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    1、INDIVIDUALIZED EDUCATION PROGRAM (IEP)PR-07 Rev. 7/01/05 Page of . Services PlanName Date of Birth Grade Level Male FemaleStudent Identification Number Child/Student Address Parent/Guardian Parent Address Home Phone Work Phone Effective IEP Dates from to Meeting Date Initial IEP Periodic ReviewDistr

    2、ict of Residence District of Service Step 1 Discuss future planning.(Family and student preferences and interests)Step 2 Discuss present levels of academic and functional performance.(What do we know about this child, and how does that relate in the context of content standards, or for preschool chi

    3、ldren, in the context ofappropriate activities and how the disability affects the students involvement in the general education curriculum.)INDIVIDUALIZED EDUCATION PROGRAM (IEP)PR-07 Rev. 7/01/05 Page of . Step 2 (cont.) Discuss present levels of academic and functional performance.(What do we know

    4、 about this child, and how does that relate in the context of content standards, or for preschool children, in the context ofappropriate activities and how the disability affects the students involvement in the general education curriculum.)INDIVIDUALIZED EDUCATION PROGRAM (IEP)PR-07 Rev. 7/01/05 Pa

    5、ge of . Annual Goals and Short-Term ObjectivesStep 3: Identify needs that require specially designed instructionStep 4: Identify measurable annual goals, including academic and functional goalsGoal # Content area addressed: Benchmarks or short-term objectivesStatement of Student ProgressStep 5: Iden

    6、tify servicesService: Initiation date: Expected duration: Frequency: (how often) Step 6: Determine least restrictive environmentDetermine where services will be providedINDIVIDUALIZED EDUCATION PROGRAM (IEP)PR-07 Rev. 7/01/05 Page of . Annual Goals and Short-Term ObjectivesStep 3: Identify needs tha

    7、t require specially designed instructionStep 4: Identify measurable annual goals, including academic and functional goalsGoal # Content area addressed: Benchmarks or short-term objectivesStatement of Student ProgressStep 5: Identify servicesService: Initiation date: Expected duration: Frequency: (ho

    8、w often) Step 6: Determine least restrictive environmentDetermine where services will be providedINDIVIDUALIZED EDUCATION PROGRAM (IEP)PR-07 Rev. 7/01/05 Page of . Annual Goals and Short-Term ObjectivesStep 3: Identify needs that require specially designed instructionStep 4: Identify measurable annu

    9、al goals, including academic and functional goalsGoal # Content area addressed: Benchmarks or short-term objectivesStatement of Student ProgressStep 5: Identify servicesService: Initiation date: Expected duration: Frequency: (how often) Step 6: Determine least restrictive environmentDetermine where

    10、services will be providedINDIVIDUALIZED EDUCATION PROGRAM (IEP)PR-07 Rev. 7/01/05 Page of . Annual Goals and Short-Term ObjectivesStep 3: Identify needs that require specially designed instructionStep 4: Identify measurable annual goals, including academic and functional goalsGoal # Content area add

    11、ressed: Benchmarks or short-term objectivesStatement of Student ProgressStep 5: Identify servicesService: Initiation date: Expected duration: Frequency: (how often) Step 6: Determine least restrictive environmentDetermine where services will be providedINDIVIDUALIZED EDUCATION PROGRAM (IEP)PR-07 Rev

    12、. 7/01/05 Page of . Special FactorsBased on discussions of the information provided regarding relevant special factors and other considerations as noted below, the following is applicable and incorporated into the IEP. Incorporated into IEP(Check box)Behavior: In the case of a student whose behavior

    13、 impedes his or her learning or that of others. Limited English proficiency (LEP)Children/students with visual impairments (See IEP page )Communication Deaf or hard of hearing Assistive technology services and devices Other ConsiderationsPhysical education Extended school year services Beginning at

    14、age 14transition service needs which focus on the students courses of study See IEP page Transition services statement, no later than age 16 See IEP page Testing and assessment programs, including proficiency tests See IEP page )Transfer of rights beginning at least one year before the student reach

    15、es the age of majority under state law (Ohio law is age 18)Relevant Information/Suggestions (e.g., medical information, other information):INDIVIDUALIZED EDUCATION PROGRAM (IEP)PR-07 Rev. 7/01/05 Page of . Children/Students with Visual ImpairmentsCHILD/STUDENT GRADE LEVEL SERVICE INSTRUCTIONS: This

    16、form shall be completed during the IEP meeting for each child/student who has a visual impairment, as defined by Ohios Amended Substitute House Bill Number 164, which requires a statement specifying one or more reading and writing media in which instruction is appropriate to meet the childs/students

    17、 educational needs. A copy of this completed form is part of, and must be attached to, the childs/students IEP form.Yes No1. Annual assessment of reading and writing skills was conducted with each child/student in all media considered appropriate. The results of these assessments are included in “Pr

    18、esent Levels of Development/Functioning/Performance” on the IEP and indicate both strengths and weaknesses. 2. The IEP contains a requirement for instruction in Braille reading and writing when that medium is appropriate and is indicated by adding “Standard English Braille” as a special service in S

    19、tep 4, listing the date initiated and the anticipated duration of services. 3. Instruction in Braille reading and writing was carefully considered for this child/student and pertinent literature describing the educational benefits of instruction in Braille reading and writing was reviewed by the per

    20、sons developing this childs/students IEP. 4. The following visual condition(s) was taken into account and discussed in making the above decision:Condition is degenerative and progressive loss is expected. Condition is currently unpredictable in nature and will be reviewed if change in visual conditi

    21、on is noted. Condition is temporary and expected to improve. Condition is stable and will be monitored. 5. Indicate the appropriate instructional mediaStandard English Braille Large Print Regular Print Tape/auditory Pre-reader 6. Complete if Braille reading and writing ARE appropriate at this timeAn

    22、nual goals provided Short-term objectives provided Date of initiation indicated Frequency and duration of instructional sessions indicated Level of competency to be achieved annually indicated Objective determinants used to measure achievement provided 7. Reasons Braille reading and writing ARE NOT

    23、appropriate this timeDocumented visual acuity allowing the choice of larger type/regular type Child/student is considered a pre-reader Other INDIVIDUALIZED EDUCATION PROGRAM (IEP)PR-07 Rev. 7/01/05 Page of . Statewide and Districtwide TestingStudent Name: Student Grade (when scheduled to take this t

    24、est): Student ID: School Year: IEP Meeting Date: STATEWIDE TESTING DISTRICTWIDE TESTINGAreas of Assessment Grade Level of Test to be AdministeredWill Take Test without IEP AccommodationsWill Take Test with IEP AccommodationsWill Participate inAlternate AssessmentGrade Level of Test to be Administere

    25、dWill Take Test without AccommodationsWill Take Test with AccommodationsWill Participate in Alternate AssessmentReading Writing Math Science Citizenship Technology ITAC A statement of why the child cannot participate in the regular assessment and will be taking alternate assessmentExcused from the c

    26、onsequences associated with not passing the test (Graduation Test) in the following area(s) of assessment:Met participation requirements (Graduation Tests) Yes No Date Area of Assessment List Accommodations to AssessmentArea of Assessment List AccommodationsReading Other (Specify) Writing Other (Spe

    27、cify) Math Other (Specify) Science Other (Specify) Citizenship Other (Specify) INDIVIDUALIZED EDUCATION PROGRAM (IEP)PR-07 Rev. 7/01/05 Page of . Name IEP summary for effective dates Date of next IEP review IEP Team Meeting ParticipantsCheck one of the following: This IEP team meeting was a Face to

    28、face meeting Video conference Telephone Conference/ Conference Call._ Participated Excused _ Participated Excused _ Participated Excused_ Participated Excused _ Participated Excused _ Participated Excused_ Participated Excused _ Participated Excused _ Participated Excused_ Participated Excused _ Par

    29、ticipated Excused _ Participated ExcusedSummary of special education services: Initial IEP I give consent to initiate special education and related services specified in this IEP.* I give consent to initiate special education and related services specified in this IEP except for * I do not give cons

    30、ent for special education services at this time.*Parent Signature Date: * This IEP serves as prior written notice if there is agreement.*If there is not agreement, the district must provide prior written notice to the parents.Parent Notice of Procedural Safeguards/Copy of the IEPI have received a co

    31、py of the parent notice of procedural safeguards for the current year.Parent has requested and received a copy of the IEPParent Signature Date: Note: The student receives notice of procedural safeguards at least one year prior to his/her 18th birthday. Student Signature Date: Consent for Change in P

    32、lacement I give consent for the change of placement as identified in this IEP.* I give consent for the special education and related services specified in this IEP except for * I do not give consent for a change of placement as identified in this IEP. I revoke consent for Special Education service.P

    33、arent Signature Date: * This IEP serves as prior written notice if there is agreement.*If there is not agreement, the district must provide prior written notice to the parents.Periodic Review Agreement I am signing to show my attendance/participated at the IEP team meeting but I do not agree with th

    34、e special education and related services specified in this IEP I give consent to implement this IEP and I agree with this IEP.Signature _ Date: _ _Reason for Placement in Separate Facility (If applicable)Having considered the continuum of services and the needs of the student, this IEP team has decided that placement in a separate facility is appropriate because:

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