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INVITATION TO A MEETING OF THE

INDIVIDUALIZED EDUCATION PROGRAM (IEP) TEAM


Form I-1 (Rev. 10/06)

HUDSON SCHOOL DISTRICT


[If you need this invitation in a different language or communicated in a different way, or have
questions about this invitation, please contact Jeryn Waldera at 715-377-3820.]

Dear Bela and Dipak Shetty, Date 04/24/16

You are a participant on the IEP Team which will meet to address the educational needs of your child, Rashmi Shetty.
IEP team meetings must be held at a mutually agreeable time and place. An IEP team meeting has tentatively been
scheduled for the following date 4/26/16, at 1:00PM, in the Conference Room. If these meeting arrangements are not
agreeable to you, please call Jeryn Waldera at 715-377-3820. You may bring other people who you believe have
knowledge or special expertise about your child to the meeting with you. If your child is transferring from a Birth to 3
Early Intervention Program we will, at your request, send to the Birth to 3 coordinator or other representative an
invitation to the IEP meeting.

The purpose of this IEP team meeting is (check all that apply):

EVALUATION AND REEVALUATION


Determine initial eligibility for special education
Determine continuing eligibility for special education

INDIVIDUALIZED EDUCATION PROGRAM (IEP) (if student is eligible)


Develop an initial IEP
X Develop an annual IEP
Review/revise IEP
Transition the consideration of postsecondary goals and transition services
(required for students beginning at age 14)

PLACEMENT (if student is eligible)


Determine initial placement
X Determine continuing placement
OTHER
Review existing information to determine need for additional assessments or other evaluation materials
(meeting optional)
Conduct a manifestation determination (check appropriate boxes under IEP and placement if changes in
either are contemplated)
Determine setting for services during disciplinary change in placement (must also check appropriate
boxes under IEP & placement)
Specify: _______________________________________________________________
______________________________________________________________________________________
If transition is checked as one of the purposes of this meeting, your child will be invited to attend. Because you provided
your consent we are also inviting representatives from the following agencies who may assist in the transition planning for
your child: None
________________________________________________________________________
1General Education Assessments in Wisconsin refer to content reflective of the Wisconsin Academic Standards. Alternate
assessments in Wisconsin assess content reflective of the Wisconsin Essential Elements. Students who are English language
learners are required to participate in an annual English language proficiency assessment.
Agency Name (if known), and Title/Position

________________________________________________________________________
Agency Name (if known), and Title/Position

If at any point during this meeting you or other IEP team participants believe that additional time is needed to permit your
meaningful involvement, additional time will be provided. Decisions related to the purpose(s) checked above may be
made in one meeting or may require more than one meeting, depending on individual circumstances. In addition and
upon request you may receive a copy of the IEP teams most recent evaluation report.

The following individuals have been appointed as IEP team participants and will attend the meeting.

John Smith, Regular Education Teacher Josh Baker, Special Education Teacher
Name/Reg. Ed. Teacher Name/Sp. Ed. Teacher

Anna Johnson, LEA Rep, Principal Bela Shetty, Mother


Name/LEA Representative Name &Title

Dipak Shetty, Father Sagar Shetty, Grandfather


Name & Title Name & Title

You and your child have protection under the procedural safeguards (rights) of special education law. The school district
must provide you with a copy of your procedural safeguards once a year.

You received a copy of your procedural safeguard rights in a brochure about parent and child rights earlier this year.
If you would like another copy of this brochure, please contact the district at the telephone number above.

A copy of the parent and child rights brochure is enclosed with this invitation.

In addition to district staff, you may also contact Jeryn Waldera at 715-377-3820 if you have questions about your rights.

Sincerely,

Jeryn Waldera
Name and Title of District Contact Person
EVALUATION REPORT AND IEP COVER SHEET
Form I-3 (Rev. 10/06)
Name of Student DOB Sex Grade
Rashmi Shetty 01/18/08 Female 4

Parent or Legal Guardian Telephone (area/number)


Bela and Dipak Shetty 123-456-7899

District of Residence Current District of Placement Race/Ethnic (if parent chooses to


Hudson identify)
Hudson Indian
Address For students transferring between public agencies:
IEP reviewed and adopted by ________________________________________________
1500 Spruce Dr On _____________________________________________
Hudson, WI 54016
For students transferring between public agencies:
Evaluation report reviewed and adopted by _____________________________________
On _____________________________________________

PURPOSE OF MEETING (Check all that apply):

Evaluation including determination of eligibility X Initial or annual IEP development

IEP review/revision Develop a statement of transition goals and services


(required for students age 14 and older, or younger if
appropriate)
X Placement Manifestation determination

Alternate assessment Determine setting for services during disciplinary change


in placement

Other: _____________________________ Other: _____________________________

If a purpose of this meeting is IEP development, review, and/or revision related to the academic, developmental and
functional needs of the child, the IEP team considered the results of:

Initial or most recent evaluation X Yes Not applicable


Statewide assessments Yes X Not applicable
District-wide assessments Yes X Not applicable
Date of Meeting: 4/26/16, at 1:00PM
(month/day/year)

IEP Team Participants Attending or Participating by Alternate Means in the Meeting:


Parent/Guardian Parent/Guardian Regular education teacher/title:
Bela Shetty Dipak Shetty John Smith

Student (if appropriate): Special education teacher/title: Special education teacher/title:


Josh Baker Jeryn Waldera
LEA Representative/Title: Other: Other:
Anna Johnson
Other: Other: Other:

If the parent did not attend or participate in the meeting by other means and did not agree to the time and place of the IEP team
meeting, document 3 efforts to involve the parents:
INDIVIDUALIZED EDUCATION PROGRAM: PRESENT LEVEL
OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Form I-4 (Rev. 9/13)

Name of Student: Rashmi Shetty

Describe the students strengths and the concerns of the parents about the students education.

Rashmi is a nine-year-old girl diagnosed with autism and a significant cognitive delay. She enjoys school and participates
in activities with her peers. She enjoys play as well as attention from staff. Parents report that Rashmi has become close
with her grandfather who lives with the family. Parents are concerned with Rashmis eating challenges and increased
behaviors in the classroom. They hypothesize this due to Dipaks absence due to work and Rashmis grandfather taking
care of all of the children during the morning routine.

Describe the students present level of academic achievement and functional performance including how the
students disability affects his or her involvement and progress in the general education curriculum. For preschool
children, describe how the disability affects involvement in age-appropriate activities. (Note: Present level of
performance must include information that corresponds with each annual goal)

Rashmi receives individualized intervention in Positive Behavior Supports (PBS). At this time, Rashmi engages in
disruptive behaviors, such as crying, screaming, hitting herself on the ears, and biting herself on the hands when
transitioning to the table for group work time. Rashmi is removed from the group, but continues to engage in these
behaviors after removal. Based on the Functional Behavioral Assessment (FBA) completed by Josh Baker, Rashmis
behaviors may function to escape group work or to gain access to an item such as food. The behaviors did not occur when
Rashmi was getting attention nor did they serve as automatic reinforcement. In addition, when Rashmi is engaged in these
behaviors, she cannot complete other actions, so Mr. Baker ruled out self-regulation as a function. On 3 out of 4 days,
Rashmi engaged in these behaviors at the start of group work time, and on 1 out of 4 days, she engaged in these behaviors
to access food, as the behaviors started before lunch but did not continue during lunch. Parents report eating is difficult for
Rashmi and typically takes a long duration to complete. With Rashmis father traveling for work, Rashmis grandfather,
Sagar Shetty, has taken on the role of getting all 4 children ready for school in the morning. Without attending to Rashmi
during mealtimes, she typically eats less food, which may cause her to become hungry earlier.

Will the student be involved full-time in the general education curriculum or, for preschoolers, in age-appropriate
activities? Yes No
(If no, describe the extent to which the student will not be involved full-time in the general curriculum or, for
preschoolers, in age-appropriate activities)

Rashmis schedule consists of a combination of academic work in the CID classroom and other school activities. She will
also have reverse mainstreaming opportunities for socialization purposes. Rashmis cognitive communication, sensory,
and motor skills differ significantly from her peers and she needs small group and 1:1 assistance to make progress on her
goals.

SPECIAL FACTORS After consideration for special factors (behavior, limited English proficiency, Braille needs,
communication needs including deaf/hard of hearing, and assistive technology), is there a need in any of the areas?
X Yes No (If yes or student has a visual impairment, attach I-5, Special Factors page)
INDIVIDUALIZED EDUCATION PROGRAM
SPECIAL FACTORS
Form I-5 (Rev. 7/06)

Note: For any need(s) identified below, there must be a statement of the service(s) to meet that need (including amount/frequency,
location, and duration) on the Program Summary page (I-9).

Name of Student: Rashmi Shetty

A. Does the students behavior impede his/her learning or that of others? X Yes No
(If yes, include the positive behavioral interventions, strategies, and supports to address that behavior)

Rashmi benefits from:


Access to a snack time during morning instruction
Utilize a visual schedule and keep learning sessions short
Provide reinforcement at a high rate and use a highly motivating reinforcer to decrease frustration with a task
Present material in a wide variety of ways so she does not satiate or memorize the task
Incorporate sensory and movement breaks throughout the day so that she is receiving the necessary amount of input
needed to maintain a calm body during learning sessions.

B. Is the student an English Language Learner? Yes X No


(If yes, include the language needs that relate to this IEP)

C. If visually impaired, does the student need instruction in Braille or the use of Braille?
Yes No X Not Applicable
(If yes, include Braille needs; if no or cannot be determined, attach ER-3, Determining Braille Needs from the
latest evaluation/reevaluation)

D. Does the student have communication needs that could impede his/her learning? X Yes No
(If yes, include communication needs)

{If yes and the student is deaf or hard of hearing, identify the communication needs including (a) the students language; (b)
opportunities for direct communication with peers and professional personnel in the students language and communication mode;
and, (c) academic level and full range of needs including opportunities for direct instruction in the students language and
communicative mode}:

Rashmi does not engage in verbal speech and uses a picture board to communicate to access her basic needs,
which negatively impacts her ability to communicate her thoughts, feelings, and desires.

E. Does the student need assistive technology services or devices? X Yes No


{If yes, specify particular device(s) and service(s)}

Rashmi requires low-tech picture symbols for communication, as well as to create a visual schedule. During
instruction, she may utilize an electronic whiteboard, computer, and tablet to complete academic tasks and to aid in
communication when she is not able to effectively communicate verbally.
INDIVIDUALIZED EDUCATION PROGRAM
ANNUAL GOAL
Form I-6 (Rev. 10/06)

Name of Student: Rashmi Shetty

Measurable annual academic or functional goal to enable the student to be involved in and progress in the general
education curriculum, and to meet other educational needs that result from the students disability. (Note: present levels
of academic achievement and functional performance must include information that corresponds with each annual goal)
Upon review: Goal met Goal not met

Goal #1: Emotional, Social, Behavioral

During instruction, Rashmi will increase her ability to use functional communication from inconsistent use to using
spontaneous functional communication in 3 out of 4 opportunities.

Procedures for measuring the students progress toward meeting the annual goal.

1. With a model prompt, Rashmi will use her communication board to ask for a break from academic activities in 4
out of 5 opportunities.
2. With a model prompt, Rashmi will use her communication board to request for items she wants (including, but
not limited to asking for a snack, requesting an activity, gaining attention) in 4 out of 5 opportunities.
3. Rashmi will independently use her communication board to ask for a break from academic activities in 3 out of 5
opportunities.
4. Rashmi will independently use her communication board to request for items she wants (including, but not limited
to asking for a snack, requesting an activity, gaining attention) in 3 out of 5 opportunities.

Will the student participate in an alternate assessment aligned with alternate achievement standards for students with
disabilities in any subject area? X Yes No
(If yes, include benchmarks or short-term objectives for the student)

Rashmi will participate in alternative assessments due to her diagnoses of autism and significant cognitive delay.

When will reports about the students progress toward meeting the annual goal be provided to parents?

Reports of progress will be provided to parents 3 times a year when grades are assigned.
INDIVIDUALIZED EDUCATION PROGRAM
ANNUAL GOAL
Form I-6 (Rev. 10/06)

Name of Student: Rashmi Shetty

Measurable annual academic or functional goal to enable the student to be involved in and progress in the general
education curriculum, and to meet other educational needs that result from the students disability. (Note: present levels
of academic achievement and functional performance must include information that corresponds with each annual goal)
Upon review: Goal met Goal not met

Goal #2: Reading

Rashmi will identify 20 community signs in her immediate environment with 80% accuracy in a field of 3.

Procedures for measuring the students progress toward meeting the annual goal.

1. Rashmi will identify 5 community signs in her immediate environment (stop, exit, elevator, police, nurse) with
80% accuracy in a field of 3.
2. Rashmi will identify 10 community signs in her immediate environment (stop, exit, elevator, police, nurse, fire,
first aid, office, bus, telephone) with 80% accuracy in a field of 3.
3. Rashmi will identify 15 community signs in her immediate environment (stop, exit, elevator, police, nurse, fire,
first aid, office, bus, telephone, danger, caution, women, men, stairs) with 80% accuracy in a field of 3.
4. Rashmi will identify 20 community signs in her immediate environment (stop, exit, elevator, police, nurse, fire,
first aid, office, bus, telephone, danger, caution, women, men, stairs, do not walk, walk, closed, fire extinguisher,
open) with 80% accuracy in a field of 3.

Will the student participate in an alternate assessment aligned with alternate achievement standards for students with
disabilities in any subject area? X Yes No
(If yes, include benchmarks or short-term objectives for the student)

Rashmi will participate in alternative assessments due to her diagnoses of autism and significant cognitive delay.

When will reports about the students progress toward meeting the annual goal be provided to parents?

Reports of progress will be provided to parents 3 times a year when grades are assigned.
INDIVIDUALIZED EDUCATION PROGRAM
ANNUAL GOAL
Form I-6 (Rev. 10/06)

Name of Student: Rashmi Shetty

Measurable annual academic or functional goal to enable the student to be involved in and progress in the general
education curriculum, and to meet other educational needs that result from the students disability. (Note: present levels
of academic achievement and functional performance must include information that corresponds with each annual goal)
Upon review: Goal met Goal not met

Goal #3: Math

Rashmi will fluently solve single-digit addition and subtraction problems with 80% accuracy in 2 minutes.

Procedures for measuring the students progress toward meeting the annual goal.

1. Rashmi will solve single-digit addition problems with 80% accuracy.


2. Rashmi will solve single-digit subtraction problems with 80% accuracy.
3. Rashmi will solve single-digit addition problems with 80% accuracy in 5 minutes.
4. Rashmi will solve single-digit subtraction problems with 80% accuracy in 5 minutes.
5. Rashmi will solve single-digit addition problems with 80% accuracy in 3 minutes.
6. Rashmi will solve single-digit subtraction problems with 80% accuracy in 3 minutes.

Will the student participate in an alternate assessment aligned with alternate achievement standards for students with
disabilities in any subject area? X Yes No
(If yes, include benchmarks or short-term objectives for the student)

Rashmi will participate in alternative assessments due to her diagnoses of autism and significant cognitive delay.

When will reports about the students progress toward meeting the annual goal be provided to parents?

Reports of progress will be provided to parents 3 times a year when grades are assigned.
INDIVIDUALIZED EDUCATION PROGRAM
ANNUAL GOAL
Form I-6 (Rev. 10/06)

Name of Student: Rashmi Shetty

Measurable annual academic or functional goal to enable the student to be involved in and progress in the general
education curriculum, and to meet other educational needs that result from the students disability. (Note: present levels
of academic achievement and functional performance must include information that corresponds with each annual goal)
Upon review: Goal met Goal not met

Goal #3: Writing

Rashmi will increase her ability to independently write her first and last name from 1 out of 5 opportunities to 3 out of 5
opportunities.

Procedures for measuring the students progress toward meeting the annual goal.

1. Rashmi will print the letters from her name in isolation in 3 out of 5 opportunities.
2. Rashmi will trace her first and last name in 4 out of 5 opportunities.
3. With a hand-over-hand prompt, Rashmi will write her first and last name in 4 out of 5 opportunities.
4. With a model prompt, Rashmi will write her first and last name in 3 out of 5 opportunities.
5. Rashmi will independently write her first and last name in 3 out of 5 opportunities.

Will the student participate in an alternate assessment aligned with alternate achievement standards for students with
disabilities in any subject area? X Yes No
(If yes, include benchmarks or short-term objectives for the student)

Rashmi will participate in alternative assessments due to her diagnoses of autism and significant cognitive delay.

When will reports about the students progress toward meeting the annual goal be provided to parents?

Reports of progress will be provided to parents 3 times a year when grades are assigned.
INDIVIDUALIZED EDUCATION PROGRAM
ANNUAL GOAL
Form I-6 (Rev. 10/06)

Name of Student: Rashmi Shetty

Measurable annual academic or functional goal to enable the student to be involved in and progress in the general
education curriculum, and to meet other educational needs that result from the students disability. (Note: present levels
of academic achievement and functional performance must include information that corresponds with each annual goal)
Upon review: Goal met Goal not met

Goal #4: Social Skills

Rashmi will take turns with a peer in a structured activity in 4/5 trials with visual prompts.

Procedures for measuring the students progress toward meeting the annual goal.

1. Rashmi will take turns with a peer in a structured activity in 2/5 trials with hand over hand assistance and a
visual/verbal prompt.
2. Rashmi will take turns with a peer in a structured activity in 4/5 trials with a physical signal such as a tap or
gesture and a visual/verbal prompt.
3. Rashmi will take turns with a peer in a structured activity in 2/5 trials with a visual/verbal prompt.
4. Rashmi will take turns with a peer in a structured activity in 4/5 trials with a visual/verbal prompt.

Will the student participate in an alternate assessment aligned with alternate achievement standards for students with
disabilities in any subject area? X Yes No
(If yes, include benchmarks or short-term objectives for the student)

Rashmi will participate in alternative assessments due to her diagnoses of autism and significant cognitive delay.

When will reports about the students progress toward meeting the annual goal be provided to parents?

Reports of progress will be provided to parents 3 times a year when grades are assigned.
INDIVIDUALIZED EDUCATION PROGRAM
ANNUAL GOAL
Form I-6 (Rev. 10/06)

Name of Student: Rashmi Shetty

Measurable annual academic or functional goal to enable the student to be involved in and progress in the general
education curriculum, and to meet other educational needs that result from the students disability. (Note: present levels
of academic achievement and functional performance must include information that corresponds with each annual goal)
Upon review: Goal met Goal not met

Goal #5: Communication

Rashmi will initiate requests using a visual personal communication system in 4 out of 5 opportunities per day in various
activities.

Procedures for measuring the students progress toward meeting the annual goal.

1. With a prompt, Rashmi will use her personal communication system to make a request in 4 out of 5 opportunities.
2. Rashmi will use her personal communication system to request for attention from staff in 4 out of 5 opportunities.
3. Rashmi will use her personal communication system to initiate a request in 3 out of 5 opportunities.

Will the student participate in an alternate assessment aligned with alternate achievement standards for students with
disabilities in any subject area? X Yes No
(If yes, include benchmarks or short-term objectives for the student)

Rashmi will participate in alternative assessments due to her diagnoses of autism and significant cognitive delay.

When will reports about the students progress toward meeting the annual goal be provided to parents?

Reports of progress will be provided to parents 3 times a year when grades are assigned.
PARTICIPATION GUIDELINES FOR ALTERNATE ASSESSMENT
Form I-7-A (Rev. 9/15)

Name of Student: Rashmi Shetty

IEP teams are responsible for deciding whether students with disabilities will participate in general
education assessments with or without testing accommodations, or in the alternate assessment with or
without accommodations.1 In a given year, a student must participate in either all general education
assessments or all alternate assessments, not parts of both.

Agree (Yes) or
Participation Criterion Participation Criterion Descriptors Disagree (No)?

Review of student record indicates a disability (i.e.


Autism, Intellectual Disability, or Traumatic Brain
1. The student has a
Injury) that significantly impacts intellectual
significant cognitive
functioning and adaptive behavior. Adaptive behavior
Yes / No
disability.
is defined as essential for someone to live
independently and to function safely in daily life.

2. The student is primarily Goals listed in the IEP for this student are linked to
being instructed using the the enrolled grade level Wisconsin Essential
Wisconsin Essential Elements and address knowledge and skills that are
Yes / No
Elements. appropriate and challenging for this student.

3. The student requires


The student
extensive direct
a. requires extensive, repeated, individualized instruction
individualized instruction
and support that is not of a temporary nature and
and substantial supports
to achieve measureable
b. uses substantially adapted materials and individualized Yes / No
methods of accessing information in alternative ways
gains in the grade-and
age-appropriate to acquire, maintain, generalize, demonstrate and
curriculum. transfer skills across multiple settings.

When the IEP team concurs that all three of the criteria above accurately characterize a students current educational
situation, an alternate assessment should be used to provide a meaningful evaluation of the students current academic
achievement.

The IEP team determined the student must participate in alternate assessments. Yes / No

Decisions for determining participation in the alternate assessment must not be based solely on any of the
following:
1. A disability category or label 9. Low reading level/achievement level
2. Poor attendance or extended absences 10. Anticipated students disruptive behavior
3. Native language/social/cultural or 11. Impact of student scores on
economic difference accountability system
4. Expected poor performance on the 12. Administrator decision
general education assessment 13. Anticipated emotional distress
5. Academic and other services student 14. Need for accommodations (e.g., assistive
receives technology/Augmentative and Alternative
6. Educational environment or instructional Communication) to participate in
setting assessment process
7. Percent of time receiving special
education
8. English Language Learner (ELL) status
Page ____ of ____

1General Education Assessments in Wisconsin refer to content reflective of the Wisconsin Academic Standards.
Alternate assessments in Wisconsin assess content reflective of the Wisconsin Essential Elements. Students who
are English language learners are required to participate in an annual English language proficiency assessment.
Page ____ of ____ Form I-9

INDIVIDUALIZED EDUCATION PROGRAM: To be completed for students participating


in
PARTICIPATION IN DISTRICT-WIDE ASSESSMENTS district-wide assessments
Form I-7 District-wide Assessment (Rev. 3/16)

Name of Student: Rashmi Shetty

Students with disabilities must be included in district-wide assessments1. The student will be in (circle) K, 1st,
2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, or 12th grade when the district-wide assessment is given.

PARTICIPATION IN DISTRICT-WIDE ASSESSMENTS

District-wide assessments given X District-wide assessments not given


Student will not be in the grade when a district-wide assessment is given

District-wide assessments include the high school civics exam requirement under Wis. Stat. 118.33(1m).
It is not appropriate to administer the high school civics exam to the student.

List district-wide assessment(s) student will take:

Describe appropriate testing accommodations, if any:

Alternate Assessment If the IEP team determines the student will take an alternate assessment, describe why
the student cannot participate in the regular assessment and an alternate district-wide assessment is appropriate.

Rashmi will participate in alternative assessments due to her diagnoses of autism and significant cognitive
delay.

1 Wis. Stat. 115.77(1m)(bg)


INDIVIDUALIZED EDUCATION PROGRAM: To be completed for students
participating
PARTICIPATION IN STATEWIDE ASSESSMENTS in Dynamic Learning Maps
Form I-7-DLM (Rev 2/16)

Name of Student: Rashmi Shetty

The student will be in (circle one) 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th or 11th grade when the Dynamic Learning
Maps assessment is administered in English language arts, mathematics, and/or science. The student will be taking
the alternate assessment1 for all content areas required at this grade level (the I-7-A Participation Guidelines for
Alternate Assessment must be included with the IEP).

Accommodations for Dynamic Learning Maps are specific to this assessment. IEP determinations regarding the use
of accommodations on the DLM assessment apply to the both content areas of English language arts, mathematics,
and/or science. The DLM assessment was designed using the principles of universal design for learning, as such the
term accommodation is replaced with the phrases accessibility features and supports. Please refer to the Office
of Student Assessment website for the current policies.

Category 1: Accessibility features/supports provided within the DLM system must be activated via the Personal
Needs Profile (PNP) prior to administering the assessment. Please list required supports:

Human Read Aloud

Category 2: Accessibility features/supports requiring additional tools/materials. Please list required supports:

None

Category 3: Accessibility features/supports provided outside of the DLM system. Please list required supports:

Human Read Aloud


Administration on Touch Screen
Page ____ of ____ Form I-9

INDIVIDUALIZED EDUCATION PROGRAM:


SUMMARY
Form I-9 (Rev. 10/06)

Name of Student: Rashmi Shetty

Projected beginning and ending date(s) of IEP services & modifications 04/25/16 to 04/24/17

Physical education: Regular X Specially designed


Vocational education: Regular X Specially designed
Include a statement for each of I, II, III and IV below to allow the student (1) to advance appropriately toward
attaining the annual goals; (2) to be involved and progress in the general education curriculum; (3) to be
educated and participate with other students with and without disabilities to the extent appropriate, and (4) to
participate in extracurricular and other nonacademic activities. Include frequency, location, & duration (if
different from IEP beginning and ending dates).
I. Special education Frequency/ Location Duration
Amount
Special
Specially designed instruction in Emotional, Social, 45 minutes Education Duration of
Behavioral daily Setting IEP

Frequency/ Location Duration


Amount
Specially designed instruction in Reading Special
45 minutes Education Duration of
daily Setting IEP

Frequency/ Location Duration


Amount
Special
Specially designed instruction in Mathematics 45 minutes Education Duration of
daily Setting IEP

Frequency/ Location Duration


Amount
Specially designed instruction in Writing Special
45 minutes Education Duration of
daily Setting IEP

Frequency/ Location Duration


Amount
Specially designed instruction in Social Skills Special
45 minutes Education Duration of
daily Setting IEP

II. Related services needed to benefit from special education including frequency, location, and
duration (if different from IEP beginning and ending dates).
Transportation Frequency/ Location Duration
Amount
Hudson Duration of
To and from Elementary IEP
school (am School
& pm)

None needed to benefit from special education


Freq / Amt Location Duration
X Assistive Technology Daily All School Duration of
Environments IEP
X Occupational Therapy 2 times per Special Duration of
month, 30 Education IEP
minutes Setting
X Speech / Language 2 times per Special Duration of
week, 30 Education IEP
minutes Setting
Page ____ of ____ Form I-9

III. Supplementary aids and services: aids, services,


Freq / Amt Location Duration
and other supports provided to or on behalf of the
student in regular education or other educational
settings.
X Yes No (If yes, describe)
Daily Special Duration of
Modified Curriculum: Alternative curriculum Education IEP
(TouchMath, Edmark Reading) and teacher Setting
made materials

Modified Testing Procedures: Rashmis Daily Special Duration of


progress will be evaluated based on criteria on Education IEP
IEP goals rather than grade level benchmarks Setting

Modified Grading: Rashmis progress will be Daily Special Duration of


evaluated based on criteria on IEP goals rather Education IEP
than grade level benchmarks Setting

Educational Assistant: Rashmi needs a 1:1 or Daily Special Duration of


1:2 adult support when in mainstream Education IEP
environment or when needed in CID in order to Setting
benefit from the educational materials presented

IV. Program modifications or supports for school


personnel that will be provided.
X Yes No (If yes, describe)
CID support Multiple Duration of
Training: Training for educational assistants on staff will School IEP
autism spectrum disorders and the best strategies meet weekly Settings
to use with Rashmi. with CID
teacher
regarding
autism
teaching
strategies.
Page ____ of ____

1General Education Assessments in Wisconsin refer to content reflective of the Wisconsin Academic Standards.
Alternate assessments in Wisconsin assess content reflective of the Wisconsin Essential Elements. Students
who are English language learners are required to participate in an annual English language proficiency
assessment.
Page 2 of 2 Form I-1

V. Participation in Regular Education Classes

The student will participate full-time with non-disabled peers in regular education
classes, or for preschoolers, in age-appropriate settings.

X The student will not participate full-time with non-disabled peers in regular
education classes, or for preschoolers, in age-appropriate settings. (If you have
indicated a location other than regular education classes or age-appropriate settings in the
case of a preschooler in I, II, or III above, you must check this box and explain why full-time
participation with non-disabled peers is not appropriate.)

Because of Rashmis unique needs outlined in the IEP by the IEP team, Rashmi will continue to
benefit from a modified curriculum, small group setting, and direct instruction that cannot be
provided in the general education setting.

VI. Participation in Extracurricular and Nonacademic Activities

Will the student be able to participate in extracurricular and nonacademic activities with
nondisabled students? X Yes No
(If yes, include under I., II., III., and IV. any special education, related services, supplementary
aids and services, and program modifications or supports necessary to assist the student. If no,
describe the extent to which the student will not be involved in extracurricular and nonacademic
activities with nondisabled students)

Rashmi is able to participate in appropriate extra-curricular activities. If her parents believe she
requires supports or accommodations in order to participate, the IEP will meet to consider the
appropriateness of the activity. If the activity is appropriate, then the IEP team would consider
necessary supports and accommodations.
Form I-1 Page 3 of 3
WORKSHEET FOR DETERMINING
EDUCATIONAL ENVIRONMENT CODES
Worksheet EE-1 (Rev. 7/10)

School District HUDSON SCHOOL DISTRICT

Name of Student: Rashmi Shetty

For codes A, B, C
Divide #of minutes student is removed
Environment Code
from nondisabled peers in one week by the
total # of minutes in the school week,
For Students Age 6 through 21 multiply by 100. Subtract this percent
from 100.

A (inside the regular classroom with nondisabled peers 80% or more of the time)

B (inside the regular classroom with nondisabled peers 40 to 79% of time)

X C (inside the regular classroom with nondisabled peers less than 40% of the time)

D (public separate day school) I (hospital)

E (private separate day school) J (homebound)

F (public residential facility) S (correctional facilities)

G (private residential facility) T (parentally placed private)

For Students Age 3 through 5

Regular Early Childhood Setting (Program includes at least 50% nondisabled children)
R1 (in regular early childhood at least 10 hours per week & majority of hours of special
education and related services are delivered in EC program)

R2 (in regular early childhood at least 10 hours per week & majority of hours of special
education and related services are delivered in other location)

R3 (in regular early childhood less than 10 hours per week & majority of hours of
special education and related services are delivered in EC program)

R4 (in regular early childhood less than 10 hours per week & majority of hours of
special education and related services are delivered in other location)

Special Education Early Childhood Setting (Program includes less than 50% nondisabled
children)
B1 (special education classroom B2 (separate school) B3 (residential
facility)

I-9 (2) Revised 7/1/06


Page 2 of 2 Form I-1

Neither Regular Early Childhood nor Special Education Early Childhood Setting
B4 (home B5 (service provider location)
Form I-1 Page 3 of 3
Behavior Intervention Plan

Proactive Strategies:

Strategies and environmental adjustments that will be used to increase positive behaviors/interactions
include keeping the environment as calm as possible. This includes removing Rashmi from the group
environment. Staff should keep demands and language short, clear, and should be consistent among staff.
Staff should use visuals, such as a visual duration map to make expectations clear. Rashmi should be
reinforced for positive behaviors using a token system. A snack time should be incorporated to aid in
regulation.

Desired Behaviors to Increase, Maintain and/or Teach:

Rashmi will functional communication to inform staff if she needs an item or a break.

Positive Interventions, Accommodations, and/or Strategies:

-Staff model requests during structured and non-structured activities


-Staff models I need a break during structured and non-structured activities
-Immediately reinforce Rashmi when she makes a choice to communicate her wants, needs, or a break

Consequences/Interactions which serve to Increase Desired Behavior:

Rashmi will use her communication book/device to communicate her wants, needs, or a break to staff
rather than engaging in challenging behaviors.

Implementation Considerations

Staff will model functional language; as well as utilize visuals to offer choice and set clear expectations
(visual duration maps). Staff in the special education room will work to encourage generalization across
settings. These will be implemented during the duration of the IEP and be monitored by the special
education teacher and IEP team.

Progress monitoring will take place as behaviors occur and weekly for collaboration among staff and the
team will meet to evaluate progress at Rashmis annual IEP meeting.

I-9 (2) Revised 7/1/06


Page 2 of 2 Form I-1

Summary of IEP Writing

I chose Rashmi due to her diagnosis of autism and her placement in a self-contained special education
classroom. This case study only included information about Rashmis behaviors and their functions. It did
not include any academic data. Based on the mention of a self-contained classroom, I could infer that
Rashmi would require minutes in all other academic areas besides emotional, social, or behavioral. Due to
the academic information being absent from the case study, I chose goals that I believed a fourth grader
would likely be targeting. I would have liked to read more academic information about Rashmi to better
choose goals to fit her specific needs, such as a test of academics or curriculum based assessments.

Based on Rashmis behavioral needs, I included a Behavior Intervention Plan (BIP) in her IEP. It is
necessary for the team to have training on her BIP plan and positive behavioral supports to ensure
consistency when managing Rashmis behaviors and to consistently strive towards the overall goal of
independent functional communication. In addition, the team must have training on how to prompt
functional communication to aid Rashmis independence in this skill. I also included adding a snack in
her BIP due to access of food (hunger) was a function of Rashmis behaviors. I would also like to read
more information about what proactive strategies are used with Rashmi to set her up for success during
times of increased behaviors, although I provided some basic strategies in the BIP.

Due to the limited academic information provided in the case study, I made many inferences on what a
fourth grade student may be working on based on cues about her level of functioning. I chose goals that
would be applicable to Rashmis level of need at her age level. Throughout the IEP, I focused on
Rashmis behavioral and communication needs based on the information provided. I believe that with
functional communication training and consistent proactive strategies, Rashmis behaviors will likely
decrease in the self-contained classroom.