IEP Cover Sheet



IEP Conference Summary Report Cover Sheet

(Indicate the pages included with this IEP conference report by circling the letter to the right. Be sure to indicate the number of goal sheets

(Form I), as well as the number of IEP Progress Report pages (Form W) included.

|STUDENT’S LAST NAME |

|      |

|FIRST NAME |

|      |

|STUDENT'S DATE OF BIRTH (Month/Day/Year) |

|      |

|DATE OF CONFERENCE / AMENDED IEP |

|      |

|PERSON COMPLETING REPORT (Name/Title) |

|      |

Check if Tracking form sent to

BASSC

Check if H13 form completed

and sent to BASSC

-----------------------

BASSC

|Referral for Consideration for Need of Special Education Evaluation |A1 |

|Referral Documentation |A2 |

|Parent/Guardian Notification of Decision Regarding Request for an Evaluation |A3 |

|IEP Conference Request Form |B |

|Parent/Guardian Notification of Conference |C |

|IEP Conference Data Form |D |

|Identification of Needed Assessments |E1 |

|Parent/Guardian Consent for Initial Evaluation |E2 |

|Parent/Guardian Consent for Re-evaluation |E3 |

|Documentation of Evaluation Results |F1 |

|Eligibility Determination (all disabilities other than Specific Learning Dis.) |F2 |

|Documentation of Intervention/Evaluation Results (Specific Learning Dis.) |F3 |

|Data Chart – Report of Performance (Reading, Writing, Math) |F4 |

|Eligibility Determination (Specific Learning Disability)-1 |F5 |

|Eligibility Determination (Specific Learning Disability)-2 |F6 |

|Present Levels of Academic Achievement and Functional Performance – 1 |G1 |

|Present Levels of Academic Achievement and Functional Performance – 2 |G2 |

|Secondary Transition |H1/H13 |

|Transition Services (Address by age 14 ½ ) |H2 |

|_____# pages: Measurable Annual Goals with Short Term Objectives/Benchmarks |I |

|Functional Behavioral Assessment |J1 |

|Behavioral Intervention Plan – 1 |J2 |

|Behavioral Intervention Plan – 2 |J3 |

|Educational Accommodations and Supports |K1 |

|Educational Services and Placements |K2 |

|Educational Services and Placements – Transportation |K3 |

|Assessment |L |

|Parent/Guardian Consent for Initial Provision of Special and Related Services |M |

|Extended School Year (ESY) Plan |N |

|Parent/Guardian Notification of Conference Recommendations |O |

|Manifestation Determination (as appropriate) |Q |

|+ |R |

| | |

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|CJU[pic]1jh£3ÅCJOJPJQJU[pic]^JmHnHo([pic]u[pic][?]?jParent/Guardian and Student Notification Transfer of Rights Due to | |

|Age of Majority | |

|Consent for Release of Confidential Information |T |

|Home/Hospital Instruction Program Referral & Medical Certification Form |U1 |

|Home/Hospital Instruction Individualized Education Program Form |U2 |

|Additional Notes |V |

|_____ Report of Progress on Annual Goals (Option 1) |W |

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