Individualized Education Program (IEP) Cover Page

Students Name ________________ IBP Date 01102012 Grade 8 Age~Disability (if identified) _Healthlmpairmenls_________________

ParentGuardianAdult Student _______Primary language at home _EN1G_LIS_H______

Parent interpreter needed 0Yes 0No Surrogate parent 0Yes lli]No Ifyes name______________

Home Address Phone CJ) ________________Phone _________

_________Attending Schoolmiddot Is this students neighborhood school Yes 0No

Most recent evaluation date 1215201 1 Plan start date 01102012

Next re-evaluation must occur before this date 121512014 Plan end date 01092013 Date ofPlan meeting 01102012

Date parent notified ofPlan meeting 01062012 Date student notified ofPlan meeting (if transition will be discussed)

Primary StaffContact---middotS=--P=E=D-L=RC_________________________

Phone Number

The list below indicates that the individual participated in the development of this Plan and the placement decision it does not authorize consent

Excused Name of Participant Title

_________________

ligtistrlcVAdmjn Designee D General Education Teacher

ParenUGuardian D D

Special ~ducation Teacher D D Studento o_________________o ________________ o___________ o ___________ o ___________o ___________

The student must be informed at lcnst one year prior to turning 18 that the IDEA procedural safeguards (lights) transfer to hlmher at age 18 and be provided with an explanation of those procedural safeguards

Date informed_____ _ _ _ __ Projected GraduationExit Date ______

Comments If the parent did not attend what method was used to ensure their participation

0

RECEIVED W~20112

Judividualized Education Program (IBP) Cover Page Page 3

_______________________________________ _

To

Review Individualized Education Program (IEP) Invitation

____________________ Date Sent to Participants 01062012

PURPOSEThis invitation requests your attendance at a meeting concerning the educational programneeds of your child You have the opportunity to participate in any meeting regarding the identification evaluation educational placement and the provision of a free appropriate public education for your child

This is to notify you that aan IEP n1eetihg hns been scheduled for the above student Your participation and attendance at this meeting are very important This Review meeting 1uust be scheduled at a mutually agreed upon time and place The purpose of this meeting is to (check all that apply)

_ Develop an Initial IEP L Review Current IEP

Discuss Transition Services Discuss Graduation

_ Discuss Annual Goa] Progress Review Instructional Needs

Consider Tennination ofSe1-vices Determine Placement

_ Develop ESY Discuss Attendance Issues

Manifestation Determination Behavioral Intervention Plan

Other

This me~scheduled for Location

Date 01102012 Time 245 PM

The following are invited to attend and participate in the Review meeting

_DistrjclAdmin Designee General Education Teacher

ParentGuardian

- Special EducsJtion Teacher

The parentadult student or school may invite individuals who have knowledge or special expertise regarding tbe student inch1ding related services personnel to participate The detem1ination of the knowledge or special expe1tise shall be made by the personparty extending the invitation Ifyou the parent or adult student are bringing other individuals to the meeting please let us know This will ensure that the meeting space will accommodate all team members

uestions or would like additional information or assistance to help you prepare for this IEP meeting please contact e-mail

Notice ofProcedural Safeguardsor S(Jecial Education Students and Their Families has been provided to parents

Review hldividualized Education Program (IEP) Invitation Page I

Date ofBirth

Contact Attempt Report

r

Notification Area _pian ___ __

Meeting Date 01102012 Time 245 PM Location ~-----------------------------shy

Contact Attempt Report Puge2

Team Considerations

MeetingDate 01102012

PURPOSEDuring the IBP meeting the following factors must be considered by the IBP team Best practice suggests that the IBP team document that the factors were considered and any decision made relative to each The factors are addressed in other sections of the IBP ifnot documented on this naQe (for exannle see Present Levels ofAcademic and Functional Performance)

~ The strengths of the student and the concerns ofthe parents for enhancing the education of their child 1111 is a very bright student when he takes the time to focus to his academics -isa very kind young man at heart

~ The results ofthe student~nance on any general state or district-wide assessments On the 6th grade MSP-scored a 362 in reading352 In math level 1 in writing and science was not tested On the Scholastic Reading Inventory he scored a 710 shich places him at the basic level - and reading below grade level

~ The communication needs of the student In the case of a sn1dent who is deafor hard ofhearing consider the students language and communication needs opportunities for direct communications with peers and professional personnel in the students language and communication mode m11demic level and full range of needs including opportunities for direct instrnction in the students language and communication mode

NIA

XI The students assistive technology devices and services needs NA

~ In the case of a student whose behavior impedes his or her learning or that ofothers consider when appropriate strategies including ~ behavioral interventions strategies and supports to address that behavior - needs to be given positive feedback whenever possible

XI In the case ofa student with limited English proficiency consider the language needs of the child as such needs relate to the childs IEP NIA

[xi In the case of a student who is blind or has a visual impainnent provide for instruction in Braille and the use of Braille unless the JEP leam determines after an evaluation of the students reading and writing skills needs and appropriate reading and writing media (including an evaluation of the students future needs for instruction in Braille or the use ofBraille) that instmction in Braille or the use ofBraille is not appropriate for the student

NA

Team Considerntions Page4

Present Level of Educational Performance

Meeting Date 01102012 PURPOSEThe Present Levelof Educational Perfonnance describes the effects oftbe shtdents disability upon the students involvement and progress in the general curricllum and area(s) ofneed This includes the students perfonnance in academic achievement (reading math communications etc) and functional perfonnance (behavior social skills daily life activities mobility extra-curricular activities etc) jn objective terms Test scores if appropriate should be self-explanatory or an explanation should be included For preschool students this section should include how the srt1dents disability affects the students participation in appropriate activities There should be a direct relationship between the present level of educational performance and the other components of the IEP

-sa 7th grade student at-Middle School and receives specially designed instruction in the area of writing

Writin truggles with wr~ple sentence with the required conventions This delay also transferes lo llis ability to

bullwr mple paragraphs- struggles with getting started but once gicen individual direction he can do well

Present Level ofEducational Performance Pnge5

Date ofBirth

Measurable AnnunJ Goals

Meeting Date 01102012

PURPOSEIEPs must include a statement ofmeasurable annual goals including academic and functional goals designed to meet each ol the students educational needs Iha result from the students disability to enable the student to be involved and make progress in the general education curriculum lu order to be measurable the goal should include a baseline (from) a target (to) and a unit of measure

By 01092013 when given prompts -viii be able to write a compund sentnece with appropriate conventions and traits improving fluency and structure from~sentences to compound sentences in 3 consecutive attempts as measured by classroom work assessments

How will progress toward this goal be repmted (check all that apply)0 Written Progress Report

How often will progress be reported middotmiddot Monthly fRJ Quarterly [J Trimester ] Semester Cl Other

By 01092013 when given Qrade level promP1 inflrmationaJ ficltonal-will write a 5 sentence paragraph with topic sentence 3 examplesmiddot- details conclusion with appropriate conventions and traits improving fluency and overall structure from 3 sentence paragraph in both genres to 5 sentence paragraph in both genres in 2 consecutive attempts as measured by classrrom assesssments performance

gow will progress townrd this goal be reported (check all that apply)fJ Written Progress Report

How often will progr~s be reported middot Monthly 1u Quarterly Ll Trimester O SemesterO Other

Measurable Annual Goals Page6

Date ofBirth

Program Accommodations Modifications and Support for Schoo] Personnel

MeetingDate 01102012 PURPOSEThe purpose of th is page is to document the modifications andor accommodations that the student requires based on the students assessed needs in order to advance appropriately toward attaining the identified annual goals to be involved and make progress in the general education curriculum and to be educated with non-disabled peers to the maximum extent appmpriate Accommodations may be in but not limited to the areas ofpresentation timingscheduling setting aids and format The impact of

any modifications listed should be discussed This includes the earning of credits for graduation

This student will be provided access to the general education special education other school services and activities including non-academic activities and extracurricular activities and education related settings

0 with no accommodationsmodifications IRJ with the following accommodntionsmodifications

Accommod11tion(s)Mod iflcation(s)

Testing AccommodationMore Time

Testing Accommodationgive teits in small group setting or 11

Testing Presenlationassessment directions can be reread verbatim

Frequency Duration mdy to 111dy

Location

01102012 to 01092013

01102012 to 01092013

01102012 to 01092013

Supports for School Personnel ( training professional development etc) Teachers will be made aware of modifications through cum file and or advisor

Program Accommodations Modificnlions and Support for School Fersonnel Page7

DateofBi1th shy

State otmiddot Districtwide Assessments ofStudent Achievement

Meeting Date __0_11_1_012_01_2__

PURPOSEThe IEP team makes the determination ofwhat type of assessment the student will take and what admiuistrative modification and individual accommodations are necessary Accommodations provided on state and districtwide assessments should be those that are provided as nart of the re011lar instmctional pro2u11n For Measurement ofStudent Progress (MSP) High School Proficiency Exam (HSPE) or Washington Alternate Assessment (WAAS) see Guidelines for Inclusion and Accommodations for Special Populations on State-Level Assessments

Assessment Participation

Reading X Science X

Wriling X

Accommodations Modifications

If YES List Accommodation(s) andor Modification(s) by Assesunent

Dliffii - itt~hf -~w~~~~bull~~ ~li( ~w ~middot--middot-NM Math X X More Time give tests In small group setting or 11 assessment

directions can be reread verbatim

Reading X

Science X

Writing X

Ma~ X Reading X Science Writing

Wiffir~~~~iJL asr Malh Reading Science

Reading Science

X X

Ji~~frtfrac12lftyj~j X X X

X X

Reading X Writing X

X

X

X

More Time give tests In small group seUing or 11 assessment directions can be reread verbatim

More Time give tests In small group setting or 11 assessment directions can be reread verbatim

More Time give tests in small group setting or 11 assessment directions can be reread verbatim

1Y _ bull bullJlf

Stlt1te or Districtwide Assessmenls ofStucten Achievement Page 8

Date ofBirth

Special Education and Related Services

Meeting Date 011 02012

PURPOSEThe information on this page is a summary of the students programservices including when services will begin where they will be provided who will be re~ponsible for providing them and when they will end

No Written Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Language Teacher Education Weekly

Teacher

No Mathematics Special Education Special 55 Minules 5 Times Special Education 01102012 01092013 Calculation Teacher Education Weekly

Teacher

No Reading Special lducotion Special 55 Minutes 5 Times Special Education 01102012 0)092013 Compreheusi Teaclier Education Weekly

on Teacher

No Study Skills Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Teacher Education Weekly

Teacher

Total minutes per week student spends in school 1soo minutes per week Total minutes per week student is served in a special education setting 1100 minutes per week Percent of time in geneul education setting 38 89 in General Education Se1tjng

Page9SJgtecinl Education and Related Services

Student ID

WASSID shyDate ofBirth shy

Special Education and Related Services

PURPOSEThe purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum participate in extracurricular and nonacademic activities and be educated and participate with other special education students and non-disabled students Other education-related factors that mav impact the student should also be considered Least Restrictive Environment (LRE) When discussing least resnmiddotictive environment and placement options the following must be considered

To the maximum extent appropriate the student is educated with children without disabilities - Special classes separate schooling or other removal of the student from the regular educational envirorunent occurs only if the

nature or severity of lhe disability is such that education in regular classes with the use ofsupplementary aids and services cannot be achieved satisfactorily

- The students placement should be as close as possible to the childs home and unless the IBP ofthe student with a disabi lity requires some other arrangement the student is educated in the school that he or she would attend ifhe or she did not have a disability

- In selecting the LRE considerntion is given to any potential harmful effect on the student or on the quality of services that heshe needs

- The student with a disability is not removed from education in age-appropriate regular classrooms solely because ofneeded modifications in the general cunfoulum

Placement Options Setting 1 01102012 - 01092013

Placement Ootions for LRE SELECTION ORREASONS REJECTED Considered Selected (only Academic benefit Non-academic Bffect student will

l) cannot be benefit ca11not be hove on teacher and satisfactorily satisfactorily other students

achieved achieved Exnlanation

80-100 in Reaular Class 40-79 in Remilar Class 0-39 in Reaular Class X X

Best meets cademic needs Publiclnrivate seoarate dav school PublicJPrivate residenti al Correctional Faciiitv Private School P lacement bv Parents HomeHosoital PJacement Decision An explanation ofthe extent if any to wh ich the student will not participate with nondisabled students in the general education class and in nonacademic and extracurricular activities including a description of any adaptations needed for participation in physical education

Best meets ~ cademic needs

Other Considerations 1 Transportation [RJ Regular 2 Extended School Year D Yes 3 Genci-al PE [fil Yes

D Special [RJ No

D No

IfYes must complete ESY form

Special Education and Related Services Page 10

DateofBirth shy

Prior Written Notice

To Date 011120 12 Re Students Name ---------- shyPURPOSEAs a parentguardian of a special education child suspected of needing special education services the school district is req11ired to provide you with prior written notice whenever it proposes or refuses to initiate or change the identification evaluation educational placement or provision ofa free appropriate public education to your child This notice should be given to you after a district makes a decision and before action is taken on the decision The notice should be given to you in a reasom1ble amount of time before the district takes action

The purpose of t his pri01middot written notice is to inform you that we a re

1 ra proposing D refusing to 2 D ini tiate D change ~ continue Ddiscontinue aan (marlc one ofthe above) (mark one oftbe above)

Mark all items below that apply

3 sectReferral Initial Evaluation sectEligibility Category Educational Placement IBP Reevaluation Disciplinary action tbat is a change of ~ 504 Plan Other placement

Description ofthe proposed or reftlsed action Yearly review evalua tion

The reason we are proposing or refosing to take action is require d by state new to school district

Description ofany other optio11s considered and rejected Best meets students a cademic needs

The reasons we re~ se options were Does not mee t -needs

A description of each procedure test record or report we used or plan to use as the basis for taking this action is as follows evaluationstatedistrict teststeacher feedbackcum fi le

Any other factors that are relevant to the action none at this time

The action will be initiated on _o111~1111i2~0~1lta2 _ _______

Your child bas procedural protections under IDEA These protections are explained in the Notice ofProcedural Safeguards for Special Education Students and Their Families If this prior written notice is given to you (l) as pat1 ofyour childs initial refemil for evaluation (2) as part of a request for reevaluation or (3) notice to you regarding disciplinary action that constitutes a change ofplacement the procedural safeguards accompanies th is notice If a copy of the Notice ofProceduml Safeguard~ for Special Education Students and Their Families is not enclosed and ym would Iike a copy or you would like help in understanding the content please contact

at

Page 11Prior Written Notice

-

Date ofBirth

Contact Attempt Report

r

Notification Area _pian ___ __

Meeting Date 01102012 Time 245 PM Location ~-----------------------------shy

Contact Attempt Report Puge2

Team Considerations

MeetingDate 01102012

PURPOSEDuring the IBP meeting the following factors must be considered by the IBP team Best practice suggests that the IBP team document that the factors were considered and any decision made relative to each The factors are addressed in other sections of the IBP ifnot documented on this naQe (for exannle see Present Levels ofAcademic and Functional Performance)

~ The strengths of the student and the concerns ofthe parents for enhancing the education of their child 1111 is a very bright student when he takes the time to focus to his academics -isa very kind young man at heart

~ The results ofthe student~nance on any general state or district-wide assessments On the 6th grade MSP-scored a 362 in reading352 In math level 1 in writing and science was not tested On the Scholastic Reading Inventory he scored a 710 shich places him at the basic level - and reading below grade level

~ The communication needs of the student In the case of a sn1dent who is deafor hard ofhearing consider the students language and communication needs opportunities for direct communications with peers and professional personnel in the students language and communication mode m11demic level and full range of needs including opportunities for direct instrnction in the students language and communication mode

NIA

XI The students assistive technology devices and services needs NA

~ In the case of a student whose behavior impedes his or her learning or that ofothers consider when appropriate strategies including ~ behavioral interventions strategies and supports to address that behavior - needs to be given positive feedback whenever possible

XI In the case ofa student with limited English proficiency consider the language needs of the child as such needs relate to the childs IEP NIA

[xi In the case of a student who is blind or has a visual impainnent provide for instruction in Braille and the use of Braille unless the JEP leam determines after an evaluation of the students reading and writing skills needs and appropriate reading and writing media (including an evaluation of the students future needs for instruction in Braille or the use ofBraille) that instmction in Braille or the use ofBraille is not appropriate for the student

NA

Team Considerntions Page4

Present Level of Educational Performance

Meeting Date 01102012 PURPOSEThe Present Levelof Educational Perfonnance describes the effects oftbe shtdents disability upon the students involvement and progress in the general curricllum and area(s) ofneed This includes the students perfonnance in academic achievement (reading math communications etc) and functional perfonnance (behavior social skills daily life activities mobility extra-curricular activities etc) jn objective terms Test scores if appropriate should be self-explanatory or an explanation should be included For preschool students this section should include how the srt1dents disability affects the students participation in appropriate activities There should be a direct relationship between the present level of educational performance and the other components of the IEP

-sa 7th grade student at-Middle School and receives specially designed instruction in the area of writing

Writin truggles with wr~ple sentence with the required conventions This delay also transferes lo llis ability to

bullwr mple paragraphs- struggles with getting started but once gicen individual direction he can do well

Present Level ofEducational Performance Pnge5

Date ofBirth

Measurable AnnunJ Goals

Meeting Date 01102012

PURPOSEIEPs must include a statement ofmeasurable annual goals including academic and functional goals designed to meet each ol the students educational needs Iha result from the students disability to enable the student to be involved and make progress in the general education curriculum lu order to be measurable the goal should include a baseline (from) a target (to) and a unit of measure

By 01092013 when given prompts -viii be able to write a compund sentnece with appropriate conventions and traits improving fluency and structure from~sentences to compound sentences in 3 consecutive attempts as measured by classroom work assessments

How will progress toward this goal be repmted (check all that apply)0 Written Progress Report

How often will progress be reported middotmiddot Monthly fRJ Quarterly [J Trimester ] Semester Cl Other

By 01092013 when given Qrade level promP1 inflrmationaJ ficltonal-will write a 5 sentence paragraph with topic sentence 3 examplesmiddot- details conclusion with appropriate conventions and traits improving fluency and overall structure from 3 sentence paragraph in both genres to 5 sentence paragraph in both genres in 2 consecutive attempts as measured by classrrom assesssments performance

gow will progress townrd this goal be reported (check all that apply)fJ Written Progress Report

How often will progr~s be reported middot Monthly 1u Quarterly Ll Trimester O SemesterO Other

Measurable Annual Goals Page6

Date ofBirth

Program Accommodations Modifications and Support for Schoo] Personnel

MeetingDate 01102012 PURPOSEThe purpose of th is page is to document the modifications andor accommodations that the student requires based on the students assessed needs in order to advance appropriately toward attaining the identified annual goals to be involved and make progress in the general education curriculum and to be educated with non-disabled peers to the maximum extent appmpriate Accommodations may be in but not limited to the areas ofpresentation timingscheduling setting aids and format The impact of

any modifications listed should be discussed This includes the earning of credits for graduation

This student will be provided access to the general education special education other school services and activities including non-academic activities and extracurricular activities and education related settings

0 with no accommodationsmodifications IRJ with the following accommodntionsmodifications

Accommod11tion(s)Mod iflcation(s)

Testing AccommodationMore Time

Testing Accommodationgive teits in small group setting or 11

Testing Presenlationassessment directions can be reread verbatim

Frequency Duration mdy to 111dy

Location

01102012 to 01092013

01102012 to 01092013

01102012 to 01092013

Supports for School Personnel ( training professional development etc) Teachers will be made aware of modifications through cum file and or advisor

Program Accommodations Modificnlions and Support for School Fersonnel Page7

DateofBi1th shy

State otmiddot Districtwide Assessments ofStudent Achievement

Meeting Date __0_11_1_012_01_2__

PURPOSEThe IEP team makes the determination ofwhat type of assessment the student will take and what admiuistrative modification and individual accommodations are necessary Accommodations provided on state and districtwide assessments should be those that are provided as nart of the re011lar instmctional pro2u11n For Measurement ofStudent Progress (MSP) High School Proficiency Exam (HSPE) or Washington Alternate Assessment (WAAS) see Guidelines for Inclusion and Accommodations for Special Populations on State-Level Assessments

Assessment Participation

Reading X Science X

Wriling X

Accommodations Modifications

If YES List Accommodation(s) andor Modification(s) by Assesunent

Dliffii - itt~hf -~w~~~~bull~~ ~li( ~w ~middot--middot-NM Math X X More Time give tests In small group setting or 11 assessment

directions can be reread verbatim

Reading X

Science X

Writing X

Ma~ X Reading X Science Writing

Wiffir~~~~iJL asr Malh Reading Science

Reading Science

X X

Ji~~frtfrac12lftyj~j X X X

X X

Reading X Writing X

X

X

X

More Time give tests In small group seUing or 11 assessment directions can be reread verbatim

More Time give tests In small group setting or 11 assessment directions can be reread verbatim

More Time give tests in small group setting or 11 assessment directions can be reread verbatim

1Y _ bull bullJlf

Stlt1te or Districtwide Assessmenls ofStucten Achievement Page 8

Date ofBirth

Special Education and Related Services

Meeting Date 011 02012

PURPOSEThe information on this page is a summary of the students programservices including when services will begin where they will be provided who will be re~ponsible for providing them and when they will end

No Written Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Language Teacher Education Weekly

Teacher

No Mathematics Special Education Special 55 Minules 5 Times Special Education 01102012 01092013 Calculation Teacher Education Weekly

Teacher

No Reading Special lducotion Special 55 Minutes 5 Times Special Education 01102012 0)092013 Compreheusi Teaclier Education Weekly

on Teacher

No Study Skills Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Teacher Education Weekly

Teacher

Total minutes per week student spends in school 1soo minutes per week Total minutes per week student is served in a special education setting 1100 minutes per week Percent of time in geneul education setting 38 89 in General Education Se1tjng

Page9SJgtecinl Education and Related Services

Student ID

WASSID shyDate ofBirth shy

Special Education and Related Services

PURPOSEThe purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum participate in extracurricular and nonacademic activities and be educated and participate with other special education students and non-disabled students Other education-related factors that mav impact the student should also be considered Least Restrictive Environment (LRE) When discussing least resnmiddotictive environment and placement options the following must be considered

To the maximum extent appropriate the student is educated with children without disabilities - Special classes separate schooling or other removal of the student from the regular educational envirorunent occurs only if the

nature or severity of lhe disability is such that education in regular classes with the use ofsupplementary aids and services cannot be achieved satisfactorily

- The students placement should be as close as possible to the childs home and unless the IBP ofthe student with a disabi lity requires some other arrangement the student is educated in the school that he or she would attend ifhe or she did not have a disability

- In selecting the LRE considerntion is given to any potential harmful effect on the student or on the quality of services that heshe needs

- The student with a disability is not removed from education in age-appropriate regular classrooms solely because ofneeded modifications in the general cunfoulum

Placement Options Setting 1 01102012 - 01092013

Placement Ootions for LRE SELECTION ORREASONS REJECTED Considered Selected (only Academic benefit Non-academic Bffect student will

l) cannot be benefit ca11not be hove on teacher and satisfactorily satisfactorily other students

achieved achieved Exnlanation

80-100 in Reaular Class 40-79 in Remilar Class 0-39 in Reaular Class X X

Best meets cademic needs Publiclnrivate seoarate dav school PublicJPrivate residenti al Correctional Faciiitv Private School P lacement bv Parents HomeHosoital PJacement Decision An explanation ofthe extent if any to wh ich the student will not participate with nondisabled students in the general education class and in nonacademic and extracurricular activities including a description of any adaptations needed for participation in physical education

Best meets ~ cademic needs

Other Considerations 1 Transportation [RJ Regular 2 Extended School Year D Yes 3 Genci-al PE [fil Yes

D Special [RJ No

D No

IfYes must complete ESY form

Special Education and Related Services Page 10

DateofBirth shy

Prior Written Notice

To Date 011120 12 Re Students Name ---------- shyPURPOSEAs a parentguardian of a special education child suspected of needing special education services the school district is req11ired to provide you with prior written notice whenever it proposes or refuses to initiate or change the identification evaluation educational placement or provision ofa free appropriate public education to your child This notice should be given to you after a district makes a decision and before action is taken on the decision The notice should be given to you in a reasom1ble amount of time before the district takes action

The purpose of t his pri01middot written notice is to inform you that we a re

1 ra proposing D refusing to 2 D ini tiate D change ~ continue Ddiscontinue aan (marlc one ofthe above) (mark one oftbe above)

Mark all items below that apply

3 sectReferral Initial Evaluation sectEligibility Category Educational Placement IBP Reevaluation Disciplinary action tbat is a change of ~ 504 Plan Other placement

Description ofthe proposed or reftlsed action Yearly review evalua tion

The reason we are proposing or refosing to take action is require d by state new to school district

Description ofany other optio11s considered and rejected Best meets students a cademic needs

The reasons we re~ se options were Does not mee t -needs

A description of each procedure test record or report we used or plan to use as the basis for taking this action is as follows evaluationstatedistrict teststeacher feedbackcum fi le

Any other factors that are relevant to the action none at this time

The action will be initiated on _o111~1111i2~0~1lta2 _ _______

Your child bas procedural protections under IDEA These protections are explained in the Notice ofProcedural Safeguards for Special Education Students and Their Families If this prior written notice is given to you (l) as pat1 ofyour childs initial refemil for evaluation (2) as part of a request for reevaluation or (3) notice to you regarding disciplinary action that constitutes a change ofplacement the procedural safeguards accompanies th is notice If a copy of the Notice ofProceduml Safeguard~ for Special Education Students and Their Families is not enclosed and ym would Iike a copy or you would like help in understanding the content please contact

at

Page 11Prior Written Notice

-

Team Considerations

MeetingDate 01102012

PURPOSEDuring the IBP meeting the following factors must be considered by the IBP team Best practice suggests that the IBP team document that the factors were considered and any decision made relative to each The factors are addressed in other sections of the IBP ifnot documented on this naQe (for exannle see Present Levels ofAcademic and Functional Performance)

~ The strengths of the student and the concerns ofthe parents for enhancing the education of their child 1111 is a very bright student when he takes the time to focus to his academics -isa very kind young man at heart

~ The results ofthe student~nance on any general state or district-wide assessments On the 6th grade MSP-scored a 362 in reading352 In math level 1 in writing and science was not tested On the Scholastic Reading Inventory he scored a 710 shich places him at the basic level - and reading below grade level

~ The communication needs of the student In the case of a sn1dent who is deafor hard ofhearing consider the students language and communication needs opportunities for direct communications with peers and professional personnel in the students language and communication mode m11demic level and full range of needs including opportunities for direct instrnction in the students language and communication mode

NIA

XI The students assistive technology devices and services needs NA

~ In the case of a student whose behavior impedes his or her learning or that ofothers consider when appropriate strategies including ~ behavioral interventions strategies and supports to address that behavior - needs to be given positive feedback whenever possible

XI In the case ofa student with limited English proficiency consider the language needs of the child as such needs relate to the childs IEP NIA

[xi In the case of a student who is blind or has a visual impainnent provide for instruction in Braille and the use of Braille unless the JEP leam determines after an evaluation of the students reading and writing skills needs and appropriate reading and writing media (including an evaluation of the students future needs for instruction in Braille or the use ofBraille) that instmction in Braille or the use ofBraille is not appropriate for the student

NA

Team Considerntions Page4

Present Level of Educational Performance

Meeting Date 01102012 PURPOSEThe Present Levelof Educational Perfonnance describes the effects oftbe shtdents disability upon the students involvement and progress in the general curricllum and area(s) ofneed This includes the students perfonnance in academic achievement (reading math communications etc) and functional perfonnance (behavior social skills daily life activities mobility extra-curricular activities etc) jn objective terms Test scores if appropriate should be self-explanatory or an explanation should be included For preschool students this section should include how the srt1dents disability affects the students participation in appropriate activities There should be a direct relationship between the present level of educational performance and the other components of the IEP

-sa 7th grade student at-Middle School and receives specially designed instruction in the area of writing

Writin truggles with wr~ple sentence with the required conventions This delay also transferes lo llis ability to

bullwr mple paragraphs- struggles with getting started but once gicen individual direction he can do well

Present Level ofEducational Performance Pnge5

Date ofBirth

Measurable AnnunJ Goals

Meeting Date 01102012

PURPOSEIEPs must include a statement ofmeasurable annual goals including academic and functional goals designed to meet each ol the students educational needs Iha result from the students disability to enable the student to be involved and make progress in the general education curriculum lu order to be measurable the goal should include a baseline (from) a target (to) and a unit of measure

By 01092013 when given prompts -viii be able to write a compund sentnece with appropriate conventions and traits improving fluency and structure from~sentences to compound sentences in 3 consecutive attempts as measured by classroom work assessments

How will progress toward this goal be repmted (check all that apply)0 Written Progress Report

How often will progress be reported middotmiddot Monthly fRJ Quarterly [J Trimester ] Semester Cl Other

By 01092013 when given Qrade level promP1 inflrmationaJ ficltonal-will write a 5 sentence paragraph with topic sentence 3 examplesmiddot- details conclusion with appropriate conventions and traits improving fluency and overall structure from 3 sentence paragraph in both genres to 5 sentence paragraph in both genres in 2 consecutive attempts as measured by classrrom assesssments performance

gow will progress townrd this goal be reported (check all that apply)fJ Written Progress Report

How often will progr~s be reported middot Monthly 1u Quarterly Ll Trimester O SemesterO Other

Measurable Annual Goals Page6

Date ofBirth

Program Accommodations Modifications and Support for Schoo] Personnel

MeetingDate 01102012 PURPOSEThe purpose of th is page is to document the modifications andor accommodations that the student requires based on the students assessed needs in order to advance appropriately toward attaining the identified annual goals to be involved and make progress in the general education curriculum and to be educated with non-disabled peers to the maximum extent appmpriate Accommodations may be in but not limited to the areas ofpresentation timingscheduling setting aids and format The impact of

any modifications listed should be discussed This includes the earning of credits for graduation

This student will be provided access to the general education special education other school services and activities including non-academic activities and extracurricular activities and education related settings

0 with no accommodationsmodifications IRJ with the following accommodntionsmodifications

Accommod11tion(s)Mod iflcation(s)

Testing AccommodationMore Time

Testing Accommodationgive teits in small group setting or 11

Testing Presenlationassessment directions can be reread verbatim

Frequency Duration mdy to 111dy

Location

01102012 to 01092013

01102012 to 01092013

01102012 to 01092013

Supports for School Personnel ( training professional development etc) Teachers will be made aware of modifications through cum file and or advisor

Program Accommodations Modificnlions and Support for School Fersonnel Page7

DateofBi1th shy

State otmiddot Districtwide Assessments ofStudent Achievement

Meeting Date __0_11_1_012_01_2__

PURPOSEThe IEP team makes the determination ofwhat type of assessment the student will take and what admiuistrative modification and individual accommodations are necessary Accommodations provided on state and districtwide assessments should be those that are provided as nart of the re011lar instmctional pro2u11n For Measurement ofStudent Progress (MSP) High School Proficiency Exam (HSPE) or Washington Alternate Assessment (WAAS) see Guidelines for Inclusion and Accommodations for Special Populations on State-Level Assessments

Assessment Participation

Reading X Science X

Wriling X

Accommodations Modifications

If YES List Accommodation(s) andor Modification(s) by Assesunent

Dliffii - itt~hf -~w~~~~bull~~ ~li( ~w ~middot--middot-NM Math X X More Time give tests In small group setting or 11 assessment

directions can be reread verbatim

Reading X

Science X

Writing X

Ma~ X Reading X Science Writing

Wiffir~~~~iJL asr Malh Reading Science

Reading Science

X X

Ji~~frtfrac12lftyj~j X X X

X X

Reading X Writing X

X

X

X

More Time give tests In small group seUing or 11 assessment directions can be reread verbatim

More Time give tests In small group setting or 11 assessment directions can be reread verbatim

More Time give tests in small group setting or 11 assessment directions can be reread verbatim

1Y _ bull bullJlf

Stlt1te or Districtwide Assessmenls ofStucten Achievement Page 8

Date ofBirth

Special Education and Related Services

Meeting Date 011 02012

PURPOSEThe information on this page is a summary of the students programservices including when services will begin where they will be provided who will be re~ponsible for providing them and when they will end

No Written Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Language Teacher Education Weekly

Teacher

No Mathematics Special Education Special 55 Minules 5 Times Special Education 01102012 01092013 Calculation Teacher Education Weekly

Teacher

No Reading Special lducotion Special 55 Minutes 5 Times Special Education 01102012 0)092013 Compreheusi Teaclier Education Weekly

on Teacher

No Study Skills Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Teacher Education Weekly

Teacher

Total minutes per week student spends in school 1soo minutes per week Total minutes per week student is served in a special education setting 1100 minutes per week Percent of time in geneul education setting 38 89 in General Education Se1tjng

Page9SJgtecinl Education and Related Services

Student ID

WASSID shyDate ofBirth shy

Special Education and Related Services

PURPOSEThe purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum participate in extracurricular and nonacademic activities and be educated and participate with other special education students and non-disabled students Other education-related factors that mav impact the student should also be considered Least Restrictive Environment (LRE) When discussing least resnmiddotictive environment and placement options the following must be considered

To the maximum extent appropriate the student is educated with children without disabilities - Special classes separate schooling or other removal of the student from the regular educational envirorunent occurs only if the

nature or severity of lhe disability is such that education in regular classes with the use ofsupplementary aids and services cannot be achieved satisfactorily

- The students placement should be as close as possible to the childs home and unless the IBP ofthe student with a disabi lity requires some other arrangement the student is educated in the school that he or she would attend ifhe or she did not have a disability

- In selecting the LRE considerntion is given to any potential harmful effect on the student or on the quality of services that heshe needs

- The student with a disability is not removed from education in age-appropriate regular classrooms solely because ofneeded modifications in the general cunfoulum

Placement Options Setting 1 01102012 - 01092013

Placement Ootions for LRE SELECTION ORREASONS REJECTED Considered Selected (only Academic benefit Non-academic Bffect student will

l) cannot be benefit ca11not be hove on teacher and satisfactorily satisfactorily other students

achieved achieved Exnlanation

80-100 in Reaular Class 40-79 in Remilar Class 0-39 in Reaular Class X X

Best meets cademic needs Publiclnrivate seoarate dav school PublicJPrivate residenti al Correctional Faciiitv Private School P lacement bv Parents HomeHosoital PJacement Decision An explanation ofthe extent if any to wh ich the student will not participate with nondisabled students in the general education class and in nonacademic and extracurricular activities including a description of any adaptations needed for participation in physical education

Best meets ~ cademic needs

Other Considerations 1 Transportation [RJ Regular 2 Extended School Year D Yes 3 Genci-al PE [fil Yes

D Special [RJ No

D No

IfYes must complete ESY form

Special Education and Related Services Page 10

DateofBirth shy

Prior Written Notice

To Date 011120 12 Re Students Name ---------- shyPURPOSEAs a parentguardian of a special education child suspected of needing special education services the school district is req11ired to provide you with prior written notice whenever it proposes or refuses to initiate or change the identification evaluation educational placement or provision ofa free appropriate public education to your child This notice should be given to you after a district makes a decision and before action is taken on the decision The notice should be given to you in a reasom1ble amount of time before the district takes action

The purpose of t his pri01middot written notice is to inform you that we a re

1 ra proposing D refusing to 2 D ini tiate D change ~ continue Ddiscontinue aan (marlc one ofthe above) (mark one oftbe above)

Mark all items below that apply

3 sectReferral Initial Evaluation sectEligibility Category Educational Placement IBP Reevaluation Disciplinary action tbat is a change of ~ 504 Plan Other placement

Description ofthe proposed or reftlsed action Yearly review evalua tion

The reason we are proposing or refosing to take action is require d by state new to school district

Description ofany other optio11s considered and rejected Best meets students a cademic needs

The reasons we re~ se options were Does not mee t -needs

A description of each procedure test record or report we used or plan to use as the basis for taking this action is as follows evaluationstatedistrict teststeacher feedbackcum fi le

Any other factors that are relevant to the action none at this time

The action will be initiated on _o111~1111i2~0~1lta2 _ _______

Your child bas procedural protections under IDEA These protections are explained in the Notice ofProcedural Safeguards for Special Education Students and Their Families If this prior written notice is given to you (l) as pat1 ofyour childs initial refemil for evaluation (2) as part of a request for reevaluation or (3) notice to you regarding disciplinary action that constitutes a change ofplacement the procedural safeguards accompanies th is notice If a copy of the Notice ofProceduml Safeguard~ for Special Education Students and Their Families is not enclosed and ym would Iike a copy or you would like help in understanding the content please contact

at

Page 11Prior Written Notice

-

Present Level of Educational Performance

Meeting Date 01102012 PURPOSEThe Present Levelof Educational Perfonnance describes the effects oftbe shtdents disability upon the students involvement and progress in the general curricllum and area(s) ofneed This includes the students perfonnance in academic achievement (reading math communications etc) and functional perfonnance (behavior social skills daily life activities mobility extra-curricular activities etc) jn objective terms Test scores if appropriate should be self-explanatory or an explanation should be included For preschool students this section should include how the srt1dents disability affects the students participation in appropriate activities There should be a direct relationship between the present level of educational performance and the other components of the IEP

-sa 7th grade student at-Middle School and receives specially designed instruction in the area of writing

Writin truggles with wr~ple sentence with the required conventions This delay also transferes lo llis ability to

bullwr mple paragraphs- struggles with getting started but once gicen individual direction he can do well

Present Level ofEducational Performance Pnge5

Date ofBirth

Measurable AnnunJ Goals

Meeting Date 01102012

PURPOSEIEPs must include a statement ofmeasurable annual goals including academic and functional goals designed to meet each ol the students educational needs Iha result from the students disability to enable the student to be involved and make progress in the general education curriculum lu order to be measurable the goal should include a baseline (from) a target (to) and a unit of measure

By 01092013 when given prompts -viii be able to write a compund sentnece with appropriate conventions and traits improving fluency and structure from~sentences to compound sentences in 3 consecutive attempts as measured by classroom work assessments

How will progress toward this goal be repmted (check all that apply)0 Written Progress Report

How often will progress be reported middotmiddot Monthly fRJ Quarterly [J Trimester ] Semester Cl Other

By 01092013 when given Qrade level promP1 inflrmationaJ ficltonal-will write a 5 sentence paragraph with topic sentence 3 examplesmiddot- details conclusion with appropriate conventions and traits improving fluency and overall structure from 3 sentence paragraph in both genres to 5 sentence paragraph in both genres in 2 consecutive attempts as measured by classrrom assesssments performance

gow will progress townrd this goal be reported (check all that apply)fJ Written Progress Report

How often will progr~s be reported middot Monthly 1u Quarterly Ll Trimester O SemesterO Other

Measurable Annual Goals Page6

Date ofBirth

Program Accommodations Modifications and Support for Schoo] Personnel

MeetingDate 01102012 PURPOSEThe purpose of th is page is to document the modifications andor accommodations that the student requires based on the students assessed needs in order to advance appropriately toward attaining the identified annual goals to be involved and make progress in the general education curriculum and to be educated with non-disabled peers to the maximum extent appmpriate Accommodations may be in but not limited to the areas ofpresentation timingscheduling setting aids and format The impact of

any modifications listed should be discussed This includes the earning of credits for graduation

This student will be provided access to the general education special education other school services and activities including non-academic activities and extracurricular activities and education related settings

0 with no accommodationsmodifications IRJ with the following accommodntionsmodifications

Accommod11tion(s)Mod iflcation(s)

Testing AccommodationMore Time

Testing Accommodationgive teits in small group setting or 11

Testing Presenlationassessment directions can be reread verbatim

Frequency Duration mdy to 111dy

Location

01102012 to 01092013

01102012 to 01092013

01102012 to 01092013

Supports for School Personnel ( training professional development etc) Teachers will be made aware of modifications through cum file and or advisor

Program Accommodations Modificnlions and Support for School Fersonnel Page7

DateofBi1th shy

State otmiddot Districtwide Assessments ofStudent Achievement

Meeting Date __0_11_1_012_01_2__

PURPOSEThe IEP team makes the determination ofwhat type of assessment the student will take and what admiuistrative modification and individual accommodations are necessary Accommodations provided on state and districtwide assessments should be those that are provided as nart of the re011lar instmctional pro2u11n For Measurement ofStudent Progress (MSP) High School Proficiency Exam (HSPE) or Washington Alternate Assessment (WAAS) see Guidelines for Inclusion and Accommodations for Special Populations on State-Level Assessments

Assessment Participation

Reading X Science X

Wriling X

Accommodations Modifications

If YES List Accommodation(s) andor Modification(s) by Assesunent

Dliffii - itt~hf -~w~~~~bull~~ ~li( ~w ~middot--middot-NM Math X X More Time give tests In small group setting or 11 assessment

directions can be reread verbatim

Reading X

Science X

Writing X

Ma~ X Reading X Science Writing

Wiffir~~~~iJL asr Malh Reading Science

Reading Science

X X

Ji~~frtfrac12lftyj~j X X X

X X

Reading X Writing X

X

X

X

More Time give tests In small group seUing or 11 assessment directions can be reread verbatim

More Time give tests In small group setting or 11 assessment directions can be reread verbatim

More Time give tests in small group setting or 11 assessment directions can be reread verbatim

1Y _ bull bullJlf

Stlt1te or Districtwide Assessmenls ofStucten Achievement Page 8

Date ofBirth

Special Education and Related Services

Meeting Date 011 02012

PURPOSEThe information on this page is a summary of the students programservices including when services will begin where they will be provided who will be re~ponsible for providing them and when they will end

No Written Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Language Teacher Education Weekly

Teacher

No Mathematics Special Education Special 55 Minules 5 Times Special Education 01102012 01092013 Calculation Teacher Education Weekly

Teacher

No Reading Special lducotion Special 55 Minutes 5 Times Special Education 01102012 0)092013 Compreheusi Teaclier Education Weekly

on Teacher

No Study Skills Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Teacher Education Weekly

Teacher

Total minutes per week student spends in school 1soo minutes per week Total minutes per week student is served in a special education setting 1100 minutes per week Percent of time in geneul education setting 38 89 in General Education Se1tjng

Page9SJgtecinl Education and Related Services

Student ID

WASSID shyDate ofBirth shy

Special Education and Related Services

PURPOSEThe purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum participate in extracurricular and nonacademic activities and be educated and participate with other special education students and non-disabled students Other education-related factors that mav impact the student should also be considered Least Restrictive Environment (LRE) When discussing least resnmiddotictive environment and placement options the following must be considered

To the maximum extent appropriate the student is educated with children without disabilities - Special classes separate schooling or other removal of the student from the regular educational envirorunent occurs only if the

nature or severity of lhe disability is such that education in regular classes with the use ofsupplementary aids and services cannot be achieved satisfactorily

- The students placement should be as close as possible to the childs home and unless the IBP ofthe student with a disabi lity requires some other arrangement the student is educated in the school that he or she would attend ifhe or she did not have a disability

- In selecting the LRE considerntion is given to any potential harmful effect on the student or on the quality of services that heshe needs

- The student with a disability is not removed from education in age-appropriate regular classrooms solely because ofneeded modifications in the general cunfoulum

Placement Options Setting 1 01102012 - 01092013

Placement Ootions for LRE SELECTION ORREASONS REJECTED Considered Selected (only Academic benefit Non-academic Bffect student will

l) cannot be benefit ca11not be hove on teacher and satisfactorily satisfactorily other students

achieved achieved Exnlanation

80-100 in Reaular Class 40-79 in Remilar Class 0-39 in Reaular Class X X

Best meets cademic needs Publiclnrivate seoarate dav school PublicJPrivate residenti al Correctional Faciiitv Private School P lacement bv Parents HomeHosoital PJacement Decision An explanation ofthe extent if any to wh ich the student will not participate with nondisabled students in the general education class and in nonacademic and extracurricular activities including a description of any adaptations needed for participation in physical education

Best meets ~ cademic needs

Other Considerations 1 Transportation [RJ Regular 2 Extended School Year D Yes 3 Genci-al PE [fil Yes

D Special [RJ No

D No

IfYes must complete ESY form

Special Education and Related Services Page 10

DateofBirth shy

Prior Written Notice

To Date 011120 12 Re Students Name ---------- shyPURPOSEAs a parentguardian of a special education child suspected of needing special education services the school district is req11ired to provide you with prior written notice whenever it proposes or refuses to initiate or change the identification evaluation educational placement or provision ofa free appropriate public education to your child This notice should be given to you after a district makes a decision and before action is taken on the decision The notice should be given to you in a reasom1ble amount of time before the district takes action

The purpose of t his pri01middot written notice is to inform you that we a re

1 ra proposing D refusing to 2 D ini tiate D change ~ continue Ddiscontinue aan (marlc one ofthe above) (mark one oftbe above)

Mark all items below that apply

3 sectReferral Initial Evaluation sectEligibility Category Educational Placement IBP Reevaluation Disciplinary action tbat is a change of ~ 504 Plan Other placement

Description ofthe proposed or reftlsed action Yearly review evalua tion

The reason we are proposing or refosing to take action is require d by state new to school district

Description ofany other optio11s considered and rejected Best meets students a cademic needs

The reasons we re~ se options were Does not mee t -needs

A description of each procedure test record or report we used or plan to use as the basis for taking this action is as follows evaluationstatedistrict teststeacher feedbackcum fi le

Any other factors that are relevant to the action none at this time

The action will be initiated on _o111~1111i2~0~1lta2 _ _______

Your child bas procedural protections under IDEA These protections are explained in the Notice ofProcedural Safeguards for Special Education Students and Their Families If this prior written notice is given to you (l) as pat1 ofyour childs initial refemil for evaluation (2) as part of a request for reevaluation or (3) notice to you regarding disciplinary action that constitutes a change ofplacement the procedural safeguards accompanies th is notice If a copy of the Notice ofProceduml Safeguard~ for Special Education Students and Their Families is not enclosed and ym would Iike a copy or you would like help in understanding the content please contact

at

Page 11Prior Written Notice

-

Date ofBirth

Measurable AnnunJ Goals

Meeting Date 01102012

PURPOSEIEPs must include a statement ofmeasurable annual goals including academic and functional goals designed to meet each ol the students educational needs Iha result from the students disability to enable the student to be involved and make progress in the general education curriculum lu order to be measurable the goal should include a baseline (from) a target (to) and a unit of measure

By 01092013 when given prompts -viii be able to write a compund sentnece with appropriate conventions and traits improving fluency and structure from~sentences to compound sentences in 3 consecutive attempts as measured by classroom work assessments

How will progress toward this goal be repmted (check all that apply)0 Written Progress Report

How often will progress be reported middotmiddot Monthly fRJ Quarterly [J Trimester ] Semester Cl Other

By 01092013 when given Qrade level promP1 inflrmationaJ ficltonal-will write a 5 sentence paragraph with topic sentence 3 examplesmiddot- details conclusion with appropriate conventions and traits improving fluency and overall structure from 3 sentence paragraph in both genres to 5 sentence paragraph in both genres in 2 consecutive attempts as measured by classrrom assesssments performance

gow will progress townrd this goal be reported (check all that apply)fJ Written Progress Report

How often will progr~s be reported middot Monthly 1u Quarterly Ll Trimester O SemesterO Other

Measurable Annual Goals Page6

Date ofBirth

Program Accommodations Modifications and Support for Schoo] Personnel

MeetingDate 01102012 PURPOSEThe purpose of th is page is to document the modifications andor accommodations that the student requires based on the students assessed needs in order to advance appropriately toward attaining the identified annual goals to be involved and make progress in the general education curriculum and to be educated with non-disabled peers to the maximum extent appmpriate Accommodations may be in but not limited to the areas ofpresentation timingscheduling setting aids and format The impact of

any modifications listed should be discussed This includes the earning of credits for graduation

This student will be provided access to the general education special education other school services and activities including non-academic activities and extracurricular activities and education related settings

0 with no accommodationsmodifications IRJ with the following accommodntionsmodifications

Accommod11tion(s)Mod iflcation(s)

Testing AccommodationMore Time

Testing Accommodationgive teits in small group setting or 11

Testing Presenlationassessment directions can be reread verbatim

Frequency Duration mdy to 111dy

Location

01102012 to 01092013

01102012 to 01092013

01102012 to 01092013

Supports for School Personnel ( training professional development etc) Teachers will be made aware of modifications through cum file and or advisor

Program Accommodations Modificnlions and Support for School Fersonnel Page7

DateofBi1th shy

State otmiddot Districtwide Assessments ofStudent Achievement

Meeting Date __0_11_1_012_01_2__

PURPOSEThe IEP team makes the determination ofwhat type of assessment the student will take and what admiuistrative modification and individual accommodations are necessary Accommodations provided on state and districtwide assessments should be those that are provided as nart of the re011lar instmctional pro2u11n For Measurement ofStudent Progress (MSP) High School Proficiency Exam (HSPE) or Washington Alternate Assessment (WAAS) see Guidelines for Inclusion and Accommodations for Special Populations on State-Level Assessments

Assessment Participation

Reading X Science X

Wriling X

Accommodations Modifications

If YES List Accommodation(s) andor Modification(s) by Assesunent

Dliffii - itt~hf -~w~~~~bull~~ ~li( ~w ~middot--middot-NM Math X X More Time give tests In small group setting or 11 assessment

directions can be reread verbatim

Reading X

Science X

Writing X

Ma~ X Reading X Science Writing

Wiffir~~~~iJL asr Malh Reading Science

Reading Science

X X

Ji~~frtfrac12lftyj~j X X X

X X

Reading X Writing X

X

X

X

More Time give tests In small group seUing or 11 assessment directions can be reread verbatim

More Time give tests In small group setting or 11 assessment directions can be reread verbatim

More Time give tests in small group setting or 11 assessment directions can be reread verbatim

1Y _ bull bullJlf

Stlt1te or Districtwide Assessmenls ofStucten Achievement Page 8

Date ofBirth

Special Education and Related Services

Meeting Date 011 02012

PURPOSEThe information on this page is a summary of the students programservices including when services will begin where they will be provided who will be re~ponsible for providing them and when they will end

No Written Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Language Teacher Education Weekly

Teacher

No Mathematics Special Education Special 55 Minules 5 Times Special Education 01102012 01092013 Calculation Teacher Education Weekly

Teacher

No Reading Special lducotion Special 55 Minutes 5 Times Special Education 01102012 0)092013 Compreheusi Teaclier Education Weekly

on Teacher

No Study Skills Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Teacher Education Weekly

Teacher

Total minutes per week student spends in school 1soo minutes per week Total minutes per week student is served in a special education setting 1100 minutes per week Percent of time in geneul education setting 38 89 in General Education Se1tjng

Page9SJgtecinl Education and Related Services

Student ID

WASSID shyDate ofBirth shy

Special Education and Related Services

PURPOSEThe purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum participate in extracurricular and nonacademic activities and be educated and participate with other special education students and non-disabled students Other education-related factors that mav impact the student should also be considered Least Restrictive Environment (LRE) When discussing least resnmiddotictive environment and placement options the following must be considered

To the maximum extent appropriate the student is educated with children without disabilities - Special classes separate schooling or other removal of the student from the regular educational envirorunent occurs only if the

nature or severity of lhe disability is such that education in regular classes with the use ofsupplementary aids and services cannot be achieved satisfactorily

- The students placement should be as close as possible to the childs home and unless the IBP ofthe student with a disabi lity requires some other arrangement the student is educated in the school that he or she would attend ifhe or she did not have a disability

- In selecting the LRE considerntion is given to any potential harmful effect on the student or on the quality of services that heshe needs

- The student with a disability is not removed from education in age-appropriate regular classrooms solely because ofneeded modifications in the general cunfoulum

Placement Options Setting 1 01102012 - 01092013

Placement Ootions for LRE SELECTION ORREASONS REJECTED Considered Selected (only Academic benefit Non-academic Bffect student will

l) cannot be benefit ca11not be hove on teacher and satisfactorily satisfactorily other students

achieved achieved Exnlanation

80-100 in Reaular Class 40-79 in Remilar Class 0-39 in Reaular Class X X

Best meets cademic needs Publiclnrivate seoarate dav school PublicJPrivate residenti al Correctional Faciiitv Private School P lacement bv Parents HomeHosoital PJacement Decision An explanation ofthe extent if any to wh ich the student will not participate with nondisabled students in the general education class and in nonacademic and extracurricular activities including a description of any adaptations needed for participation in physical education

Best meets ~ cademic needs

Other Considerations 1 Transportation [RJ Regular 2 Extended School Year D Yes 3 Genci-al PE [fil Yes

D Special [RJ No

D No

IfYes must complete ESY form

Special Education and Related Services Page 10

DateofBirth shy

Prior Written Notice

To Date 011120 12 Re Students Name ---------- shyPURPOSEAs a parentguardian of a special education child suspected of needing special education services the school district is req11ired to provide you with prior written notice whenever it proposes or refuses to initiate or change the identification evaluation educational placement or provision ofa free appropriate public education to your child This notice should be given to you after a district makes a decision and before action is taken on the decision The notice should be given to you in a reasom1ble amount of time before the district takes action

The purpose of t his pri01middot written notice is to inform you that we a re

1 ra proposing D refusing to 2 D ini tiate D change ~ continue Ddiscontinue aan (marlc one ofthe above) (mark one oftbe above)

Mark all items below that apply

3 sectReferral Initial Evaluation sectEligibility Category Educational Placement IBP Reevaluation Disciplinary action tbat is a change of ~ 504 Plan Other placement

Description ofthe proposed or reftlsed action Yearly review evalua tion

The reason we are proposing or refosing to take action is require d by state new to school district

Description ofany other optio11s considered and rejected Best meets students a cademic needs

The reasons we re~ se options were Does not mee t -needs

A description of each procedure test record or report we used or plan to use as the basis for taking this action is as follows evaluationstatedistrict teststeacher feedbackcum fi le

Any other factors that are relevant to the action none at this time

The action will be initiated on _o111~1111i2~0~1lta2 _ _______

Your child bas procedural protections under IDEA These protections are explained in the Notice ofProcedural Safeguards for Special Education Students and Their Families If this prior written notice is given to you (l) as pat1 ofyour childs initial refemil for evaluation (2) as part of a request for reevaluation or (3) notice to you regarding disciplinary action that constitutes a change ofplacement the procedural safeguards accompanies th is notice If a copy of the Notice ofProceduml Safeguard~ for Special Education Students and Their Families is not enclosed and ym would Iike a copy or you would like help in understanding the content please contact

at

Page 11Prior Written Notice

-

Date ofBirth

Program Accommodations Modifications and Support for Schoo] Personnel

MeetingDate 01102012 PURPOSEThe purpose of th is page is to document the modifications andor accommodations that the student requires based on the students assessed needs in order to advance appropriately toward attaining the identified annual goals to be involved and make progress in the general education curriculum and to be educated with non-disabled peers to the maximum extent appmpriate Accommodations may be in but not limited to the areas ofpresentation timingscheduling setting aids and format The impact of

any modifications listed should be discussed This includes the earning of credits for graduation

This student will be provided access to the general education special education other school services and activities including non-academic activities and extracurricular activities and education related settings

0 with no accommodationsmodifications IRJ with the following accommodntionsmodifications

Accommod11tion(s)Mod iflcation(s)

Testing AccommodationMore Time

Testing Accommodationgive teits in small group setting or 11

Testing Presenlationassessment directions can be reread verbatim

Frequency Duration mdy to 111dy

Location

01102012 to 01092013

01102012 to 01092013

01102012 to 01092013

Supports for School Personnel ( training professional development etc) Teachers will be made aware of modifications through cum file and or advisor

Program Accommodations Modificnlions and Support for School Fersonnel Page7

DateofBi1th shy

State otmiddot Districtwide Assessments ofStudent Achievement

Meeting Date __0_11_1_012_01_2__

PURPOSEThe IEP team makes the determination ofwhat type of assessment the student will take and what admiuistrative modification and individual accommodations are necessary Accommodations provided on state and districtwide assessments should be those that are provided as nart of the re011lar instmctional pro2u11n For Measurement ofStudent Progress (MSP) High School Proficiency Exam (HSPE) or Washington Alternate Assessment (WAAS) see Guidelines for Inclusion and Accommodations for Special Populations on State-Level Assessments

Assessment Participation

Reading X Science X

Wriling X

Accommodations Modifications

If YES List Accommodation(s) andor Modification(s) by Assesunent

Dliffii - itt~hf -~w~~~~bull~~ ~li( ~w ~middot--middot-NM Math X X More Time give tests In small group setting or 11 assessment

directions can be reread verbatim

Reading X

Science X

Writing X

Ma~ X Reading X Science Writing

Wiffir~~~~iJL asr Malh Reading Science

Reading Science

X X

Ji~~frtfrac12lftyj~j X X X

X X

Reading X Writing X

X

X

X

More Time give tests In small group seUing or 11 assessment directions can be reread verbatim

More Time give tests In small group setting or 11 assessment directions can be reread verbatim

More Time give tests in small group setting or 11 assessment directions can be reread verbatim

1Y _ bull bullJlf

Stlt1te or Districtwide Assessmenls ofStucten Achievement Page 8

Date ofBirth

Special Education and Related Services

Meeting Date 011 02012

PURPOSEThe information on this page is a summary of the students programservices including when services will begin where they will be provided who will be re~ponsible for providing them and when they will end

No Written Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Language Teacher Education Weekly

Teacher

No Mathematics Special Education Special 55 Minules 5 Times Special Education 01102012 01092013 Calculation Teacher Education Weekly

Teacher

No Reading Special lducotion Special 55 Minutes 5 Times Special Education 01102012 0)092013 Compreheusi Teaclier Education Weekly

on Teacher

No Study Skills Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Teacher Education Weekly

Teacher

Total minutes per week student spends in school 1soo minutes per week Total minutes per week student is served in a special education setting 1100 minutes per week Percent of time in geneul education setting 38 89 in General Education Se1tjng

Page9SJgtecinl Education and Related Services

Student ID

WASSID shyDate ofBirth shy

Special Education and Related Services

PURPOSEThe purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum participate in extracurricular and nonacademic activities and be educated and participate with other special education students and non-disabled students Other education-related factors that mav impact the student should also be considered Least Restrictive Environment (LRE) When discussing least resnmiddotictive environment and placement options the following must be considered

To the maximum extent appropriate the student is educated with children without disabilities - Special classes separate schooling or other removal of the student from the regular educational envirorunent occurs only if the

nature or severity of lhe disability is such that education in regular classes with the use ofsupplementary aids and services cannot be achieved satisfactorily

- The students placement should be as close as possible to the childs home and unless the IBP ofthe student with a disabi lity requires some other arrangement the student is educated in the school that he or she would attend ifhe or she did not have a disability

- In selecting the LRE considerntion is given to any potential harmful effect on the student or on the quality of services that heshe needs

- The student with a disability is not removed from education in age-appropriate regular classrooms solely because ofneeded modifications in the general cunfoulum

Placement Options Setting 1 01102012 - 01092013

Placement Ootions for LRE SELECTION ORREASONS REJECTED Considered Selected (only Academic benefit Non-academic Bffect student will

l) cannot be benefit ca11not be hove on teacher and satisfactorily satisfactorily other students

achieved achieved Exnlanation

80-100 in Reaular Class 40-79 in Remilar Class 0-39 in Reaular Class X X

Best meets cademic needs Publiclnrivate seoarate dav school PublicJPrivate residenti al Correctional Faciiitv Private School P lacement bv Parents HomeHosoital PJacement Decision An explanation ofthe extent if any to wh ich the student will not participate with nondisabled students in the general education class and in nonacademic and extracurricular activities including a description of any adaptations needed for participation in physical education

Best meets ~ cademic needs

Other Considerations 1 Transportation [RJ Regular 2 Extended School Year D Yes 3 Genci-al PE [fil Yes

D Special [RJ No

D No

IfYes must complete ESY form

Special Education and Related Services Page 10

DateofBirth shy

Prior Written Notice

To Date 011120 12 Re Students Name ---------- shyPURPOSEAs a parentguardian of a special education child suspected of needing special education services the school district is req11ired to provide you with prior written notice whenever it proposes or refuses to initiate or change the identification evaluation educational placement or provision ofa free appropriate public education to your child This notice should be given to you after a district makes a decision and before action is taken on the decision The notice should be given to you in a reasom1ble amount of time before the district takes action

The purpose of t his pri01middot written notice is to inform you that we a re

1 ra proposing D refusing to 2 D ini tiate D change ~ continue Ddiscontinue aan (marlc one ofthe above) (mark one oftbe above)

Mark all items below that apply

3 sectReferral Initial Evaluation sectEligibility Category Educational Placement IBP Reevaluation Disciplinary action tbat is a change of ~ 504 Plan Other placement

Description ofthe proposed or reftlsed action Yearly review evalua tion

The reason we are proposing or refosing to take action is require d by state new to school district

Description ofany other optio11s considered and rejected Best meets students a cademic needs

The reasons we re~ se options were Does not mee t -needs

A description of each procedure test record or report we used or plan to use as the basis for taking this action is as follows evaluationstatedistrict teststeacher feedbackcum fi le

Any other factors that are relevant to the action none at this time

The action will be initiated on _o111~1111i2~0~1lta2 _ _______

Your child bas procedural protections under IDEA These protections are explained in the Notice ofProcedural Safeguards for Special Education Students and Their Families If this prior written notice is given to you (l) as pat1 ofyour childs initial refemil for evaluation (2) as part of a request for reevaluation or (3) notice to you regarding disciplinary action that constitutes a change ofplacement the procedural safeguards accompanies th is notice If a copy of the Notice ofProceduml Safeguard~ for Special Education Students and Their Families is not enclosed and ym would Iike a copy or you would like help in understanding the content please contact

at

Page 11Prior Written Notice

-

DateofBi1th shy

State otmiddot Districtwide Assessments ofStudent Achievement

Meeting Date __0_11_1_012_01_2__

PURPOSEThe IEP team makes the determination ofwhat type of assessment the student will take and what admiuistrative modification and individual accommodations are necessary Accommodations provided on state and districtwide assessments should be those that are provided as nart of the re011lar instmctional pro2u11n For Measurement ofStudent Progress (MSP) High School Proficiency Exam (HSPE) or Washington Alternate Assessment (WAAS) see Guidelines for Inclusion and Accommodations for Special Populations on State-Level Assessments

Assessment Participation

Reading X Science X

Wriling X

Accommodations Modifications

If YES List Accommodation(s) andor Modification(s) by Assesunent

Dliffii - itt~hf -~w~~~~bull~~ ~li( ~w ~middot--middot-NM Math X X More Time give tests In small group setting or 11 assessment

directions can be reread verbatim

Reading X

Science X

Writing X

Ma~ X Reading X Science Writing

Wiffir~~~~iJL asr Malh Reading Science

Reading Science

X X

Ji~~frtfrac12lftyj~j X X X

X X

Reading X Writing X

X

X

X

More Time give tests In small group seUing or 11 assessment directions can be reread verbatim

More Time give tests In small group setting or 11 assessment directions can be reread verbatim

More Time give tests in small group setting or 11 assessment directions can be reread verbatim

1Y _ bull bullJlf

Stlt1te or Districtwide Assessmenls ofStucten Achievement Page 8

Date ofBirth

Special Education and Related Services

Meeting Date 011 02012

PURPOSEThe information on this page is a summary of the students programservices including when services will begin where they will be provided who will be re~ponsible for providing them and when they will end

No Written Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Language Teacher Education Weekly

Teacher

No Mathematics Special Education Special 55 Minules 5 Times Special Education 01102012 01092013 Calculation Teacher Education Weekly

Teacher

No Reading Special lducotion Special 55 Minutes 5 Times Special Education 01102012 0)092013 Compreheusi Teaclier Education Weekly

on Teacher

No Study Skills Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Teacher Education Weekly

Teacher

Total minutes per week student spends in school 1soo minutes per week Total minutes per week student is served in a special education setting 1100 minutes per week Percent of time in geneul education setting 38 89 in General Education Se1tjng

Page9SJgtecinl Education and Related Services

Student ID

WASSID shyDate ofBirth shy

Special Education and Related Services

PURPOSEThe purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum participate in extracurricular and nonacademic activities and be educated and participate with other special education students and non-disabled students Other education-related factors that mav impact the student should also be considered Least Restrictive Environment (LRE) When discussing least resnmiddotictive environment and placement options the following must be considered

To the maximum extent appropriate the student is educated with children without disabilities - Special classes separate schooling or other removal of the student from the regular educational envirorunent occurs only if the

nature or severity of lhe disability is such that education in regular classes with the use ofsupplementary aids and services cannot be achieved satisfactorily

- The students placement should be as close as possible to the childs home and unless the IBP ofthe student with a disabi lity requires some other arrangement the student is educated in the school that he or she would attend ifhe or she did not have a disability

- In selecting the LRE considerntion is given to any potential harmful effect on the student or on the quality of services that heshe needs

- The student with a disability is not removed from education in age-appropriate regular classrooms solely because ofneeded modifications in the general cunfoulum

Placement Options Setting 1 01102012 - 01092013

Placement Ootions for LRE SELECTION ORREASONS REJECTED Considered Selected (only Academic benefit Non-academic Bffect student will

l) cannot be benefit ca11not be hove on teacher and satisfactorily satisfactorily other students

achieved achieved Exnlanation

80-100 in Reaular Class 40-79 in Remilar Class 0-39 in Reaular Class X X

Best meets cademic needs Publiclnrivate seoarate dav school PublicJPrivate residenti al Correctional Faciiitv Private School P lacement bv Parents HomeHosoital PJacement Decision An explanation ofthe extent if any to wh ich the student will not participate with nondisabled students in the general education class and in nonacademic and extracurricular activities including a description of any adaptations needed for participation in physical education

Best meets ~ cademic needs

Other Considerations 1 Transportation [RJ Regular 2 Extended School Year D Yes 3 Genci-al PE [fil Yes

D Special [RJ No

D No

IfYes must complete ESY form

Special Education and Related Services Page 10

DateofBirth shy

Prior Written Notice

To Date 011120 12 Re Students Name ---------- shyPURPOSEAs a parentguardian of a special education child suspected of needing special education services the school district is req11ired to provide you with prior written notice whenever it proposes or refuses to initiate or change the identification evaluation educational placement or provision ofa free appropriate public education to your child This notice should be given to you after a district makes a decision and before action is taken on the decision The notice should be given to you in a reasom1ble amount of time before the district takes action

The purpose of t his pri01middot written notice is to inform you that we a re

1 ra proposing D refusing to 2 D ini tiate D change ~ continue Ddiscontinue aan (marlc one ofthe above) (mark one oftbe above)

Mark all items below that apply

3 sectReferral Initial Evaluation sectEligibility Category Educational Placement IBP Reevaluation Disciplinary action tbat is a change of ~ 504 Plan Other placement

Description ofthe proposed or reftlsed action Yearly review evalua tion

The reason we are proposing or refosing to take action is require d by state new to school district

Description ofany other optio11s considered and rejected Best meets students a cademic needs

The reasons we re~ se options were Does not mee t -needs

A description of each procedure test record or report we used or plan to use as the basis for taking this action is as follows evaluationstatedistrict teststeacher feedbackcum fi le

Any other factors that are relevant to the action none at this time

The action will be initiated on _o111~1111i2~0~1lta2 _ _______

Your child bas procedural protections under IDEA These protections are explained in the Notice ofProcedural Safeguards for Special Education Students and Their Families If this prior written notice is given to you (l) as pat1 ofyour childs initial refemil for evaluation (2) as part of a request for reevaluation or (3) notice to you regarding disciplinary action that constitutes a change ofplacement the procedural safeguards accompanies th is notice If a copy of the Notice ofProceduml Safeguard~ for Special Education Students and Their Families is not enclosed and ym would Iike a copy or you would like help in understanding the content please contact

at

Page 11Prior Written Notice

-

Date ofBirth

Special Education and Related Services

Meeting Date 011 02012

PURPOSEThe information on this page is a summary of the students programservices including when services will begin where they will be provided who will be re~ponsible for providing them and when they will end

No Written Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Language Teacher Education Weekly

Teacher

No Mathematics Special Education Special 55 Minules 5 Times Special Education 01102012 01092013 Calculation Teacher Education Weekly

Teacher

No Reading Special lducotion Special 55 Minutes 5 Times Special Education 01102012 0)092013 Compreheusi Teaclier Education Weekly

on Teacher

No Study Skills Special Education Special 55 Minutes 5 Times Special Education 01102012 01092013 Teacher Education Weekly

Teacher

Total minutes per week student spends in school 1soo minutes per week Total minutes per week student is served in a special education setting 1100 minutes per week Percent of time in geneul education setting 38 89 in General Education Se1tjng

Page9SJgtecinl Education and Related Services

Student ID

WASSID shyDate ofBirth shy

Special Education and Related Services

PURPOSEThe purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum participate in extracurricular and nonacademic activities and be educated and participate with other special education students and non-disabled students Other education-related factors that mav impact the student should also be considered Least Restrictive Environment (LRE) When discussing least resnmiddotictive environment and placement options the following must be considered

To the maximum extent appropriate the student is educated with children without disabilities - Special classes separate schooling or other removal of the student from the regular educational envirorunent occurs only if the

nature or severity of lhe disability is such that education in regular classes with the use ofsupplementary aids and services cannot be achieved satisfactorily

- The students placement should be as close as possible to the childs home and unless the IBP ofthe student with a disabi lity requires some other arrangement the student is educated in the school that he or she would attend ifhe or she did not have a disability

- In selecting the LRE considerntion is given to any potential harmful effect on the student or on the quality of services that heshe needs

- The student with a disability is not removed from education in age-appropriate regular classrooms solely because ofneeded modifications in the general cunfoulum

Placement Options Setting 1 01102012 - 01092013

Placement Ootions for LRE SELECTION ORREASONS REJECTED Considered Selected (only Academic benefit Non-academic Bffect student will

l) cannot be benefit ca11not be hove on teacher and satisfactorily satisfactorily other students

achieved achieved Exnlanation

80-100 in Reaular Class 40-79 in Remilar Class 0-39 in Reaular Class X X

Best meets cademic needs Publiclnrivate seoarate dav school PublicJPrivate residenti al Correctional Faciiitv Private School P lacement bv Parents HomeHosoital PJacement Decision An explanation ofthe extent if any to wh ich the student will not participate with nondisabled students in the general education class and in nonacademic and extracurricular activities including a description of any adaptations needed for participation in physical education

Best meets ~ cademic needs

Other Considerations 1 Transportation [RJ Regular 2 Extended School Year D Yes 3 Genci-al PE [fil Yes

D Special [RJ No

D No

IfYes must complete ESY form

Special Education and Related Services Page 10

DateofBirth shy

Prior Written Notice

To Date 011120 12 Re Students Name ---------- shyPURPOSEAs a parentguardian of a special education child suspected of needing special education services the school district is req11ired to provide you with prior written notice whenever it proposes or refuses to initiate or change the identification evaluation educational placement or provision ofa free appropriate public education to your child This notice should be given to you after a district makes a decision and before action is taken on the decision The notice should be given to you in a reasom1ble amount of time before the district takes action

The purpose of t his pri01middot written notice is to inform you that we a re

1 ra proposing D refusing to 2 D ini tiate D change ~ continue Ddiscontinue aan (marlc one ofthe above) (mark one oftbe above)

Mark all items below that apply

3 sectReferral Initial Evaluation sectEligibility Category Educational Placement IBP Reevaluation Disciplinary action tbat is a change of ~ 504 Plan Other placement

Description ofthe proposed or reftlsed action Yearly review evalua tion

The reason we are proposing or refosing to take action is require d by state new to school district

Description ofany other optio11s considered and rejected Best meets students a cademic needs

The reasons we re~ se options were Does not mee t -needs

A description of each procedure test record or report we used or plan to use as the basis for taking this action is as follows evaluationstatedistrict teststeacher feedbackcum fi le

Any other factors that are relevant to the action none at this time

The action will be initiated on _o111~1111i2~0~1lta2 _ _______

Your child bas procedural protections under IDEA These protections are explained in the Notice ofProcedural Safeguards for Special Education Students and Their Families If this prior written notice is given to you (l) as pat1 ofyour childs initial refemil for evaluation (2) as part of a request for reevaluation or (3) notice to you regarding disciplinary action that constitutes a change ofplacement the procedural safeguards accompanies th is notice If a copy of the Notice ofProceduml Safeguard~ for Special Education Students and Their Families is not enclosed and ym would Iike a copy or you would like help in understanding the content please contact

at

Page 11Prior Written Notice

-

Student ID

WASSID shyDate ofBirth shy

Special Education and Related Services

PURPOSEThe purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum participate in extracurricular and nonacademic activities and be educated and participate with other special education students and non-disabled students Other education-related factors that mav impact the student should also be considered Least Restrictive Environment (LRE) When discussing least resnmiddotictive environment and placement options the following must be considered

To the maximum extent appropriate the student is educated with children without disabilities - Special classes separate schooling or other removal of the student from the regular educational envirorunent occurs only if the

nature or severity of lhe disability is such that education in regular classes with the use ofsupplementary aids and services cannot be achieved satisfactorily

- The students placement should be as close as possible to the childs home and unless the IBP ofthe student with a disabi lity requires some other arrangement the student is educated in the school that he or she would attend ifhe or she did not have a disability

- In selecting the LRE considerntion is given to any potential harmful effect on the student or on the quality of services that heshe needs

- The student with a disability is not removed from education in age-appropriate regular classrooms solely because ofneeded modifications in the general cunfoulum

Placement Options Setting 1 01102012 - 01092013

Placement Ootions for LRE SELECTION ORREASONS REJECTED Considered Selected (only Academic benefit Non-academic Bffect student will

l) cannot be benefit ca11not be hove on teacher and satisfactorily satisfactorily other students

achieved achieved Exnlanation

80-100 in Reaular Class 40-79 in Remilar Class 0-39 in Reaular Class X X

Best meets cademic needs Publiclnrivate seoarate dav school PublicJPrivate residenti al Correctional Faciiitv Private School P lacement bv Parents HomeHosoital PJacement Decision An explanation ofthe extent if any to wh ich the student will not participate with nondisabled students in the general education class and in nonacademic and extracurricular activities including a description of any adaptations needed for participation in physical education

Best meets ~ cademic needs

Other Considerations 1 Transportation [RJ Regular 2 Extended School Year D Yes 3 Genci-al PE [fil Yes

D Special [RJ No

D No

IfYes must complete ESY form

Special Education and Related Services Page 10

DateofBirth shy

Prior Written Notice

To Date 011120 12 Re Students Name ---------- shyPURPOSEAs a parentguardian of a special education child suspected of needing special education services the school district is req11ired to provide you with prior written notice whenever it proposes or refuses to initiate or change the identification evaluation educational placement or provision ofa free appropriate public education to your child This notice should be given to you after a district makes a decision and before action is taken on the decision The notice should be given to you in a reasom1ble amount of time before the district takes action

The purpose of t his pri01middot written notice is to inform you that we a re

1 ra proposing D refusing to 2 D ini tiate D change ~ continue Ddiscontinue aan (marlc one ofthe above) (mark one oftbe above)

Mark all items below that apply

3 sectReferral Initial Evaluation sectEligibility Category Educational Placement IBP Reevaluation Disciplinary action tbat is a change of ~ 504 Plan Other placement

Description ofthe proposed or reftlsed action Yearly review evalua tion

The reason we are proposing or refosing to take action is require d by state new to school district

Description ofany other optio11s considered and rejected Best meets students a cademic needs

The reasons we re~ se options were Does not mee t -needs

A description of each procedure test record or report we used or plan to use as the basis for taking this action is as follows evaluationstatedistrict teststeacher feedbackcum fi le

Any other factors that are relevant to the action none at this time

The action will be initiated on _o111~1111i2~0~1lta2 _ _______

Your child bas procedural protections under IDEA These protections are explained in the Notice ofProcedural Safeguards for Special Education Students and Their Families If this prior written notice is given to you (l) as pat1 ofyour childs initial refemil for evaluation (2) as part of a request for reevaluation or (3) notice to you regarding disciplinary action that constitutes a change ofplacement the procedural safeguards accompanies th is notice If a copy of the Notice ofProceduml Safeguard~ for Special Education Students and Their Families is not enclosed and ym would Iike a copy or you would like help in understanding the content please contact

at

Page 11Prior Written Notice

-

DateofBirth shy

Prior Written Notice

To Date 011120 12 Re Students Name ---------- shyPURPOSEAs a parentguardian of a special education child suspected of needing special education services the school district is req11ired to provide you with prior written notice whenever it proposes or refuses to initiate or change the identification evaluation educational placement or provision ofa free appropriate public education to your child This notice should be given to you after a district makes a decision and before action is taken on the decision The notice should be given to you in a reasom1ble amount of time before the district takes action

The purpose of t his pri01middot written notice is to inform you that we a re

1 ra proposing D refusing to 2 D ini tiate D change ~ continue Ddiscontinue aan (marlc one ofthe above) (mark one oftbe above)

Mark all items below that apply

3 sectReferral Initial Evaluation sectEligibility Category Educational Placement IBP Reevaluation Disciplinary action tbat is a change of ~ 504 Plan Other placement

Description ofthe proposed or reftlsed action Yearly review evalua tion

The reason we are proposing or refosing to take action is require d by state new to school district

Description ofany other optio11s considered and rejected Best meets students a cademic needs

The reasons we re~ se options were Does not mee t -needs

A description of each procedure test record or report we used or plan to use as the basis for taking this action is as follows evaluationstatedistrict teststeacher feedbackcum fi le

Any other factors that are relevant to the action none at this time

The action will be initiated on _o111~1111i2~0~1lta2 _ _______

Your child bas procedural protections under IDEA These protections are explained in the Notice ofProcedural Safeguards for Special Education Students and Their Families If this prior written notice is given to you (l) as pat1 ofyour childs initial refemil for evaluation (2) as part of a request for reevaluation or (3) notice to you regarding disciplinary action that constitutes a change ofplacement the procedural safeguards accompanies th is notice If a copy of the Notice ofProceduml Safeguard~ for Special Education Students and Their Families is not enclosed and ym would Iike a copy or you would like help in understanding the content please contact

at

Page 11Prior Written Notice

-