INDIVIDUALIZED EDUCATION PROGRAM

I. PERSONAL INFORMATION
NAME OF CHILD : Marvelan A. Autida
DATE OF BIRTH : march 19, 1997
ADDRESS : Cabgan, Tambulig, Zamboanga del sur
PARENTS : Mr. and Mrs. Alan Autida
NAME OF SCHOOL : Cabgan Elementary School
NAME OF PRINCIPAL : Mrs. Marlita C. Apa
NAME OF TEACHER : Geraldine B. Gemina
NAME OF SPED TEACHER : none
GRADE LEVEL : Grade 1
LANGUAGE SPOKEN : Cebuano
HEALTH REFERRAL :

II. BACKGROUND AND REFERRAL INFORMATION

HIS/HER DISABILITY IS:

III. TEST RESULT AND INTERPRETATION:

IV. SUMMARY AND RECOMMENDATION:

FAMILY DATA

A. Parents and Guardian

Father Mother
Name Alan D. Autida Marianita O. Autida

Age 40 36

DOB November 23, 1974 june 29, 1978

Nationality Filipino Filipino

Religion Christian Christian
Occupation Fishing housewife

Educational Attainment Elementary graduate High School Undergraduate

General Health Healthy sickly (weak lungs )

Any Disability none none
Monthly Income 5,000 3,000
B. Number of Brothers and Sisters Brothers 1 Sisters 0

C. Other Individual living with Family? Yes No x

D. Is there any member of the family who has disabilities?

Name Age Relationship Disability

_____________________ ____________ ____________ __________
_____________________ ____________ ____________ __________
_____________________ ____________ ____________ __________

E. Dialect spoken at home Cebuano

F. Living Condition good condition

G. Person who is directly taking care of the child mother

H. Is the family a member of any community development organization?

Yes______ No x
If Yes, please specify _________________________________
PUPIL FAMILY BACKGROUND QUESTIONNAIRE

I. PERSONAL DATA

A. Pupil’s Name : Marvelan O. Autida

Address : purok 1 , Cabgan , Tambulig , Zamboanga del sur
Number Street Municipality/ City/ Province
Age 17 : Sex: male
Nationality : Filipino Religion: Christian
Ethnic affiliation:
Date of Birth : March 19, 1997
Place of Birth : Cabgan , Tambulig , Zamboanga del sur
Birth Registered : Yes _____________________ No ___________________
Disabilities : cerebral palsy Age of Onset : infantile

B. Has the pupil ever dropped out of school?

YES _____________ NO x
If Yes, how long? ________________________________________________
What reason(s) _________________________________________________

C. Distance from home to school: 800 m.

Means of transportation to school
________ Car _________ Motorized side car
________ Jeepney _________ Others
________ Pedicab

D. Has any member of the family ever dropped out of school?

Yes ____________ No x
E. Is the pupil receiving any type of financial assistance to attend school?
Yes x No ________________
If Yes, from what source/s: 4P’s

F. With whom does the pupil live?

____x_____ Both parents
_________ Mother
_________ Father
_________ Others

G. Who helps the pupil in doing homework?

_____ None ____ Both Parents __x__ Mother _____ Father _____ Others

II. MATERNAL HISTORY (From Conception to Present)

A. Was it a wanted birth? Yes ___x_____ No _________

B. Was Mom sick during pregnancy? yes

What? Asthma
C. What quarter? 1st trimester Was medication given? yes

What? Oral medication

D. Was there stress/ trauma/ accident during pregnancy?

Specify ___________________________________________________

III. EDUCATIONAL DATA

A. Child age when he entered school 17

B. Performance of the Child ___________________________________

Excellent ___________
Very Good ___________
Good ___________
Fair _____x______

C. School Drop-out Experience Yes __________ No _____x_______

D. Physical and Motor Characteristics

__no__1. Is the pupil slightly lighter in weight than most children of his
own age group?
__yes__2. Is the pupil has tendency to drop objects while walking?
__yes__3. Is the pupil has difficulty in using scissors?
__yes__4. Is the pupil has difficulty in holding pencil correctly?
__yes__5. Is the pupil has difficulty in drawing different shapes?
 __yes__6. Is the pupil has difficulty in writing letters?
__yes__7. Is the pupil has difficulty in writing umbers?
__yes__8. Is the pupil has difficulty in maintaining balance while
jumping, hopping and skipping?

E. Personal/Social Characteristics
__yes__1. Has tendency to be alone most of the time.
__no__2. Easily cries
__no__3. Has tendency to get angry at a slight provocation.
__yes__4. Lacks concern and attention to events and people around him.
__no__5. Does not care about the feelings of others
__no__6. Does not laugh easily when confronted to funny situation.
__no__7. Does not show interest to learn.
__yes__8. Has tendency to play with younger children.
__yes__9. Participates in school programs and activities like dancing,
singing and games.
__no__10. Lack the habit of listening.

F. Self- Help Skills

The Child:

1. Attends to group grooming needs independently.

_x_a. bathing
___b. dressing/undressing
_x_c. combing hair
___d. brushing teeth
___e. trimming fingernails/toenails
_x_f. washing hands and face with soap and water
_x_g. dries face and hands with towel
___h. uses sanitary napkins
___i. washes genital with soap and water during menstruation
___j. Shares/pills underarms hair

2. Eats/drinks correctly and without spilling.

___a. uses fork and spoon
_x_b. scoop food with spoon from a plate
_x_c. eats food: semi solid food
_x_d. chews food
___e. holds glasses, cup, bottle, can with assistance while drinking
___f. flushes toilet
_x_g. washes and dries hands/ attends to toilet needs

3. Observe Proper Toileting Habits

___a. makes signs to use the toilet
___b. uses potty seat
___c. sit on toilet bowl
___d. uses toilet paper
___e. washes genitals
___f. flushes toilet
_x_g. washes and dries hands/ attends to toilet needs
 4. Prepares/ fixes beddings/ personal items/ home wares/ toys without
any help.
Is independent in self-direction
____a. Running errands
____b. Buying
____c. Commuting
5. Intellectual Skills
The child:
____a. has poor memory
_x__b. has limited vocabulary
_x__c. has poor oral language facility
_x__d. has poor academic performance
_x__e. has short attention span
_x__f. has difficulty in finishing his work that has been started.
____g. has revearsals in written work
_x__h. has poor conceptual abilities like:
- Reasoning
- Comprehending
6. Psychological Skills
The child:
_x__ decision making
___ lacks the ability to cooperate with others
_x__ delayed in understanding, observing social propriety
___refuse to talk
___ delayed speech
___ tendency to have articulation problems such as;
- Omission
- Substitution
- Addition
- Distortion
- Reversals
 Prepared by:

DIVISION Tambulig
SCHOOL Cabgan , Tambulig , Zamboanga del sur

Individualized Education Program (IEP)

1st Quarter IEP/ Date: __________________________

Student Information

Name: Marvelan O. Autida Date of Birth: march 19, 1997

Place of Birth: Cabgan , Tambulig , Zamboanga del sur

Male/Female: male

Age: 17

Grade: preschool
Home Language : cebuano

Address: Cabgan , Tambulig , Zamboanga del sur

School Address: Cabgan , Tambulig , Zamboanga del sur

Parent/Guardian Information
Name: Marianita O. Autida
Address: Cabgan , Tambulig , Zamboanga del sur
Phone Number/ Mobile Number: none
Interpreter Required: ____________________________________
Assessment Information/Profile of CSN: _________________________________
___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_______________________________________________

Modification Needed in National/ Regional. Division wide Assessment:

_____________________________________________________________________________
_________________________________________________________

Why needed/ Why not? ______________________________________________

___________________________________________________________________

Primary Placement: ______________________

Type: __________________________________
IEP Information

Date of Next IEP: ____________________________

Primary Disability/ Category: cerebral palsy

Primary Placement: Cabgan Elementery School

Type: Inclusion
Priority: ___________________________________________________________
___________________________________________________________

Terminal Objectives
Objectives Lesson/ Activity & Procedure Duration

Special Provisions: _______________________________________________

Evaluation:

Extent to which the student will not participate with nondisabled students in regular class:

Explanation:

Parents/ Guardian will be informed of student’s progress via:

As appropriate, the following factors were considered in the development of this IEP

______ for students whose behaviour impedes learning, positive behavioural

interventions, strategies and support
______ for students with limited English proficiency, language needs
______ communication needs of the student
______ student has been informed of this IEP and his rights and responsibility

Signatures:
My due process have been explained to me.

Name of parent/guardian & signature Marianita O. Autida Date October 10, 2014

IEP Team (Name & Signature)

Documentation
 Western Mindanao State University
Aurora External Studies Unit

PROJECT IN IEP
(a sample IEP)

SUBMITTED TO:

JANICE JAECTIN

SUBMITTED BY:

BOVELYN A. AUTIDA-MASING