation and Provisions
State Assessment—Michigan Merit Exam: Grades 11-12

For students at grade level 11: In which assessment will the student participate? Michigan Merit Exam (MME) MI-Access
For students at grade level 12: For MME retest eligibility, see details in the MME Student Eligibility document at
www.michigan.gov/mme. Will the student participate in the MME? Yes No
If the IEP team determines the student will participate in the MME, identify any individual appropriate accommodations that
are necessary on these state assessments. See the MME Chart of Accommodations Dates – ACT-Approved and State-Allowed at
www.michigan.gov/mme.
Assessment Area Accommodations

ACT Reading Comprehension
ACT English
ACT Mathematics
ACT Science
ACT Writing
WorkKeys Reading for Information
WorkKeys Applied Math
WorkKeys Locating Information
Michigan Mathematics
Michigan Science
Michigan Social Studies
State Assessment—MI-Access: Grade 11

For Grade 11: If the IEP team determines the MME is not appropriate, identify the alternate assessment in which the student
will participate and complete the Rationale column. Identify any individual appropriate accommodations that are necessary on
these state assessments. See the Revised Assessment Accommodation Summary Table at www.michigan.gov/mi-access.
MI-Access/
Assessment Area Rationale Accommodations
Functional The MME is not appropriate because:

English
Language Arts Supported The alternate assessment is appropriate because:
Grade 11
Participation

Mathematics
Supported
Grade 11 The alternate assessment is appropriate because:
Participation

Science
Supported The alternate assessment is appropriate because:
Grade 11
Participation
District-Determined The MME is not appropriate because:

Social Studies* Assessment
Grade 11 The alternate assessment is appropriate because:

* If the MME Social Studies Assessment is inappropriate for the student, the IEP team MUST identify a district-determined
assessment until there is a state-developed MI-Access Social Studies Assessment.
“District-wide assessments: Grades 10-12” on next page
Page 18 of 21
District-wide Assessments: Grades 10-12

Is a district-wide assessment administered at the grade level(s) covered by this IEP? Yes No
If a district-wide assessment is being administered, indicate in the Assessment column in which assessment the student will
participate. If the IEP team determines that district-wide assessment is not appropriate and that the student must take an
alternate assessment, identify the alternate assessment and complete the Rationale column.
Identify any individual appropriate accommodations that are necessary on these assessments.

because:



because:



because:


Page 19 of 21
Section 6: ELPA/NAEP (Grades K-12)

Assessment—Participation and Provisions: ELPA
State Assessment: English Language Proficiency Assessment (ELPA)

The Home Language Survey (HLS), a Title VI reporting requirement, is given to all students at the time of enrollment.
Please consider these two questions annually:
Is the student’s native tongue a language other than English? Yes No
Is a language other than English spoken in the student’s home or environment? Yes No
When either answer is Yes, complete the following section.
Assessment Level and Grade for Spring ELPA

Initial Screening Spring ELPA
and ELPA Initial Screening
Level I—Grade K
Level II—Grades 1-2
Level III—Grades 3-5
Level IV—Grades 6-8
Level V—Grades 9-12
For additional information regarding ELPA or the ELPA screener, or to identify any individual appropriate accommodations that
are necessary for each of the ELPA domains, see the Revised Assessment Accommodation Summary Table at
www.michigan.gov/elpa.
Assessed Domains Accommodations
Listening
Reading
Writing
Speaking
Assessment—Participation and Provisions: NAEP

National Assessment: National Assessment of Educational Progress (NAEP)

Is a NAEP assessment administered to the student’s district at the grade level(s) covered by this IEP? Yes No
Has the student participated in the Michigan Educational Assessment Program (MEAP) in the subject being tested? Yes No
Can the student participate in the NAEP with allowable accommodations? See the Revised Assessment Accommodation
Summary Table at www.michigan.gov/naep. Yes No
Can the student participate in the NAEP with allowable accommodations, even if the student did not participate in the MEAP, or
needs accommodations not allowed by the NAEP? Yes No
If YES, for each content area, indicate any assessment accommodation(s) that the
Assessment Participation student may need.
If NO, state the reason why a specific NAEP assessment is not appropriate.
Yes No
Yes No
Yes No
Page 20 of 21
Section 7
Special Education Services and Programs
Rule Specific Amount of

Related Service Location Duration*
Number Time and Frequency

Does the student have needs that require placement with a teacher with a particular endorsement? Yes No
Rule Depart- Specific Amount of

Program Location Duration*
Number mentalized Time and Frequency
Yes No
Yes No
Yes No
* All programs and services listed above will begin on the implementation date of the IEP and continue for the duration of the IEP,
unless otherwise indicated above in the column “Duration.”
EXTENDED SCHOOL YEAR (ESY) SERVICES
Extended School Year (ESY) services were considered.

It was determined that no ESY services are needed.
Current annual goals address one or more skills that require ESY services.
Specific Amount of
Service Location Duration
Time and Frequency

INSTRUCTIONAL TIME
General Education Instruction (+) Special Education Instruction (=) Total

(minutes/hours per week) (minutes/hours per week) (minutes/hours per week)
+ =
EDUCATIONAL ENVIRONMENT
The district ensures that, to the maximum extent appropriate, the student will be educated with students who are nondisabled;
and special classes, separate schools, or other removal of the student from the general education environment occurs only when
the student’s needs cannot be met satisfactorily in the general education setting with supplemental aids and services.
Participation in a Regular Early Childhood Program (students age 3-5)
At least 10 hours per week and:
receives the majority of special education and related services IN a regular early childhood program.
receives the majority of special education and related services OUTSIDE of a regular early childhood program.
Less than 10 hours per week and:

receives the majority of special education and related services IN a regular early childhood program.
receives the majority of special education and related services OUTSIDE of a regular early childhood program.
Participation in General Education (students age 6-26)

80% of the day or more 79% to 40% of the day less than 40% of the day separate facility
SPECIAL TRANSPORTATION
Yes (specify):

No
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Jay&#39;s IEP

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Jay&#39;s IEP

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Individualized Education Program (IEP)

Instructions for Fillable Version

Microsoft Word version 2007

Microsoft Word version 2003

IEP Team Meeting Initial IEP Annual/Review IEP Reevaluation IEP

Offer of a FAPE: Offer of a FAPE: Offer of a FAPE:

Individualized Education Program (IEP)

Last: First: M:

Address: City: State: Zip:

Resident District: Operating District:

County: Attending Building:

Last: First: M:

Native Language or Other Communication Mode:

Home Phone: Work Phone: Pager/Cell:

Parent Last: First: M: Relationship to Student:

Native Language or Other Communication Mode:

Home Phone: Work Phone: Pager/Cell:

Check one of the following: Check all others that apply:

PARENTAL RIGHTS AND AGE OF MAJORITY

Check all that apply:

IEP MEETING PARTICIPANTS IN ATTENDANCE

Parent and District Agreement on Attendance Not Necessary

Parent and District Agreement on Excusal Prior to Meeting

ELIGIBILITY FOR SPECIAL EDUCATION

Oral expression Listening comprehension Written expression Basic reading skill

Determination of eligibility was made in accordance with IDEA regulations at § 300.306(c)(1).

The IEP team must consider each of the following:

The strengths of the student:

The results of the most recent evaluation(s) of the student:

The communication needs of the student.

Braille instruction because the student is blind or visually impaired.

Section 2-B: Option I

ACADEMIC/PRE-ACADEMIC

GENERAL EDUCATION

SECONDARY TRANSITION

COMMUNICATION/

SOCIO-EMOTIONAL/

PERCEPTION/MOTOR/

INDEPENDENT LIVING

MEDICAL

Section 2-B: Option II

Section 2-B: Option III

What is the identified area of need?

STUDENT’S POSTSECONDARY GOALS (VISION)

Adult Living—As an adult, where do you want to live?

Career/Employment—As an adult, what kind of work do you want to do?

PLANNING/COMMUNITY SECONDARY TRANSITION SERVICES

Activity: Responsible agency/other:

PLANNING/COMMUNITY SECONDARY TRANSITION SERVICES continued

Activity: Responsible agency/other:

THE COURSE OF STUDY TRANSITION SERVICE

Short-Term Objective/Benchmark:

Status Date: Status Date:

Status Date: Status Date:

Short-Term Objective/Benchmark:

Status Date: Status Date:

Status Date: Status Date:

SCHEDULE FOR REPORTING PROGRESS

a)identify the letters verbally with flashcards (lowercase and capital)

SCHEDULE FOR REPORTING PROGRESS

Insert Progress Monitoring Data

• To advance appropriately toward attaining the annual goals.

Jay's IEP

Jay's IEP