Betar 347 Iep

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name: Josh Jones
INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age

IEP Team Meeting Date (mm/dd/yy): 04/23/2020
IEP Implementation Date (Projected Date when Services and Programs Will Begin): 04/24/2020
Anticipated Duration of Services and Programs: 04/23/2021
Date of Birth: 08/31/2015
Age: 4
Grade: Pre-K
Anticipated Year of Graduation: 2032
Local Education Agency (LEA): Steubenville City School District
County of Residence: Jefferson County
Name and Address of Parent/Guardian/Surrogate: Phone (Home): (222)-222-2222
Max and Ruby Jones Phone (Work): (777)-777-7777
0000 Streetname Road
Steubenville, Ohio 43952
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
Page 1 of 30 April 2020

IEP TEAM/SIGNATURES
The Individualized Education Program team makes the decisions about the student’s program and placement. The student’s parent(s), the student’s special
education teacher, and a representative from the Local Education Agency are required members of this team. Signature on this IEP documents attendance, not
agreement.
Role Printed Name Signature

Parent/Guardian/Surrogate Max Jones
Parent/Guardian/Surrogate Ruby Jones
Student* N/A
Regular Education Teacher** Kathleen Price
Special Education Teacher N/A
Local Ed Agency Rep N/A
Career/Tech Ed Rep*** N/A
Community Agency Rep N/A
Teacher of the Gifted**** N/A
Speech and Language Pathologist John Smith
Occupational Therapist Lucy Peller
Principal Laura Norman
* The IEP team must invite the student if transition services are being planned or if the parents choose to have the student participate.
** If the student is, or may be, participating in the regular education environment
*** As determined by the LEA as needed for transition services and other community services
**** A teacher of the gifted is required when writing an IEP for a student with a disability who also is gifted.
One individual listed above must be able to interpret the instructional implications of any evaluation results.
Written input received from the following members:
N/A
Transfer of Rights at Age of Majority
For purposes of education, the age of majority is reached in Pennsylvania when the individual reaches 21 years of age. Likewise, for purposes of the Individuals
with Disabilities Education Act, the age of majority is reached for students with disabilities when they reach 21 years of age.

PROCEDURAL SAFEGUARDS NOTICE
I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides information about my rights,
including the process for disagreeing with the IEP. The school has informed me whom I may contact if I need more information.
Signature of Parent/Guardian/Surrogate:
MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

(Applicable only to parents who have consented to the release of billing information to Medical Assistance programs)
I understand that the school may charge the School-Based Access Program (“SBAP”)—or any program that replaces or supplements the SBAP—the cost of certain
special education and related services described in my child’s IEP. To make these charges to the SBAP, the school will release to the administrator of that
program the name, age, and address of my child, verification of Medicaid eligibility for my child, a copy of my child’s IEP, a description of the services
provided and the times and dates during which such services were provided to my child, and the identity of the provider of such services. I understand that
such information will not be disclosed, and such charges will not be made, unless I consent to the disclosure. I acknowledge that I have provided written
consent to disclose such information.
I understand that my consent is ongoing from year-to-year unless and until I withdraw it. I can withdraw my consent in writing, or orally if I am unable to
write, at any time. My refusal to consent or my withdrawal of consent will not relieve the school of the obligation to provide, at no cost to me or my family,
any service or program to which my child is entitled under the Individuals with Disabilities Education Act (“IDEA”) or that is necessary to enable my child to
receive a free appropriate public education as described in my child’s IEP.
I understand that the school cannot—
Require me or my family to sign up for or enroll in any public benefits or insurance program, such as Medicaid, as a condition of receiving a free appropriate
public education for my child;
Require me or my family to incur any expense for the provision of a free appropriate public education to my child, including co-payments and deductibles,
unless it agrees to pay such expenses on my or my family’s behalf;
Cause a decrease in available lifetime coverage or any other insured benefit;
Cause me or my family to pay for services that would otherwise be covered by a public benefits or insurance program and that are required for my child
outside the time that he or she is in school;
Risk the loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.

I. SPECIAL CONSIDERATIONS THE IEP TEAM MUST CONSIDER BEFORE DEVELOPING THE IEP. ANY FACTORS CHECKED AS “YES” MUST BE ADDRESSED IN THE IEP.
Is the student blind or visually impaired?

Yes The IEP must include a description of the instruction in Braille and the use of Braille unless the IEP team determines, after
an evaluation of the student’s reading and writing skills, needs, and appropriate reading and writing media (including an
evaluation of the student’s future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use
of Braille is not appropriate for the student.
X No
Is the student deaf or hard of hearing?

Yes The IEP must include a communication plan to address the following: language and communication needs; opportunities for
direct communications with peers and professional personnel in the student’s language and communication mode; academic
level; full range of needs, including opportunities for direct instruction in the student’s language and communication mode;
and assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The
Communication Plan must be completed and is available at www.pattan.net
X No
Does the student have communication needs?

X Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)
No
Does the student need assistive technology devices and/or services?

Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)
X No
Does the student have limited English proficiency?

Yes The IEP team must address the student’s language needs and how those needs relate to the IEP.
X No

Does the student exhibit behaviors that impede his/her learning or that of others?
Yes The IEP team must develop a Positive Behavior Support Plan that is based on a functional assessment of behavior and that
utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in the Present Levels
section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially Designed Instruction
sections of the IEP or in the Positive Behavior Support Plan if this is a separate document that is attached to the IEP. A
Positive Behavior Support Plan and a Functional Behavioral Assessment form are available at www.pattan.net
X No
Other (specify):
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
Introduction:
Josh is a four-year-old boy in preschool. A few weeks into the school year, Josh was diagnosed with
autism and was placed in an inclusion classroom with a total of 24 other students, 10 of whom are
students with disabilities. At this time, Josh is nonverbal. He struggles with social skills as well as some
fine motor skills.
Present levels of academic achievement:

Literacy: Josh is able to identify 20/26 uppercase letters and 19/26 lowercase letters. He was only able
to point and identify these letters when asked “Can you find the letter C?”. Josh struggles to say his
alphabet in order and can only recite it from A-C. Josh can only verbalize the letters A, B, and C. Josh
does not seem interested in reading books and when he does sit down at the carpet to listen to a story,
he does not ask questions, make comments, or understand how text progresses. He is not able to
verbalize letter sounds, identify rhymes consistently, or segment words.
Mathematics: Josh is able to rote count to 7 with no assistance and count to 13 with some assistance.
Josh is unable to correspond the shape of the number to its name. In other words, when asked to “Find
the number 3”, Josh is unable to point to the correct number. Josh has no understanding of number
concepts, sorting, matching quantities, identifying numerals, or word problems. Josh is able to name,
sort, and match objects by color and shape. He is also able to make simple ABAB patterns when given
color and shape manipulatives.
Present levels of functional performance:

Behavior: Josh demonstrates a willingness to be helpful in the classroom. He helps put toys away and he
appears to enjoy doing simple favors like helping the paraprofessional get everyone’s lunches ready as
well as helping take the attendance to the office in the morning. He loves hugs, but only when he is the
one to initiate the physical touch. He usually does not need to be reminded to clean up his toys before
moving onto the next activity. He is sometimes kind to his classmates and his teachers. When Josh does
not get his way, he becomes quickly upset and aggravated. When he reaches this level, he often yells,
screams, and hits to communicate that he is upset. He usually ignores his peers until they do something
that he does not like, then he gets upset and either starts to yell or sometimes gets physically
aggressive. Josh does not actively engage in learning opportunities. He rarely raises his hand to
participate even when simple yes/no questions are asked. When given directions during learning
activities, Josh responds quickly when he is interested in the activity. However, Josh quickly becomes
distracted and does not tend to stay engaged in one activity for more than 10 minutes.
Communication: Josh is nonverbal at this time and mostly communicates using one-word phrases. His
vocabulary includes words such as, hello, yes, no, done, and more. Josh is able to identify and name
common objects around the classroom such as pencil, crayon, carpet, and books. Because he is
nonverbal at this time, his expressive language is not at the Pre-Kindergarten level. His speech
articulation is low, and peers and teachers often have to ask yes or no questions to identify what Josh is
trying to say. While his expressive language is low, he has a very high receptive language. He is able to
follow simple commands with up to three or four steps. When asked, “What sound does a cow make”,
Josh is able to moo. He is able to perform this same function for three other animals (i.e., dog, cat, and
snake). Josh is unable to distinguish between right and left. When Josh needs help or cannot verbalize
what he wants, he either points to the object or grabs your hand and physically takes you to wherever
the item is located. Josh is unable to name or identify any parts of the body.
Social Skills: Josh has moderate relationships with adults and loves to initiate hugs. This is the only
social skill that Josh has shown great mastery. While he has relationships with adults, he does not have
any relationships with any peers. He does not try to interact with his peers. He usually engages in
solitary or parallel play, but he rarely participates in cooperative play with his peers. He is, however,
able to share his toys when prompted by an adult. Because he is nonverbal at this time, Josh is unable
to initiate, create, or maintain friendships with the other students in his classroom. When given positive
reinforcement, Josh gets very happy and enthusiastic.
Gross and Fine Motor Skills: Josh is a very active child who usually does not sit still for long. His gross
and fine motor skills are age appropriate. Josh is able to walk in a straight line with ease. He is able to
balance on his preferred foot for 8 seconds and his nonpreferred foot for 5 seconds. He is able to hop on
one foot but after one to two hops, he loses his balance. Josh is also able to walk backwards, skip, and
tiptoe. Josh struggles to gallop and to walk forward heel-to-toe. He can jump up and down 7 times
consecutively. Josh can walk up and down the stairs with ease but tends to grab onto the railing for
support. He can throw and catch a large ball such as a kickball and can throw a smaller ball, but he
struggles to catch a smaller ball such as a tennis ball. Josh is able to build towers using big, plush
blocks. Josh is able to correctly hold a pencil in his hands, but he struggles to control the writing tool.
He is also able to draw a straight line and shapes such as a circle and a square. He struggles with
drawing hearts, diamonds, triangles, and rectangles. Josh knows how to correctly hold and utilize
scissors to cut paper. Josh is able to write the first letter of his name but is unable to write his full
name. Josh is also unable to write any letters of the alphabet or numerals.
Adaptive Skills: Josh has reasonably strong adaptive skills. He is able to eat independently but is unable
to correctly use silverware when needed. He can get dressed with little to no assistance. He cannot,
however, tie his shoes or zip up his jacket. When he gets to school in the morning, he needs assistance
taking his backpack off, but he is able to take his jacket off and hang both of them up in his cubby. Josh
is able to use the bathroom by himself, but he needs some assistance when washing his hands. Josh is
able to tell you his first name, his last name, and his age. He is unable to verbalize his birthday,
telephone number, or street address.
Present level related to current post secondary transition goals:

Transition services are not appropriate at this time.
Parental concerns for enhancing the education of the student:

Josh’s parents would like Josh to be able to show how he is feeling without needing to scream and get
upset, they would also like to see him interact with his peers more, to make a friend, to voluntarily
participate more during whole group instruction, and to learn to write his name.
How the student’s disability affect involvement in the general education curriculum:
There is not a significant difference between his functional performance and his chronological age. Josh
is not too far behind his typically developing peers. The support and services given in this document will
be beneficial and help close the small gap.
Strengths:
- Josh has strong receptive language and responds to verbal commands quickly.
- Josh can go to the bathroom, eat, and put his coat on independently.
- Josh can run and jump well.
- Josh is helpful around the classroom and enjoys helping the teacher.
- Josh is able to apologize after he has done something wrong.

- Josh loves to listen to music and is often more engaged in classroom activities when they have to do
with music or dancing.
Academic, developmental, and functional needs related to student’s disability:

Cognitive (Mathematics):
Josh is unable to identify isolated numbers and is unable to count past 7 without assistance. Counting is
the basic prerequisite skill of all mathematical functions.
Cognitive (Literacy):
Josh is unable to recite the alphabet in order. Josh is unable to identify all of the letters in the
alphabet with accuracy. The skill of identifying letters is the most basic prerequisite skill of reading.
Communication:
Josh is nonverbal at this time. This inhibits most of his academic, developmental, and adaptive skills.
He uses gestures to communicate. Josh is unable to create peer friendships because of his
communication needs. His communication must be improved so he is able to live an independent life.
Physical Development:
Josh is unable to write his name or any letters of the alphabet. While he knows how to correctly hold a
pencil, he has not mastered the ability to control the pencil in his hand. This skill is something he must
learn in the writing process.
III. TRANSITION SERVICES – This is required for students age 14 or younger if determined appropriate by the IEP team. If the student does not attend the
IEP meeting, the school must take other steps to ensure that the student’s preferences and interests are considered. Transition services are a coordinated
set of activities for a student with a disability that is designed to be within a results oriented process, that is focused on improving the academic and
functional achievement of the student with a disability to facilitate the student’s movement from school to post school activities, including postsecondary
education, vocational education, integrated employment (including supported employment), continuing and adult education, adult services, independent
living, or community participation that is based on the individual student’s needs taking into account the student’s strengths, preferences, and interests.
POST SCHOOL GOALS – Based on age appropriate assessment, define and project the appropriate measurable postsecondary goals that address education
and training, employment, and as needed, independent living. Under each area, list the services/activities and courses of study that support that goal.
Include for each service/activity the location, frequency, projected beginning date, anticipated duration, and person/agency responsible.
For students in Career and Technology Centers, CIP Code:
N/A

Postsecondary Education and Training Goal:

Measurable Annual Goal
N/A Yes/No
(Document in Section V)
Courses of Study:
N/A
Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible
Employment Goal:
N/A
Yes/No
Courses of Study:
N/A


Independent Living Goal, if appropriate:

N/A Yes/No
Courses of Study:
N/A

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Instructions for IEP Teams:
Please select the appropriate assessment option. Information on available testing accommodations may be found in the Accommodations Guidelines
available on www.education.state.pa.us.
State Assessments
Not Assessed
X No statewide assessment is administered at this student’s grade level.
X No English proficiency assessment administered because the student is not an English Language Learner.
PSSA (Math administered in grades 3-8; Science administered in grades 4 and 8; Reading administered in grades 3-8; Writing administered in grades 5
and 8; and ELA*)
Without With
Tested Subject Accommodation Accommodation Accommodations to be Provided
s s
Math
Science
Reading
Writing
ELA*
*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.

Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11th grade)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1
Literature
Biology
Keystone Project Based Assessment (Available when student is unable to demonstrate proficiency on a Keystone Exam or Keystone Exam module.)
Without With
Algebra 1
Literature
Biology
Validated Local Assessment (Available when selected as option by LEA)

Without With
Algebra 1
Literature
Biology
PASA (Administered in grades 3-8, 11 for Reading and Math; Grades 4, 8, 11 for Science)
Student will participate in the PASA.
Explain why the student cannot participate in the PSSA or the Keystone Exam for Reading/Literature, Math/Algebra 1,
Science/Biology, and Composition (The Composition exam will be available for the 2016-17 school year):
Explain why the PASA is appropriate:
Choose how the student’s performance on the PASA will be documented.

Videotape (preferred method)
Written narrative notes (requires prior approval in accordance with PDE

guidance)

ACCESS for ELLs (Administered in grades K-12)

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to
Accommodations Accommodations Participate Participate in Selected Domains
Listening
Reading
Writing
Speaking
Alternate ACCESS for ELLs (Administered in grades 1-12)

Student will participate in the Alternate ACCESS for ELLs.
Explain why the student cannot participate in the ACCESS for ELLs:
Explain why the Alternate ACCESS for ELLs is appropriate:
Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to

Accommodations Accommodations Participate Participate in Selected Domains
Listening
Reading
Writing
Speaking
Local Assessments
X Local assessment is not administered at this student’s grade level; OR
Student will participate in local assessments without accommodations; OR
Student will participate in local assessments with the following accommodations; OR

The student will take a local alternate assessment.
Explain why the student cannot participate in the local regular assessment:
Explain why the local alternate assessment is appropriate:

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.
MEASURABLE ANNUAL GOAL Describe WHEN

Include: Condition, Name, Behavior, and Criteria Describe HOW the student’s progress toward periodic reports on Report of
(Refer to Annotated IEP for description of these meeting this goal will be measured progress will be Progress
components) provided to parents
When presented with a piece of paper and a Once a week, the inclusive education teacher will Progress will be
writing tool, Josh will write his first name with present Josh with a piece of paper and a writing reported to parents
80% accuracy, in four out of five trials. utensil. The special education teacher will then quarterly with report
prompt the student to write his name on the paper. cards.
The special education teacher will observe and
record the number of letters Josh is able to print
correctly, in the correct order, out of the four
letters in his name.
During group instruction on the carpet, when Once a week, the inclusive education teacher will Progress will be
given the opportunity, Josh will raise his hand to check Josh’s progress by using a simple method to reported to parents
participate, with 80% accuracy in two out of three keep track of how many times Josh raises his hand. quarterly with report
trials. Each time Josh raises his hand during group cards.
instruction, the teacher will move a counter from
one pocket of her smock to the other pocket. After
the lesson is over, the teacher will count how many
counters she has moved. Data will be kept and
graphed.
During unstructured play, Josh will play with one Once a week, the inclusive education teacher will Progress will be
to two peers for five minutes with no more than present Josh with three 5-minute trials of reported to parents
one adult prompt in two out of three unstructured play time. The teacher will start a quarterly with report
opportunities. timer for 5 minutes and will observe the student cards.
during this time. The teacher will look for how
many peers the student is engaging with and
whether or not they are engaging in cooperative
play (i.e., students are playing together to achieve
the same goal, such as building a tower or
completing a puzzle).
SHORT TERM OBJECTIVES – Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).
Short term objectives / Benchmarks
N/A

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.
Modifications and SDI Location Frequency Projected Beginning Date Anticipated Duration
SDI for Goal 1
The inclusive education teacher will
provide explicit and direct
instruction by working one-on-one
with Josh to teach him how to write
his name. The teacher will
implement the “I do, we do, you
do” strategy to help him write his General Education 2 times per week for 15
04/24/20 04/24/20 – 4/23/21
name. First the teacher will model Classroom minutes
how to write his name, then the
teacher will use physical guidance
to help Josh write his name, then
the teacher will let Josh attempt to
write his own name independently.
Continuous reinforcement will be
used.
SDI for Goal 1:
provide Josh with bold lined paper
during any instruction involving
writing. The paper will have thick
lines and lots of space between the
lines. Josh will be taught where to General Education 2 times a week for 10
04/24/20 04/24/20 – 4/23/21
start writing on this paper (i.e., top Classroom minutes
left) by the inclusive education
teacher. The teacher will do this
through direct instruction and
guided practice. Reinforcement will
be provided continuously.
SDI for Goal 2: General Education 2 times a week for 15 04/24/20 04/24/20 – 4/23/21

provide instructions of how to
respond to verbal prompts. During
instruction, after the teacher has
asked a question, the teacher will
use a time delay and give the Classroom minutes
student a gestural prompt to
indicate that it is time to answer a
question. Reinforcement will be
provided continuously.
SDI for Goal 2:

provide instruction to Josh by
teaching him, with the help from
peer models, how to appropriately
raise his hand. During small group
instruction, Josh, and a group of
General Education 3 times a week for 20
one to three peers will listen to a 04/24/20 04/24/20 – 4/23/21
Classroom minutes
story. Then the teacher will ask a
question. Before she calls on
someone who has their hand raised,
the teacher will use a think aloud to
walk through the process of raising
your hand. Reinforcement will be
provided continuously.
SDI for Goal 3: social skills
provide instructions using social
stories to help the student learn
how he should behave in
unstructured play time. During General Education 2 times a week for 20
04/24/20 04/24/20 – 4/23/21
stations, Josh will have a station Classroom minutes
that focuses on this social skill. He
will be given an iPad that has a
video model of the desired behavior
of playing cooperatively with
friends.
SDI for Goal 3:
The inclusive education teacher will General Education 2 times a week for 20
04/24/20 04/24/20 – 4/23/21
provide direct instruction of de- Classroom minutes
escalation strategies. The teacher
will first teach these skills through

repeated teaching. Then the
teacher will use guided practice and
ask the student, “What can you do
if you begin to get upset?”.
Reinforcement will be provided
continuously.
B. RELATED SERVICES – List the services that the student needs in order to benefit from his/her special education program.
Service Location Frequency Projected Beginning Date Anticipated Duration
With speech and language

Speech and Language pathologist, in his 30 minutes twice a week 04/24/20 04/24/20 – 4/23/21
classroom
General education
Social Skills Training 30 minutes once a week 04/24/20 04/24/20 – 4/23/21
classroom with
paraeducator
With occupational therapist

Occupational Therapy 30 minutes twice a week 04/24/20 04/24/20 – 4/23/21
in her classroom
C. SUPPORTS FOR SCHOOL PERSONNEL – List the staff to receive the supports and the supports needed to implement the student’s IEP.
School Personnel to Projected Beginning

Support Location Frequency Anticipated Duration
Receive Support Date
Update from the

Speech and
Inclusive Education Twice a month for 20
Language Inclusive Classroom 04/24/20 04/24/20 – 4/23/21
Teacher minutes
Pathologist on Josh’s
progress
Inclusive Education Inclusive Classroom Once a month for 20 04/24/20 04/24/20 – 4/23/21
Teacher Update from the minutes
Paraeducator on
Josh’s progress
Update from the

Inclusive Education Occupational Twice a month for 20
Inclusive Classroom 04/24/20 04/24/20 – 4/23/21
Teacher Therapist on Josh’s minutes
progress

D. GIFTED SUPPORT SERVICES FOR A STUDENT IDENTIFIED AS GIFTED WHO ALSO IS IDENTIFIED AS A STUDENT WITH A DISABILITY – Support services are
required to assist a gifted student to benefit from gifted education (e.g., psychological services, parent counseling and education, counseling services,
transportation to and from gifted programs to classrooms in buildings operated by the school district).
Support Service N/A

Support Service N/A
Support Service N/A
E. EXTENDED SCHOOL YEAR (ESY) – The IEP team has considered and discussed ESY services, and determined that:
Student IS eligible for ESY based on the following information or data reviewed by the IEP team:
OR
X As of the date of this IEP, student is NOT eligible for ESY based on the following information or data reviewed by the IEP team:
Currently Josh does not qualify, however data will continue to be collected before and after the winter break session in order to
see if the student qualifies for ESY based on regression and recoupment data.
The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the student’s ESY Program are:
N/A
If the IEP team has determined ESY is appropriate, complete the following:
ESY Service to be Provided Location Frequency Projected Beginning Date Anticipated Duration


VII. EDUCATIONAL PLACEMENT
A. QUESTIONS FOR IEP TEAM – The following questions must be reviewed and discussed by the IEP team prior to providing the explanations regarding
participation with students without disabilities.
It is the responsibility of each public agency to ensure that, to the maximum extent appropriate, students with disabilities, including those in public
or private institutions or other care facilities, are educated with students who are not disabled. Special classes, separate schooling or other removal
of students with disabilities from the general educational environment occurs only when the nature or severity of the disability is such that education
in general education classes, EVEN WITH the use of supplementary aids and services, cannot be achieved satisfactorily.
 What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the supplementary
aids and services will or will not enable the student to make progress on the goals and objectives (if applicable) in this IEP in the general
education class.
 What benefits are provided in the general education class with supplementary aids and services versus the benefits provided in the special
education class?
 What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the other students in the
class, even with supplementary aids and services?
 To what extent, if any, will the student participate with nondisabled peers in extracurricular activities or other nonacademic activities?
Explanation of the extent, if any, to which the student will not participate with students without disabilities in the regular education class:
Josh is performing at a level, both academically and functionally, that is lower than his chronological
age. While some of these skills need refined, Josh will spend a majority, 93%, of his day in the inclusive
classroom. Josh will spend a total of two hours a week outside of the classroom. One hour a week will
be spent in the speech therapist’s classroom while the other hour will be spent in the occupational
therapist’s classroom. Josh’s social skills training will take place within the classroom with a
paraprofessional. His speech and occupational therapy will take place outside of the classroom so as to
not cause distractions for Josh or for his classmates. The social skills training will take place in the back
of the classroom because the paraprofessional might need to pull Josh’s peers to help him engage in
social activities.
Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
Josh is performing at a level, both academically and functionally, that is lower than his chronological
age. However, Josh will participate in all of the general education curriculum because his goals are age
appropriate and are consistent with the goals that his typically developing peers are working towards.
With his specifically designed instruction and accommodations, Josh will be able to succeed in the
inclusive classroom.

B. Type of Support
1. Amount of special education supports
X Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day
Supplemental: Special education supports and services provided by special education personnel for more than 20% of the day but less than
80% of the school day
Full-Time: Special education supports and services provided by special education personnel for 80% or more of the school day
2. Type of special education supports
x Autistic Support
Blind-Visually Impaired Support
Deaf and Hard of Hearing Support
Emotional Support
Learning Support
Life Skills Support
Multiple Disabilities Support
Physical Support
X Speech and Language Support

C. Location of student’s program
Name of School District where the IEP will be implemented: Steubenville City School District
Name of School Building where the IEP will be implemented: Pugliese West Elementary School
Is this school the student’s neighborhood school (i.e., the school the student would attend if he/she did not have an IEP)?
X Yes
No. If the answer is “no,” select the reason why not.

Special education supports and services required in the student’s IEP cannot be provided in the neighborhood school
Other. Please explain:

VIII. PENNDATA REPORTING: Educational Environment (Complete either Section A or B; Select only one Educational Environment)
To calculate the percentage of time inside the regular classroom, divide the number of hours the student spends inside the regular classroom by the total number of hours in the school day (including
lunch, recess, study periods). The result is then multiplied by 100.
SECTION A: For Students Educated in Regular School Buildings with Non Disabled Peers – Indicate the Percentage of time INSIDE the regular classroom for this student:
Time spent outside the regular classroom receiving services unrelated to the student’s disability (e.g., time receiving ESL services) should be considered time inside the regular classroom.
Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as college campuses or vocational sites, should be counted as time
spent inside the regular classroom.
Calculation for this Student:
Column 1 Column 2 Calculation Indicate Percentage Percentage Category

Total hours the student Total hours in a typical (Hours inside regular Section A: The percentage of
school day classroom ÷ hours in
spends in the regular time student spends inside the
school day) x 100 = %
classroom per day regular classroom: Using the calculation result – select the appropriate percentage
(including lunch, recess category
& study periods) (Column 1 ÷ Column 2)
x 100 = %
5.6 6 (5.6 ÷ 6) x 100 93% of the day X INSIDE the Regular Classroom 80% or More of the Day
INSIDE the Regular Classroom 79-40% of the Day
INSIDE the Regular Classroom Less Than 40% of the Day
SECTION B: This section required only for Students Educated OUTSIDE Regular School Buildings for more than 50% of the day – select and indicate the Name of School
or Facility on the line corresponding with the appropriate selection: (If a student spends less than 50% of the day in one of these locations, the IEP team must do the
calculation in Section A)
Approved Private School (Non Residential) _________________________ Other Public Facility (Non Residential) _________________________
Approved Private School (Residential) _________________________ Hospital/Homebound _________________________
Other Private Facility (Non Residential) _________________________ Correctional Facility _________________________
Other Private Facility (Residential) ________________________ Out of State Facility _________________________
Other Public Facility (Residential) ________________________ Instruction Conducted in the Home _________________________
EXAMPLES for Section A: How to Calculate PennData–Educational Environment Percentages

Column 1 Column 2 Calculation Indicate Percentage
Total hours the student spends in the Total hours in a typical school (Hours inside regular classroom ÷ hours in school day) Section A: The percentage of time student
day (including lunch, recess & x 100 = % spends inside the regular classroom:
regular classroom per day
study periods)
(Column 1 ÷ Column 2) x 100 = %
Example 1 5.5 6.5 (5.5  6.5) x 100 = 85% 85% of the day
(Inside 80% or More of Day)
Example 2 3 5 (3 5) x 100 = 60% 60% of the day
(Inside 79-40% of Day)
Example 3 1 5 (1 5) x 100 = 20% 20% of the day
(Inside less than 40% of Day)
For help in understanding this form, an annotated IEP is available on the PaTTAN website at www.pattan.net Type “Annotated Forms” in the Search feature on the website. If you do not have access
to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.

Appendix A
Teacher Interview
Date: 3/23/2020 Time: 8:45AM Duration: 30 minutes
Student Pseudonym: Josh
Grade: Preschool
Age: 4 years old
Environment: Urban
Parents/Guardians: Mom and dad are married. Mom works as a nurse and dad works in construction.
Siblings: Younger sister who is 2 years old
Current Grades in School: Can count to ten, can name and sort all shapes and colors. Non-verbal at this time.
Present Level of Performance:
Reading: He is non-verbal. Is not interested in listening to books being read aloud. Does
not pick up books when asked to find something in the room to occupy himself.
Spelling: He can identify most letters of the alphabet when prompted. He cannot recite
the alphabet in order.
Writing: He does not know how to write his name. He does know how to correctly hold a
pencil.
Math: He is able to count to ten but cannot identify isolated numbers. He can
identify shapes when prompted by the teacher (i.e., find the circle).
Any adaptations in place for taking assessments? No
Academic Strengths: He becomes interested and engaged when the content being presented is in the form of a video or a song.
Academic Areas for Improvement: Non-verbal, needs lots of verbal prompts, has trouble staying on task during carpet time,
Behavioral Strengths: Can be affectionate and loving when he wants to be, enjoys hugs
Behavioral Areas for Improvement: Wanders around the room during whole group instruction, throws tantrums when he does not have his way,
physically pushes and hits teachers and other peers, screams when he becomes upset or aggravated
Behavior Intervention Plan (BIP)? No
Describe the level of independent functional skills: He can dress himself in the morning and he is able to use the toilet by himself. He is unable to
zipper his jacket and wash his hands correctly.
Describe social skills and relationships with peers: He lacks any sort of social skills and does not have any relationship with his peers. He usually
engages in solitary play or parallel play, but he rarely plays with his peers in tandem with them. He usually ignores his peers until they do something
that he does not like, then he gets upset and either starts to yell or sometimes gets physically aggressive.
Describe organization and decision-making skills: When he wants something, he either points to it or grabs your hand and physically takes you to
where the item is located.
Describe things that he finds motivating and reinforcing: He loves Smarties and Skittles. He also enjoys getting to play with his toy sea animals.
Goals or aspirations the parents have for their child for this school year: His parents would like Josh to be able to show how he is feeling without
needing to scream and get upset, they would also like to see him interact with his peers more, and become more independent in his daily living skills
(ADDED) What are some of the challenges that you face on a daily basis with this student?: Josh often shows noncompliance and it takes a lot of
convincing to get him to do his work. It is hard for me to focus on the others student’s in the class when I am dealing with Josh.
(ADDED) What about Josh makes him a good student in your opinion?: Josh is very affectionate towards people he loves. It has been a joy to have
him in my classroom and to see him grow in little ways every day. He has made huge strides from the beginning of the year to now.


Appendix B
Review of Records Form
Reviewed 3/23/2020
1. What items did you review (e.g., sample work, report card, progress reports, behavioral records, IEP, BIP, FBA, anecdotal notes, etc.)?
○ IEP
○ Anecdotal notes from his classroom teacher and the paraeducator who conducts his social skills training
○ He has a diagnosis of autism and is non-verbal at this time
○ He has poor social skills when associating with peers
○ He can identify shapes, letters, and numbers
2. Record information on the student’s current level of performance as it related to their grades, goals, and current level of development.
○ Can identify alphabet letter
○ Can count to 10
○ Knows how to properly hold scissors and a pencil
○ Currently nonverbal
3. Does the student receive any accommodations or modifications in the classroom or during assessments?
○ The student does not receive any accommodations or modifications in the classroom or during assessments
4. How much of the school day does the student spend in the general education environment per the IEP?
○ 60 minutes/week = speech
○ 60 minutes/week = OT
○ Josh spends 7 hours and 36 minutes in the general education environment
○ Or 95% of his day
5. Does the student have a completed FBA, BIP, or another behavior-specific plan?
○ He does not have an FBA, BIP, or another behavior specific plan
6. After reviewing the information, what was most helpful and interesting? What impact, guidance, or influence does it have on your chaining
project?
○ It was most helpful to have some background information on his physical strengths. This helped me to be prepared and to expect that
the student would have some mobile difficulties performing the tasks in the task analysis. The task analysis was able to be prepared in
a way that would best fit his present levels of performance.
7. What additional information would you be interested in obtaining?
○ I would like to have seen more information and data on his behaviors. I would like to see when these behaviors are happening most
often and how they affect his functional skills.

Appendix C
Observation Document (Hypothetical Summary of Both Observation Sessions)
1. How does the student interact socially in the class?

a. Josh does not initiate any social interactions
b. He has no friends
c. He would prefer to socialize with adults rather than his peers
d. He engages in solitary and parallel play
e. Does share his toys when prompted
2. How does the student respond to complete academic work?

a. Avoids any academic work by walking around the room, ignoring teachers
b. He needs hand over hand guidance for most activities he is tasked with achieving
c. Likes to learn through song and dance
3. How would you describe the student’s strength and areas of need relative to behavior?
a. Josh can go to the bathroom, eat, and put his coat on independently.
b. Josh is helpful around the classroom and enjoys helping the teacher.
c. Josh is able to apologize after he has done something wrong.
4. If you have to pick 2 areas for academic and 2 areas for behavior to work on, what would you suggest?
a. Writing his name
b. Identifying the letters of the alphabet
c. Engaging in cooperative play with peers
d. Channeling his anger and engaging in strategies that will help him calm down
5. Do you think this student would benefit from accommodation during assessments? If so, what would you recommend? No
6. What are some current modification and accommodation being implemented for this student in the classroom?
a. Social skills training, iPad reinforcement system (15 minutes of learning, 5 minutes of iPad)
7. Does the student currently participate in any related services (e.g., speech and language therapy, occupational therapy, vision support, hearing
support, physical therapy, nursing services, etc.)?
a. Speech and language therapy and occupational therapy
8. Is there any other information about the student you feel is important to document? N/A

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student’s Name: Josh Jones

INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age

Student’s Name: Josh Jones

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

Page 1 of 30 April 2020

Role Printed Name Signature

Written input received from the following members:

Transfer of Rights at Age of Majority

Page 2 of 30 April 2020

PROCEDURAL SAFEGUARDS NOTICE

MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

I understand that the school cannot—

Cause a decrease in available lifetime coverage or any other insured benefit;

Page 3 of 30 April 2020

Is the student blind or visually impaired?

Is the student deaf or hard of hearing?

Does the student have communication needs?

Does the student need assistive technology devices and/or services?

Does the student have limited English proficiency?

Page 4 of 30 April 2020

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Include the following information related to the student:

Present levels of academic achievement:

verbalize letter sounds, identify rhymes consistently, or segment words.

Present levels of functional performance:

reinforcement, Josh gets very happy and enthusiastic.

Present level related to current post secondary transition goals:

Parental concerns for enhancing the education of the student:

- Josh is able to apologize after he has done something wrong.

Academic, developmental, and functional needs related to student’s disability:

For students in Career and Technology Centers, CIP Code:

Page 8 of 30 April 2020

Postsecondary Education and Training Goal:

Projected Anticipated Person(s)/Agency

Projected Anticipated Person(s)/Agency

Page 9 of 30 April 2020

Independent Living Goal, if appropriate:

Projected Anticipated Person(s)/Agency

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Page 10 of 30 April 2020

Validated Local Assessment (Available when selected as option by LEA)

Explain why the PASA is appropriate:

Choose how the student’s performance on the PASA will be documented.

Written narrative notes (requires prior approval in accordance with PDE

Page 11 of 30 April 2020

ACCESS for ELLs (Administered in grades K-12)

Alternate ACCESS for ELLs (Administered in grades 1-12)

Explain why the Alternate ACCESS for ELLs is appropriate:

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to

X Local assessment is not administered at this student’s grade level; OR

Student will participate in local assessments without accommodations; OR

Student will participate in local assessments with the following accommodations; OR

Page 12 of 30 April 2020

The student will take a local alternate assessment.

Explain why the local alternate assessment is appropriate:

Page 13 of 30 April 2020

MEASURABLE ANNUAL GOAL Describe WHEN

Short term objectives / Benchmarks

Page 15 of 30 April 2020

A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)

The inclusive education teacher will

SDI for Goal 2: