PURPOSE:

TheIEPisdesignedtoclearlycommunicatetotheparents,thestudent,andprovidersthetypeandamountofspecialeducationandanynecessaryrelatedservicesor
supportsthatwillbemadeavailabletothestudent.ThemostrecentevaluationreportisusedtodeveloptheIEP.TheIEPisindividualizedtoreflecttheuniqueneedsofthestudentand
howtheseneedswillbeaddressedtopermitthestudenttobeincludedandprogressinthegeneraleducationcurriculum.

INDIVIDUALIZEDEDUCATIONPROGRAM

Studentname:
StudentIDNo.:
DateofIEPmeeting:

Birthdate:

Grade:
Age:
IEPannualreviewdate:

Eligibilitycategory:

Dateofmostrecenteval:

Race/Ethnicity:
Reevaluationduedate:
Primarylanguage:

District:
ResidentSchool:
ServingSchool
(ifdifferent):
Parent(s)name(s):

Primarylanguageathome:
Parentinterpreterneeded?

YesNo
Ifyes,name:
Surrogateparent:YesNo

Primarystaffcontactname:
Title:

PRESENTLEVELSOFACADEMICACHIEVEMENTANDFUNCTIONALPERFORMANCE
Presentlevelsofacademicachievement:

Presentlevelsoffunctionalperformance

(i.e.communication,motor,social,behavior,life/adaptiveskills,etc.)
:

Form6cIEP(withoutTransition)

Page1

POINTSTHATMUSTBE
CONSIDEREDIN
DEVELOPINGTHEIEP(refer
toWAC392172A03110):
Resultsofthemostcurrent
evaluation,andtheacademic,
developmental,andfunctional
needsofthestudent.
Positivebehavioralsupportsand
interventions,ifthestudents
behaviorimpedesthestudents
learningorthatofothers.
Languageneedsofstudentswith
limitedEnglishproficiencyas
theyrelatetothechildsIEP.
Supportsforblind/visually
impairedstudents,include
Brailleinstruction.
Communicationneedsofthe
student,includingtheneedsfor
deafandhardofhearing
students.
Assistivetechnologydevicesand
services.
Supplementaryaids/services,
programmodifications,and
supportforschoolpersonnel.
August2008
(revisedJanuary2016)

Effectofthedisabilityonthestudentsinvolvementandprogressinthegeneraleducationcurriculum(orforpreschoolchildren,as
appropriate,howthedisabilityaffectsthechildsparticipationinappropriateactivities):

CONSIDERATIONOFSPECIALFACTORS:
Ifyes,describe(ifnotaddressedontheservicematrix):

1. Doesthisstudentrequirespecial
transportation?

YesNo

2. DoesthisstudentrequireExtendedSchool
Year(ESY)services?
3. Doesthestudentsbehaviornegativelyimpact
his/herlearningorthelearningofothers?

Form6cIEP(withoutTransition)

YesNo
Willbedeterminedby
theIEPteamby:
Date:

IfESYisdeterminedbytheIEPteamtobenecessary,completeand
attachtheESYaddendum.

YesNo

Page2

Ifyes,considerthestudentsneedforpositivebehavioralsupports/
interventions,aFunctionalBehavioralAssessment(FBA),and/ora
BehavioralInterventionPlan(BIP).

August2008
(revisedJanuary2016)

ABehavioralInterventionPlanhasbeendevelopedforthis
student(refertotheBIPaddendum).
Ifyes,describe:
4. Arethereanyotherfactorsnotalready
addressed(suchasmedicalconcernsorother
issues),orotheradaptationsneeded?

YesNo

Theparentandtheschooldistricthaveagreedthatthisstudentrequiresadvancededucationalplanningthatmayinvolvetheuseofisolation,
restraint,orarestraintdevice.RefertotheEmergencyResponseProtocoladdendumtothisIEP.

Form6cIEP(withoutTransition)

Page3

August2008
(revisedJanuary2016)

PURPOSE:
IEPsmustincludeastatementofmeasurableannualgoals,includingacademicandfunctionalgoals,designedtomeeteachofthestudentseducationalneedsthatresult
fromthestudentsdisabilitytoenablethestudenttobeinvolvedandmakeprogressinthegeneraleducationcurriculum.Inordertobemeasurable,thegoalshouldinclude
abaseline,
atarget,andaunitofmeasure.
Forstudentsusinganalternateassessmentalignedtoalternateachievementstandards,theIEPteamshouldusetheMeasurableAnnualGoal(s)with
ShorttermObjectives/Benchmarkspage(seenextpage).

MEASURABLEANNUALGOAL(S)

Goa
l
#

MeasurableAnnualGoal

Method/Criteriafor
EvaluatingProgress
(ifnotaddressedina
separatedocument)

ProgressNotes

(ifnotmaintainedseparately)

Date

Date

Date

Date

POINTSTO
CONSIDER:
Measurable
annualgoalsstem
fromthe
recommendations
forspecially
designed
instructioninthe
evaluationreport.
Measurable
annualgoalsmust
relatetothe
generaleducation
curriculumor,for
preschool
students,
participationin
appropriate
activities.
Measurable
annualgoalsmust
alsoaddressother
educationalneeds
thatresultfrom
thestudents
disability.
TheIEPmust
includea
descriptionof
howthedistrict
willmeasurethe
studentsprogress
andwhen
progresswillbe
reportedto
parents.

Copyadditionalpagesasnecessary

Form6cIEP(withoutTransition)

Page4

August2008
(revisedJanuary2016)

PURPOSE:
IEPsmustincludeastatementofmeasurableannualgoals,includingacademicandfunctionalgoals,designedtomeeteachofthestudentseducationalneedsthatresult
fromthestudentsdisabilitytoenablethestudenttobeinvolvedandmakeprogressinthegeneraleducationcurriculum.
Forstudentsusinganalternateassessmentalignedtoalternate
achievementstandards,benchmarksorshorttermobjectivesintheareasbeingassessedmustalsobeincluded.
Inordertobemeasurable,thegoalshouldinclude
abaseline,atarget,
andaunitofmeasure.

MEASURABLEANNUALGOAL(S)WITHSHORTTERMOBJECTIVES/BENCHMARKS

Goa
l
#

MeasurableAnnualGoal

Method/Criteriafor
EvaluatingProgress
(ifnotaddressedina
separatedocument)

ProgressNotes

(ifnotmaintainedseparately)

Date

Date

Date

Date

BenchmarksorShortTermObjectives

POINTSTO
CONSIDER:
Measurableannual
goalsstemfromthe
recommendations
forspecially
designedinstruction
intheevaluation
report.
Measurableannual
goalsmustrelateto
thegeneral
education
curriculumor,for
preschoolstudents,
participationin
appropriate
activities.
Measurableannual
goalsmustalso
addressother
educationalneeds
thatresultfromthe
studentsdisability.
TheIEPmust
includea
descriptionofhow
thedistrictwill
measurethe
studentsprogress
andwhenprogress
willbereportedto
parents.

Copyadditionalpagesasnecessary

Form6cIEP(withoutTransition)

Page5

August2008
(revisedJanuary2016)

Form6cIEP(withoutTransition)

Page6

August2008
(revisedJanuary2016)

PURPOSE:

Thepurposeofthereportofstudentprogressistoinformtheparentsandthestudentofthestudentsprogresstowardmeetingthemeasurableannualgoal(s)andto
specifyhowandwhenparentswillbeinformed.

REPORTOFSTUDENTPROGRESS:

POINTSTOCONSIDER:
Parentsshouldbeprovidedperiodicreportsonthestudentsprogress(suchasthroughthe
useofquarterlyorotherperiodicreports,concurrentwiththeissuanceofreportcards).

Statehowthestudentsprogresstowardmeetingtheannualgoal(s)willbemeasured
(ifnotalreadyaddressedonmeasurableannualgoalpage(s))
:

Statehowtheparentswillbeperiodicallyinformedofthestudentsprogresstowardmeetingtheannualgoal(s):

PARTICIPATIONINSTATEANDDISTRICTWIDEASSESSMENTSOFSTUDENTACHIEVEMENT
POINTSTOCONSIDER:
StateAssessments
Thestudentwillparticipateinthefollowing
stateassessment(s)
duringthisannualIEP:
TheIEPteammakesthe

English/

determinationofwhattype
LangArtsMathScience
ofassessmentthestudent
willtakeandwhat
RegularStateAssessment
administrativemodifications
andindividual
RegularStateAssessmentwithAccommodations
accommodationsare
AlternateAssessment
necessary.
Accommodationsprovided
Other:
onstateanddistrictwide
assessmentsshouldbethose
DistrictwideAssessments
Thestudentwillparticipateinthefollowing
districtwideassessment(s)
duringthisannual
IEP:

Accommodations
Listanyindividualaccommodationsintheadministrationofthestateordistrictwideassessments
thatarenecessaryforthestudenttoparticipate:

Ifthestudent:(a)willnotparticipateintheregularstateassessment(withorwithoutaccommodations)or(b)isunableto
participateinaregulardistrictwideassessment,explainwhythestudentcannotparticipateintheregularassessmentand
whytheselectedassessmentoptionisappropriate:

Form6cIEP(withoutTransition)

Page7

thatareprovidedaspartof
theregularinstructional
program.
Forfurtherinformation
regardingthestate
assessmentsystem,
allowableaccommodations,
andgraduationrequirements,
pleaserefertoOSPIs
website
(
www.k12.wa.us/assessment
)
.

August2008
(revisedJanuary2016)

PURPOSE:
Thepurposeofthispageistodocumentthemodificationsand/oraccommodationsthatthestudentrequires,basedonthestudentsassessedneeds,inordertoadvance
appropriatelytowardattainingtheidentifiedannualgoals,tobeinvolvedandmakeprogressinthegeneraleducationcurriculum,andtobeeducatedwithnondisabledpeerstothe
maximumextentappropriate.

ACCOMMODATIONS,MODIFICATIONS,ANDASSISTIVETECHNOLOGY
Subject Accommodations/ModificationsNeeded
Accommodations/ModificationsNeeded
(codesbelow)

Subject
(codesbelow)

Presentation

Uselargeprint/Braille/recordedbooks
Alterformatofmaterials

(highlight,type,spacing,colorcodeetc.)
Lowvisiondevices
(magnifiers,ClosedCircuitTV,etc.)
SignLanguageASLorSEE
Shortenedassignments
Previewtestprocedures
Limitedmultiplechoice
Rephrasetestquestionsand/ordirections
Providetest/quizstudyguide
Provideextracreditoptions
Simplifytestwording
Readclassmaterialsorally
Assignpeertutor/notetaker
Other:

Timing/Scheduling

Priornoticeoftests/quizzes
Extratimetocompleteassignments
Modifystudentsschedule(
describebelow
):

Setting

Response

Extratimeontests/quizzes

Allowbreaks
(duringwork,betweentasks,duringtesting,etc.)

Other:

AssistiveTechnology
Describe:

Form6cIEP(withoutTransition)

Page8

Provideindividualized/smallgroupinstruction
Readclassmaterialsorally
Providestudyoutlines/guides/graphicorganizers
Modify/repeat/modeldirections
Taketestinseparatelocation
Preferentialseating
Other:
Utilizeoralresponsestoassignments/tests
TexttoSpeech
(Kurzweil,WYNN,TextHelp,etc.)
Allowdictationtoascribe
Allowuseofacalculator
Allowuseoftaperecorder
Spellingandgrammardevices
Speechtotextsoftware
Handsonassignments
Other:

Other
Providedesktoplistoftasks
Providehomeworklists
Behaviorplan/contract
Providedailyassignmentlist
Modifiedgrading
Other:

POINTSTO
CONSIDER:
TheIEPteam
makesthe
determinationof
what
modificationsand
individual
accommodations
arenecessaryfor
thestudent.
Copiesofthis
pageshouldbe
providedtothe
generaleducation
teacher(s)or
otherstaffwho
willbe
responsiblefor
makingthese
accommodations.
Accommodations
providedonstate
anddistrictwide
assessments(as
notedonthe
previouspage)
shouldbethose
thatareprovided
aspartofthe
regular
instructional
program.

August2008
(revisedJanuary2016)

a.
b.
c.
d.

Describe:
Describe:

Allsubjects
Reading
English
Spelling

e.
f.
g.
h.

Math
Science
SocialStudies
History

i.
j.
k.
l.

Health
Economics
PhysicalEducation
Music/Art

m. Vocational
n. Lunch/Recess
o. Library

p. ExtracurricularActivities
q. Other:
r. Other:

Form6cIEP(withoutTransition)

Page9

August2008
(revisedJanuary2016)

PURPOSE:
Theinformationonthispageisasummaryofthestudentsprogram/services,includingwhenserviceswillbegin,wheretheywillbeprovided,whowillberesponsiblefor
providingthem,andwhentheywillend.

SUMMARYOFSERVICESMATRIX

Initiation
Date

Service

Frequency
(i.e.minutesperweek)

Locationof
Service
(setting)

Duration

StaffResponsiblefor
DeliveringService

SpecialEducation
(speciallydesignedinstruction):

RelatedServices
(i.e.speech,motor,counseling,vision/hearing,transportation,interpretingservices,orientation/mobility,parenttraining,etc.):

SupplementaryAidsandServices
(allowsstudenttobeeducatedwithnondisabledpeerstothemaximumextentingeneraleducationorother
educationalsetting):

ProgramModificationsorSupportforSchoolPersonnel
(i.e.staffdevelopment/training,technicalassistance,etc.):

POINTSTO
CONSIDER:
Iftheposition
responsiblefor
deliveringthe
specially
designed
instructionis
anyoneotherthan
acertificated
specialeducation
teacherorrelated
serviceprovider,
thenthe
certificated
specialeducation
teacher/related
serviceprovider
mustdesignand
supervisethe
instruction,and
monitorand
evaluatethe
students
progress.
Fordefinitionsof
specialeducation,
relatedservices,
and
supplementary
aidsandservices,
refertoWAC
392172A01020
through01200.

Form6cIEP(withoutTransition)

Page10

August2008
(revisedJanuary2016)

PURPOSE:
Thepurposeofthispageistodocumenttheextenttowhichthestudentwillbeinvolvedandprogressinthegeneralcurriculum,participateinextracurricularand
nonacademicactivitiesandbeeducatedandparticipatewithotherspecialeducationstudentsandnondisabledstudents.

LEASTRESTRICTIVEENVIRONMENT:
Studentsages3to5
ARegularEarlyChildhood(REC)program
meansaprogramoutsidethechildshome
thatincludesatleast50%childrenwithout
disabilities.

IfthechildattendsaRECprogram,checkthe
appropriateboxfromthefirstfourchoices.If
thechilddoesnotattendaRECprogram,
checktheappropriateboxfromthefive
remainingoptions.

Chooseone:

InaRECprogram:

RECProgram10hoursperweek&:

Specialeducationserviceswith
nondisabledpeers
Specialeducationserviceselsewhere

RECProgram<10hoursperweek&:
Specialeducationserviceswith
nondisabledpeers
Specialeducationserviceselsewhere

Studentsages6andabove
A.

B.

=Percentoftimespentinageneraleducation
setting(AminusBdividedbyA)

Anexplanationoftheextent,ifany,towhich
thestudentwillnotparticipatewith
nondisabledstudentsinthegeneraleducation
class,andinnonacademicandextracurricular
activities,includingadescriptionofany
adaptationsneededforparticipationin
physicaleducation:

NotinaRECprogram:

Separateclass
Inseparatedayschool(public
orprivate)
Residentialfacility(publicor
private)
Home
Serviceproviderlocation

Chooseone:

=Totalminutesperweekofbuilding
instructionaltimeavailableforthisstudent
(excludinglunch)
=TotalofthoseminutesinA.aboveinwhich
thisstudentisinaspecialeducationsetting
(excludinglunch)

POINTSTOCONSIDER:
Childrenshouldbe

Ingeneraled.setting
80to100%
ofthetime
Ingeneraled.setting
40to79%
ofthetime
Ingeneraled.setting
0to39%
ofthetime
Inseparatedayschool(publicorprivate)
Residentialfacility(publicorprivate)
Correctionalfacility
Homebound/hospital
Homeschool/parentallyplacedprivateschool

educatedwith
nondisabledpeerstothe
maximumextent
appropriate.
TheIEPTeam,including
theparent(s),is
responsiblefor
determiningthe
educationalplacementof
thechild.
Jobplacementsand
communitybased
instructionareconsidered
tobegeneraleducation
settings,unlessonly
disabledindividualsare
present(suchasina
shelteredworkshop).
Foradditionalinformation
onLREforstudentsages
3to5andages6and
above,refertothe
LRE
Calculator.

Form6cIEP(withoutTransition)

Page11

August2008
(revisedJanuary2016)

PARTICIPANTSINIEPMEETING
(Signaturesareusedtodocumentparticipationinthemeetinganddonotconstitute
agreementordisagreement):

Parent/Guardian

Name/Title

Parent/Guardian

Name/Title

Student

Name/Title

SpecialEducationTeacher

Name/Title

GeneralEducationTeacher

Name/Title

DistrictRepresentative

Name/Title

POINTSTOCONSIDER:
IEPteammembershipisdescribed
inWAC392172A03095.
Schooldistrictmustgiveprior
writtennoticewhenproposingor
refusingtoinitiateorchangethe
identification,evaluation,
educationalplacement,or
provisionofFAPE.
Arequiredteammembermaybe
excusedfromattendinganIEP
meetingwiththeagreement/
consentoftheparent(s)andthe
district,dependinguponwhether
thatmembersareaisbeing
discussedormodifiedatthe
meeting.SeeWAC
392172A03095(5)foradditional
relatedrequirements.
TheIEPmustincludethedistricts
proceduresfornotifyingparents
regardingtheuseofrestraintor
isolation.Districtsmustalso
provideparentswithacopyofthe
districtspolicyontheuseof
isolationandrestraint.

Otherindividualswhoshouldbeinformedofhis/herresponsibilitiesinimplementingtheIEP(busdriver,librarian,etc.):

Thedistricthasproceduresfornotifyingparentsregardingtheuseofrestraintorisolation.AcopyofthoseproceduresisattachedtothisIEP.

*Note:Beforeprovidinginitialspecialeducationservicestoastudent,thedistrictmustobtaininformedwrittenparentalconsent.
(Seemodelform3)
Form6cIEP(withoutTransition)

Page12

August2008
(revisedJanuary2016)