PURPOSE: The IEP is designed to clearly communicate to the parents, the student, and providers the type and

amount of special education and any necessary related services or

supports that will be made available to the student. The most recent evaluation report is used to develop the IEP. The IEP is individualized to reflect the unique needs of the student and
how these needs will be addressed to permit the student to be included and progress in the general education curriculum.

INDIVIDUALIZED EDUCATION PROGRAM (WITH SECONDARY TRANSITION)

Jordan Smith
12345
Student name:
Student ID No.:
Date of IEP meeting: 5/20/16
6/27/98
17
11
Birthdate:
Age:
Grade:
IEP annual review date: 12/19/17
Multiple Disabilities
Adult student: Yes No
Eligibility category:
Date of most recent eval: 2/5/16
English
Race/Ethnicity:
Primary language:
Reevaluation due date: 11/17/18
Newport High School
District: Bellevue School District Resident School:
Serving School (if different):
Derek
and
Emma
Smith
English
Parent(s) name(s):
Primary language at home:
Parent interpreter needed? Yes No
Surrogate parent: Yes No If yes, name:
Megan
Erwin
Special Education Teacher
Primary staff contact name:
Title:

PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Present levels of academic achievement:
Jordan is a hardworking young man. He has shown improvements throughout his time in High School, and is working
towards his goals. Jordan has slowely began to open up a bit more socially, however, he enjoys keeping to himself.
Jordan is currently recieving Special Education Services in Reading, Writing, and Math as a student diagnosed with
Multiple Disabilities. Jordan has been diagnosed with Emotional Disability, a Communication Disorder, and a Specific
Learning Disability.
Reading- Jordan achieved a below average Reading Composite Score of 70. On the Letter & Word Recogonition section
of the assessment he achieved a below average standard score (SS) or 77 at a 4.8 grade equivalent (GE). He scored lower
extreme on the Reading Comprehension section, obtaining a SS=66, 3.6 GE. Jordan was able to use letter word
combinations to sound out words including: blossomed, conductor, guarded, and meant. He was not yet able to sound
out the words: limosine, archaeologist, kerosene, and alibi. Inferential Comprehension was identified as an area of
weakness for Jordan. This is, his ability to answer comprehension questions requiring him to infer actions,beliefs,
authors intent, or purpose when not directly stated in the passage.
Written Language- Writing continues to be an area of weakness for Jordan. On the written expression section of the
test, he obtained a below average standard score of 72, 2.2 GE. Jordan has difficulty with structure (the ability to
combine sentences or compose sentences or paragraphs that are well constructed), Captialization and Punctuation. His
written expression is also low due to limited vocabulary and fluency. When asked to combine 2 or 3 sentences into once
coherent sentence, Jordan did not attent to use transition workds or phrases. He is able to write with purpose but
struggles writing correctly structured complex sentences. On the essay portion of the assessment, Jordan was provided
10 minutes on what should have been the longer response on the test. He was only able to produce 1 sentences with
effected his overall score. On a recent classroom base writing assignment, given the prompt What would you do if you
Form 6d - IEP (with Secondary Transition)

Page 1

POINTS THAT MUST BE

CONSIDERED IN
DEVELOPING THE IEP (refer
to WAC 392-172A-03110):
Results of the most current
evaluation, and the academic,
developmental, and functional
needs of the student.
Positive behavioral supports
and interventions, if the
students behavior impedes the
students learning or that of
others.
Language needs of students
with limited English
proficiency as they relate to the
childs IEP.
Supports for blind/visually
impaired students, include
Braille instruction.
Communication needs of the
student, including the needs for
deaf and hard of hearing
students.
Assistive technology devices
and services.
Supplementary aids/services,
program modifications, and
support for school personnel.
August 2008 (revised January 2016)

had a snow day?. Jordan was asked to write two paragraphs explaining what he would do if you had a snow day and
including 5 provided vocabulary words. Jordan was able to produce one paragraph. His paragraph was on topic, but
lacked elaboration and included multiple spelling and grammar errors. He only included only 2 of the 5 provided words.
His same aged peers are able to produce clear and coherent writing in which the development, organization, and style are
approximate to task, purpose and audience.
Math- Math concepts and application with a relative strength for Jordan. His scores were in the below average to lower
extreme range compared to that of his same age. On the math concepts and applications section he achieve a belowaverage standard score (SS) of 84, 6.5 GE. On the map computations section of the test he achieved a lower extreme SS
of 71, 3.6 grade equivalent (GE). Jordan was able to use several strategies when attempting to solve problems including
paper, half mark, reducing tree, counting on his fingers, self-talk, and mental math. Jordan was (without a calculator)
able to add and subtract single and double digit numbers, and multiply single digit number by a double digit number.
Jordan was not able to multiply a double digit number with double digit number without a calculator, nor add numbers
with decimals, reduced, multiply, divide fractions, or solve simple equations.

Present levels of functional performance (i.e. communication, motor, social, behavior, life/adaptive skills, etc.):
Social/Emotional Behavior- Results indicate overall average range externalizing problems and internalizing problems
by parent and teacher ratings. Jordan self report indicates clinically significant to at-risk ratings for internalizing
problems, emotional symptoms index, and personal adjustment. Parent and teacher ratings indicate elevated areas in
school problems, learning problems, and related to social skills (withdrawal, atypicality, adaptability, and functional
communication).
Language Receptive/Expressive- Jordan was tested in the areas of expressive/receptive vocabulary, language, and
pragmatics. He presents with a language impairment in the area of applying social communication (CELF-5: Pragmatic
Profile) in the educational environment yet within the average range of the CASL-Pragmatic Judgement Test. In class
Jordan does not readily answer questions, rarely participates in small or large group activities, and speak so others
cannot hear him. He prefers to not be seen or heard and will wear his hood up, cover his mouth when speaking and uses
a volume that is too quiet to be heard easily. Due to this, Jordan struggles to demonstrate his understanding of academic
curriculum and appears uninterested in developing relationships with peers.

Form 6d - IEP (with Secondary Transition)

Page 2

August 2008 (revised January 2016)

Effect of the disability on the students involvement and progress in the general education curriculum:
Jordan's learning disability interferes with his involvement with and progress and the general education curriculum. He is developing reading, math,
and written expression skills at a rate and levels significantly below his same age. Despite general education interventions and accommodations.
Specifically designed instruction in Reading, Writing, and math would be beneficial to support his progress towards meeting grade-level learning
expectations in these areas.

CONSIDERATION OF SPECIAL FACTORS:

If yes, describe (if not already addressed on the service matrix):

1.
Does this student require special
transportation?

3.
Does this student require Extended
School Year (ESY) services?

Yes No
Yes No
Will be determined by
the IEP team by:

If ESY is determined by the IEP team to be necessary, complete and

attach the ESY addendum.

Date:

4.
Does the students behavior
negatively impact his/her learning or the
learning of others?

Yes No

5.
Are there any other factors not
already addressed (such as medical concerns
or other issues) or other adaptations needed?

Yes No

If yes, consider the students need for positive behavioral supports/

interventions, a Functional Behavioral Assessment (FBA), and/or a
Behavioral Intervention Plan (BIP).
A Behavioral Intervention Plan has been developed for this
student (refer to the BIP addendum).
If yes, describe:

The parent and the school district have agreed that this student requires advanced educational planning that may involve the use of isolation,
restraint, or a restraint device. Refer to the Emergency Response Protocol addendum to this IEP.
Form 6d - IEP (with Secondary Transition)

Page 3

August 2008 (revised January 2016)

Form 6d - IEP (with Secondary Transition)

Page 4

August 2008 (revised January 2016)

PURPOSE: The purpose of transition planning is to develop a coordinated set of activities designed within a results-oriented process that is focused on improving the academic
achievement and functional performance of the student in order to facilitate the students movement from school to post-school activities, including postsecondary education/training,
employment, and if appropriate, independent living skills.

SECONDARY TRANSITION
Student participated in IEP meeting? If no, what steps were taken to ensure that the students preferences/interests were considered?
Yes

No

AGE APPROPRIATE TRANSITION ASSESSMENTS (include results of informal and/or formal assessments including
students needs, strengths, preferences, and interests):
surveys/questionnaires profiles/portfolios vocational assessment(s) other: Functional Vocational Interview

Result Description:
Expressed: Jordan reports that he likes to draw, specifically in pen and pencil. He does not like to draw in color. When he is
bored, Jordan likes to go for walks. He reports that he used to be into gaming.
Observed: Jordan has been observed drawing.
Work Preferencess:
Expressed: Jordan prefers to be self-directed. He does not mind working indoors or outdoors, depending on the weather. He
prefers to have a routine and structure with predictable tasks, however he reports that when he does not like a task he will
just wait for time to pass and the task to be over. He does not have a preference for doing physical or non physical activities.
He reports that his preference for working by himself or others depends on who he is working with. He admits that he gets
bored sometimes, however he gets used to tasks. Jordan reports that he prefers face-to-face instructions, otherwise he misses
some instruction do to his hair and hood covering his ears. Jordan prefers to be read to and be given verbal directions
individually. When he reads to himself, he gets stuck on sentences or questions and has difficulty moving beyond that
phrase.
Observed: Jordan previous IEP indicated that he prefer some extra time on assignments, to work independently, to do group
work, and hands-on activities.
Strengths:
Interpersonal: Jordan reports that he has strength in keeping a schedule, talking to his family, and talking to older people. He
sees himself as a giving person. Jordan says that he tries to make other people feel good and, bring them up, by dressing a
certain way and to go unnoticed.
Academic: math and art.
Community/Vocational: Jordan reports that he is good at cleaning and asking people if they want their lawns mowed.
Limitations/Supports Needed:
Interpersonal: Jordan reports that he is not always comfortable. He does not see himself as intelligent. Jordan says that he
gets bored easily when someone talks too much and continues to explain themselves. He reports this happens in some of his
classes when the teacher is interupted and continues to repeat the instruction. Jordan will, blank out for a while, and then
get behind and the instruction. Jordan reports that he has a few acquaintances, however he cannot be relied upon for favors.
Academic: Jordan does not like Sciences, particularly because he does not like talking about religion, and he feels that the
Form 6d - IEP (with Secondary Transition)

Page 5

POINTS TO CONSIDER:
Secondary transition
must be addressed in the
first IEP to be in effect
when the student turns
16, or younger if
determined appropriate
by the IEP team, and
updated annually.
Measurable
postsecondary goals,
based upon ageappropriate transition
assessment results, must
be included in the areas
of education/training,
employment, and (if
appropriate) independent
living skills.
Transition services
should be based on the
individual students
needs, taking into
account the students
strengths, preferences,
and interests, and may
include instruction,
related services,
community experiences,
the development of
employment and other
postschool adult living
objectives, and if
appropriate, the
acquisition of daily living
skills and provision of a
functional vocational
evaluation.

August 2008 (revised January 2016)

two get mixed up. He reports that he is not much of a talker in class.
Community/Vocational: Jordan says that it is hard for him to communicate what he is thinking to others. He reports that he
will have clear ideas in his head, however when he goes to express his ideas, they do not come out clearly and other people
have difficulty understanding.
Work Experiences:
School Based: Jordan has work in the student store doing cleaning tasks. As a tenth grader he attended the job fair at the
local community college.
Community Based: Jordan has mowed lawns and I move the logs for his neighbors. Sometimes he will go grocery shopping
with his parents. At home, Jordan is responsible for feeding animals and cleaning up the house.

EDUCATION/TRAINING (Required to be addressed for all students)

Measurable Postsecondary Goal(s)
(What the student will do after graduation from high
school in the area of education/training)

After High School Jordans goal is to attend college to obtain a degree in art
design.

Transition Services (list Transition Services related to Education/Training, including IEP goal number(s) if applicable)
Transition Service
Staff/Agency Responsible

IEP Goal #

EMPLOYMENT (Required to be addressed for all students)

Measurable Postsecondary Goal(s)
(What the student will do after graduation from
high school in the area of employment)

Jordan is interested in pursuing a career as a graphic artist. He has also done

career research in the areas of multimedia artist and animator and being a
fine artist. Jordans backup plan is to be a grounds keeper, and anticipats
doing grounds maintenance while he figures out his post-secondary plans.

Transition Services (list Transition Services related to Employment, including IEP goal number(s) if applicable)
Transition Service
Staff/Agency Responsible

Form 6d - IEP (with Secondary Transition)

Page 6

IEP Goal #

POINTS TO CONSIDER
(continued):
Transition services
may be special education, if
provided as specially
designed instruction or
related services, if required
to assist the student in
benefitting from special
education.
August 2008 (revised January 2016)

 Representatives of
any agencies that are likely
to be responsible for
providing or paying for
transition services to the
student should be invited to
the IEP meeting, with parent
consent.
INDEPENDENT LIVING SKILLS (Must be addressed if determined appropriate by the IEP Team)
Measurable Postsecondary Goal(s) Jordan is not sure where he will live after high school. He is worried about
(What the student will do after graduation from
high school in the area of living skills)

being lonely if he ends up living alone.

Transition Services (list Transition Services related to Independent Living Skills, including IEP goal number(s) if applicable)
Transition Service
Staff/Agency Responsible

IEP Goal #

COURSE(S) OF STUDY (list the course(s) of study needed to assist the student in reaching his/her postsecondary goals, unless already
described above, or attach a list of courses)

Form 6d - IEP (with Secondary Transition)

Page 7

POINTS TO CONSIDER
(continued):
Independent living
skills are those skills or
tasks that contribute to the
successful independent
functioning of an
individual in adulthood
(Cronin, 1996) in the
following domains:
leisure/recreation, home
maintenance and personal
care, and community
participation.

POINTS TO
CONSIDER
The IEP must
include a description or
list of the course(s) of
study needed to assist
the student in reaching
his/her specific
postsecondary goals.

August 2008 (revised January 2016)

PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet each of the students educational needs that result
from the students disability to enable the student to be involved and make progress in the general education curriculum. In order to be measurable, the goal should include a baseline,
a target, and a unit of measure. For students using an alternate assessment aligned to alternate achievement standards, the IEP team should use the Measurable Annual Goal(s) with
Short-term Objectives/Benchmarks page (see next page).

MEASURABLE ANNUAL GOAL(S)

Goa
l#

Measurable Annual Goal

Method/Criteria for
Evaluating Progress
(if not addressed in a
separate document)

Reading-

Form 6d - IEP (with Secondary Transition)

Page 8

Progress Notes (if not maintained separately)

Date

Date

Date

Date

POINTS TO
CONSIDER:
Measurabl
e annual goals
stem from the
recommendations
for specially
designed
instruction in the
evaluation report.
Measurable
annual goals must
relate to the
general education
curriculum or, for
preschool
students,
participation in
appropriate
activities.
Measurable
annual goals must

August 2008 (revised January 2016)

also address other

educational needs
that result from
the students
disability.
The IEP must
include a
description of
how the district
will measure the
students progress
and when
progress will be
reported to
parents.

Writen Language-

Copy additional pages as necessary

PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet each of the students educational needs that result
from the students disability to enable the student to be involved and make progress in the general education curriculum. For students using an alternate assessment aligned to alternate
achievement standards, benchmarks or short-term objectives in the areas being assessed must also be included. In order to be measurable, the goal should include a baseline, a target,
and a unit of measure.

MEASURABLE ANNUAL GOAL(S) WITH SHORT-TERM OBJECTIVES/BENCHMARKS

Goa
l#

Measurable Annual Goal

Method/Criteria for
Evaluating Progress

Progress Notes (if not maintained separately)

Date

(if not addressed in a

separate document)

Form 6d - IEP (with Secondary Transition)

Page 9

Date

Date

Date

POINTS TO
CONSIDER:
Measurable annual
goals stem from the

August 2008 (revised January 2016)

recommendations
for specially
designed instruction
in the evaluation
report.
Measurable annual
goals must relate to
the general
education
curriculum or, for
preschool students,
participation in
appropriate
activities.
Measurable annual
goals must also
address other
educational needs
that result from the
students disability.
The IEP must
include a description
of how the district
will measure the
students progress
and when progress
will be reported to
parents.

Math-

Benchmarks or Short-Term Objectives

Copy additional pages as necessary

Form 6d - IEP (with Secondary Transition)

Page 10

August 2008 (revised January 2016)

Form 6d - IEP (with Secondary Transition)

Page 11

August 2008 (revised January 2016)

PURPOSE: The purpose of the report of student progress is to inform the parents and the student of the students progress toward meeting the measurable annual goal(s) and to specify
how and when parents will be informed.

REPORT OF STUDENT PROGRESS:

POINTS TO CONSIDER:
Parents should be provided periodic reports on the students progress (such as through the
use of quarterly or other periodic reports, concurrent with the issuance of report cards).

State how the students progress toward meeting the annual goal(s) will be measured (if not already addressed on measurable annual goal page(s)):
Jordans progress toward meeting annual goals will be measured by classroom assingments, observations, written work, and teacher gathered data.

State how the parents will be periodically informed of the students progress toward meeting the annual goal(s):
Jordans parents will be periodically informed of the students progress after each grading period.

PARTICIPATION IN STATE AND DISTRICTWIDE ASSESSMENTS OF STUDENT ACHIEVEMENT

POINTS TO CONSIDER:
State Assessments The student will participate in the following state assessment(s) during this annual IEP:
The IEP team makes the
English/
determination of what type
Lang Arts
Math
Science
of assessment the student
will take and what

Regular State Assessment

administrative

Regular State Assessment with Accommodations

modifications and

Alternate Assessment
individual accommodations
are necessary.

Other:
Accommodations provided
Districtwide Assessments The student will participate in the following districtwide assessment(s) during this annual
on state and districtwide
IEP:

Accommodations List any individual accommodations in the administration of the state or districtwide assessments
necessary for the student to participate:
Individual or small group setting for testing
Extended time
A scribe
Breaks as needed
If the student: (a) will not participate in the regular state assessment (with or without accommodations) or (b) is unable
to participate in a regular districtwide assessment, explain why the student cannot participate in the regular assessment
and why the selected assessment option is appropriate:
N/A

Form 6d - IEP (with Secondary Transition)

Page 12

assessments should be those

that are provided as part of
the regular instructional
program.
For further information
regarding the state
assessment system,
allowable accommodations,
and graduation
requirements, please refer
to OSPIs website
(www.k12.wa.us/assessment
).
Other assessment options
are available to students if
required to meet graduation
requirements.

August 2008 (revised January 2016)

Graduation If the student requires other assessments in order to meet graduation requirements, describe
here (specify assessment and grade level as appropriate):
Obtained from: http://www.k12.wa.us/assessment/StateTesting/

Parents and students should be informed

that any assessment other than the regular
state assessment (with or without
accommodations) leads to a Certificate of
Individual Achievement (CIA), rather than a
Certificate of Academic Achievement
(CAA).

PURPOSE: The purpose of this page is to document the modifications and/or accommodations that the student requires, based on the students assessed needs, in order to advance
appropriately toward attaining the identified annual goals, to be involved and make progress in the general education curriculum, and to be educated with non-disabled peers to the
maximum extent appropriate.

Subject
(codes below)

ACCOMMODATIONS, MODIFICATIONS, AND ASSISTIVE TECHNOLOGY

Subject Accommodations/Modifications Needed
Accommodations/Modifications Needed
(codes below)

Presentation

b,c,d,e
b,c,d,e
b,c,d,e
b,c,d,e
b,c,d,e

Use large print/Braille/recorded books

Alter format of materials (highlight, type, spacing, color-code etc.)
Low-vision devices (magnifiers, Closed Circuit TV, etc.)
Sign Language ASL or SEE
Shortened assignments
Preview test procedures
Limited multiple choice
Rephrase test questions and/or directions
Provide test/quiz study guide

Form 6d - IEP (with Secondary Transition)

Setting
b,c,d,e
b,c,d,e
b,c,d,e

Provide individualized/small group instruction

Read class materials orally
Provide study outlines/guides/graphic organizers
Modify/repeat/model directions
Take test in separate location
Preferential seating
Other:

POINTS TO
CONSIDER:
The IEP team
makes the
determination of
what

Response
b,c,d,e
Page 13

Utilize oral responses to assignments/tests

August 2008 (revised January 2016)

b,c,d,e
b,c,d,e
b,c,d,e

Provide extra credit options

Simplify test wording
Read class materials orally
Assign peer tutor/note taker
Other:

b,c,d,e
b,c,d,e

Prior notice of tests/quizzes

Extra time to complete assignments
Modify students schedule (describe below):

Timing/Scheduling

b,c,d,e
a

Text-to-Speech (Kurzweil, WYNN, Text Help, etc.)

Allow dictation to a scribe
Allow use of a calculator
Allow use of tape recorder
Spelling and grammar devices
Speech-to-text software
Hands-on assignments
Other:

Other

Extra time on tests/quizzes

Allow breaks (during work, between tasks, during testing, etc.)
Other:

a
a
a
a

Provide desktop list of tasks

Provide homework lists
Behavior plan/contract
Provide daily assignment list
Modified grading
Other:

Assistive Technology
Describe:
Describe:
Describe:
a.
subjects
b.
ding
c.
ish
d.
ling

All

e.

Mat

f.

Scie

h
Rea
nce
Engl
Spel

g.
Soci
al Studies
h.
Hist
ory

Form 6d - IEP (with Secondary Transition)

i.
Health
j.
Economics
k.
Physical
Education
l.
Music/Art

Page 14

m.
Voca
tional
n.
Lun
ch/Recess
o.
Libr
ary

p.
q.
r.

Extracurricular Activities
Other:
Other:

August 2008 (revised January 2016)

PURPOSE: The information on this page is a summary of the students program/services, including when services will begin, where they will be provided, who will be responsible for
providing them, and when they will end.

SUMMARY OF SERVICES MATRIX

Service

Initiation
Date

Frequency
(i.e. minutes per week)

Location of
Service

Duration

(setting)

Staff Responsible
for Delivering
Service

Special Education (specially designed instruction):

Reading

5/20/16

Writing

5/20/16

Math

5/20/16

240 minutes per

week
240 minutes per
week
240 minutes per
week

Specia Education
Classroom
Special Education
Classroom
Special Education
Classroom

5/19/17
5/19/17
5/19/17

Special Education
Teacher
Special Educatin
Teacher
Special Education
Teacher

Related Services (i.e. speech, motor, counseling, vision/hearing, transportation, interpreting services, orientation/mobility, parent training, etc.):

Supplementary Aids and Services (allows student to be educated with non-disabled peers to the maximum extent in general education or other

POINTS TO
CONSIDER:
If the position
responsible for
delivering the
specially designed
instruction is anyone
other than a
certificated special
education teacher or
related service
provider, then the
certificated special
education
teacher/related
service provider must
design and supervise
the instruction, and
monitor and evaluate
the students
progress.
For definitions of
special education,
related services, and
supplementary aids
and services, refer to
WAC 392-172A01020 through
-01200.

educational setting):

Program Modifications or Support for School Personnel (i.e. staff development/training, technical assistance, etc.):

Form 6d - IEP (with Secondary Transition)

Page 15

August 2008 (revised January 2016)

PURPOSE: The purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum, participate in extracurricular and
nonacademic activities and be educated and participate with other special education students and non-disabled students. Other education-related factors that may impact the student
should also be considered.

LEAST RESTRICTIVE ENVIRONMENT:

Students ages 6 and above
A.

B.

1660

1080

35%

Choose one:

= Total minutes per week of building

instructional time available for this student
(excluding lunch)
= Total of those minutes in A. above in which
this student is in a special education setting
(excluding lunch)

= Percent of time spent in a general education

setting (A minus B divided by A)

In general education setting 80 to 100% of the time

In general education setting 40 to 79% of the time
In general education setting 0 to 39% of the time
In separate day school (public or private)
Residential facility (public or private)
Correctional facility
Homebound/hospital
Home-school/parentally-placed private school

POINTS TO CONSIDER:

Children should be educated

with non-disabled peers to the
maximum extent appropriate.
The IEP Team, including the
parent(s), is responsible for
determining the educational
placement of the child.
Job placements and
community-based instruction
are considered to be general
education settings, unless only
disabled individuals are present
(such as in a sheltered
workshop).
For additional information on
LRE for students ages 6 and
above, refer to the LRE
Calculator.

An explanation of the extent, if any, to

which the student will not participate
with nondisabled students in the general
education class, and in nonacademic and
extracurricular activities, including a
description of any adaptations needed for
participation in physical education:

Form 6d - IEP (with Secondary Transition)

Page 16

August 2008 (revised January 2016)

PARTICIPANTS IN IEP MEETING (Signatures are used to document participation in the meeting and do not constitute agreement
or disagreement):
Parent/Guardian

Name/Title

Parent/Guardian

Name/Title

Student

Name/Title

Special Education Teacher

Name/Title

General Education Teacher

Name/Title

District Representative

Name/Title

POINTS TO CONSIDER:
IEP team membership is described
in WAC 392-172A-03095.
School district must give prior
written notice when proposing or
refusing to initiate or change the
identification, evaluation,
educational placement, or
provision of FAPE.
A required team member may be
excused from attending an IEP
meeting with the agreement/
consent of the parent(s) and the
district, depending upon whether
that members area is being
discussed or modified at the
meeting. See WAC 392-172A03095 (5) for additional related
requirements.
The IEP must include the districts
procedures for notifying parents
regarding the use of restraint or
isolation. Districts must also
provide parents with a copy of the
districts policy on the use of
isolation and restraint.

Other individuals who should be informed of his/her responsibilities in implementing the IEP (bus driver, librarian, etc.):

TRANSFER OF RIGHTS: Beginning at least one year before reaching age 18,
the student has been informed that all rights will transfer to the student at age 18,
unless there is a guardianship or other determination that the student cannot make
educational decisions.

Yes No

POINTS TO CONSIDER:
When the student reaches age 18 (or majority), the
district must notify the parents and the student that
rights have transferred to the student, and provide
any notices required to the student and parents.

The district has procedures for notifying parents regarding the use of restraint or isolation. A copy of those procedures is attached to this IEP.

*Note: Before providing initial special education services to a student, the district must obtain informed written parental consent.
(See model form 3)
Form 6d - IEP (with Secondary Transition)

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August 2008 (revised January 2016)

Form 6d - IEP (with Secondary Transition)

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August 2008 (revised January 2016)