_______________Madison________________School District

Individual Education Program

Page 1

Student Name Meeting Date. 1/20/19 Purpose of Meeting

Jesse Brown Initial Eligibility, IEP, Placement
Annual Review of IEP
Student Information Management System Age 10 Grade. 4th Three Year Reevaluation
(SIMS) Number Dismissal from Services Date: _______________________
Date of Birth. 10/19/2000 Parent Request
Other: __________________________________________
Male Female Date Services Begin Discussed evaluation results/progress/assessment method
Yes ____ (Parent/Guardian initial)
1/20/19
Ethnicity: (H/L, AI/AN, A, B/AA, NH/OPI or W)
indian
Copy of evaluation results received Yes ____
(Parent initial)
School of Residence Annual Review Date
Madison Elementary *Transition Planning Needed No
1/20/20 Yes (If yes, attach applicable transition pages.)

Attendance Center Parent/Guardian Name, Address, Phone Student is eligible for special education or special education and related
Madison Ele Susan Wolf- Wyoming services as determined by the IEP team
Yes No
Niles Brown
Date of Eligibility Determination: 2020 Ups # 101 An annual copy of Parent/Guardian Rights was received and reviewed
1/20/19 Madison, SD 57042
____Dec. 20___________(Date) ________ (Parent/Guardian
Initial)

Hm: 256-1141 Wk:

Three Year Reevaluation Due By: Parent/Guardian Name, Address, Phone A copy of the IEP was provided to parent/guardian
Yes _______ (Parent/Guardian Initial)

1/20/21
Hm: Wk:
IEP Team Membership Signature Date
Parent/Guardian. Niles Brown 1/20/19

Parent/Guardian

Student Jesse Brown 1/20/19

Superintendent/Designee. 1/20/19
Ms.Brown

General Classroom Teacher 1/20/19

Ms. Jensen

Special Education Teacher 1/20/19

Samantha Nogelmeier

Speech/Language Pathologist 1/20/19

Evaluator 1/20/19
Ms. Art
Counselor 1/20/19
Ms. Hepper
PE teacher 1/20/19
Mr.Shay
Bus Driver 1/20/19
Mr. Bovill
Child Count Information (Required Information) Placement
Disabling Condition
0500-D/B 0505 -ED 0510-CD 0515-HL 0525-SLD 0100 General Class with Modifications 80-100%
0530-MD 0535-OI 0540 –VL 0545 –D 0550-S/L 0110 Resource Room 40-79%
0555-OHI 0560-A 0565-TBI 0570-DD 0120 Self-Contained Classroom 0-39%
0130 Separate Day School
0140 Residential Facility
0150 Home/Hospital
A. Minutes per week in Special Education ___300______ 0310 Early Childhood Setting-10 hrs./week
Minutes Services A1-services in ECH program
B. Minutes per week in Related Services 0315 Early Childhood Setting-10hrs/week
__________ __________ A2-services in other location
__________ __________ 0325 Early Childhood Setting-Less than 10hrs/wk.
 __________ __________ B-1 – services in ECH program
0330 Early Childhood Setting-Less than 10hrs/wk.
C. A + B = (Total minutes of Special Education/Related Services) _____300_____ B2 – services in other location
0335 Separate Class
0345 Separate School
0355 Residential Facility
0365 Home
0375 Service Provider Location

Present Levels of Academic Achievement and Functional Performance Page 2

Based on evaluation, include 1) strengths and weaknesses (academic achievement (skill based assessment)
and functional performance) in each skill areas affected by the student’s disability, including transition; 2)
parent input; and 3) how the student’s disability affects the student’s involvement and progress in the
general education curriculum. (For a preschool child, how the disability affects his/her participation in
appropriate activities.)

Student Name: IEP Date:

Jesse Brown 1/20/19

Strengths: Jesse likes to be outside… likes books about hunting… Previous teachers states he has more
potential that she shows

Weaknesses: He is experiencing extreme difficulty with 4 grade work. He has poor reading skills, which
th

tend to affect his writing, spelling, math, science, and social studies. His classroom teachers report that Jesse
rarely is on task, is very distractible, does very little school work and of very poor quality.

Reading: The school psychologist recently diagnosed Jesse, with a reading disability. Jessie’s achievement test results
include the following
- Kaufman Test of Educational Achievement: Reading Standard Score–80
- Kaufman Test of Educational Achievement: Math Standard Score–105
- Curriculum-based measurement: Reads second-grade-level passage with 93 correct words per minute with 4 errors
and 70 percent comprehension.
- Curriculum-based measurement: Reads third-grade-level passage with 60 correct words per minute with 8
errors and 50 percent comprehension.

Parent Concerns: Jesse does not bring work home, and if he does he refuses to do it.

Transition: N/A

How the student’s disability affects his/her involvement/progress in the general education curriculum:
Jesse will struggle keeping up with the reading in the regular classroom... His comprehension will prevent him from learning materials
expected... slow reader… Jesse refused to work on skills at home so it will be difficult for him to catch up

* Remember to address:
 Strengths & Needs (Academic achievement (skill based assessment) AND functional performance)
 Transition Areas (strength and needs) (must be in the student’s IEP by age 16)
 How the student’s disability affects his/her involvement/progress in the general education curriculum
 Parent input
 Consideration of Special Factors
Page 3

Is the student limited English proficient? Yes No

If the answer to this question is “yes”, please explain the language needs of the student as these needs relate to
the student’s IEP.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________

Are there any special communication needs? Yes No

If the answer to this question is “yes”, what direct instruction will be provided in the student’s mode of
communication?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________

Does the student require Braille? Yes No

If the answer to this question is “yes”, what Braille services will be provided?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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Does the student’s behavior impede his or her learning or that of others? Yes No
If yes, what strategies are required to appropriately address this behavior, including positive behavioral
interventions and supports?
_BIP___Jesse_will_follow_his_BIP_____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________
Assistive Technology Devices and Services? Yes No
If yes, what device or service will be provided?
_____________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________________

Physical Education: Regular Not Required Adaptive: Refer to Goals/Goals & Objectives

Hearing Aid Maintenance: Not Applicable Yes: Personnel Responsible for Monitoring
____________________________
Describe the monitoring process/frequency necessary for maintenance:
__________________________________________________
__________________________________________________________________________________________
______

__________________________________________________________________________________________
______________________________

Assessment

1. Student will be taking state and district wide assessments with or without accommodations.
(Accommodations will be
determined on page 7.) (Annual goals required)

2. Student will be taking an alternate assessment (The alternate assessment is for students working in the
alternate
achievement standards) (Annual goal and short term objectives required)

a. Does the student meet the significant cognitive disability criteria? (If no, student is not eligible to take
the alternate assessment) Yes No

b. Explain the reason why the student cannot participate in the regular assessment.
__________________________________

__________________________________________________________________________________________
_________

__________________________________________________________________________________________
_________

__________________________________________________________________________________________
_________

c. Explain the reason why the alternate assessment selected is appropriate for this
student_____________________________

__________________________________________________________________________________________
________

__________________________________________________________________________________________
________

__________________________________________________________________________________________
________

3. State and/or district-wide assessments are not required at this student’s grade level during the course of
this annual IEP.

Student Name Title of Personnel Responsible

Jesse Brown
Measurable Annual Goal #___1__ Proc. Date Prog. Comments:
Code Cod
When given a 3rd grade passage, Jesse will /s e
increase his reading fluency from 60 words per 8 1 qt p 1qt 65 wpm
minute to 100 words per minute with 9/10 2nd qt 60 or 70 wpm
consecutive assessments 3rd 90wpm
When given a 3rd grade passage, Jesse will
increase his reading comprehension with 50% to 8
90% accuracy with 9/10 consecutive assessments

When given a 3rd grade passage, Jesse will 8

decrease his reading errors from 8 errors to less
less than 3 errors with 9/10 consecutive
assessments.

Short Term Instructional Objectives or Proc. Date Prog. Comments:

Code/s Code
Benchmarks (Required for students who take
alternate assessments aligned to alternate
achievement standards.
Accommodations/Modifications/Supplementary Aides and Services Frequency Location Begin Date Duration
1._________________________________________________________ __________ ______ ______ ______
___________ ______ ______ ______ ______
2._________________________________________________________ ______ ______ ______ ______
___________ ______ ______ ______ ______
3._________________________________________________________ ______ ______ ______ ______
___________ ______ ______ ______ ______
4._________________________________________________________ __ ____ ____ ____
___________
5.
___________________________________________________________
_________

Statement of the program modifications or supports for school personnel (as Frequency Location Begin Date Duration
appropriate):

Procedure Codes (Complete at IEP meeting) Progress Codes Reporting Frequency to Parents
1. Teacher-made tests 6. Work Samples P= Progress being made Quarterly Reports
2. Observations 7. Portfolios I= Insufficient Progress to meet goal Trimester Reports Other: _______
3. Weekly tests 8. Oral Tests X= Not addressed this Reporting Period Reporting Method to Parents
4. Unit tests 9. Data Response M=Met goal Conferences Report Card
5. Student Conferences 10. Other: Goal Page Copy Other:
Educational Goals and Objectives/Benchmarks Page 5 ___

Related Services to Be Provided Page 6

Related Service to be Provided Title of Person Amount of Location of Duration of

Responsible Service Service Service (If less
than duration
of IEP)
A. Occupational Therapy

B. Physical Therapy

C. Psychological Services

D. Counseling Services (including

rehabilitation counseling)
E. Social Work Services (in schools)

F. Audiological Services

G. Recreation Therapy

H. School Nurse/Health Services

I. Speech/Language Therapy

J. Transportation (Specify when, how

often,
where, distance, costs, etc.)
 K. Orientation and Mobility

L. Medical Services (Diagnostic

Services
only)
M. Interpreting Services

N. Parent Counseling/Training

O. Other

State/District Assessment Accommodations Page 7

1. Student will be taking the assessment without accommodations.

2. Student will be taking the assessment with the accommodations.

***Teams must consider if the accommodations are approved for the applicable test administration.

***List the accommodations the student will be taking for each test/test area.
(Only those accommodations identified for instruction on the goal pages can be considered for state and district wide
testing. The accommodations selected for use must relate to the students disability.)

Grades 3-8 & 11 Grades 5,7 & 10 District Specific Tests

Dakota STEP
Reading
__read the test to jesse
_____quiet seating _____________
____________________________
____________________________
____________________________
Write To Learn Name:
Area(s)
____________________________________________________
______________________________ ____________________________
______________________________ ____________________________
______________________________ ____________________________

Math
____________________________
____________________________
____________________________
____________________________
______________________________ ____________________________
______________________________ ____________________________
______________________________ ____________________________
______________________________ ____________________________
Grades 5-8 &11
Science
____________________________
____________________________
____________________________
______________________________ ____________________________
______________________________ ____________________________
______________________________ ____________________________

* Alternate Assessment
All accommodations documented in the IEP are allowed to be used for students taking the alternate assessment.
 Least Restrictive Environment Page 8

Continuum of Alternative Placements Continuum of Alternative Placements (Ages 3-5)

0100 General Classroom with Modifications 80-100% 0310 Early Childhood Setting-10 hrs./week
0110 Resource Room 40-79% A1-services in ECH program
0120 Self-Contained Classroom 0-39% 0315 Early Childhood Setting-10hrs/week
A2-services in other location
0130 Separate Day School
0325 Early Childhood Setting-Less than 10hrs/wk.
0140 Residential Facility B-1 – services in ECH program
0150 Home/Hospital 0330 Early Childhood Setting-Less than 10hrs/wk.
B2 – services in other location
0335 Separate Class
0345 Separate School
0355 Residential Facility
0365 Home
0375 Service Provider Location
Special Education to be provided:
Description of services Amount of service Location of service

Reading remediation. 45mins/day resource room

Behavior study/social skills 15 min/day resource room

Participation with Non-Disabled Peers (Complete for all students Ages 6-21)
Program Options Comments
Art Vocational Education
Industrial Technology Family & Consumer Science
Music Other____________________
Non-Academic Comments
Counseling Recess
Meals Health Services
Employment Referrals Other____________________

Extracurricular Comments
Athletics Recreation
Clubs Other____________________
Groups

Justification for Placement--An explanation of the extent, if any, to which the child will not participate with non-disabled children in regular
classes, and non-academic activities. (Please use accept/reject format for each alternative placement considered.)

Regular classroom with modification. Accept – Jesse that he should be able to work in the classroom due to his ability levels.

Potential harmfull effects: Jesse may not success due to his behaviors

The team addressed the potential harmful effects of the special education placement.
 Extended School Year Page 9

Extended School Year Services: needed not needed to be determined by (Date

4/20/19

Beginning
*Type of Ending Date Minutes
Goal(s) # Date **Based on
Service mm/dd/yy Per Week
mm/dd/yy

* Instruction, related services (specify), other (list)

** Regression/Recoupment, Emerging Skills, or Maintenance of Critical Life Skills

Parent/Guardian Consent Required For Initial Placement Only

“Consent” means that the parent(s)/guardian(s) have been fully informed of all information relevant to the
activity for which consent is sought, in the native language, or other mode of communication; the
parent(s)/guardian(s) understand and agree in writing to the carrying out of the activity for which consent is
sought, and the consent describes that activity and lists any records which will be released and to whom; and the
granting of consent by the parent(s)/guardian(s) is voluntary and may be revoked in writing at any time.

__________________________________ ________________________
Parent/Guardian Signature Date

Clarifying Comments: