STATE OF DELAWARE
Individualized Education Program (IEP) – PRE-SCHOOL
State of Delaware
School District
302-
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|Student Name: | | | |
|Student ID#: | |D.O.B.: | | |IEP Status | |
|Address: | | |Meeting Date | |Most Recent Evaluation | |
| | | | | |Summary Report Date | |
|City: | |State: | | | | | | |
|Zip: | |Cur| | |IEP Initiation | |
| | |ren| | |Date | |
| | |t | | | | |
| | |Gra| | | | |
| | |de:| | | | |
|Attending Building: | | |IEP End Date | |IEP Revision Date | |
|Disability Classification: | |Unless revised, this IEP is in effect for the school year including those |
| | |students eligible for longer school years because of disability |
| | |classification. |
|Parent 1: | | P | S | G | |
|Address (if different): | | |
|Phone (H): | |(W): | | |Temporary Placement |
|Cell: | |Email: | | |Agency | |
| | | | | |Representative: | |
|Parent 2: | | P | S | G | |Parent: | |
|Address (if different): | | |Date: | |
|Phone (H): | |(W): | | |Within 60 days, an IEP meeting must be held. |
|Cell: | |Email: | | | |
|P S G – check if parent, surrogate, or guardian | | |
|Meeting Participants |
|Role |Print Name |Signature |
|Parent 1 | | |
|Parent 2 | | |
|Student | | |
|General Ed. Teacher | | |
|Special Ed. Teacher | | |
|Administrator / Designee | | |
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|Data Considerations |
|1. What are the student’s strengths? |
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|2. What are the educational concerns of the parent (or student, if appropriate)? |
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|3. What multiple data sources (including district or statewide assessments) are being used to create this IEP? |
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|4. How are extracurricular and non-academic areas affected by the student’s disability? |
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|Other Factors to Consider: |
|IEP team must consider each of the factors. |
|If there is a need identified, check “yes” and address in the IEP. |
|Y |N | |
| | |Communication needs of the student |
| | |Braille instruction for students who are blind or visually impaired |
| | | Communication and language needs for students who are deaf/hard of hearing |
| | |Language needs for students with limited English proficiency |
| | |Positive behavior interventions, supports, and strategies for students whose behavior impedes learning |
| | | Need for assistive technology devices or services |
|IEP team must consider each of the following when determining the needs to be addressed within this IEP: |
|How is the student progressing in the general education curriculum (on grade-level)? |
|How does the child’s disability affect progress in the general education curriculum? |
|What are the child’s other educational needs that result from the child’s disability (e.g., organizational skills, self care, fine/gross motor)? |
|Unique Educational Needs and |A statement of the special education and related services and supplementary aids and services, based on peer-reviewed research to|
|Characteristics |the extent practicable, to be provided to the child, or on behalf of the child, and a statement of the program modifications or |
| |supports for school personnel. |
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|Services, Aids & Modifications |Start Date |Frequency |Duration |Location |
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|PLEP (Present Level of Educational Performance): |
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|Benchmark #1 | |Progress |[ m ] |[ y ] | |
| | | M |
| | | S |
| | | N |
|Narrative (Benchmark #1): |
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|Benchmark #2 | |Progress |[ m ] |[ y ] | |
| | | M |
| | | S |
| | | N |
|Narrative (Benchmark #2): |
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|Benchmark #3 | |Progress |[ m ] |[ y ] | |
| | | M |
| | | S |
| | | N |
|Narrative (Benchmark #3): |
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|Benchmark #4 | |Progress |[ m ] |[ y ] | |
| | | M |
| | | S |
| | | N |
|Narrative (Benchmark #4): |
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|Annual Goal: |
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|M – mastered annual goal |S – sufficient progress to meet annual goal |N – not sufficient progress to meet annual goal |
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|Therapist Signature: | |Date: | |(For Medicaid Cost Recovery) |
|Transportation |
|Special transportation needs? |YES |NO |
|If yes, specify: | | |
|It is necessary to place this student, who is transported from the school by bus into the charge of a |YES |NO |
|parent or other authorized responsible person. | | |
|Transportation Department will be notified by: | | |
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|Discipline |
|The student will adhere to School Code of Conduct. |
|(Check below if any of the following are needed): |
| |Interventions and supports are described under services/supports and/or in goals. |
| |Behavior intervention and support plan (see attached). |
| |Other: |
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|Consideration of Eligibility for Extended School Year Services (ESY) |
|IEP team must consider each of the following factors: |
|Regression / Recoupment |Vocational Skills |Degree of Impairment |
| |Breakthrough Skills |Extenuating Circumstances |
|Is ESY needed? |
| Yes | No | To Be Determined |
| ESY offered, but declined by parent |
|Rationale for decision: |
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|Specify goals and services: |
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| See attached page (if needed) |
|Educational Environments of Children with Disabilities Ages 3-5 |
|Use the option below to determine the appropriate setting and transfer the setting type to page 1 of the IEP. |
|(A) |Children Attending a Regular Early Childhood Program: a program that includes at least 50 percent children without disabilities. Attendance at|
| |an early childhood program need not be funded by IDEA, Part B funds. |
| |(A1) |In the regular early childhood program at least 80% of the time. |
| |(A2) |In the regular early childhood program 40% to 79% of the time. |
| |(A3) |In the regular early childhood program less than 40% of the time. |
|*Calculating Time: For A1-A3, a calculation is necessary to determine the percentage of time the child spends in a regular early childhood program. The numerator|
|is the amount of time per week the child spends in regular early childhood program. The denominator is the total number of hours the child spends in a regular |
|early childhood program PLUS any time the child is receiving special education and related services OUTSIDE of a regular early childhood program. The sum is |
|multiplied by 100. |
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|Numerator: = X 100 = % |
|Denominator: |
|(B) |Children not attending a regular early childhood program or kindergarten: a program that includes less then 50 percent children without |
| |disabilities. |
| |(B1) |Separate Class: children who attend a special education program in a class with less than 50% non-disabled children. |
| |(B2) |Separate School: children who receive special education in a public or private day school designed specifically for children with disabilities.|
| |(B3) |Residential Facility: children who receive special education in a publicly or privately operated residential school/facility on an inpatient |
| | |basis. |
| |(B4) |Home: children who receive special education and related services in the principal residence of the children’s family or caregivers and who did|
| | |not attend an early childhood program or a special education program provided in a separate class, school or residential facility. Include |
| | |children who receive special education both at home and in a service provider location. Caregiver can include a babysitter. |
| |(B5) |Service Provider Location: children who receive all of their special education and related services from a service provider and who did not |
| | |attend an early childhood program or a special education program and related services from a service provider and who did not attend an early |
| | |childhood program or a special education program provided in a separate class, separate school, or residential facility. Examples include |
| | |service in a private clinician’s office, hospital facility on an outpatient basis, library and other public location. Children who receive |
| | |special education both in a service provider location and at home should be reported in the home category. |
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|Student Parent Signatures |
| Yes | No |I acknowledge that I have received a copy of the Procedural Safeguards. My due process rights under those Procedural Safeguards |
| | |have been explained to me. |
| Yes | No |I agree with the program described in this document. |
| Yes | No |I agree with the placement decision as noted above and discussed at this meeting. |
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|Parent/Guardian/Surrogate/Student Signature Date |
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|Parent/Guardian/Surrogate/Student Signature Date |
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|If Parent Does Not Attend |
|Staff member below is responsible for forwarding a copy of the IEP and Procedural Safeguards and explaining content, if necessary to the Parent. |
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|Name Position Method of Contact |
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