Document Date: Individual Education Program (IEP) Page 1 of8 This IEP is an: W naat Fannuat Review Projected Triennial Reevaluation Date: Student Name: M\ -® District 1: State ID: Grade: F Sex M Native Lang: Englta we Ethnicity: Birthdate: Age: (D District: (AMMO Fall school iMLtH#A! — schoot ywesteide Elementary — Phone: CONTACT INFORMATION Parent/Guardian Name: beni fee Primary Phone Number: Mailing Address: ‘Secondary Phone Number: Native Language: Email Address: Parent/Guardian Name: Primary Phone Number: Malling Address: Secondary Phone Number: Native Language: Email Address: ‘Case Manager Name; Direct Contact Number. Email Address: IEP INFORMATION Elgbity Category: AUATOYY Meszatinomstor: qo 40 (F peclualaich aund see Travis Onvitins er PROCEDURAL SAFEGUARDS sternsnse | have been provided the special education procedural safeguards in my native language or other mode of communication: Plotiered and Accepted © Offered and Decined Raion 0 Rat Sint Sains Bas IEP TEAM INFORMATION ‘Student (whenever eppro} stornsoassunn| © Yes Jan fe Parent/Guardian uomsnacin] OSYes ONO Chavow District Administrator or Designee aorn scoszueranm] 3 Yes ONo | ME-witd [General Education Teacher wom seoxwa] QD Yes _OQNo WE Special Education Teacher stom sass] Yes _ONo YUL Pad LOgist rer One Upto Aus 2016Document Date: Individual Education Program (IEP) Page2 of 8 This IEP is en: © Initial © Annual Review Projected Triennial Reevaluation Date: ‘Student Name: District ID: State 1D: Grade: Sex Native Lang: Ethnicity: Birthdate: Age: District: ‘Schoo! Phone: O Early Childhood 1EP © Standard 1EP O Secondary EP suse Agee 38 Stet ges 64 Sudo ges 1821 PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE. secrnamszay) Skill Area Current Level of Performance orn sos.) rengths ofthe student in this Skill Area: of Makoss. Hey () xansomen ASIC COUNTING TDS \s asmen c 2 oii Sete ‘education in thig Skill Area: We Ee WWabLe momamanecno ONL av. Awrne math. Reetnd vunbersand wort be alu Ts path cypce tin Mat iets Sabi the sae voteren androgen he gover cui an parton Wappopfte aces Ps St va ae MaKds disability wrypacts bys abi li atti pate un Le rir kaceeus sarin "ip ¢ Up we Annual Géal “Peng i COUPLE omens audit iter hilt Pi fe i iy e07] J scr s002490 went ff ako eae can tecognice Wa” UC fo ot sppertuie Saerions OS 3, Objectives and Benchmarks (REQUIRED FOR STUDENTS TAKING THE ALTERNATE ASSESSMENT) 4m xos24ai2¥) 4 Annuel Gos et ven CHOU I UINbes MED vm (LUD neu ug" 20°% ot "sort 5 tu)i4 oan O- (Steere a tae Ope t Tu 5. Procedure for data collection: eauh er sass a Observation [] Rubric [1] Work Sample Z] Assessment] Other 8. Schedule: em scsi WNUY Wk. pasa: Agus 2076Document Date Individual Education Program (IEP) Page 3of 8 This IEP is an; © Initial © Annual Review Projected Triennial Reevaluation Date: Student Name: Distt 1D State ID: Grade: Sex Native Lang Ethiety: Birthdate Age: District: ‘School: Phone: Cl deiy =] Weekly 1] Monthly] Bi-Monthiy 7. General Education Content Standard(s): +34 CFR 200.2208N210¥A) 8. Assistive Technology (AT)/Accessible Educational Materials (AEM) in use or considered new: 24 CFR s00.226¢0K2K0) O No @ vee Nok going fo be used Reporting Progress sermon Witten progress wil vy progren Fzporr WVLYY two wees IEP SERVICES 34 CFR 00 320IaKe) a (7) pla 1 Statement of Service Delivery, % 10 a ot culpa % LEAST RESTRICTIVE ENVIRONMENT (LRE) -sacrR s00 308) ‘er urea onenn, fey nenerin pee betes ee pe ate ea Tenors or ate eae Seudnewemiebmad 0 tbipaad —@ sunt medd Minutes Weekly Averages : Tohlrindes ne steotwees rte stden: 950 Welt day KUNdYE Average time outside the general education environment: Ve min ‘Special Ed Percentage: 0% ‘Average time inside the general education environment®: \){ YAW. General Ed Percentage: 0% * even speci ecvction series ae beng proved pate: gst 2018‘Document Date: Individual Education Program (IEP) Page 4 of 8 This IEP isan: © Initial © Annual Review Projected Triennial Reevaluation Date: ‘Student Name: District 1D: State 1D: Grade: Sex Native Lang Ethnicity Birthdate Age: District: ‘School: Phone: Educational Environment for Ages 6-21 ore sae m8 (0%) Students inside the general educeton classroom 80% or more ofthe school day, In@ 6 hour schol day, the stoen is inside te rgularcaes at last 4 ours and 48 minutes. © (02) Student inside the general education cesaroem atleact 40% but not mare than 79% o the schon day. n a § hour school dy, the students isi the regular cass at east 2 hours, 25 minutes, but not more than 4 hous, 47 mites. © (03) Stents ini the general education ciseroem lee than 40% ofthe sche! cay. In a6 hour schoo ay, te tudont is Inside the regular cass 2 ours, 24 minutos ores, (11) Students in a ditt sa-contained classroom in a separate special educaton school for more than 60% ofthe chee! ‘day-more than 3 hous in &6 hour schoo dey (#2) Students placed in privat special edicaon day schoolacily at pubic expense for more than 60% ofthe school day “mor than 3 hous in aS hour school day. (3) Student resives education services in pub residential fcity for more than 50% ofthe school day and resides in that facly during the seeel week (14) Student receives education services in a private residential facility at public expense for more then 50% of the school day lnc resides in at faity uring the eco! week. (15) Student coves special education services ins hospital or homebound seting (do ntncude home-schooled students ‘ritual charter sco! etn), © (1) Studont receives spiel ecucaton service in detention canter or correctional city. © a2 suerte vata nr in a pve schol by parents o0o0000 Placement Considerations e Yes Qo Is this placement based on the student's educational needs documented in this IEP? 2 crnaoos« Yes No —_ Is the student able to be satisfactorily educated inthe general education environment for the ‘entre school day? oman (Pves — O.No _ removal from the regular environment is necessary, ist based on the nature and severity of the student's disability and not the need for modifications in the general curriculum? Momsarasiog) Pes O.No _Is the educational placement as close as possible tothe student's home? econ en em Wh Yes O/No _Is the educational placement in the school the student would attend ifthe student dd not have @ isabity? ren Yves Cone Did no team consider any potential harm efecto the educational placement? some Gres Oo Does the student have the opportunity to participate in extracurricular and nonacademic events with nondisabled students? ‘oman? OTHER CONSIDERATIONS. A. Special transportation is a related servico, secre ‘The student requires: © Regular © Special Q No Transporation Deserve, if necessary ama: agin 2088Document Date: Individual Education Program (IEP) Page 5 of 8 This IEP is an: © Initial © Annual Review Projected Triennial Reevaluation Date: ‘Student Name: District 1D: State ID: Grade: Sex Native Lang Ethnicity Birthdate: Age: District Schoo! Phone: B. Are extended school year (ESY) services required for this student? ecrascaon QNo OYes OBO ©. Does the student have limited proficiency in English? ern snszdenae Gano Oves D. Is the student deaf or hard of hearing? secrmaenszasran No Ores E, Does the student have unique communication needs? swormscnaeesyzin Bro Ores F.Is the student blind or visually impaired? aor aen saan B No OYes G. Does the student have health care needs? No OYes BEHAVIOR INTERVENTION PLANNING secre anaemia 0098080 Does behavior impede the student's learning or that of others? JO No O Yes AGCOMMODATIONS, ADAPTATIONS, AND/OR SUPPORTS IN GENERAL AND SPECIAL EDUCATION Secreto) accommodations andy adaptations the sunt requires, based on assessed needs, inorder to advance be involved and make progress (goneral education curicuum, and be educated in genere! education tothe maximum extent posse Include all necessary classroom accommodations and adaptations. ‘A. Accommodation/Adaptations, If Needed Presentation Timing/Schedule mrvide mg wills a rnctiared Sched sete utd yeuceue perteaeieal | assigned Seating Un Tre Cyeirounn: Response i nok A LOIN Deva Fens GUCK ne WLLALte and 2Kt7% perso UE ua DOANE Le That \y predi table pa: gust 2016Document Date: Individual Education Program (IEP) Page 6 of 8 This IEP is an: © Initial @ Annual Review Projected Triennial Reevaluation Date: Student Name District 1D: State ID: Grade: Sex Native Lang: Ethnicity Birthdate: Age’ District: Schoo! Phone: Other Modification to the General Education Curriculum PARTICIPATION IN STATEWIDE AND DISTRICTWIDE ASSESSMENT Mores s2900 (Onl those aesonmodations lst nthe “Aecommedatons, Adaptations. sdb Support n General and Special Education” section of Ws IEP and regulary {sed bythe student elasarcam hntrueton and classroom fsling may be used durng satowde or dshictwde aseessments ELA/Reading (Grades K-11) it OiRHAt = QUISATCJISAT-An —CJNAEP—[Jother [Not tested at this grade level Math (Grades 3-11) [lsat = JISAT-At = CJNAEP —JOther Not tested at this grade level Science (Grades 6, 7, 11) Cisat CUISAT-At = CJNAEP —LJOther—[] Not tested at this grade level Other DlAccess JAccess-At [Civics at'z0m — ([] College Entrance Exam — [] Other WRITTEN NOTICE OF SPECIAL EDUCATION ACTION A. Actions Proposed stem ons © The student is due for a reevaluation to determine continued eligibility, and it has been determined that further assessment is not necessary. g The school district proposes to initiate/change identification. O The schoo! district proposes to nitate/change educational placement. © The schoo! district proposes to initiate/change educational placement due to disciplinary action. Other, describe: B. Actions Refused sor cose © The schoo! district refuses to intiate/change identification. O The schoo! district refuses to initiate/change evalustion/reevaluation. © The schoo! district refuses to intiate/change educational placement. © The schoo! district refuses to change the Individualized Education Program (IEP). peat August 2016Document Date: Individual Education Program (IEP) Page 7 of 8 This IEP is an: © Initial © Annual Review Projected Triennial Reevaluation Date: ‘Student Name: District 1D: State ID: Grade: Sex: Native Lang Ethnicity: Birthdate: Age: District: Schoo! Phone: Other, deseribe: . Explanation of why actions were proposed or refused Moms anseDsE9NNTH2 ‘© The student has completed the semester in which he or she tuned 21 years old and is no longer entitled to special ‘education services. © The student has met IEP or district graduation requirements. ‘© The current data on schoo! performance along with previous assessments are adequate. © The student's disabilty adversely affects his or her educational performance, preventing satisfactory achievement, {2 Special eduction services are required in order orth student to benef fom an educational program. (© The students disability does not adversely affect his or her educational performance. (© Behavioral and academic interventions can be implemented within the current placement, Other, describe: D. The following options were considered and rejected because: : d Tw 9 Ms asceacanvert Scores PFOVe a Nee adit a Saeco env Cet. E. The following evaluation procedures, tests, recorde, and reports wore used as a basis for the decision: domsnsae gee ey Ae F. The following information and other factors are relevant to the decision: seornmosan) promsvosonme) This written notice is provided in the native language of the parent/guardian or other mode of communication used by the parent, unless It is clearly not feasible to do so. Morn se0s04eK 2) Yrs Om CONSENT FOR INITIAL PLACEMENT Is this an initial placement? ves ON A copy of the IEP has been provided to the parent/guardian. stern amnszan Ofres ONo if you need assistance, contact your schoo! district using the contact information below: ‘School District Contact information: dt Avge 2010Document Date: Individual Education Program (IEP) Page &0f 8 This IEP is an: © Initial © Annual Review Projected Triennial Reevaluation Date: ‘Student Name: District 10: State ID: Grade: Sex Native Lang Ethnicity Birthdate: Age: District: ‘Schoot Phone: In addition to contacting your schoo! district, if further assistance is needed, you may contact any of the agencies below: Kdaho State Department of Education Idaho Parents Unlimited, Inc, DisAbility Rights Idaho 650 W. State Street 4619 Emerald 4477 Emerald Svest P.O. Box 83720 Suite ‘Suite B-100 Bose idaho 83720 oiso, Idaho 83706 Bolsa, idaho 83705-2066 2081352-6910 8000242-4785 ver: 208/336-5353 800/432-4604 VAT 208/342-5884 ‘ITT 860262-3462 “TT: 8000877-9529 Web: wm inulidaho ora ‘Web: hiodisabiliyrihtsidaho ors ‘Web: wad idaho.coy Idaho Legal Aid Services Idaho Bar Association Wrightslaw Idaho Yellow Pages for ‘Adminetvation Oe P.0. Box 805 Kids 4447 Tyrell Lane Boise Idaho 83701 ‘wow velounsassfockids.comhalpi.him Boise idaho 83708, Phone (208) 334-4500 Phone: (208) 336-8080 Fax 334-4515 Fase 342-2561 Web: Web: wo idaholegalai oral Online Lawyer Referral: * Offces in Boise, Celdwel, Coeur CAene, eho Fas, hiipsJisb idaho govmember_services! \ewton, Poca and Twn Fas Hrs_search panel cfm Upaaine Augus 2016measurement): Ys_se_. i at’ Assistive Technology: weighted Pg ano Progress Reporting (How/When): _icaned Yes Jno _ Annual Senice = (Soe ee ing Weekly minutes bag — Progress Manitre. Academic: lg lomin ty telat — Proghess mon (toe. | Academics MACE $0 mun bye Acadentex caer: Behavioral ; Behavioral a1** PSR) on Wansitionin = 7 i ee ceiggors ||lOsmatmmitiea” as men (x won't omay from edus handwriting ‘**Physical Therapy: iN fe **Speach Therpy mo gouk *tanguags There owt 0 onl ss ohee el 7 (Gee) Parent ciscusion thet Service times may be Annual goal data aligns to PLOP data (same skil/same {iTPacted by absences +/-, and school related conflicts +/+ ‘** PHYSICIAN'S REFERRAL MUST BE REQUESTED BY CASE MANAGER IMMEDIATELY AFTER MEETING, gructwed Sone: ¢ Senin g AOA ive [extra cme in ransportation: cesnesves iio | Special considerations ema poitna, bean weak Extended Schoo! Year: Discs Yes Xno_—| No A ‘Accommodations: Dicpaadver ne | Statewide testing: cae es Peden) gy = perp iar admins fre teating on positive ‘sneer to PUllid fer progrias money, on Behavioral issues/plans: ‘icusses ves 71 Transitions Hel Least Restrictive Environment: Waltten fi wove furw ard Consent initial Placement Signed/Date: 2/2V 13, Medicaid Authorization Signature Date /2//2® reenGo Soon: mbt Dac? Yes_ to Greene Soliton Accepted arent Yea 690.fohn Adams Parkway, Kaho Falls, 1D 83401 Phone: 208-525-7500 wwwed9L.kI2éd.us Form Revised 5/13/2016 UWutial LEP