School District Name:

School District Address:

School District Contact Person/Phone #:

Individualized Education Program

IEP Dates: from
Student Name: Charles Hendrix

DOB:

to

8/12/1987 ID#:

Grade/Level: 9

Parent and/or Student Concerns

What concern(s) does the parent and/or student want to see addressed in this IEP to enhance the student's education?

Charles' parents have expressed the following concerns: that Charles will make adequate reading progress throughout
his classes, develop strategies to increase his ability to focus, acquires organizational skills concerning recording
assignments. There is a strong concern that Charles develops coping strategies for stressful situations.

Student Strengths and Key Evaluation Results Summary

What are the students educational strengths, interest areas, significant personal attributes and personal accomplishments?
What is the students type of disability(ies), general education performance
including MCAS/district test results, achievement towards goals and lack of expected progress, if any?

Charles demonstrates strengths in both math and art, especially in terms of graphic design. He is also an avid member
of the varsity hockey and lacrosse teams. Charles exhibits an extroverted personality. He acquires friends easily and enjoys
spending time with peers in a social setting. He regularly volunteers for youth sports programs in his community. Charles is
eligible for special education under the Specific Learning Disabilities due to his diagnosis of Dyslexia. He is also eligible under
the Health Impairments section due to the presence of ADHD in his evaluation.
Charles struggles to maintain academic progress in subjects which require reading and reading comprehension skills. He
has difficulty reading and following directions. Due to his inability to understand instructions he often feels pressure and reacts
inappropriately to superiors as a result of stress.

Vision Statement: What is the vision for this student?

Consider the next 1 to 5 year period when developing this statement. Beginning no later than age 14,
the statement should be based on the students preferences and interest,
and should include desired outcomes in adult living, post-secondary and working environments.

Massachusetts DOE/Individualized Education Program

It is the team's vision that Charles will attend a 2-4 year college pursuing a degree in graphic design, in which he has
expressed interest. We envision that Charles will someday live on his own and secure a career in graphic design, specifically
in the area of logo design.

IEP 1

Individualized Education Program

IEP Dates: from

Student Name:

DOB:

to

ID#:

Present Levels of Educational Performance

A: General Curriculum
Check all that apply.
General curriculum area(s) affected by this students disability(ies):
English Language Arts

Consider the language, composition, literature (including reading) and media strands.

History and Social Sciences

Consider the history, geography, economic and civics and government strands.

Science and Technology

Consider the inquiry, domains of science, technology and science, technology and human affairs
strand.
Consider the number sense, patterns, relations and functions, geometry and measurement and
statistics and probability strands.

Mathematics
Other Curriculum Areas

Specify:

How does the disability(ies) affect progress in the curriculum area(s)?

Massachusetts DOE/Individualized Education Program

Charles' disability impacts achievement and performance in the curriculum areas identified above in the following ways:
Reading Fluency
In respect to reading fluency Charles reads fluently at a 5th grade level. During readings, issues that manifest are confusion of small words,
prepositions, interior details, insertions, line omissions.
Reading Comprehension
Charles has difficulty understanding written instruction, word problems, grade level material, writing accurate summaries, confusion of relevant
and irrelevant details, and locating main ideas.
Listening Comprehension
Charles is unable to re verbalize instructions, take oral information and transfer to written, create to-do lists or bullet lists, sequence oral
information, recognize cause-effect relationships.
What type(s) of accommodation, if any, is necessary for the student to make effective progress?
Setting
Charles will utilize preferential seating at the front of class facing teacher to maintain focus. During test taking he will be offered a corral to
limit stress and distraction.
Presentation
Material and directions will be presented utilizing multiple modalities such as modeling expectations and the steps of instructions as well as
presenting directions both in written and oral forms.
Mathematical word problems will be read aloud to the student.
Timing
Charles will be given extended time to complete assignments and assessments that involve reading.
What type(s) of specially designed instruction, if any, is necessary for the student to make effective progress?
Check the necessary instructional modification(s) and describe how such modification(s) will be made.

Content:

In Social Studies, Science, and Language Arts, reading level of content materials will be modified to his
current reading fluency level and amount of required material will be adjusted to include the most relevant
information.
His Language Arts class should be limited to maximum of 10 students. Charles will
attend individualized sessions with reading specialist twice a week during art class. Also
during mathematics class, he will receive therapy for stress reducing strategies once a
week.
Implementation of weighted graded system. Performance for Science and Social studies
performance will be assessed though samples of student work.

Methodology/Delivery of Instruction:

Performance Criteria:

Use multiple copies of this form as needed.

IEP 2

Massachusetts DOE/Individualized Education Program

IEP Dates: from

Individualized Education Program

Student Name:

DOB:

to

ID#:

Present Levels of Educational Performance

B: Other Educational Needs
Check all that apply.

General Considerations

Adapted physical education

Assistive tech devices/services

Behavior

Braille needs (blind/visually impaired)

Communication (all students)

Communication (deaf/hard of hearing students)

Extra curriculum activities

Language needs (LEP students)

Nonacademic activities

Social/emotional needs

Travel training

Skill development related to vocational

preparation or experience

Other

Age-Specific Considerations
For children ages 3 to 5 participation in appropriate activities
For children ages 14+ (or younger if appropriate) students course of study
For children ages 16 (or younger if appropriate) to 22 transition to post-school activities including community experiences, employment
objectives, other post school adult living and, if appropriate, daily living skills
How does the disability(ies) affect progress in the indicated area(s) of other educational needs?

What type(s) of accommodation, if any, is necessary for the student to make effective progress?

What type(s) of specially designed instruction, if any, is necessary for the student to make effective progress?
Check the necessary instructional modification(s) and describe how such modification(s) will be made.

Content:

Methodology/Delivery of Instruction:

Performance Criteria:

Use multiple copies of this form as needed.

Massachusetts DOE/Individualized Education Program

IEP 3

Massachusetts DOE/Individualized Education Program

Individualized Education Program

IEP Dates: from

Student Name:

DOB:

to

ID#:

Current Performance Levels/Measurable Annual Goals

Goal #

Specific Goal Focus:

Lee - Reading Fluency

Current Performance Level: What can the student currently do?

Charles can read fluently materials at a 5th grade level at a rate of 120 words per minute with minimal errors, 2 errors per 100 words.
Charles has difficulty reading fluently materials at a 6 th-7th grade level, reading at an average rate of 80 words per minute with 5-8 errors per
100 words. His errors include the confusion of small words, most notably conjunctions and articles, and interior and final details in multisyllabic words.
Measurable Annual Goal: What challenging, yet attainable, goal can we expect the student to meet by the end of this IEP period?
How will we know that the student has reached this goal?

Charles will use reading fluency skills such as increasing the number of words he reads per minute and reading materials
at a higher reading level with greater speed and accuracy to demonstrate ability beyond the current performance level as
measured by the following objectives and as documented from quarter to quarter.

Benchmark/Objectives: What will the student need to do to complete this goal?

When reading orally, Charles will read 5th grade reading material at a rate greater than 120 words per minute with fewer than 2 errors per
100 words in 4 out of 5 measured occasions.
-When reading orally, Charles will read materials at a level greater than fifth grade reading level at a rate greater than 100 words per minute with
fewer than 5 errors per 100 words in 7 out of 10 measured occasions.
-When reading orally a list of phrases that include small words, Charles will read at a rate of at least 100 words per minute with fewer than 3
errors per 100 words in 7 out of 10 measured occasions.
-When reading orally a list of multi-syllabic words and similar word pairs, Charles will read at a rate of at least 80 words per minute with fewer
than 5 errors in 7 out of 10 measured occasions.

Watson - Reading Comprehension

Goal #
Specific Goal Focus:
Current Performance Level: What can the student currently do?

Charles can provide an accurate description orally of what happened during a story read prior to assessment. He has the ability to pull out
concrete details from the text and verbalize them during class discussion. Charles can provide a verbal summary of events although it
sometimes may lack sequential ordering. Charles has difficulty sorting between irrelevant and relevant details in order to grasp the main idea of
readings when given a writing prompt.
Measurable Annual Goal: What challenging, yet attainable, goal can we expect the student to meet by the end of this IEP period?
How will we know that the student has reached this goal?

Charles will use active reading skills to increase his ability to comprehend written material. Charles will demonstrate reading
comprehension skills through actively engaging in the text such as forming questions and predictions relevant to the topic. After each reading
Charles will answer questions designed to assess his comprehension of concrete details. He will begin to identify main ideas from multiple
choice questions about each reading.
Benchmark/Objectives: What will the student need to do to complete this goal?

Prior to reading selections in class, Charles will form 4-5 questions and predictions relevant to the topic in 9 out of 10
measured instances.
After reading a selection, whether orally or silently, Charles will answer 3-5 questions designed to assess his comprehension of
concrete details accurately in 7 out of 10 measured occasions.
After reading a selection independently, Charles will indicate the correct main idea in a multiple choice questions by selecting the
correct response in 8 out of 10 questions.
Progress Reports are required to be sent to parents at least
1. What is the students progress toward the annual goal?
as often as parents are informed of their nondisabled
2. Is the progress sufficient to enable the student to achieve
childrens progress. Each progress report must answer the
the annual goal by the end of the IEP period?
following two questions for each goal:

Massachusetts DOE/Individualized Education Program

Individualized Education Program

IEP Dates: from

Student Name:

DOB:

to

ID#:

Current Performance Levels/Measurable Annual Goals

Goal #

Specific Goal Focus:

Koufman - Pragmatics

Current Performance Level: What can the student currently do?

Charles can speak politely to superiors when in a one-on-one situation without peers present. Charles can raise counterarguments and
challenge what is taught to him.
Charles responds aggressively by insisting that he is correct when his teacher corrects his mistakes during class discussion. Charles debates
with his teacher when the teacher redirects Charles's attention away from a discussion with his peers and back to the task at hand.
Charles becomes flustered during impromptu conversations with adults outside of class. Charles becomes noticeably anxious and
noncompliant during conversations with school faculty and other adults that he is not familiar with.

Measurable Annual Goal: What challenging, yet attainable, goal can we expect the student to meet by the end of this IEP period?
How will we know that the student has reached this goal?

Charles will demonstrate improvement of his pragmatics skills in the areas of responding to corrections made by his teacher in class on
assignments, and in responding to his teacher's requests in front of his peers to retain focus on the task at hand. Charles will demonstrate
progress in his responses during conversations to adults in the lunchroom, and in other general settings.
Charles will work with a pragmatics instructor to improve his pragmatic skills during one class period per week. The pragmatics instructor
will help Charles understand his aggression and stubbornness. The pragmatics instructor will also help Charles understand what is being
asked in different scenarios. For example, Charles will study the interaction between a train conductor and a person purchasing a ticket. The
pragmatics teacher will assess Charles's progress both through in-class assessments and by talking to Charles's teachers. Charles should
maintain at least a B+ in his pragmatics course.
Benchmark/Objectives: What will the student need to do to complete this goal?
When Charles takes issue with a piece of the content, he will voice his interjection in the form of a question in 8 out of 10 measurable
instances.
When corrected by his teacher in class for making errors on an assignment, Charles will avoid debating with his teacher for 5 instances per
week.
When redirected by his teacher during class back to the task at hand, Charles will apologize to his teacher, will cease speaking with his peers,
and redirect his focus to class materials in no more than 30 seconds in 1 out of 3 occasions.

Metterville - Organizational Skills

Goal #
Specific Goal Focus:
Current Performance Level: What can the student currently do?

Charles has difficulty taking the initiative to record homework assignments in his agenda on a daily basis. He often does not complete
homework and when asked why, responds that he didn't write it down and forgot. He has trouble understanding the value and use of the
homework recording templates provided in his school agenda.
Measurable Annual Goal: What challenging, yet attainable, goal can we expect the student to meet by the end of this IEP period?
How will we know that the student has reached this goal?

Charles will improve organization specifically with recording homework. When homework is given out, Charles will take out his
school provided agenda and record the given assignment. Teacher will place a check mark next to the recorded assignment. Charles will use
these skills to demonstrate ability beyond his current performance level as measured through the following objectives and documented quarter
to quarter.
Benchmark/Objectives: What will the student need to do to complete this goal?

Massachusetts DOE/Individualized Education Program

When provided with an organizational template, Charles will organize his materials according to the template with fewer
than 10 teacher checks in 8 out of 10 occurrences.

Progress Reports are required to be sent to parents at least

as often as parents are informed of their nondisabled
childrens progress. Each progress report must answer the
following two questions for each goal:

3.

What is the students progress toward the annual goal?

4.

Is the progress sufficient to enable the student to achieve

the annual goal by the end of the IEP period?

Use multiple copies of this form as needed.

IEP 4

Massachusetts DOE/Individualized Education Program

IEP Dates: from

Individualized Education Program

Student Name:

DOB:

to

ID#:

Service Delivery
What are the total service delivery needs of this student?
Include services, related services, program modifications and supports (including positive behavioral supports, school personnel and/or parent
training/supports). Services should assist the student in reaching IEP goals, to be involved and progress in the general curriculum, to participate in
extracurricular/nonacademic activities and to allow the student to participate with nondisabled students while working towards IEP goals.

School District Cycle:

5 day cycle

6 day cycle

10 day cycle

other:

A. Consultation (Indirect Services to School Personnel and Parents)

Focus on
Goal #

Type of Service

Type of Personnel

Frequency and
Duration/Per Cycle

Start Date

End Date

Reading Instruction

Reading Specialist/Para to
all faculty

1x@15 min

9/11

6/12

Pragmatics Consult

Speech and Language

Pathologist to all faculty

1x@10 min.

9/11

6/12

B. Special Education and Related Services in General Education Classroom (Direct Service)
Focus on
Goal #

2,4

Type of
Service

Type of
Personnel

Frequency and
Duration/Per Cycle

Start Date

End Date

Special educator/Para

5x@45min

9/11

6/12

2,4

Academic SupportLanguage Art

Academic Support-Science

Special Educator/Para

3x@45 min

2,4

Academic Support-History

Special Educator/Para

5x@45 min

C. Special Education and Related Services in Other Settings (Direct Service)

Focus on
Goal #

Type of
Service

Type of
Personnel

Frequency and
Duration/Per Cycle

Start Date

End Date

Reading Instruction

Reading Specialist

3x@45 min

9/11

6/12

Pragmatics Instruction

1x@45 min

Speech and Language

Pathologist/Para

Massachusetts DOE/Individualized Education Program

Use multiple copies of this form as needed.

IEP 5

Massachusetts DOE/Individualized Education Program

IEP Dates: from

Individualized Education Program

Student Name:

DOB:

to

ID#:

Nonparticipation Justification
Is the student removed from the general education classroom at any time? (Refer to IEP 5Service Delivery, Section C.)
No

Yes

If yes, why is removal considered critical to the students program?

Charles is removed from the general education classroom in order to participate in reading instruction because he needs individual
instruction in reading fluency and comprehension. Charles is also removed from the general education classroom to receive pragmatics
instruction in order to remediate his response to criticism.

IDEA 97 Regulation 300.550(b)(2): ... removal of children with disabilities from the regular educational environment occurs only if the nature
or severity of the disability is such that education in regular classes with the use of supplementary aids and services cannot be achieved
satisfactorily. (Emphasis added.)

Schedule Modification
Shorter: Does this student require a shorter school day or shorter school year?
No

Yes shorter day

Yes shorter year

If yes, answer the questions below.

Longer: Does this student require a longer school day or a longer school year to prevent substantial loss of previously learned
skills and / or substantial difficulty in relearning skills?
No

Yes longer day

Yes longer year

If yes, answer the questions below.

How will the students schedule be modified? Why is this schedule modification being recommended?
If a longer day or year is recommended, how will the school district coordinate services across program components?

Transportation Services
Does the student require transportation as a result of the disability(ies)?
No

Regular transportation will be provided in the same manner as it would be provided for students without disabilities. If
the child is placed away from the local school, transportation will be provided.

Yes

Special transportation will be provided in the following manner:

on a regular transportation vehicle with the following modifications and/or specialized equipment and precautions:

on a special transportation vehicle with the following modifications and/or specialized equipment and precautions:

After the team makes a transportation decision and after a placement decision has been made, a parent may choose to provide
transportation and may be eligible for reimbursement under certain circumstances. Any parent who plans to transport their child
to school should notify the school district contact person.

Massachusetts DOE/Individualized Education Program

IEP 6

Massachusetts DOE/Individualized Education Program

Individualized Education Program

IEP Dates: from

Student Name:

DOB:

to

ID#:

State or District-Wide Assessment

Identify state or district-wide assessments planned during this IEP period:

Fill out the table below. Consider any state or district-wide assessment to be administered during the time span covered by this IEP. For each
content area, identify the students assessment participation status by putting an X in the corresponding box for column 1,2, or 3.
1. Assessment participation: Student 2. Assessment participation: Student 3. Assessment participation: Student
participates in
participates in
participates in alternate
on-demand testing under routine
on-demand testing with
assessment in this content area.
conditions in this content area.
accommodations in this content
(See below)
area. (See below)
CONTENT AREAS

COLUMN 1

COLUMN 2

COLUMN 3

English Language Arts

History and Social Sciences
Mathematics
Science and Technology
Reading

For each content area identified by an X in the column 2 above: note in the space below, the content area and describe the
accommodations necessary for participation in the on-demand testing. Any accommodations used for assessment purposes
should be closely modeled on the accommodations that are provided to the student as part of his/her instructional program.
For all content areas Charles will receive the following accommodations:
-Specified area: Front of room, in a study carrel, or other enclose area.
-Test Administrator reads test aloud.
-Test Directions clarified.

For each content area identified by an X in column 3 above: note in the space below, the content area, why the on-demand
assessment is not appropriate and how that content area will be alternately assessed. Make sure to include the learning
standards that will be addressed in each content area, the recommended assessment method(s) and the recommended
evaluation and reporting method(s) for the students performance on the alternate assessment.

NOTE
When state model(s) for
alternate assessment are
adopted, the district may
enter use of state model(s)
for how content area(s) will
be assessed.

Massachusetts DOE/Individualized Education Program

IEP 7

Massachusetts DOE/Individualized Education Program

IEP Dates: from

Individualized Education Program

Student Name:

DOB:

to

ID#:

Additional Information
Include the following transition information: the anticipated graduation date; a statement of interagency responsibilities or
needed linkages; the discussion of transfer of rights at least one year before age of majority; and a recommendation for
Chapter 688 Referral.
Document efforts to obtain participation if a parent and if student did not attend meeting or provide input.
Record other relevant IEP information not previously stated.
Anticipated graduation date June 2015.
Charles is expected to consult with the Massachusetts Rehab Commission (MRC) upon graduation. This consultation will
develop strategies to ensure Charles has safe and productive learning environment. In addition, Charles will continue to
effectively use self-advocacy skills to further his confidence in requesting services needed.
Transfer rights will be determined on the next IEP review session after reviewing the upcoming school year and progress

Response Section
School Assurance
I certify that the goals in this IEP are those recommended by the Team and that the indicated services will be
provided.
Signature and Role of LEA Representative

Joshua Krumbe

Date

Parent Options / Responses

It is important that the district knows your decision as soon as possible. Please indicate your response by checking at
least one (1) box and returning a signed copy to the district. Thank you.
I accept the IEP as developed.

I reject the IEP as developed.

I reject the following portions of the IEP with the understanding that any portion(s) that I do not reject will be considered
accepted and implemented immediately. Rejected portions are as follows:

I request a meeting to discuss the rejected IEP or rejected portion(s).

Signature of Parent, Guardian, Educational Surrogate Parent, Student 18 and Over*

Date

*Required signature once a student reaches 18 unless there is a court appointed guardian.
Parent Comment: I would like to make the following comment(s) but realize any comment(s) made that suggest changes to the
proposed IEP will not be implemented unless the IEP is amended.

Massachusetts DOE/Individualized Education Program

IEP 8

Massachusetts DOE/Individualized Education Program