Childs Name: Janie Smith Date of Birth: __________________

2009-05-01
Local Program: __________________________________________ x ID#:__________________________

Office of Child Development and Early Learning

Individualized Family Service Plan (IFSP)

Individualized Education Program (IEP)
The IFSP and IEP are plans that identify services and supports so that family members and early education
programs are actively engaged in promoting the childs learning and development.

The IFSP/IEP team determines the skills/abilities and appropriate supports and services either in the
natural environment or the least restrictive environment to accomplish the established goals and outcomes.

These decisions are not made by matching the childs areas of delay with a particular early intervention
discipline. Rather, supports and strategies are individualized and build on the strengths and skills the child
demonstrates in all areas of development.

The IFSP and IEP are plans that consider: the strengths of the child; concerns of the parent/guardian; most
recent evaluation results; academic, developmental and functional needs of the child; communication
needs of the child; and will incorporate revisions to the plan to address lack of progress.

Meetings for the IFSP/IEP

Date meeting(s) held Purpose Of Meeting(s)
(Ex.: Initial IFSP/IEP, Annual, Revisions)

March 2014 1
Childs Name: Janie Smith Date of Birth: __________________
2009-05-01
Local Program: __________________________________________ x ID#:__________________________

I. Demographics and IFSP/IEP Team Membership

Child Information Family Information
Childs Name:Janie Smith Gender:Female Name: Sally Smith Relationship:Female
Date of Birth:2009-05-01 Age:2 Address:222 East Second Street
EIX#: City/State/Zip:Pall, NE 68789
Referral Date: Phone (home): Phone (cell):
Referral Source: Phone (work): Email:
Childs Address:222 East Second Street Name: Relationship:
City/State/Zip: Pall, NE 65789 Address:
Phone #: City/State/Zip:
Primary Language: Phone (home): Phone (cell):
School District of Residence: Phone (work): Email:
County of Residence: Primary Language:
Interpreter Needed: Yes No
School District of Residence:
County of Residence:
IFSP/IEP Team Membership:
Members shall include: parent and others as requested by the parent (if feasible); the County Designee/Service Coordinator (infant/toddler) or Local Education Agency
Representative (preschool) must be present for the meeting; a person directly involved with evaluation and assessment results who can interpret instructional implications; a person
who will be providing services, as appropriate (infant/toddler); a regular education and a special education teacher (preschool).
Role Printed Name Attendance Signature
Parent/Guardian Sally Smith
Parent/Guardian
Service Coordinator Sue Bainter

The following individuals provided information to the IFSP/IEP team but did not attend or were excused from the meeting.

Role Printed Name

Parent(s) received copy of Procedural Safeguards/Parents Rights Agreement: Yes No

Parent/Guardian Signature: __________________________

March 2014 2
Childs Name: Janie Smith Date of Birth: __________________
2009-05-01
Local Program: __________________________________________ x ID#:__________________________

II. Child and Family Information

Summary of the Childs Present Performance
Provide a summary from the Evaluation Report, if current, or update with current information. This summary describes the childs strengths (including strengths that exist in areas of
concern) and the childs needs. Include developmental, academic achievement (preschool), and functional performance. Describe how the childs developmental delay or disability
affects the childs involvement in everyday routines and appropriate activities. Describe instructional strategies that have been successful and how they can be incorporated into the
childs educational program and curriculum that will support the child. Describe the childs favorite activities and materials, and factors that motivate the child to participate and learn.

Janie likes to be around other children and goes to the local daycare 3 mornings per week. Janie likes to play with babies and her older sister's barbie dolls. Sally says that about a few months ago, she could not understand
anything Janie would say but could figure out what she wanted by having Janie take her to what she wanted. She doesnt know why she can understand a few words now, but no one else can. Janie can see things across the
room on the floor or table. She gets around the house and daycare safely. She sees and recognizes pictures in books because she tries to say them. Janie passed her newborn hearing screen and Mom has no current
concerns. Janie has only had one ear infection and can hear Mom calling her from across the house or when she is upstairs. Janie has been very healthy. She recently got her H1N1 shot. Janie likes to take care of babies and
puts them in blankets. she pretends to feed them with a bottle. She also likes to play with dishes and stacks them up as well as pretending to eat from them. Janie likes to do puzzles with her older sister. She also likes to play
barbies if her sister lets her. Janie loves books, especially ones about animals and brings books to her family to read to her. She points to pictures and if Mom says the name, Janie will sometimes say something that is not
understandable, other times she smiles or laughs. She tries to make animal sounds too. Janie follows routine directions from Mom and also will go to her room, the bathroom, to the car, etc. if she hears Mom or another family
member talking about it. Janie says a few words that mostly only Mom can understand: da for her name when asked, dee when asked how old she is; also owie, mommy, mama (for gramma). She occasionally tries to
put a couple words together I ite for I write, no baba for hold baby. Sometimes Janie will take Mom or another family member by the hand to show what she wants but other times she gets frustrated and will cry or whine.
Janie loves music and likes to dance to it. She can even hum some of her favorite songs. She likes to be outside and chase the cat around. She plays well with the other children at daycare - usually this is alongside if in the
house, but also will do puzzles with other children her age or slightly older, or simple games. She also loves to go to Grandmas house. Janie is a really good eater and usually eats just about anything that Mom gives her . She
drinks from a regular cup and uses silverware. She can undress herself and gets her pajamas on at night. She is very nearly potty trained and has just started to tell Mom when she has to go pe. Janie likes to scribble on
paper. She picks up small pieces of food using her thumb and index finger. She uses the knobs on puzzles which are pretty small. she likes to color in her coloring book if her sister is doing this too. Janie can kick a ball and tries
to peddle on her big wheel. sometimes she can and other times she might just push with her feet. She runs, jumps, and climbs on furniture. She can go down the slide by herself at the park and likes to swing.

Summary of Family Information

Provide a summary from the Evaluation Report, if current, or update with current information.
Sally would like Janie to use more words and maybe even some phrases that are understandable to someone outside of their
immediate family. Sally wants to take some night classes. She is not sure yet what she wants to do for a job. Sally wants to use a
Services Coordinator. Sally has made an appointment to talk to the local community college about possible coursework. Sally's Mom
lives nearby and Janie and the family see her often.

With parent consent, list assistance to the family in helping them access community, medical or other non-EI funded services.
If the parent does not want to address this item, document in the childs record.

March 2014 3
Childs Name: Janie Smith Date of Birth: __________________
2009-05-01
Local Program: __________________________________________ x ID#:__________________________

III. Special Considerations

Following are special factors the IFSP/ IEP team must consider before developing the IFSP/ IEP. Each question must be answered. If YES is checked, the
IFSP/IEP must address the childs needs related to any identified special factor.
1. Is the child blind or visually impaired?
NO YES - As developmentally appropriate for the infant, toddler, and preschooler, the IFSP/IEP team should evaluate the childs early literacy needs,
including reading and writing media. The IFSP/IEP must consider the current and future needs of the child related to the use of Braille if the team
decides that this is appropriate for the child.

2. Is the child deaf or hard of hearing?

NO YES - Team must consider the infants, toddlers or preschooler's language and communication needs, opportunities for direct communication with
peers and professionals in the child's language and communication mode, academic level, and full range of needs including opportunities for direct
instruction in the child's language and communication mode in the development of the IFSP/IEP.

3. Does the child exhibit behaviors that impede the childs learning or that of others?
NO YES - Team must base the use of positive behavior interventions and supports, and other strategies to address that behavior on a functional
behavior assessment.

4. Does the child have limited English proficiency (e.g., the childs home language is not English)?
NO YES - Team must consider the family and childs language needs as those needs relate to the development and implementation of the IFSP/IEP.

5. Does the child have communication needs?

NO YES - Team must consider the communication needs of the child in the development of the IFSP/IEP.

6. Does the child need assistive technology devices and/or services?

NO YES - Team must consider the infants, toddlers or preschooler's assistive technology needs in the development of the IFSP/IEP.
Proloquo2Go iPad App
7. Is it anticipated that the infant/toddler or preschooler will be transitioning from the Early Intervention program because of a transition in the life of
the family and child?
NO YES - The IFSP/IEP should address the childs transition to future community programs and the needs of the family related to the transition.

8. Is this an IFSP for a toddler who is at least 2 years 3 months of age?

NO YES - The IFSP must include a transition plan that addresses the child and familys needs related to the transition to the Part B program if eligible or
to other community programs.

9. Is this a preschooler within 1 year of transition to a program for Kindergarten age children?
NO YES - The IEP must include a transition plan that addresses the transition process.

March 2014 4
Childs Name: Janie Smith Date of Birth: __________________
2009-05-01
Local Program: __________________________________________ x ID#:__________________________

IV. Measurable Results/Outcome/Goal #____

Activity/behavior/skill in everyday life, identified by the family and the IFSP/IEP team, that they would like to see happen. Includes information on the routine/activity of the family,
community, or early childhood setting where the behavior/skills will be incorporated. Should address the childs needs identified in the evaluation and the priorities of the family. Be
functional and measurable to provide a framework for ongoing progress monitoring. Goal should be developed in accord with the PA Early Learning Standards and enable the child
to be involved in and make progress in the general curriculum.

Measurable Results/Outcome/Goal: #1, 2, 3 Date outcome/goal developed: ___________ Date outcome/goal completed: ___________
Measurable Results/Outcome/Goal Statement:
1: Janie will spontaneously use words and phrases during mealtime, while reading books, and when playing babies/Barbies with her sister or other children at home and daycare. We will know she can do this when all family members and other children
can understand her words and phrases and she does not have to show them what she wants/means. This should happen at least once per day at home and daycare.
2: Sally will meet with the community college counselor and find at least one course to enroll in by January of 2012.
3: Once Janie is using more words and phrases spontaneously, Janie will answer questions when she is asked at home and at daycare. Answers will be words and short phrases.
What is happening now? What is the childs current level of performance related to this outcome/goal?
1: Janie loves playing with babies when at home and daycare. She also likes to play Barbies with her sister. Janie likes to have books read to her and sometimes tries to repeat something she hears Sally say after Janie
has pointed to a picture. Janie has a few words and 2 word phrases that are meaningful and Sally can understand her. Janie is a good eater and the family eats the evening meal together.
2: Sally has an appointment with the college already next month. Sallys Mom is willing to help with taking care of the children depending on when the course(s) may be offered. Sally will qualify for financial assistance.
3: Janie has a few words and 2 word phrases that are meaningful and Sally can understand her.

What teaching strategies are needed to reach the outcome/goal? Include specially designed instruction, supplementary aids and program personnel supports, home or
program modifications and training and materials needed by the family or team. Also include location and how all team members, including the family/caregivers/early childhood
educators, will work on this.
Speech-language therapy, use of Proloquo2Go app & Service coordination

How will we as a team measure progress and collect data for this outcome/goal? Include what is going to be measured, how it will be measured, when it will
be measured and by whom. Describe when periodic reports on progress will be provided to the parent.
1: Sally and daycare provider will: Be sure to talk about what they are doing in short words/phrases that match Janies current level of communication; Offer Janie choices between things so that she can hear the words rather than trying to guess what she wants and asking questions; Use Janies interests to offer the opportunity for her to talk about what
she likes; Repeat the words that Janie says, slowly and clearly so that Janie can hear what they sound like.
Primary Coach (SLP) will: Come during high interest or high opportunity times of day to both the home and daycare, to discuss, model and brainstorm about how to promote Janies words by using books, play with babies, etc. as opportunities for Sally to model sounds for Janie within the context of everyday language; Show Sally and other caregivers
how to use wait time when offering Janie a choice or the opportunity to say something, e.g. when Janie points to a picture in a book, say is that a puppy or a kitty? and then reinforce anything she tries to say; Share progress observed and discuss next steps, invite Sally to include her observations in the GOLD assessment system; Help Sally and other
caregivers apply successful strategies to other routines and learning opportunities; Be in contact with the early intervention team to participate in team meetings and receive coaching from the rest of the team.
Services Coordinator will: Participate in team meetings to provide updated information regarding the family; Be in contact with the family at least monthly to update the IFSP, record progress of outcomes, and assist in coordination of resources to meet ongoing needs as identified by the family.
2: Sally will: Think about what her interests are before the appointment at the college; Explore possible courses and job/career possibilities; Fill out the paperwork for the financial assistance.
Services coordinator will: Explain eligibility for use of respite funds to pay Grandma (Sallys Mom) if she watches the children; Assist Sally in completing necessary paperwork to access funding resources and explore other options such as childcare if Sally is not eligible for respite subsidy; Assist Sally in completing financial aid paperwork and any
additional needs related to college enrollment.
3: Sally and daycare provider will: Be sure to talk about what they are doing in short words/phrases that match Janies current level of communication; Ask questions that match Janies current level of communication and vocabulary; Repeat the words that Janie says, slowly and clearly so that Janie can hear what they sound like .
Primary Coach (SLP) & Service Coordinator (See #1)

After reviewing the outcome/goal and progress monitoring data, we, the team, have decided: (Check one)
We still need to work toward this outcome/goal. Lets continue with what we have been doing.
We still need to work toward this outcome/goal. Lets discuss new ways to get there.
Our situation has changed; we no longer need to work on this outcome/goal.
We are satisfied that we have finished this outcome/goal.
Other: ______________________________

Date of review: _____________

March 2014 5
Childs Name: Janie Smith Date of Birth: __________________
2009-05-01
Local Program: __________________________________________ x ID#:__________________________

2
V. Early Intervention Services
3 5
Early Intervention Location Start Date Actual Service Frequency up Session Unit Cost Estimated
1 4 3
Service Delivered End Date to a Maximum Duration Total Cost
Date
12 days/6
Speech-language therapy Home 11/04/2011 05/04/2012
month period 60 min/day
Contact Person & Phone Number: Agency:

Service Comments:

Services coordination Home 11/04/2011 05/04/2011 1 day/month 30 min/day

Contact Person & Phone Number: Agency:

Service Comments:

Contact Person & Phone Number: Agency:

Service Comments:

Contact Person & Phone Number: Agency:

Service Comments:
1
All services will be on an individual basis unless otherwise indicated within the plan here and/or in the service page.
2
If IFSP/IEP services/supports are not being provided in a natural environment or an inclusive environment, complete the sections titled Participation with Typically Developing Children.
3
If an Early Intervention service is projected to start later than 14 calendar days after the Start Date, a justification of the later date must be documented in the Service Comments section.
4
A unit is equal to 15 minutes.
5
Only completed by infant/toddler programs: This childs Infant/Toddler early intervention services may be funded through state, Medical Assistance or Infant/Toddler and Family Waiver funds.

March 2014 6
Childs Name: Janie Smith Date of Birth: __________________
2009-05-01
Local Program: __________________________________________ x ID#:__________________________

VI. Participation in Regular Early Childhood Programs

Is the child currently attending a regular early childhood program? YES NO
(Early care and education programs include, but are not limited to: Early Head Start, Head Start, preschools, or child care; including reverse mainstreaming. Attendance at an early
childhood program need not be funded by Early Intervention funds.)
If yes, how many hours per week does the child spend in the regular early childhood program? 3_______ mornings hrs/wk

P Where does the child receive the majority of hours of special education and related services?
R In the regular education program
E In some other location
S
C
H Is the child receiving special education in a specialized setting? YES NO
O If Yes, how many hours per week does the child spend in a specialized setting? _______ hrs/wk
O Special Education Class
L Separate School
Residential facility
O Is the child receiving the majority special education and related services in the residence of the childs family or caregiver?
N Yes - Home
L No - Service Provider Location or some other location not in any other category
Y
EI Preschool Location of Intervention (LRE): ________________________________________________

VII. Participation with Typically Developing Children

For infants and toddlers: Explain why and to what extent the eligible child does not receive Early Intervention services in their natural environment.
For preschool age children: Explain why and to what extent the eligible child will not participate with typically developing peers in appropriate preschool activities.
For eligible infants, toddlers and preschool children: Include in what environment the child will receive Early Intervention services, the reason for this
placement, and ways to maximize the opportunities for the child to participate with typically developing peers in natural/inclusive environments.

All services will be provided in a natural environment

March 2014 7
Childs Name: Janie Smith Date of Birth: __________________
2009-05-01
Local Program: __________________________________________ x ID#:__________________________

VIII. Early Intervention Services during Scheduled Breaks - PRESCHOOL ONLY

All services are based upon the preschool early intervention calendar. If the IEP team determines that this child is eligible for preschool special education services
during scheduled breaks based on the educational needs of child, specify the services below.

The IEP team has considered and discussed services during scheduled breaks and determined that:
This child does NOT need services during scheduled breaks based on:
This child needs services during scheduled breaks based on:

IX. Revisions to the IFSP/IEP

Date of Name and Role of Team Members involved IFSP/IEP Section(s) Amended Reasons for Revision
Revision(s) in the Revision

March 2014 8
Childs Name: Janie Smith Date of Birth: __________________
2009-05-01
Local Program: __________________________________________ x ID#:__________________________

X. Transition Plan
A transition plan should be completed for children as identified in the Special Considerations section.
Transition Outcome/Goal:

Transition Document Dates:

Infant/Toddler: Preschool:
Date transition notification sent: Date Intent to Register sent/given to Parent/Guardian:
Transition meeting held on: Date Intent to Register received from Parent/Guardian:
Transition plan initially developed on: Date Intent to Register sent/given to School District:
Transition plan updated on:

What is happening now? What information and child and family considerations should be shared with the team in order to better prepare for
transition?

Activities/Services Designed to Ensure a Smooth Transition In Early Intervention

The plan should include at least the following:
1. Discussions with the parent regarding future support and other matters related to transition;
2. Steps to prepare the toddler/young child for changes based on developmental needs, including activities to help the
adjustment to and participation in new settings; Date Actual
3. Steps to ensure a smooth transition, including sharing of information, and convening a meeting with the family, preschool EI Person Responsible To be Completion
program and/or community provider, or school district at least 90 days and up to 9 months prior to the childs 3rd birthday Completed Date
(infant/toddler) or by February 28 of the current program year for preschool EI.

March 2014 9