INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name: Rudolf Reindeer

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Students Name:

School Age

Rudolf Reindeer

IEP Team Meeting Date (10/30/16):

10-30-2016

IEP Implementation Date (Projected Date when Services and Programs Will Begin):
Anticipated Duration of Services and Programs:
Date of Birth:
12 years. 7
Age:
mos.
Grade:
8th

10-31-2016

10-30-2017

02/16/2002

Anticipated Year of Graduation:

2021

Local Education Agency (LEA):

County of Residence:

Mastery Charter School Shoemaker Campus

Philadelphia

Name and Address of Parent/Guardian/Surrogate:

Rudolf Reindeer Sr.

Phone (Home):

215-555-5555

Phone (Work):

5005 n 50 Street
th

Philadelphia PA 19131

Other Information:

Demographic Info
Most Recent Reevaluation: 10/25/15
Primary Classification: Autism
Current Educational Program: Autistic Support
% LRE: 99%
Related Services: Counseling-900min per IEP term (average 30min/week) (social
skills group)

The LEA and parent have agreed to make the following changes to the IEP without convening an IEP meeting, as documented by:

Date of Revision(s)
Page 1 of 28

Participants/Roles

IEP Section(s) Amended

April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name: Rudolf Reindeer

Page 2 of 28

April 2014

IEP TEAM/SIGNATURES
The Individualized Education Program team makes the decisions about the students program and placement. The students parent(s), the students special
education teacher, and a representative from the Local Education Agency are required members of this team. Signature on this IEP documents attendance, not
agreement.
Role

Printed Name

Parent/Guardian/Surrogate

Rudolf Reindeer Sr.

Signature

Parent/Guardian/Surrogate
Student*

Rudolf Reindeer

Regular Education Teacher**

Lovely Lady

Special Education Teacher

Keisha Weeks

Local Ed Agency Rep

Clarissa Love

Career/Tech Ed Rep***
Community Agency Rep
Teacher of the Gifted****

*
The IEP team must invite the student if transition services are being planned or if the parents choose to have the student participate.
**
If the student is, or may be, participating in the regular education environment
***
As determined by the LEA as needed for transition services and other community services
****
A teacher of the gifted is required when writing an IEP for a student with a disability who also is gifted.
One individual listed above must be able to interpret the instructional implications of any evaluation results.
Written input received from the following members:
Mr. Ducky (7th grade numeracy, 8th grade math lab), Ms. Rossmore (7th grade science), Ms. Beets (7th
grade literature), Ms. Candy (7th grade composition), Mr. Magic (7th grade geography), Mr. Epsomsalt
(7th grade physical education), Mr. Seuss (8th grade social justice and reading and mindset), Ms. Lady
(8th grade literature)

Transfer of Rights at Age of Majority

For purposes of education, the age of majority is reached in Pennsylvania when the individual reaches 21 years of age. Likewise, for purposes of the Individuals
with Disabilities Education Act, the age of majority is reached for students with disabilities when they reach 21 years of age.

PROCEDURAL SAFEGUARDS NOTICE

I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides information about my rights,
including the process for disagreeing with the IEP. The school has informed me whom I may contact if I need more information.
Signature of Parent/Guardian/Surrogate:

MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

(Applicable only to parents who have consented to the release of billing information to Medical Assistance programs)
I understand that the school may charge the School-Based Access Program (SBAP)or any program that replaces or supplements the SBAPthe cost of certain
special education and related services described in my childs IEP. To make these charges to the SBAP, the school will release to the administrator of that
program the name, age, and address of my child, verification of Medicaid eligibility for my child, a copy of my childs IEP, a description of the services provided
and the times and dates during which such services were provided to my child, and the identity of the provider of such services. I understand that such
information will not be disclosed, and such charges will not be made, unless I consent to the disclosure. I acknowledge that I have provided written consent to
disclose such information.
I understand that my consent is ongoing from year-to-year unless and until I withdraw it. I can withdraw my consent in writing, or orally if I am unable to
write, at any time. My refusal to consent or my withdrawal of consent will not relieve the school of the obligation to provide, at no cost to me or my family,
any service or program to which my child is entitled under the Individuals with Disabilities Education Act (IDEA) or that is necessary to enable my child to
receive a free appropriate public education as described in my childs IEP.
I understand that the school cannot
Require me or my family to sign up for or enroll in any public benefits or insurance program, such as Medicaid, as a condition of receiving a free appropriate
public education for my child;
Require me or my family to incur any expense for the provision of a free appropriate public education to my child, including co-payments and deductibles,
unless it agrees to pay such expenses on my or my familys behalf;
Cause a decrease in available lifetime coverage or any other insured benefit;
Cause me or my family to pay for services that would otherwise be covered by a public benefits or insurance program and that are required for my child
outside the time that he or she is in school;
Risk the loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.

I. SPECIAL CONSIDERATIONS THE IEP TEAM MUST CONSIDER BEFORE DEVELOPING THE IEP. ANY FACTORS CHECKED AS YES MUST BE ADDRESSED IN THE IEP.
Is the student blind or visually impaired?
Yes
The IEP must include a description of the instruction in Braille and the use of Braille unless the IEP team determines, after an
evaluation of the students reading and writing skills, needs, and appropriate reading and writing media (including an
evaluation of the students future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use of
Braille is not appropriate for the student.
x No
Is the student deaf or hard of hearing?
Yes
The IEP must include a communication plan to address the following: language and communication needs; opportunities for
direct communications with peers and professional personnel in the students language and communication mode; academic
level; full range of needs, including opportunities for direct instruction in the students language and communication mode;
and assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The
Communication Plan must be completed and is available at www.pattan.net
x

No

Does the student have communication needs?

Yes
Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)
x

No

Does the student need assistive technology devices and/or services?

Yes
Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)
x

No

Does the student have limited English proficiency?

Yes
The IEP team must address the students language needs and how those needs relate to the IEP.
x

No

Does the student exhibit behaviors that impede his/her learning or that of others?
The IEP team must develop a Positive Behavior Support Plan that is based on a functional assessment of behavior and that
x Yes
utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in the Present Levels
section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially Designed Instruction
sections of the IEP or in the Positive Behavior Support Plan if this is a separate document that is attached to the IEP. A Positive
Behavior Support Plan and a Functional Behavioral Assessment form are available at www.pattan.net
No
Other (specify):

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Include the following information related to the student:
Present levels of academic achievement (e.g., most recent evaluation of the student, results of formative assessments, curriculum-based
assessments, transition assessments, progress toward current goals)
Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress
toward current goals)
Present levels related to current postsecondary transition goals if the students age is 14 or younger if determined appropriate by the IEP team
(e.g., results of formative assessments, curriculum-based assessments, progress toward current goals)
Parental concerns for enhancing the education of the student
How the students disability affects involvement and progress in the general education curriculum
Strengths
Academic, developmental, and functional needs related to students disability
Present Levels of Academic Achievement:
Introduction:
Rudolf is a 13 year old student, who is an eighth grade student that attends Mastery Charter Shoemaker
Campus (MCSC). Rudolf attended Mastery Charter Mann Campus (MCMC) before attending MCSC. Rudolfs
primary language at home is English. Rudolf likes to hang out with friends and enjoys attending MCSC.
Rudolf was re-evaluated on October 25th, 2015. According to Rudolfs re-evaluation he qualifies for
special education services with a primary classification of Autism.
Currently, Rudolf is participating in all general education classes for math, reading, writing, social
studies, and special areas classes. Rudolf receives itinerant Autistic support. Rudolf is included in

general education classes with the support of specially designed instruction. Rudolf receives small group
counseling as a related service. Counseling occurs weekly for 30 minutes a session. Over the previous
IEP term, Rudolf received ESL services as a class for language support. Rudolf previously received ESL
services. However, it has been determined by the IEP team that Rudolf does not require ESL because he
does not and has not ever spoken a second language.
Summary of most recent psycho-educational evaluation (cognitive and academics):
Rudolf was evaluated at Mastery Shoemaker during his 7th grade year. As per the reevaluation, dated
September 25, 2015, Rudolfs overall cognitive functioning was determined to be in the low average and
average range (Full Scale = 88) as measured by the Wechsler Intelligence Scale for Children- Fourth
Edition (WISC-IV) and select subtests from the Wechsler Individual Achievement Test-Third Edition
(WIAT III). The assessments reflect that Rudolfs cognitive abilities are consistently within the low
average and average range, with the exception of Processing Speed (Borderline). These results reflect
that Rudolf has trouble processing visual information quickly.
According to the WIAT III Rudolf scored average in all of his reading skills. According to all of these
assessments, Rudolfs reading skills are all equally developed (reading comprehension SS=102, Word
reading SS=90, Pseudoword decoding SS=100). Rudolfs math skills are significantly lower than his
reading skills. In the area of math problem solving Rudolf scored significantly lower than his reading
(SS=79). In the area of numerical operations Rudolf scored slightly higher (SS=83). Rudolf has needs in
solving simple word problems, determining probability, reading a calendar, solving simple geometry, and
determining the order of fractions.
Current academic levels/performance:
On the Fountas & Pinnell (F&P) Benchmark Reading Assessment, administered in December 2015,
Rudolfs independent reading level was level T. Level T represents a grade level equivalent of 4.0,
beginning fourth grade. Using a text at this level, Rudolf is able to read with 98% accuracy, excellent
comprehension (9), and reads fluently at 115 words per minute. The benchmark was repeated in June
2016 and Rudolfs independent reading level decreased to level P. Level P represents a grade level
equivalent of 3.0, beginning third grade. Using a text at this level, Rudolf is able to read with 99%
accuracy, satisfactory comprehension (6) and reads fluently at 107 words per minute.
On the PSSA state examination in grades six and seven, Rudolf scored in the below basic range for math.
On the PSSA state examination in grade six, Rudolf scored below basic in reading. During Rudolfs
seventh grade year, he scored basic in reading. When administered the science PSSA during Rudolfs
fourth grade year, he scored in the basic range. Rudolf scored in the basic range for his PSSA writing
during his fifth grade year.
Rudolf was tested on his reading and math skills as measured by the TerraNova assessment during his
seventh grade year. Rudolf scored at the 3.5, third grade range for both reading and math.
SEVENTH GRADE REPORT CARD SUMMARY

Physical Education- 81%

Numeracy- 88%
ESL-90%
Science-80%
Composition-79%
Literature-77%
Geography-76%
Trans Math-88%
CURRENT GRADES AS OF 9/22/2016
Science-54%
Composition-84%
Social Justice-74%
Art-73%
Numeracy-78%
Math-79%
Literature-27%
Reading and Mindset-60%
Progress towards previous IEP goals:
Math Goal #1: Rudolf will be given the opportunity to increase his math problem solving skills from 9
digits correct to 34 digits correct (75th percentile) on the grade 4 level digits correct assessment in 3
out 4 trials each report period. Baseline: 9 digits.
Math Summary: Throughout the 2015-2016 school year Rudolf was given the Digits correct assessment
once per marking period to track his progress. Rudolf was able to achieve 55 digits correct on the
second grade level which shows an increase from the beginning of the year when his baseline was 37
digits correct on a second grade level. Most recently, on 9/23/16, Rudolf scored at 11 digits correct at
fourth grade level.
Writing Goal #1:Rudolf will be given the opportunity to achieve at least an average of 3 on the 7th
grade PSSA writing rubric in the areas of focus, content and organization in 3 out of 4 prompts as
measured by performance on a PSSA writing prompt given each report period. Baseline: average of 1 on
focus, content and organization on 6th grade PSSA rubric and prompt.
Writing Summary: During the 2015-2016 school year Rudolf began the year with an average of 1 for the
6th grade writing prompt. Throughout the year Rudolf was given a writing prompt 3 more times.
Rudolfs highest score was a 2 in the areas of focus, content, and organization. Rudolfs growth remained
consistent and was recommended to attend a composition class for eighth grade. On 9/23/16, Rudolf
scored a 2 in the area of focus, 1 in the area of content, 1 for organization, 1 for style and 1 for
conventions on a 6th grade PSSA writing prompt.

Teacher Input (related to academics):

Mr. Ducky, Rudolfs numeracy teacher reported that Rudolf would always come to make up work. Office
hours were the strongest intervention that worked in Rudolfs benefit. Ms. Candy, Rudolfs composition
teacher reported that Rudolf worked well independently but needed improvement in the classwork and
homework area. Ms. Candy reported that office hours and adjusted assignment lengths would help with
Rudolf staying up to date in class. Rudolfs literature teacher, Ms. Beets, reported that Rudolfs area of
focus in her class was homework completion as well as classwork completion. Ms. Beets also provided
information that a strength that Rudolf demonstrated in her class was comprehension. An intervention
that Ms. Beets tried with Rudolf that worked well was holding office hours with Rudolf.

Present Level of Functional Performance:

Culture data:
Since the beginning of the 2015-2016 academic year, Rudolf has filled nine demerit cards (8 demerits = 1 full
demerit card), one merit card, and has received one impromptu conversation with a dean. Rudolf has also
received seven uniform violations.
Attendance data:
Unexcused Absences: 2
Excused Absences: 1
Unexcused Tardies: 2
Dismissed Unexcused: 1
Overview:
9/1/2015: Tardy Unexcused
9/4/2015: Tardy Unexcused
10/20/2015: Absent Unexcused
10/21/2015: Absent Excused
3/18/2016: Absent Unexcused
6/14/2016: Dismissed Unexcused
Summary of most recent psycho-educational evaluation (functional/behavior/social-emotional):
Due to behavior concerns, Rudolfs social-emotional-functioning was also assessed as part of the reevaluation process dated September 25th, 2015. The Behavior Assessment System for Children- Second

Edition (BASC-II) rating scale was utilized to assess Rudolfs emotional functioning behavior in various
settings. In a report generated based on Rudolfs Special Education Case Manager, Ms. Hayde, Rudolf scored
in the Clinically Significant range suggestive of high level maladjustment. Rudolf also scored in the At-Risk
range which may identify a significant problem that may not be severe enough to require formal treatment
or may identify the potential of developing a problem that needs careful monitoring. Rudolf scored Average
in the areas of Externalizing Problems and Internalizing Problems. In the areas of Atypicality, Withdrawal,
and Adaptive Skills Rudolf scored in the Clinically Significant range. Rudolf scored At-Risk in the School
Problems area. Rudolfs mother, Ms. Reindeer, also rated Rudolf using the BASC-II rating scale. Ms. Reindeer
rated Rudolf as Average in the areas of Externalizing Problems, Internalizing Problems, Withdrawal, and
Adaptive Skills. Ms. Reindeer rated Rudolf as At-Risk in the Attention Problems area.
Rudolf was also rated on the Gilliam Autism Scales-Third Edition (GARS-III) to assist in the diagnosis of
Autism. Items on the GARS-III are based on the definition of Autism adopted by the American Psychiatric
Association and by the Autism Society of America. The GARS-III was administered to Ms. Reindeer and the
overall autism index indicated that the likelihood of autism is probable and the Severity Level was scored
as 1 indicating that Rudolf requires minimal support according to his mothers ratings. The GARS-III was also
administered to Ms. Hayde and the overall autism index indicated that the probability of autism is very
likely and the Severity Level was scored as 2 indicating that Rudolf requires substantial support.
These behaviors have had a significant impact on Rudolfs educational functioning and the progress he has
been making this year. The results of the BASC-II and the GARS-III indicate that Rudolf has a
primary classification of Autism and continues to need specially designed instruction.
Teacher input (related to behavior):
Mr. Ducky, Rudolfs 7th and 8th grade numeracy teacher reported that Rudolf is usually well behaved in his
class. Mr. Ducky reported that some of Rudolfs behavioral concerns are in the areas of participation with
group work and class share outs. Ms. Candy, Rudolfs 7th grade composition teacher reported that Rudolf is
kind, compliant, and consistent in her class. Ms. Candy stated that Rudolf needs improvement on his
organizational skills. Mr. Magic, Rudolfs 7th grade geography teacher shared that Rudolf is respectful but at
times can easily lose focus. Ms. Beets, Rudolfs 7th grade literature teacher reported that Rudolf also lacks
focus in her class and often needs the directions repeated. Reports from Rudolfs 8th grade literature
teacher, Ms. Lady, fall in line with what Rudolfs 7th grade teachers reported. Ms. Lady stated that Rudolf is
kind, respectful, and well behaved however he has a tendency of losing focus and needing more than one
redirection to begin his work.
Progress Towards Previous IEP Goals (behavior):
Behavior Goal #1: Rudolf will be given the opportunity to increase his classroom participation and positive
engagement (sitting in his seat, facing forward, tracking speaker, actively writing, raising his hands to
participate or request assistance) to an average of 50% of the time based on 3 or more time
sampling/interval recording over each RP). Baseline: Rudolf is currently positively engaged 20-30% of the
time.
Behavior #1 Summary: Rudolf started the school year with a baseline of being positively engaged 20-30% of
the time. Through the marking periods Rudolf was observed using the time interval observation sheet. During
the year Rudolfs positive classroom engagement increased by 5% every marking period. During the last

marking period it was determined that Rudolfs positive engagement increased to 40%. When Rudolf is in
eighth grade his positive engagement should continue to be monitored.
Behavior Goal #2: Rudolf will be given the opportunity to increase work completion and independence in
following typical daily routines with less than 4 prompts in average per class period as noted on classroom
based tracker (Progress monitored by daily tracker and averaged each RP). Baseline: Rudolf currently
requires an average of 6 prompts to engage in independent work completion.
Behavior #2 Summary: Throughout the 2015-2016 school year, Rudolf ended the year with 40% positive
engagement and less prompts needed in order for increase work completion and independence. It was
recommended that Rudolf's positive engagement continued to be monitored and that he attend a social skills
class. Currently, Rudolf requires 3 prompts from teachers as of 9/26/16.
The current PBSP is presently supporting Rudolf and is based on the FBA dated 9/28/16. However, to address
off-task behaviors the PBSP will be adjusted. In addition, to address independent work completion, Rudolf's
PBSP will be updated to include additional supports.
Summary of FBA:
A Functional Behavior Assessment was completed in September 2015 to examine behaviors of concern.
Rudolf was observed in class, teacher input was provided, and disciplinary history was reviewed. Summary of
the FBA, dated 9/28/2015:

Antecedent strategies used

o Have a planned clear, consistent, and predictable routine
o Provide one-step directions
o Have student organize materials daily as part of class routine
o Use proximity to Student
o Have student repeat directions back
o Pair student with peer buddy who can prompt Rudolf to stay on task

Consequence strategies used

o Speak in calm and neutral tone
o Restate expectation
o Have Rudolf complete unfinished work during office hours
o Break down assignments

Direct Observation Summary

o Frequency/Intensity: Based on direct observation, Rudolf is on-task 20-30% of the time during class.
When Rudolf is not on-task he was observed fidgeting with his pencil and paper under his desk. He was not
disrupting the work of students around him.
o Pattern to occurrence: Based on direct observation, when a teacher requests that students begin a task,
Rudolf struggles to initiate the task on his own. It was only when the teacher individually checked-in with
Rudolf that he began the requested task.

Hypothesis: When teacher request is made, Rudolf G Reindeer is inattentive in order to avoid work
engagement.

Present Levels Related to Current Postsecondary Transition Goals:

Not appropriate at this time.

Parental Concerns for Enhancing the Education of the Student:

Parental feedback was requested via mail and none was received. However, at the IEP meeting, Mr. Reindeer
expressed that he doesn't always know how well Rudolf is doing. He is sometimes concerned that Rudolf
doesn't like to be singled out but he also wants to make sure that Rudolf gets all of the accommodations he
needs. Rudolf will resist those accommodations. Mr. Reindeer also expressed that he would like for Rudolf to
become more organized. Mr. Reindeer stated that he has noticed that Rudolf has become more social with
his peers and that he was happy to see Rudolf come out of his shell more. Mr. Reindeer mentioned that
Rudolf is excited about being a teenager and that he looks forward to his birthday.
How the students disability affects involvement and progress in the general education curriculum:
Due to Rudolfs primary classification of Autism, Rudolf qualifies for Autism support within the general
education curriculum. Rudolf receives office hours support, lunch office hours support, push in support,
classwork modification, specially designed instruction, and accommodations. Rudolf requires these supports
in order to maximize his growth potential. Rudolf also receives small group counseling as a related service.
Strengths
According to the October 2015 evaluation data, some strengths for Rudolf are his reading comprehension
(grade level equivalent 8.4) and his pseudoword decoding. Teachers identify respectfulness and cooperation
as areas of Rudolfs strength.
Academic, developmental, and functional needs related to students disability:
According to the October 2015 evaluation data and teacher feedback, Rudolf demonstrates the following
areas of need: math problem solving, numerical operations, written expression, and inattention and lack of
independent work completion

III. TRANSITION SERVICES This is required for students age 14 or younger if determined appropriate by the IEP team. If the student does not attend the
IEP meeting, the school must take other steps to ensure that the students preferences and interests are considered. Transition services are a coordinated
set of activities for a student with a disability that is designed to be within a results oriented process, that is focused on improving the academic and
functional achievement of the student with a disability to facilitate the students movement from school to post school activities, including postsecondary
education, vocational education, integrated employment (including supported employment), continuing and adult education, adult services, independent
living, or community participation that is based on the individual students needs taking into account the students strengths, preferences, and interests.
POST SCHOOL GOALS Based on age appropriate assessment, define and project the appropriate measurable postsecondary goals that address education
and training, employment, and as needed, independent living. Under each area, list the services/activities and courses of study that support that goal.
Include for each service/activity the location, frequency, projected beginning date, anticipated duration, and person/agency responsible.
For students in Career and Technology Centers, CIP Code:

Postsecondary Education and Training Goal: The IEP team has determined that a goal is not appropriate at this time.

Measurable Annual Goal

Yes/No
(Document in Section V)

Courses of Study:

Service/Activity

Location

Frequency

Projected
Beginning Date

Anticipated
Duration

Employment Goal: The IEP team has determined that an employment goal is not appropriate at this time.

Person(s)/Agency
Responsible

Measurable Annual Goal

Yes/No
(Document in Section V)

Courses of Study:

Service/Activity

Location

Frequency

Projected
Beginning Date

Anticipated
Duration

Person(s)/Agency
Responsible

Independent Living Goal, if appropriate: The IEP Team has determined that an independent goal is not needed at
this time.

Measurable Annual Goal

Yes/No
(Document in Section V)

Courses of Study:

Service/Activity

Location

Frequency

Projected
Beginning Date

Anticipated
Duration

Person(s)/Agency
Responsible

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Instructions for IEP Teams:
Please select the appropriate assessment option. Information on available testing accommodations may be found in the Accommodations Guidelines
available on www.education.state.pa.us.
State Assessments
Not Assessed
No statewide assessment is administered at this students grade level.
No English proficiency assessment administered because the student is not an English Language Learner.
PSSA (Math administered in grades 3-8; Science administered in grades 4 and 8; Reading administered in grades 3-8; Writing administered in grades 5
and 8; and ELA*)
Without
With
Tested Subject Accommodations Accommodations
Accommodations to be Provided
Math
X
Extended time; Small-group setting; Use of multiple shortened test periods; Simplified
directions; Read aloud test directions and requested test items; Use of calculator;
Refocusing prompts
Science
Reading
X
Extended time; Small-group setting; Use of multiple shortened test periods; Simplified
directions; Read aloud test directions and requested test items; Use of calculator;
Refocusing prompts
Writing
ELA*
X
Extended time; Small-group setting; Use of multiple shortened test periods; Simplified
directions; Read aloud test directions and requested test items; Refocusing prompts
*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.

Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11 th grade)
Without
With
Tested Subject
Accommodations
Accommodations
Accommodations to be Provided
Algebra 1
Literature
Biology
Keystone Project Based Assessment (Available when student is unable to demonstrate proficiency on a Keystone Exam or Keystone Exam module.)
Without
With
Tested Subject
Accommodations
Accommodations
Accommodations to be Provided
Algebra 1

V. GOALS AND OBJECTIVES Include, as appropriate, academic and functional goals. Use as many copies of this page as needed to plan appropriately.
Specially designed instruction may be listed with each goal/objective or listed in Section VI.
Short term learning outcomes are required for students who are gifted. The short term learning outcomes related to the students gifted program may be listed
under Goals or Short Term Objectives.
MEASURABLE ANNUAL GOAL
Include: Condition, Name, Behavior, and Criteria
(Refer to Annotated IEP for description of these
components)
Writing: Rudolf will achieve at least a 3 on the 6th
grade PSSA writing rubric in the areas of content,
organization, style, and conventions in 3 out of 4
prompts as measured by performance on a PSSA
writing prompt given each report period.
Baseline: 1 on content, organization, style, and
conventions area using 6th grade PSSA rubric and
prompt (Baseline date 9/23/2016).
Math: Rudolf will increase his math problem
solving skills to a 4.9 GLE on a research based
math assessment (Digits correct assessment) in 3
out of 4 trials given each report period. Baseline:
3.9 GLE on the Digits Correct (problem solving)
assessment (Baseline date 9/26/2016)

Math: Rudolf will increase his math computation

skills to a 5.3 GLE on a research based math
assessment (Digits correct assessment) in 3 out of
4 trials given each report period. Baseline: 4.3
GLE on the Digits Correct (computation)
assessment (Baseline date 9/23/2016)

Describe HOW the

students progress toward
meeting this goal will be
measured

Describe WHEN periodic

reports on progress will be
provided to parents

Every report period with

writing prompt

Every marking period

Through criteria based

assessments, three times
a report period

Every marking period

Through criteria based

assessments, three times
a report period

Report of Progress

Every marking period

SHORT TERM OBJECTIVES Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).

Short term objectives / Benchmarks

VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS Include, as appropriate, for nonacademic
and extracurricular services and activities.
A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)
SDI may be listed with each goal or as part of the table below.
Include supplementary aids and services as appropriate.
For a student who has a disability and is gifted, SDI also should include adaptations, accommodations, or modifications to the general
education curriculum, as appropriate for a student with a disability.
Modifications and SDI
Academic material should
be taught at his
instructional level with
opportunities to review
mastered material in order
to bolster self-esteem and
foster a sense of success.
The following
recommendations may be
helpful in addressing
Rudolfs social skills and
peer relationships:

o Modeling: Students
benefit from watching
others who interact
successfully. This is
especially beneficial for
youngsters who have
difficulty reading other
students cues. A warm and
friendly attitude should be
displayed in the classroom
to all students, to ensure
that they are modeling a
positive example.

o Use cooperative learning

activities. These activities

Location

Frequency

Projected Beginning Date

Anticipated Duration

Across all settings

Daily

10/31/2016

10/30/2017

Across all setting

Daily

10/31/2016

10/30/2017

foster cooperation and

respect and help students
with limited social skills
assimilate more adaptive
communication strategies
from more socially skilled
peers.

o Create situations in
which positive exchanges
between students can
occur.

o Choose well-matched
student groups. This
enables a good match of
students (extroverted
mixed with introverted).

o Enlist specific
classmates with welldeveloped social skills to
support Rudolf as he tries
to change his behavior and
attempts newly learned
social skills.
Teachers should provide
frequent, specific positive
feedback and praise so that
Rudolf can continue to
develop confidence in his
academic skills and
abilities.

Across all settings

Daily

10/31/2016

B. RELATED SERVICES List the services that the student needs in order to benefit from his/her special education program.

10/30/2017

Service
Counseling (RHD) Small
Group

Location
Mastery Charter School Shoemaker Campus

Frequency

Projected Beginning Date

900 minutes per IEP term

10/31/2016

Anticipated Duration
10/30/2017

C. SUPPORTS FOR SCHOOL PERSONNEL List the staff to receive the supports and the supports needed to implement the students IEP.
School Personnel to
Receive Support

Parent/Guardian

Regular Education
Teacher

Support
On-going
communication
between parent and
Mastery Charter
School's special
education
department
On-going support
and communication
between general
education teachers
and special
education
department

Location

Across All Settings

Across All Settings

Frequency

per IEP term

daily

Projected Beginning
Date

Anticipated Duration

10/31/2016

10/30/2017

9/27/2016

9/25/2017

D. GIFTED SUPPORT SERVICES FOR A STUDENT IDENTIFIED AS GIFTED WHO ALSO IS IDENTIFIED AS A STUDENT WITH A DISABILITY Support services are
required to assist a gifted student to benefit from gifted education (e.g., psychological services, parent counseling and education, counseling services,
transportation to and from gifted programs to classrooms in buildings operated by the school district).

Support Service
Support Service
Support Service
E. EXTENDED SCHOOL YEAR (ESY) The IEP team has considered and discussed ESY services, and determined that:

x Student IS eligible for ESY based on the following information or data reviewed by the IEP team:
Extended School Year (ESY) services have been considered and it has been determined that Rudolf is currently eligible for ESY
services because he requires the additional educational time over the summer to retain and teach new skills and concepts.
ESY Checklist
1. Did the student receive ESY services in the past?
YES
2. Do the present education levels between the students current IEP and previous IEPs indicate progress toward goals?
YES
3. Do the goals and objectives between the students current IEP and previous IEPs indicate progress toward the goals?
YES
4. Did the student master any of his goals from the previous or current IEP?
NO
5. Does the students IEP progress report indicate progress made on current goals and objectives?
YES
6. Has the student demonstrated self-sufficiency and independence from caretakers on any of his goals, if appropriate?
N/A
Progress reports maintained by therapists
7. If the student received therapy, do reports of therapist indicate the student made progress?
N/A
Reports by parents
8. Are there any reports by parent(s) regarding negative changes in adaptive behaviors or in other skill areas?
YES
Medical Reports
9. Are there any medical or other agency reports indicating degenerative-type difficulties which become exacerbated during breaks
in educational services?
N/A

Observation and opinions of educators

10. Has information from other school staff that work with this student been provided regarding the relevant factors that indicates
any concerns in one or more of these areas?
YES
11. Is there data indicating that successive interruptions in educational programming resulted in a consistent pattern of withdrawal
from the learning process?
YES
Results of tests
12. Do the students grades and report card indicate progress?
YES
13. Do results of tests such as criterion-referenced tests, curriculum-based assessments, ecological life skills assessments, or other
equivalent measures indicate progress?
YES
OR
As of the date of this IEP, student is NOT eligible for ESY based on the following information or data reviewed by the IEP team:

The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the students ESY Program are:
Writing: Rudolf will achieve at least a 3 on the 6th grade PSSA writing rubric in the areas of content,
organization, style, and conventions in 3 out of 4 prompts as measured by performance on a PSSA
writing prompt given each report period. Baseline: 1 on content, organization, style, and conventions
area using 6th grade PSSA rubric and prompt (Baseline date 9/23/2016).
Math: Rudolf will increase his math problem solving skills to a 4.9 GLE on a research based math
assessment (Digits correct assessment) in 3 out of 4 trials given each report period. Baseline: 3.9 GLE on
the Digits Correct (problem solving) assessment (Baseline date 9/26/2016)
Math: Rudolf will increase his math computation skills to a 5.3 GLE on a research based math
assessment (Digits correct assessment) in 3 out of 4 trials given each report period. Baseline: 4.3 GLE on
the Digits Correct (computation) assessment (Baseline date 9/23/2016)

If the IEP team has determined ESY is appropriate, complete the following:
ESY Service to be Provided
Autistic Support

Location

Frequency

Projected Beginning Date

7/3/2017

Anticipated Duration
7/29/2017

VII. EDUCATIONAL PLACEMENT

A. QUESTIONS FOR IEP TEAM The following questions must be reviewed and discussed by the IEP team prior to providing the explanations regarding
participation with students without disabilities.
It is the responsibility of each public agency to ensure that, to the maximum extent appropriate, students with disabilities, including those in public
or private institutions or other care facilities, are educated with students who are not disabled. Special classes, separate schooling or other removal
of students with disabilities from the general educational environment occurs only when the nature or severity of the disability is such that education
in general education classes, EVEN WITH the use of supplementary aids and services, cannot be achieved satisfactorily.

What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the supplementary
aids and services will or will not enable the student to make progress on the goals and objectives (if applicable) in this IEP in the general
education class.

What benefits are provided in the general education class with supplementary aids and services versus the benefits provided in the special
education class?

What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the other students in the
class, even with supplementary aids and services?

To what extent, if any, will the student participate with nondisabled peers in extracurricular activities or other nonacademic activities?

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the regular education class:
Rudolf will not participate with students without disabilities in the regular education class when he is
working with the special education teacher working on classwork and in his social skills group.
Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
Rudolf will not participate with students without disabilities in the general education curriculum when
he is working with the special education teacher on classwork and in his social skills group.

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
B. Type of Support
1. Amount of special education supports
x

Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day
Supplemental: Special education supports and services provided by special education personnel for more than 20% of the day but less than
80% of the school day
Full-Time: Special education supports and services provided by special education personnel for 80% or more of the school day

2. Type of special education supports

x

Autistic Support
Blind-Visually Impaired Support
Deaf and Hard of Hearing Support
Emotional Support
Learning Support
Life Skills Support
Multiple Disabilities Support
Physical Support
Speech and Language Support

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April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
C. Location of students program
Name of School District where the IEP will be implemented:

Mastery Charter School- Shoemaker Campus

Name of School Building where the IEP will be implemented:

Mastery Charter School Shoemaker Campus

Is this school the students neighborhood school (i.e., the school the student would attend if he/she did not have an IEP)?
X Yes
No. If the answer is no, select the reason why not.
Special education supports and services required in the students IEP cannot be provided in the neighborhood school
Other. Please explain:

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April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
VIII. PENNDATA REPORTING: Educational Environment (Complete either Section A or B; Select only one Educational Environment)
To calculate the percentage of time inside the regular classroom, divide the number of hours the student spends inside the regular classroom by the total number of hours in the school day (including
lunch, recess, study periods). The result is then multiplied by 100.

SECTION A: For Students Educated in Regular School Buildings with Non Disabled Peers Indicate the Percentage of time INSIDE the regular classroom for this student:
Time spent outside the regular classroom receiving services unrelated to the students disability (e.g., time receiving ESL services) should be considered time inside the regular classroom.
Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as college campuses or vocational sites, should be counted as time
spent inside the regular classroom.
Calculation for this Student:

Column 1

Column 2

Calculation

Indicate Percentage

Total hours the student

spends in the regular
classroom per day

Total hours in a typical

school day
(including lunch, recess
& study periods)

(Hours inside regular

classroom hours in
school day) x 100 = %
(Column 1 Column 2) x
100 = %

Section A: The percentage of

time student spends inside the
regular classroom:

6.8

6.9

(6.8 6.9) x 100 =

98.55

_99_% of the day

Percentage Category
Using the calculation result select the appropriate percentage category

INSIDE the Regular Classroom 80% or More of the Day

INSIDE the Regular Classroom 79-40% of the Day
INSIDE the Regular Classroom Less Than 40% of the Day

SECTION B: This section required only for Students Educated OUTSIDE Regular School Buildings for more than 50% of the day select and indicate the Name of School or
Facility on the line corresponding with the appropriate selection: (If a student spends less than 50% of the day in one of these locations, the IEP team must do the calculation
in Section A)
Approved Private School (Non Residential) _________________________
Approved Private School (Residential)
_________________________
Other Private Facility (Non Residential)
_________________________
Other Private Facility (Residential)
________________________
Other Public Facility (Residential)
________________________

Other Public Facility (Non Residential) _________________________

Hospital/Homebound
_________________________
Correctional Facility
_________________________
Out of State Facility
_________________________
Instruction Conducted in the Home
_________________________

EXAMPLES for Section A: How to Calculate PennDataEducational Environment Percentages

Example 1

Column 1

Column 2

Calculation

Indicate Percentage

Total hours the student spends in the

regular classroom per day

Total hours in a typical school day

(including lunch, recess & study
periods)

(Hours inside regular classroom hours in school day)

x 100 = %
(Column 1 Column 2) x 100 = %

Section A: The percentage of time student

spends inside the regular classroom:

5.5

6.5

(5.5 6.5) x 100 = 85%

85% of the day

(Inside 80% or More of Day)
Example 2
3
5
60% of the day
(3 5) x 100 = 60%
(Inside 79-40% of Day)
Example 3
1
5
20% of the day
(1 5) x 100 = 20%
(Inside less than 40% of Day)
For help in understanding this form, an annotated IEP is available on the PaTTAN website at www.pattan.net Type Annotated Forms in the Search feature on the website. If you do not have access
to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.

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April 2014