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

amount of special education and any necessary related services or

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

INDIVIDUALIZED EDUCATION PROGRAM (WITH SECONDARY TRANSITION)

Student name: Paul Dominguez Student ID No.: 123 Date of IEP meeting: 10/2/2017
Birthdate: 03/22/2001 Age: 16.5 Grade: 11 IEP annual review date: 10/2/2018
Adult student: Yes No Eligibility category: Intellectual Disability Date of most recent eval: 9/16/2016
Race/Ethnicity: Caucasian Primary language: English Reevaluation due date: 9/16/2019
District: Bellingham Resident School: Parker High School Serving School (if different):
Parent(s) name(s): Wayne Dominguez, Kate Dominguez Primary language at home: English
Parent interpreter needed? Yes No Surrogate parent: Yes No If yes, name:
Primary staff contact name: Westly Edwards Title: Special Education Teacher

PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE POINTS THAT MUST BE
CONSIDERED IN
Present levels of academic achievement: DEVELOPING THE IEP (refer
Reading to WAC 392-172A-03110):
Paul can use graphic texts, recorded texts, and Needs to be able to fill out job applications Results of the most current
computer programs that read the story with visuals Mathematics evaluation, and the academic,
Can read first and last name 10 out of 10 times Can add and subtract single digit numbers 10 out of developmental, and functional
needs of the student.
Can read general men, women, boys and girls 10 times
Positive behavioral supports
bathroom signs 10 out of 10 times Has skills to use a calculator
and interventions, if the
Needs to learn to read restaurant menus Can read an analog clock in 15 minute increments 10 students behavior impedes the
Needs to learn to read sight words out of 10 times students learning or that of
Writing Knows the concepts of more and less others.
Able to write full name and phone number correctly Can discriminate between $1, $5, $10 bills 5 out of Language needs of students
10 out of 10 times 10 times with limited English
Needs to learn to write in cursive Needs to learn to read a digital clock proficiency as they relate to the
childs IEP.
Needs to create a personal consistent signature Needs to learn to add and subtract time
Supports for blind/visually
impaired students, include
Present levels of functional performance (i.e. communication, motor, social, behavior, life/adaptive skills, etc.): Braille instruction.
Communication Social Skills Communication needs of the
Paul is able to produce sentences consisting of 4-5 Will verbally initiate greetings and social interactions student, including the needs for
words long 3 out of 10 times deaf and hard of hearing
Has a vocabulary of approximately 100 Paul shows appropriate behavior when in the general students.
Can communicate wants and needs through Board education classroom Assistive technology devices
Maker Needs to increase social interactions from 3 out of 10 and services.
Needs to learn to use an iPad communication app times to 7 out of 10 times Supplementary aids/services,
program modifications, and
support for school personnel.

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____

Effect of the disability on the students involvement and progress in the general education curriculum:

Pauls latest re-evaluation qualifies him for special education services in reading, writing, and mathematics. Paul participates in a general education
classroom with modified curriculum for reading, writing, and mathematics. In comparison to his typically developing peers Paul is performing below
average.

CONSIDERATION OF SPECIAL FACTORS:

If yes, describe (if not already addressed on the service matrix):
1. Does this student require special
Yes No
transportation?

2. Does this student require Extended School
Year (ESY) services?
Date:
3. Does the students behavior negatively impact
his/her learning or the learning of others?
4. Are there any other factors not already
addressed (such as medical concerns or other
issues) or other adaptations needed?
Yes No
Will be determined by If ESY is determined by the IEP team to be necessary, complete and
the IEP team by: attach the ESY addendum.
5/1/2017
If yes, consider the students need for positive behavioral supports/
interventions, a Functional Behavioral Assessment (FBA), and/or a
Behavioral Intervention Plan (BIP).
Yes No
A Behavioral Intervention Plan has been developed for this
student (refer to the BIP addendum).
If yes, describe:
Seizure Emergency Care Plan should be made known to all
individuals working around Paul due to Epilepsy. In order to
Yes No
communicate effectively Paul must use Board Maker and an iPad
communication app such as SonoFlex, these communication devices
should be made known to school staff.

The parent and the school district have agreed that this student requires advanced educational planning that may involve the use of isolation,
restraint, or a restraint device. Refer to the Emergency Response Protocol addendum to this IEP.

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____

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

SECONDARY TRANSITION
Student participated in IEP meeting? If no, what steps were taken to ensure that the students preferences/interests were considered? POINTS TO CONSIDER:
Yes No Secondary transition
AGE APPROPRIATE TRANSITION ASSESSMENTS (include results of informal and/or formal assessments including must be addressed in the
students needs, strengths, preferences, and interests): first IEP to be in effect
surveys/questionnaires profiles/portfolios vocational assessment(s) other: when the student turns
16, or younger if
determined appropriate
Needs Work short shifts by the IEP team, and
Learn to use an alarm clock Be impendent in work updated annually.
Independently use the transit system to get where needed Work around customers Measurable
Plan appropriate time needed to get to work on time Would rather work in evenings after school than on postsecondary goals,
Clock in and out independently at work weekends based upon age-
(Student interview, Job placement evaluation) (Student interview, survey) appropriate transition
Strengths Interests assessment results, must
be included in the areas
Can follow 2 step instructions Learning to cook of education/training,
Puts all effort into work Gardening employment, and (if
Friendly towards people Science fiction and action car chase movies appropriate) independent
Motivated to work Soccer living skills.
(Student interview, Parent interview) Dancing/Zumba Transition services
Preferences (Student interview, Questionnaire) should be based on the
Work at the local paint store, or in other retail settings individual students
needs, taking into
account the students
EDUCATION/TRAINING (Required to be addressed for all students) strengths, preferences,
and interests, and may
Measurable Postsecondary Goal(s) After high school Paul will attend a community cooking class at the include instruction,
(What the student will do after graduation from high
school in the area of education/training)
community center. related services,
community experiences,
Transition Services (list Transition Services related to Education/Training, including IEP goal number(s) if applicable) the development of
employment and other
Transition Service Staff/Agency Responsible IEP Goal # postschool adult living
objectives, and if
Paul will receive instruction on how to read a digital clock. Math teacher 3 appropriate, the
acquisition of daily living
Paul will learn to use measuring tools. Math teacher skills and provision of a
functional vocational
Home Economics/English evaluation.
Paul will learn basic cooking terminology.
teacher
Paul will receive instruction in communicating with SonoFlex on an iPad. Speech Therapist 4

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____

EMPLOYMENT (Required to be addressed for all students) POINTS TO CONSIDER
(continued):
Measurable Postsecondary Goal(s)
(What the student will do after graduation from After high school Paul will work part time in the retail industry. Transition services may be
high school in the area of employment) special education, if provided
as specially designed
Transition Services (list Transition Services related to Employment, including IEP goal number(s) if applicable) instruction or related
Transition Service Staff/Agency Responsible IEP Goal # services, if required to assist
the student in benefitting
Paul will receive instruction in communicating with SonoFlex on an iPad. Speech Therapist 4 from special education.
Representatives of any
Paul will learn to fill out a job application. English agencies that are likely to be
responsible for providing or
paying for transition services
Paul will learn common social interactions for the work place. Job coach to the student should be
invited to the IEP meeting,
with parent consent.
Paul will practice being in an interview. Job coach

INDEPENDENT LIVING SKILLS (Must be addressed if determined appropriate by the IEP Team) POINTS TO CONSIDER
(continued):
Measurable Postsecondary Goal(s) After high school Paul will use the transit system to go to work and back Independent living skills
(What the student will do after graduation from are those skills or tasks
high school in the area of living skills)
independently.
that contribute to the
Transition Services (list Transition Services related to Independent Living Skills, including IEP goal number(s) if applicable) successful independent
functioning of an
Transition Service Staff/Agency Responsible IEP Goal #
individual in adulthood
Paul will receive instruction on how to read a digital clock. Math teacher 3 (Cronin, 1996) in the
following domains:
Paul will learn to read a bus schedule. SPED teacher leisure/recreation, home
maintenance and personal
Paul will learn to use a map. SPED teacher care, and community
participation.
Paul will receive instruction on using a bus pass. SPED teacher

COURSE(S) OF STUDY (list the course(s) of study needed to assist the student in reaching his/her postsecondary goals, unless already POINTS TO
described above, or attach a list of courses) CONSIDER
The IEP must include a
description or list of the
course(s) of study
needed to assist the
student in reaching
his/her specific
Consumer math, English, biology, and home economics. postsecondary goals.

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____

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

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

Method/Criteria for POINTS TO
Goal
Progress Notes (if not maintained separately) CONSIDER:
Measurable Annual Goal Evaluating Progress
# (if not addressed in a Date Date Date Date Measurable annual
separate document) goals stem from the
recommendations
for specially
designed instruction
in the evaluation
When given an opportunity to sign his report.
name, Paul will sign a unique and Measurable annual
personal signature improving his goals must relate to
Measured by data
1 written skills from 0% of the time to the general
collected by educator. education
100% of the time on 3 consecutive
curriculum or, for
opportunities as measured by preschool students,
educator data collection. participation in
appropriate
activities.
Measurable annual
goals must also
Benchmarks or Short-Term Objectives address other
educational needs
1. By 1/1/2018 when given an opportunity to sign his name, Paul will use a template of his signature to sign his name the same that result from the
students disability.
100% of the time on 3 consecutive opportunities.
The IEP must
include a description
of how the district
2. By 4/1/2018 when given an opportunity to sign his name, Paul will sign his name the same 100% of the time without a will measure the
template on 3 consecutive opportunities. students progress
and when progress
will be reported to
parents.

Copy additional pages as necessary

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____

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

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

Method/Criteria for POINTS TO
Goal
Progress Notes (if not maintained separately) CONSIDER:
Measurable Annual Goal Evaluating Progress
# (if not addressed in a Date Date Date Date Measurable annual
separate document) goals stem from the
recommendations
for specially
designed instruction
When given a picture menu with in the evaluation
descriptions from his favorite report.
restaurant, Paul will choose 3 items Measurable annual
that he would like to try by reading goals must relate to
Measured by data
2 the descriptions, improving his the general
collected by educator. education
reading skills and independence from
curriculum or, for
0% of the time to 100% of the time on preschool students,
3 consecutive opportunities as participation in
measured by educator data collection. appropriate
activities.
Measurable annual
goals must also
Benchmarks or Short-Term Objectives address other
educational needs
that result from the
1. By 1/1/2017 Paul will read the description of 1 menu item 100% of the time on 3 consecutive opportunities. students disability.
The IEP must
include a description
of how the district
2. By 4/1/2017 Paul will read the description of 2 menu items 100% of the time on 3 consecutive opportunities. will measure the
students progress
and when progress
will be reported to
parents.
3. By 8/1/2017 Paul will read the description of a menu item and determine if it is something he would like 100% of the time on
3 consecutive opportunities.

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____

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

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

Method/Criteria for POINTS TO
Goal
Progress Notes (if not maintained separately) CONSIDER:
Measurable Annual Goal Evaluating Progress
# (if not addressed in a Date Date Date Date Measurable annual
separate document) goals stem from the
recommendations
for specially
designed instruction
in the evaluation
Given a digital clock, Paul will read report.
the current time correctly, improving Measurable annual
goals must relate to
math and independence skills from 0 Measured by data
3 the general
out of 10 correct to 9 out of 10 times collected by educator. education
correct on 3 consecutive days as curriculum or, for
measured by educator data collection. preschool students,
participation in
appropriate
activities.
Measurable annual
goals must also
Benchmarks or Short-Term Objectives address other
educational needs
that result from the
1. By 1/1/2017 given a digital clock, Paul will read the current time correctly 4 out of 10 times in one day. students disability.
The IEP must
include a description
of how the district
2. By 4/1/2017 given a digital clock, Paul will read the current time correctly 8 out of 10 times in one day. will measure the
students progress
and when progress
will be reported to
parents.
3. By 8/1/2017 given a digital clock, Paul will read the current time correctly 8 out of 10 times on 2 consecutive days.

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____

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

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

Method/Criteria for POINTS TO
Goal
Progress Notes (if not maintained separately) CONSIDER:
Measurable Annual Goal Evaluating Progress
# (if not addressed in a Date Date Date Date Measurable annual
separate document) goals stem from the
recommendations
for specially
designed instruction
in the evaluation
Given an iPad with the app SonoFlex, report.
Paul will communicate his needs Measurable annual
using symbols on the app, improving goals must relate to
Measured by data
4 communication skills with an iPad 0 the general
collected by educator. education
out of 3 times to 3 out of 3 times on 3
curriculum or, for
consecutive school days measured by preschool students,
educator data collection. participation in
appropriate
activities.
Measurable annual
goals must also
Benchmarks or Short-Term Objectives address other
educational needs
that result from the
1. By 2/1/2017 Paul will communicate 1 need using SonoFlex on 3 consecutive school days. students disability.
The IEP must
include a description
of how the district
will measure the
2. By 6/1/2017 Paul will communicate 2 needs using SonoFlex on 3 consecutive school days. students progress
and when progress
will be reported to
parents.

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____

PURPOSE: The purpose of the report of student progress is to inform the parents and the student of the students progress toward meeting the measurable annual goal(s) and to
specify how and when parents will be informed.
POINTS TO CONSIDER:
Parents should be provided periodic reports on the students progress (such as through the
REPORT OF STUDENT PROGRESS: use of quarterly or other periodic reports, concurrent with the issuance of report cards).
State how the students progress toward meeting the annual goal(s) will be measured (if not already addressed on measurable annual goal page(s)):
Measured by data collected by educator.
State how the parents will be periodically informed of the students progress toward meeting the annual goal(s):
Every quarter of the semester a report card will be sent home.

PARTICIPATION IN STATE AND DISTRICTWIDE ASSESSMENTS OF STUDENT ACHIEVEMENT

State Assessments The student will participate in the following state assessment(s) during this annual IEP: POINTS TO CONSIDER:
The IEP team makes the
English/ determination of what type of
Lang Arts Math Science assessment the student will
Regular State Assessment take and what administrative
modifications and individual
Regular State Assessment with Accommodations accommodations are
Alternate Assessment necessary.
Other: Accommodations provided on
state and districtwide
Districtwide Assessments The student will participate in the following districtwide assessment(s) during this assessments should be those
annual IEP: that are provided as part of the
regular instructional program.
For further information
regarding the state assessment
Accommodations List any individual accommodations in the administration of the state or districtwide assessments system, allowable
necessary for the student to participate: accommodations, and
graduation requirements,
please refer to OSPIs website
(www.k12.wa.us/assessment).
If the student: (a) will not participate in the regular state assessment (with or without accommodations) or (b) is unable Other assessment options are
to participate in a regular districtwide assessment, explain why the student cannot participate in the regular assessment available to students if
required to meet graduation
and why the selected assessment option is appropriate: requirements.
Given Pauls current academic skill levels the WA-AIM is the most effective assessment of his skill level.

Graduation If the student requires other assessments in order to meet graduation requirements, describe Parents and students should be informed that
here (specify assessment and grade level as appropriate): any assessment other than the regular state
assessment (with or without accommodations)
leads to a Certificate of Individual
Paul will participate in the WA-AIM to fulfill his graduation requirements. Achievement (CIA), rather than a Certificate
of Academic Achievement (CAA).

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____

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

ACCOMMODATIONS, MODIFICATIONS, AND ASSISTIVE TECHNOLOGY

Subject Subject Accommodations/Modifications Needed POINTS TO
(codes below)
Accommodations/Modifications Needed (codes below) CONSIDER:
Presentation Setting The IEP team
makes the
Use large print/Braille/recorded books Provide individualized/small group instruction
determination of
Alter format of materials (highlight, type, spacing, color-code etc.) Read class materials orally what
Low-vision devices (magnifiers, Closed Circuit TV, etc.) Provide study outlines/guides/graphic organizers modifications and
Sign Language ASL or SEE A Modify/repeat/model directions individual
accommodations
A Shortened assignments A Take test in separate location are necessary for
A Preview test procedures Preferential seating the student.
Limited multiple choice Other: Copies of this
A Rephrase test questions and/or directions Response page should be
provided to the
Provide test/quiz study guide A Utilize oral responses to assignments/tests
general education
Provide extra credit options A Text-to-Speech (Kurzweil, WYNN, Text Help, etc.) teacher(s) or other
A Simplify test wording Allow dictation to a scribe staff who will be
A Read class materials orally E Allow use of a calculator responsible for
making these
Assign peer tutor/note taker Allow use of tape recorder accommodations.
Other: Spelling and grammar devices Accommodations
Timing/Scheduling Speech-to-text software provided on state
Prior notice of tests/quizzes Hands-on assignments and districtwide
assessments (as
Extra time to complete assignments Other:
noted on the
Modify students schedule (describe below): Other previous page)
Provide desktop list of tasks should be those
Provide homework lists that are provided
as part of the
Behavior plan/contract regular
A Extra time on tests/quizzes Provide daily assignment list instructional
Allow breaks (during work, between tasks, during testing, etc.) Modified grading program.
Other: Other:
Assistive Technology
A Describe: SonoFlex Communication board on iPad
Describe:
Describe:
a. All subjects e. Math i. Health m. Vocational p. Extracurricular Activities
b. Reading f. Science j. Economics n. Lunch/Recess q. Other:
c. English g. Social Studies k. Physical Education o. Library r. Other:
d. Spelling h. History l. Music/Art

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____

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

SUMMARY OF SERVICES MATRIX

Location of Staff Responsible POINTS TO

Initiation Frequency CONSIDER:
Service (i.e. minutes per week)
Service Duration for Delivering If the position
Date (setting) Service responsible for
Special Education (specially designed instruction): delivering the
specially designed
Work Experience 10/2/2017 180 min SPED End of IEP Job Coach instruction is anyone
Reading 10/2/2017 750 min Gen Ed End of IEP Gen Ed Teacher other than a
certificated special
Math 10/2/2017 300 min Gen Ed End of IEP Gen Ed Teacher education teacher or
related service
Writing 10/2/2017 750 min Gen Ed End of IEP Gen Ed Teacher provider, then the
certificated special
education
teacher/related
service provider must
design and supervise
the instruction, and
Related Services (i.e. speech, motor, counseling, vision/hearing, transportation, interpreting services, orientation/mobility, parent training, etc.): monitor and evaluate
Transportation 10/2/2017 180 min SPED End of IEP Job Coach the students
progress.
Speech 10/2/2017 120 min SPED End of IEP Speech Therapist For definitions of
special education,
P.E. 10/2/2017 120 min Gen ED End of IEP Gen Ed Teacher related services, and
Parent Training with AT 10/2/2017 Once SPED End of IEP SPED Teacher supplementary aids
and services, refer to
WAC 392-172A-
01020 through -
Supplementary Aids and Services (allows student to be educated with non-disabled peers to the maximum extent in general education or other 01200.
educational setting):

Program Modifications or Support for School Personnel (i.e. staff development/training, technical assistance, etc.):
Communication Training 10/2/2017 Once for all staff SPED End of IEP Speech Therapist
Seizure Training 10/2/2017 Once for all staff SPED End of IEP School Nurse

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____

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

LEAST RESTRICTIVE ENVIRONMENT:

Students ages 6 and above Choose one: POINTS TO CONSIDER:
Children should be educated
= Total minutes per week of building with non-disabled peers to the
maximum extent appropriate.
A. 1800 min instructional time available for this student
The IEP Team, including the
(excluding lunch) parent(s), is responsible for
In general education setting 80 to 100% of the time determining the educational
In general education setting 40 to 79% of the time placement of the child.
= Total of those minutes in A. above in which
In general education setting 0 to 39% of the time Job placements and
B. 480 min this student is in a special education setting
(excluding lunch) In separate day school (public or private) community-based instruction
Residential facility (public or private) are considered to be general
education settings, unless only
Correctional facility
disabled individuals are present
Homebound/hospital (such as in a sheltered
Home-school/parentally-placed private school workshop).
= Percent of time spent in a general education
74% For additional information on
setting (A minus B divided by A)
LRE for students ages 6 and
above, refer to the LRE
Calculator.

An explanation of the extent, if any, to

which the student will not participate
with nondisabled students in the general
Paul is not participating with his typically developing peers during work experience, speech lessons, and
education class, and in nonacademic and
transportation between work and school.
extracurricular activities, including a
description of any adaptations needed for
participation in physical education:

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____

 PARTICIPANTS IN IEP MEETING (Signatures are used to document participation in the meeting and do not constitute
agreement or disagreement):
POINTS TO CONSIDER:
Kate Dominguez/ Mother IEP team membership is described
Parent/Guardian Name/Title in WAC 392-172A-03095.
School district must give prior
written notice when proposing or
Wayne Dominguez/ Father refusing to initiate or change the
Parent/Guardian Name/Title identification, evaluation,
educational placement, or
provision of FAPE.
Paul Dominguez/ Student A required team member may be
Student Name/Title excused from attending an IEP
meeting with the agreement/
consent of the parent(s) and the
Westly Edwards/ Special Education Teacher district, depending upon whether
Special Education Teacher Name/Title that members area is being
discussed or modified at the
meeting. See WAC 392-172A-
Lora Reed/ English Teacher 03095 (5) for additional related
General Education Teacher Name/Title requirements.
The IEP must include the districts
Bruce Morey/ Principal procedures for notifying parents
regarding the use of restraint or
District Representative Name/Title
isolation. Districts must also
provide parents with a copy of the
districts policy on the use of
isolation and restraint.

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

All staff members should be made aware of communication methods and seizure plan.

TRANSFER OF RIGHTS: Beginning at least one year before reaching age 18, POINTS TO CONSIDER:
the student has been informed that all rights will transfer to the student at age 18, When the student reaches age 18 (or majority), the
Yes No district must notify the parents and the student that
unless there is a guardianship or other determination that the student cannot make rights have transferred to the student, and provide
educational decisions. any notices required to the student and parents.

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

*Note: Before providing initial special education services to a student, the district must obtain informed written parental consent.
(See model form 3)

Student Name: Paul Dominguez Date: 9/25/2017 Page _____of ____