INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student’s Name: Sarah (pseudonym)

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student’s Name: XXXXXXX XXXX

IEP Team Meeting Date (mm/dd/yy): 11/06/17
IEP Implementation Date (Projected Date when Services and Programs Will Begin): 01/05/18
Anticipated Duration of Services and Programs: 12/05/17 – 06/18/18
Date of Birth: XX/XX/11
Age: 6
Grade 1st
Anticipated Year of Graduation: 2028
Local Education Agency (LEA): Hancock County School District
County of Residence: Hancock County
Name and Address of Parent/Guardian/Surrogate: Phone (Home): (XXX) XXX-XXXX
Mother: XXXXXXXX XXXX Phone (Work): (XXX) XXX-XXXX
Father: XXXXXX XXXX
Address: XXXXXXXXX

Other Information:

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

Date of Revision(s) Participants/Roles IEP Section(s) Amended

N/A N/A N/A

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Sarah (pseudonym)

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Include the following information related to the student:

● Present levels of academic achievement (e.g., most recent evaluation of the student, results of formative assessments, curriculum-based
assessments, transition assessments, progress toward current goals)
● Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress
toward current goals)
● Present levels related to current postsecondary transition goals if the student’s age is 14 or younger if determined appropriate by the IEP team
(e.g., results of formative assessments, curriculum-based assessments, progress toward current goals)
● Parental concerns for enhancing the education of the student
● How the student’s disability affects involvement and progress in the general education curriculum
● Strengths
● Academic, developmental, and functional needs related to student’s disability

Sarah is a six year old, first grade student. Her present levels of total development achievement show that she is in the 3 rd percentile for her
age group. She performed below age level, measuring her age equivalent to be 4 years 11 months. She performed within the 2 nd percentile of
her age group for literacy (age equivalent of 4 years 2 months) and the 6 th percentile for mathematics (age equivalent of 5 years).
Academically and cognitively, she scored in the 6th percentile (age equivalent age of 4 years 9 months). Sarah was able to identify 21 out of 26
letters and has showed that she understands concepts of books and text but struggled to recite the alphabet, read common signs, and blend
two words into one. Sarah also demonstrated difficulty with auditory discrimination. When the assessors said two words in a row, Sarah could
not distinguish if the two words that were said were the exact same words or two different words.

In the gross motor skills category, Sarah measured in the 17th percentile (age equivalent of 4 years 10 months) and in fine motor skills she
measured in the 9th percentile (age equivalent of 5 years and 1 month). Overall, in the category of physical development, Sarah scored in the
8th percentile (age equivalent of 5 years and 1 month). For gross motor skills, Sarah had a perfect score when assessed in walking, skipping,
galloping, stair climbing, rolling, throwing, and catching. Sarah was not able to balance on either foot for at least 5 seconds. For fine motor
skills, Sarah had a perfect score in early fine motor skills category of the assessment, which included holding a toy in her hand, moving objects
around, scribbling, and building a tower with multiple blocks. When asked, Sarah was unable to draw shapes and letters correctly.

In the language development category, Sarah’s achievement shows that she is in the 14 th percentile for her age group (age equivalent of 5
years 11 months). Sarah is extremely friendly and loves to talk to everyone but usually only when she directs the conversation. Her receptive
language is in the 25th percentile for her age group (age equivalent of 6 years 5 months). Sarah’s expressive language is in the 13th percentile
for her age group (age equivalent of 5 years 2 months). Sarah achieved an almost perfect score when tested on early receptive language skills
and a perfect score in early expressive language skills. Sarah had the most difficulty when asked to identify parts of the body.

Sarah is in the 3rd percentile for her age group in daily living/adaptive living category (age equivalent of 3 years 9 months). Sarah can
accomplish basic tasks like getting dressed and toileting but needs reminders and prompting.

Finally, Sarah performed in 14th percentile for her age group (age equivalent of 3 years 7 months) for social and emotional development. For
intrapersonal skills, Sarah scored in the 21st percentile (4 years 3 months) and in the 14th percentile for self-regulatory skills (age equivalent 3
years 6 months).
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Sarah (pseudonym)

Parental concerns for enhancing the education of the student: Sarah’s parents feel that she is cannot learn in the general education
curriculum because the pace of instruction is too fast for her to grasp concepts. They also noted that are concerned Sarah is not engaged in
during direct instruction and needs more individualize attention.

Concerns of the teacher are Sarah’s weak fine motor skills and social skills. Other concerns are her lack of reading skills and low math skills.
Sarah’s teacher is concerned that her inability to write any words other than her name might hinder her learning experience in the general
education curriculum.

Strengths:
● Identifying letters by pointing
● Gross motor skills (walking, skipping, galloping, stair climbing, rolling, throwing, and catching)
● Knowing books have meaning
● Comparing numbers (identifying which number is larger or which number is smaller)
● Expressive language (Talking and responding)

Weaknesses:
● Reading sight words and common signs
● Reciting the alphabet and numbers (in the correct order)
● Fine motor skills (drawing shapes, writing letters, writing numbers)
● Reading numbers higher than 10
● Auditory discrimination (listening to identify if two words are the same or different)
● Knowing words read from left to right
● Identifying body parts
● Engaging in tasks without prompting
● Social skills

V. GOALS AND OBJECTIVES – Include, as appropriate, academic and functional goals. Use as many copies of this page as needed to plan appropriately.
Specially designed instruction may be listed with each goal/objective or listed in Section VI.

Short term learning outcomes are required for students who are gifted. The short term learning outcomes related to the student’s gifted program may be
listed under Goals or Short Term Objectives.

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Sarah (pseudonym)

MEASURABLE ANNUAL GOAL Describe HOW the

Describe WHEN periodic
Include: Condition, Name, Behavior, and Criteria student’s progress toward
reports on progress will be Report of Progress
(Refer to Annotated IEP for description of these meeting this goal will be
provided to parents
components) measured

Sarah will be able to correctly identify 4/5 new There is a binder and Quarterly with report card.
sight words or common signs on a weekly basis chart that is used by the
with 80% accuracy across 10 consecutive sessions teacher to document
by the end of the IEP. Sarah’s word recognition
during the consecutive
sessions.

When asked, Sarah will be able to wash her hands Through direct Quarterly with report card.
independently without being verbally prompted observation, a teacher
by an adult at least two times a day over the will analyze Sarah’s
course of 3 consecutive weeks. ability to wash her hands.
Once Sarah successfully
completes the task
without verbal prompts,
the teacher will move a
penny from one pocket to
the other to keep track of
Sarah’s two washing
practices.
Sarah will be able to successfully recite numbers Every Friday Sarah will be Quarterly with report card.
1-20 in numerical order with 90% accuracy when asked to recite numbers
assessed weekly for 5 consecutive weeks. 1-20 in order (counting
up). A teacher will keep a
tally on how many
numbers Sarah get’s
correct in a row. The
total number of correct
numbers said in a row will
be recorded as her weekly
recitation of numbers
assessment.

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Sarah (pseudonym)

Sarah will initiate a conversation, with at least

“Free choice time” and Quarterly with report card.
two responses from the communicating peer, withrecess will be the sessions
70% success across 5 consecutive sessions by the
for which Sarah has the
end of the IEP. opportunity to initiate
conversation with peers.
During these sessions,
Sarah’s teachers will keep
a running tally of how
many times Sarah initiates
a conversation with a
peer during the school
day. After every 5
consecutive sessions,
Sarah’s teachers will find
the total percentage and
analyze the data.
VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS – Include, as appropriate, for nonacademic
and extracurricular services and activities.

A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)

● SDI may be listed with each goal or as part of the table below.
● Include supplementary aids and services as appropriate.
● For a student who has a disability and is gifted, SDI also should include adaptations, accommodations, or modifications to the general
education curriculum, as appropriate for a student with a disability.

Projected Beginning
Modifications and SDI Location Frequency Anticipated Duration
Date
New sight words will
The student will have access to premade, Quizlet A paraeducator will
be made and
flashcards in order to practice common sight words. accompany Sarah in a
reviewed once a Throughout the length
This resource will be introduced and the words resource room to January 15th, 2018
week. Reinforcement of this IEP
studied during the 10 minute transition period review the weekly
is encouraged in the
between lunch and nap on an iPad. flashcards.
home.

In the special Signs will be

Sarah will be provided with teacher made, tangible
education classrooms, individually reviewed Throughout the length
signages that are placed specifically around the January 15th, 2018
signs will be posted with Sarah once a of this IEP
classroom for her each week.
and observed weekly. week by her teacher
Sarah will complete Throughout the length
Weekly January 15th, 2018
Images will be matched with sight words through a this activity at a of this IEP
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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Sarah (pseudonym)

kinesthetic activity that will hopefully increase station once a week.

Sarah’s understanding.

A task analysis card that depicts and explains the In either the special
steps of approaching the sink or bathroom to wash education classroom Twice a day for three Throughout the length
January 15th, 2018
hands will be given to Sarah as she practices washing bathroom or at the consecutive weeks. of this IEP
her hands without verbal promptings. sink.

Sarah will be provided with a peer that will At the special

Throughout the length
demonstrate proper hand washing without needing education classroom Twice a day. January 15th, 2018
of this IEP
prompts during snack. sink.

The sink and surrounding objects necessary for hand At the special Until hand washing
washing with be labeled in numerical order to education classroom Every day January 15th, 2018 process is memorized
promote proper steps in the process. sink. and rote.

Until Sarah can sing

Sarah will use an iPad and headphones to listen to a
Once a week for five along or it no longer
song that sings the order of the numerical numbers 1- In the sensory room. January 15th, 2018
weeks. captures her
20.
attention.

This number line will

Sarah will be given a laminated number line that is Throughout the length
be tapped to Sarah’s
color coded to reinforce math language and numerical Daily January 15th, 2018 of this IEP
desk in the special
number sense.
education classroom.

Until the worksheet

These worksheets will
reviewing numbers 18,
Sarah will be provided with worksheets that introduce be completed at a
19, and 20 is
a few, ordered numbers at a time to build on prior station with a Weekly January 15th, 2018
completed.
knowledge of numerical order. paraeducator in the
special education
classroom.
In the special Throughout the length
Sarah will have a paraeducator prompt her with Daily January 15th, 2018
education classroom. of this IEP
conversational starters each morning while

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Sarah (pseudonym)

encouraging Sarah to start conversation with a peer

before lunch.

The chart is portable

and can be Throughout the length
Sarah will come to school and use a “feeling chart” to Daily January 15th, 2018
implemented of this IEP
articulate her current mood to her teacher.
anywhere.
These cards are
dispensed and
Sarah will be provided with a ue cards to practice new Throughout the length
implemented in the Weekly January 15th, 2018
and appropriate greetings/phrases. of this IEP
special education
classroom.

Page 7 of 7 November 2017