STUDENT NAME: Jane Doe

DISABILITY CLASSIFICATION: Learning Disability

DATE OF BIRTH: 7/7/2000
LOCAL ID #: 5555555
PROJECTED DATE IEP IS TO BE
PROJECTED DATE OF ANNUAL REVIEW:05/19/2016
IMPLEMENTED:02/13/2015
STUDENT NAME: Jane Doe

NYC ID:5555555
PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL NEEDS

DOCUMENTATION OF STUDENT'S CURRENT PERFORMANCE AND ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS

EVALUATION RESULTS (INCLUDING FOR SCHOOL-AGE STUDENTS, PERFORMANCE ON STATE AND DISTRICTWIDE ASSESSMENTS)
ELA State Exam 2014
Present Level 2
Proficiency Rating- 2.90
Growth Rate- 77%
Scale Score 300
MATHEMATICS State Exam 2014
Present Level- 2
Proficiency Rating- 2.57
Growth Rate- 24%
Scale Score- 324
ACADEMIC ACHIEVEMENT, FUNCTIONAL PERFORMANCE AND LEARNING CHARACTERISTICS
LEVELS OF KNOWLEDGE AND DEVELOPMENT IN SUBJECT AND SKILL AREAS INCLUDING ACTIVITIES OF DAILY
LIVING, LEVEL OF INTELLECTUAL FUNCTIONING, ADAPTIVE BEHAVIOR, EXPECTED RATE OF PROGRESS IN
ACQUIRING SKILLS AND INFORMATION, AND LEARNING STYLE:
In ELA, based on the Independent Reading Level Assessment Framework Jane Doe is reading on a 3rd grade level. This
demonstrates that Jane Doe has mastered common core reading standards up to grade 3. She is currently struggling
with skills that incorporate acquiring and using grade level academic language and word usage. When asked to use
textual evidence to explain her ideas with a grade level text, Jane Doe demonstrates challenges to achieve this task on
her own and requires supports in the form of scaffolded questions and graphic organizers. In reading, Jane Doe
demonstrates challenges with making inferences and drawing conclusions. In the ICT ELA classroom, often Jane Doe
demonstrates a lack of focus. She is very easily distracted and requires frequent monitoring to complete classroom tasks.

PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL NEEDS

DOCUMENTATION OF STUDENT'S CURRENT PERFORMANCE AND ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS

Jane Doe is able to work in small groups, but often requires re-direction to stay on task. When Jane Doe is focused she
is able to form accurate conclusions after reading texts on her independent reading level and can respond to questions
verbally and in written form. In writing Jane Doe struggles with structuring essays and short responses. Currently Jane
Doe has shown progress using the R.A.C.E formula to respond to short assessment questions. Essay writing is still a
challenge. Jane Doe benefits from using graphic organizers that outline where to place transition words, details and
explanations within a paragraph. Jane Doe has trouble completing and turning in H.W. assignments and benefits from the
reinforcement and monitoring of her school planner to stay organized and to build responsibility appropriate for middle
school.
MATHEMATICS
Jane Doe is a 6th grade student who does not particularly enjoy Mathematics. Jane Doe has had difficulty grasping the
grade level curriculum. Jane Doe has basic addition and subtraction skills. However, when subtracting numbers with
regrouping, Jane Doe is more likely to make errors. Jane Doe still requires practice with her multiplication and division
skills. Jane Doe was given flash cards to practice her multiplication and division skills. Therefore, Jane Doe was not able
to master topics such as finding the GCF and LCM. Jane Doe is constantly distracted in class. Jane Doe had difficulty
with fraction and decimal operations as well. Jane Doe was able to multiply simple fractions, however, when she was
instructed to convert mixed numbers and improper fractions before multiplying, there were many errors. Jane Doe was
able to follow the steps for dividing fractions and again, with simple fractions, she was able to display some success.
Jane Doe is often distracted in class. Due to the constant lack of focus, Jane Doe struggles with task completion. Jane
Doe is quite talkative in class and could show more progress if she would prioritize and stay focused.
SCIENCE
Jane Doe shows willingness to learn new concepts. She comes to science class prepared and ready to work. She greatly
benefits from working one on one with a teacher or in small groups with a teacher. It is helpful for Jane Doe when
instructions are broken down into clear and simple steps. Graphic organizers that chunk or section pieces of information
help Jane Doe to understand complex material. Embedded questions in chunked reading material help Jane Doe to stay
focused when reading. Jane Doe follows teacher instructions and explanation. Jane Doe is mostly well mannered and
respectful; she remains on task with frequent teacher check-ins to ensure focus and understanding. Jane Doe benefits
from additional time to complete her assignments. Jane Doe is able to comprehend scientific texts while using vocabulary
reference sources like a textbook. She also benefits from diagrams and images that portray scientific ideas and concepts,
as well as real world- science curriculum examples.
STUDENT STRENGTHS, PREFERENCES, INTERESTS:

PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL NEEDS

DOCUMENTATION OF STUDENT'S CURRENT PERFORMANCE AND ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS

Jane Doe enjoys school, she expresses a desire to learn and likes learning. Her favorite classes include, science, math,
ELA and PE class. She feels like she enjoys the social aspect of school, she has many friends in her class. Jane Doe's
extra curricular activities include dance and cheerleading. Jane Doe also enjoys spending time with her family and is
looking forwards to this summer vacation as her family has planned trips. Jane Doe plays in the school orchestra and
enjoys learning the viola.
ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS OF THE STUDENT, INCLUDING CONSIDERATION OF
STUDENT NEEDS THAT ARE OF CONCERN TO THE PARENT:
Mom is trying to make an appointment with a psychologist but is having difficulty finding someone. Mom needs a referral
for an independent psychologist.
2013, Jane Doe saw a psychologist who recommender her to not be on medication ADHD, mom feels like Jane Doe
would benefit from being on medication now.
Did she receive a promotion in doubt for this year?
Jane Doe would greatly benefit from a tutor outside of school. She requires some one-to-one instruction.
Mom feels that Jane Doe is struggling at in the ICT classes with SETSS services. At home, Jane Doe becomes distracted
when attempting to do homework more so then previous years. Mom would like Jane Doe to continue with ICT class and
SETSS services and add medication.
SOCIAL DEVELOPMENT
THE DEGREE (EXTENT) AND QUALITY OF THE STUDENTS RELATIONSHIPS WITH PEERS AND ADULTS;
FEELINGS ABOUT SELF; AND SOCIAL ADJUSTMENT TO SCHOOL AND COMMUNITY ENVIRONMENTS:
Jane Doe gets along well her peers and the staff in the school.
STUDENT STRENGTHS:
Jane Doe is a very social young lady. Jane Doe participates in school events like the school talent show, she preformed a
cheerleading routine with other girls in the school. She also participates in school concerts.
SOCIAL DEVELOPMENT NEEDS OF THE STUDENT, INCLUDING CONSIDERATION OF STUDENT NEEDS THAT
ARE OF CONCERN TO THE PARENT:
Jane Doe is very socially. It is easy for her to make friends. Mom is concerned that Jane Doe play fights with other
students and can get carried away but mom speaks to her about this frequently.
PHYSICAL DEVELOPMENT
THE DEGREE (EXTENT) AND QUALITY OF THE STUDENTS MOTOR AND SENSORY DEVELOPMENT, HEALTH,

PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL NEEDS

DOCUMENTATION OF STUDENT'S CURRENT PERFORMANCE AND ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS

VITALITY AND PHYSICAL SKILLS OR LIMITATIONS WHICH PERTAIN TO THE LEARNING PROCESS:
Jane Doe has been diagnosed with Attention Deficit/ Hyperactivity Disorder (ADHD). She does not currently take
medication. Jane Doe is otherwise reported to be in good health.
STUDENT STRENGTHS:
Jane Doe participates willingly in class and sports activities. She likes to dance and participates in extracurricular
activities.
PHYSICAL DEVELOPMENT NEEDS OF THE STUDENT, INCLUDING CONSIDERATION OF STUDENT NEEDS THAT
ARE OF CONCERN TO THE PARENT:
No concerns at this time.
MANAGEMENT NEEDS
THE NATURE (TYPE) AND DEGREE (EXTENT) TO WHICH ENVIRONMENTAL AND HUMAN OR MATERIAL
RESOURCES ARE NEEDED TO ADDRESS NEEDS IDENTIFIED ABOVE:
During classroom lessons, Jane Doe requires:
-small group instructions
-repeated directions
-on-task focusing prompts
-repeated directions
-breaks
-visual aids
-scaffolding to write extended response questions
-extended time to complete questions
EFFECT OF STUDENT NEEDS ON INVOLVEMENT AND PROGRESS IN THE GENERAL EDUCATION
CURRICULUM OR, FOR A PRESCHOOL STUDENT, EFFECT OF STUDENT NEEDS ON PARTICIPATION IN
APPROPRIATE ACTIVITES
Jane Doe continue to in a general education setting with the structure and support provided in an ICT setting with where
she can access more small group interaction and individual support throughout the day.
STUDENT NAME: Jane Doe

NYC ID:555555

STUDENT NEEDS RELATING TO SPECIAL FACTORS

BASED ON THE IDENTIFICATION OF THE STUDENT'S NEEDS, THE COMMITTEE MUST CONSIDER WHETHER THE STUDENT NEEDS
A PARTICULAR DEVICE OR SERVICE TO ADDRESS THE SPECIAL FACTORS AS INDICATED BELOW, AND IF SO, THE APPROPRIATE
SECTION OF THE IEP MUST IDENTIFY THE PARTICULAR DEVICE OR SERVICE(S) NEEDED:

Does the student need strategies, including positive behavioral interventions, supports and other strategies to address
behaviors that impede the student's learning or that of others?
Yes
No
Does the student need a behavioral intervention plan?

No

Yes

For a student with limited English proficiency, does she need a special education service to address her language needs
as they relate to the IEP?
Yes
No
Not Applicable
For a student who is blind or visually impaired, does she need instruction in Braille and the use of Braille?
No

Yes

Not Applicable

Does the student need a particular device or service to address her communication needs?

Yes

No

In the case of a student who is deaf or hard of hearing, does the student need a particular device or service in
consideration of the student's language and communication needs, opportunities for direct communications with peers
and professional personnel in the student's language and communication mode, academic level, and full range of needs,
including opportunities for direct instruction in the student's language and communication mode?
Yes
No
Not Applicable
Does the student need an assistive technology device and/or service?

Yes

No

If yes, does the Committee recommend that the device(s) be used in the student's home?

STUDENT NAME: Jane Doe

Yes

No

NYC ID:555555

BEGINNING NOT LATER THAN THE FIRST

DETERMINED APPROPRIATE)

IEP TO BE IN EFFECT WHEN THE STUDENT IS AGE 15 (AND AT A YOUNGER AGE IF

MEASURABLE POSTSECONDARY GOALS

LONG-TERM GOALS FOR LIVING, WORKING AND LEARNING AS AN ADULT

EDUCATION/TRAINING:
EMPLOYMENT:
INDEPENDENT LIVING SKILLS (WHEN APPROPRIATE):
TRANSITION NEEDS
In consideration of present levels of performance, transition service needs of the student that focus on the student's
courses of study, taking into account the students strengths, preferences and interests as they relate to transition from
school to post-school activities:
STUDENT NAME: Jane Doe

NYC ID:555555
MEASURABLE ANNUAL GOALS

THE FOLLOWING GOALS ARE RECOMMENDED TO ENABLE THE STUDENT TO BE INVOLVED IN AND
PROGRESS IN THE GENERAL EDUCATION CURRICULUM, ADDRESS OTHER EDUCATIONAL NEEDS THAT
RESULT FROM THE STUDENT'S DISABILITY, AND PREPARE THE STUDENT TO MEET HIS/HER
POSTSECONDARY GOALS.

ANNUAL GOALS
WHAT THE STUDENT WILL BE EXPECTED
TO ACHIEVE BY THE END OF THE YEAR
IN WHICH THE IEP IS IN EFFECT

SCIENCE
Determine the central ideas or
conclusions of a text; provide an
accurate summary of the text distinct
from prior knowledge or opinions.
ANNUAL GOALS

CRITERIA
MEASURE TO
DETERMINE IF
GOAL HAS
BEEN
ACHIEVED

60% Accuracy

METHOD
HOW PROGRESS WILL BE
MEASURED

SCHEDULE
WHEN PROGRESS WILL BE
MEASURED

Teacher Made Materials

Verbal Explanation
Teacher/Provider Observations

1 time per quarter

CRITERIA

METHOD

SCHEDULE

WHAT THE STUDENT WILL BE EXPECTED TO

ACHIEVE BY THE END OF THE YEAR IN WHICH THE
IEP IS IN EFFECT

MEASURE TO
DETERMINE IF
GOAL HAS BEEN
ACHIEVED

SCIENCE
Determine the meaning of symbols, key terms,
and other domain-specific words and phrases as 60 % Accuracy
they are used in a specific scientific or technical
context relevant to grades 6-8 texts and topics.

ANNUAL GOALS
WHAT THE STUDENT WILL BE EXPECTED TO
ACHIEVE BY THE END OF THE YEAR IN WHICH
THE IEP IS IN EFFECT

CRITERIA
MEASURE TO
DETERMINE IF
GOAL HAS BEEN
ACHIEVED

Common Core ELA

In one year Jane Doe will be able to determine
the meaning of words and phrases as they are
used in a text, including figurative, connotative, 75% Accuracy
and technical meanings. She will demonstrate
this skill by reading a grade level text and
identifying a new or unfamiliar word, she will
then use context clues or similar strategies to
determine the meaning.

ANNUAL GOALS
WHAT THE STUDENT WILL BE EXPECTED TO
ACHIEVE BY THE END OF THE YEAR IN WHICH
THE IEP IS IN EFFECT

Common Core ELA

CRITERIA
MEASURE TO
DETERMINE IF
GOAL HAS BEEN
ACHIEVED

HOW
PROGRESS
WILL BE
MEASURED

Teacher Made
Materials
Teacher/Provide
r Observations
Verbal
Explanation

METHOD
HOW PROGRESS WILL
BE MEASURED

Teacher Made
Materials
Class Activities
Teacher/Provider
Observations
Performance
Assessment Task

METHOD
HOW PROGRESS WILL
BE MEASURED

7 out of 10 trials for Teacher Made

WHEN PROGRESS WILL BE

MEASURED

1 time per quarter

SCHEDULE
WHEN PROGRESS WILL BE
MEASURED

1 time per quarter

SCHEDULE
WHEN PROGRESS WILL BE
MEASURED

1 time per quarter

In one year with support as needed, Jane Doe

will be able to ask and answer questions to
demonstrate understanding of a grade level
32 weeks
text. She will demonstrate this skill by referring
explicitly to the text as the basis for the
answers.

ANNUAL GOALS
WHAT THE STUDENT WILL BE EXPECTED TO
ACHIEVE BY THE END OF THE YEAR IN WHICH
THE IEP IS IN EFFECT

CRITERIA
MEASURE TO
DETERMINE IF
GOAL HAS BEEN
ACHIEVED

ELA Common Core- Writing

In one year with with guidance and support,
Jane Doe will be able to develop and
3 out of 5 trials for
strengthen her writing by planning, revising,
32 weeks
editing, rewriting, or trying a new approach.
She will demonstrate this skill by constructing
an essay on a grade level topic and
completing all 5 stages of the writing process.

ANNUAL GOALS
WHAT THE STUDENT WILL BE EXPECTED TO
ACHIEVE BY THE END OF THE YEAR IN WHICH
THE IEP IS IN EFFECT

CRITERIA
MEASURE TO
DETERMINE IF
GOAL HAS BEEN
ACHIEVED

MATHEMATICS
60% Accuracy
Within one academic school year, Jane Doe
will be able to develop an understanding of
fractions as numbers. Jane Doe will be able to
represent fractions on a number line, identify
equivalent fractions and compare fractions.
Jane Doe will also be able to demonstrate the

Materials
Class Activities
Teacher/Provider
Observations
Performance
Assessment Task

METHOD
HOW PROGRESS WILL
BE MEASURED

Teacher Made
Materials
Class Activities
Teacher/Provider
Observations
Performance
Assessment Task

METHOD
HOW PROGRESS WILL
BE MEASURED

Teacher Made
Materials
Teacher/Provider
Observations
Class Activities
Performance
Assessment Task

SCHEDULE
WHEN PROGRESS WILL BE
MEASURED

1 time per quarter

SCHEDULE
WHEN PROGRESS WILL BE
MEASURED

1 time per quarter

rules for multiplying and dividing fractions.

ANNUAL GOALS
WHAT THE STUDENT WILL BE EXPECTED TO
ACHIEVE BY THE END OF THE YEAR IN WHICH
THE IEP IS IN EFFECT

CRITERIA
MEASURE TO
DETERMINE IF
GOAL HAS BEEN
ACHIEVED

MATHEMATICS
Within one academic school year, Jane Doe
will be able to increase her ability to select and
60% Accuracy
apply mathematical operations in a variety of
contexts to compute whole numbers, fractions,
decimals and integers.

ANNUAL GOALS
WHAT THE STUDENT WILL BE EXPECTED TO
ACHIEVE BY THE END OF THE YEAR IN WHICH
THE IEP IS IN EFFECT

MATHEMATICS
Within one academic school year, Jane Doe
will increase her multiplication and division
skills. Jane Doe will be able to apply her
multiplication and division skills to perform
grade level tasks including finding the GCF
and LCM, order of operations and operations
with fractions.
ANNUAL GOALS
WHAT THE STUDENT WILL BE EXPECTED TO
ACHIEVE BY THE END OF THE YEAR IN
WHICH THE IEP IS IN EFFECT

CRITERIA
MEASURE TO
DETERMINE IF
GOAL HAS BEEN
ACHIEVED

60% Accuracy

CRITERIA
MEASURE
TO
DETERMINE
IF GOAL HAS
BEEN

METHOD
HOW PROGRESS WILL
BE MEASURED

Teacher Made
Materials
Class Activities
Teacher/Provider
Observations
Performance
Assessment Task

METHOD
HOW PROGRESS WILL
BE MEASURED

Teacher Made
Materials
Class Activities
Teacher/Provider
Observations
Performance
Assessment Task

METHOD
HOW PROGRESS
WILL BE MEASURED

SCHEDULE
WHEN PROGRESS WILL BE
MEASURED

1 time per quarter

SCHEDULE
WHEN PROGRESS WILL BE
MEASURED

1 time per quarter

SCHEDULE
WHEN PROGRESS WILL BE MEASURED

ACHIEVED

Counseling:
Within one year, Jane Doe will improve
her communication skills as demonstrated 3 out of 4
by expressing her thoughts and feelings trials
without the use of foul and/or abusive
language.
ANNUAL GOALS
WHAT THE STUDENT WILL BE EXPECTED TO
ACHIEVE BY THE END OF THE YEAR IN WHICH
THE IEP IS IN EFFECT

Check Lists
Verbal Explanation
Performance
Assessment Task
Teacher/Provider
Observations

CRITERIA
MEASURE TO DETERMINE
IF GOAL HAS BEEN
ACHIEVED

Counseling:
Within one year, Jane Doe will improve her
conflict resolution skills as demonstrated by 1)
calmly and rationally identifying the core issue
that is upsetting to her; 2) calmly and rationally
3 out of 5 trials
discussing her feelings about the same issue;
3) patiently and actively listening to the other
person's point of view; 4) actively engaging in
a process of establishing a mutually agreeable
solution to the identified problem.

METHOD
HOW PROGRESS WILL
BE MEASURED

Check Lists
Verbal Explanation
Journal or written
statemant
Performance
Assessment Task
Teacher/Provider
Observations

STUDENT NAME: Jane Doe

1 time per quarter

SCHEDULE
WHEN PROGRESS WILL BE
MEASURED

1 time per quarter

NYC ID: 555555

REPORTING PROGRESS TO PARENTS

Identify when periodic reports on the student's progress toward meeting the annual goals will be provided to the students
parents:
at the same time school report cards are issued
STUDENT NAME: Jane Doe

NYC ID:555555

RECOMMENDED SPECIAL EDUCATION PROGRAMS AND SERVICES

SPECIAL EDUCATION
PROGRAM/SERVICES

SERVICE DELIVERY FREQUENCY

RECOMMENDATION HOW OFTEN
S*
PROVIDED

DURATION
LENGTH OF
SESSION

LOCATION
WHERE SERVICE
WILL BE PROVIDED

PROJECTED
BEGINNING /
SERVICE DATE(S)

SPECIAL EDUCATION PROGRAM:

Integrated Co-Teaching
Services
ELA
Integrated Co-Teaching
Services
Math
Integrated Co-Teaching
Services
Sciences
Special Education Teacher
Support Services [SETSS]
Math
Special Education Teacher
Support Services [SETSS]
ELA

Language of
Service: English

5 time(s)
per week

Period

General Education 05/13/2015

Classroom

Language of
Service: English

5 time(s)
per week

Period

General Education 05/13/2015

Classroom

Language of
Service: English

3 time(s)
per week

Period

General Education 05/13/2015

Classroom

Direct Service
Group service
Language of
Service: English
Direct Service
Group service
Language of
Service: English

3 time(s)
per week

Period

Special Education 05/13/2015

Classroom

2 time(s)
per week

Period

Special Education 05/21/2015

Classroom

Group service
Language of
Service: English

1 time(s)
per week

30 minutes

Separate
05/13/2015
Location Counselor
's ofiice

RELATED SERVICES:

Counseling Services

SUPPLEMENTARY AIDS AND

SERVICES/PROGRAM
MODIFICATIONS/ACCOMMODATION
S:

RECOMMENDED SPECIAL EDUCATION PROGRAMS AND SERVICES

ASSISTIVE TECHNOLOGY DEVICES
AND/OR SERVICES:
SUPPORTS FOR SCHOOL
PERSONNEL ON BEHALF OF THE
STUDENT:

* Identify, if applicable, class size (maximum student-to-staff ratio), language if other than English, group or individual
services, direct and/or indirect consultant teacher services or other service delivery recommendations.
STUDENT NAME: Jane Doe

NYC ID:555555

12-MONTH SERVICE AND/OR PROGRAM - Student is eligible to receive special education services and/or program
during July/August:
No
Yes
If yes:
*
Student will receive the same special education program/services as recommended above.
OR
Student will receive the following special education program/services:

SPECIAL EDUCATION
PROGRAM/SERVICES

SERVICE DELIVERY
RECOMMENDATIONS FREQUENCY

DURATION

Name of school/agency provider of services during July and August:

For a preschool student, reason(s) the child requires services during July and August:

LOCATION

PROJECTED
BEGINNING /
SERVICE
DATE(S)

STUDENT NAME: Jane Doe

NYC ID:555555

TESTING ACCOMMODATIONS (TO BE COMPLETED FOR PRESCHOOL CHILDREN ONLY IF THERE IS AN ASSESSMENT PROGRAM
FOR NONDISABLED PRESCHOOL CHILDREN): INDIVIDUAL TESTING ACCOMMODATIONS, SPECIFIC TO THE STUDENTS DISABILITY
AND NEEDS, TO BE USED CONSISTENTLY BY THE STUDENT IN THE RECOMMENDED EDUCATIONAL PROGRAM AND IN THE
ADMINISTRATION OF DISTRICT-WIDE ASSESSMENTS OF STUDENT ACHIEVEMENT AND, IN ACCORDANCE WITH DEPARTMENT
POLICY, STATE ASSESSMENTS OF STUDENT ACHIEVEMENT.
TESTING ACCOMMODATIONS

CONDITIONS*

IMPLEMENTATION
RECOMMENDATIONS**

NONE

Extended Time

Revised Test Directions

Separate Location/Room

In all Exams including New York State

exams
In all Exams including New York State
In all Exams including New York State
with the exception of the ELA exam
where intended to assess reading skills
In all Exams including New York State
In all Exams including New York State

On-Task Focusing Prompts

In all Exams including New York State

Breaks
Revised Test Format

Time extended by 50%

Breaks given as needed.
Questions read and reread aloud to
student
Questions read aloud to student
Jane Doe needs an area with less
distractions in order to focus and
access her testing accommodations
On-Tasks focusing prompts as needed.

*Conditions Test Characteristics: Describe the type, length, purpose of the test upon which the use of testing
accommodations is conditioned, if applicable.
**Implementation Recommendations: Identify the amount of extended time, type of setting, etc., specific to the testing
accommodations, if applicable.
STUDENT NAME: Jane Doe

NYC ID:555555

BEGINNING NOT LATER THAN THE FIRST IEP TO BE IN EFFECT WHEN THE STUDENT IS AGE 15 (AND AT A YOUNGER AGE, IF
DETERMINED APPROPRIATE).
COORDINATED SET OF TRANSITION ACTIVITIES
NEEDED ACTIVITIES TO FACILITATE THE
STUDENTS MOVEMENT FROM SCHOOL
TO POST-SCHOOL ACTIVITIES

SERVICE/ACTIVITY

SCHOOL DISTRICT/AGENCY
RESPONSIBLE

Instruction
Related Services
Community Experiences
Development of Employment and
Other Post-school Adult Living
Objectives
Acquisition of Daily Living Skills (if
applicable)
Functional Vocational Assessment (if
applicable)
STUDENT NAME: Jane Doe

NYC ID:555555

PARTICIPATE IN STATE AND DISTRICT-WIDE ASSESSMENTS

(TO BE COMPLETED FOR PRESCHOOL STUDENTS ONLY IF THERE IS AN ASSESSMENT PROGRAM FOR NONDISABLED
PRESCHOOL STUDENTS)

The student will participate in the same State and district-wide assessments of student achievement that are
administered to general education students.
The student will participate in an alternate assessment on a particular State or district-wide assessment of
student achievement.
STUDENT NAME: Jane Doe

NYC ID:555555

PARTICIPATION WITH STUDENTS WITHOUT DISABILITIES

REMOVAL FROM THE GENERAL EDUCATION ENVIRONMENT OCCURS ONLY WHEN THE NATURE OR SEVERITY
OF THE DISABILITY IS SUCH THAT, EVEN WITH THE USE OF SUPPLEMENTARY AIDS AND SERVICES,
EDUCATION CANNOT BE SATISFACTORILY ACHIEVED.
FOR THE PRESCHOOL STUDENT:
Explain the extent, if any, to which the student will not participate in appropriate activities with age-appropriate
nondisabled peers (e.g., percent of the school day and/or specify particular activities):
FOR THE SCHOOL-AGE STUDENT:
Explain the extent, if any, to which the student will not participate in regular class, extracurricular and other
nonacademic activities (e.g., percent of the school day and/or specify particular activities):
If the student is not participating in a regular physical education program, identify the extent to which the student will
participate in specially-designed instruction in physical education, including adapted physical education:
EXEMPTION FROM LANGUAGE OTHER THAN ENGLISH DIPLOMA REQUIREMENT:
No
Yes - The Committee has determined that the student's disability adversely affects his/her ability to learn
a language and recommends the student be exempt from the language other than English requirement.
STUDENT NAME: Jane Doe

NYC ID:555555

SPECIAL TRANSPORTATION
TRANSPORTATION RECOMMENDATION TO ADDRESS NEEDS OF THE STUDENT RELATING TO HIS/HER DISABILITY

None.
Student needs special transportation accommodations/services as follows:
Student needs transportation to and from special classes or programs at another site:
PLACEMENT RECOMMENDATION

SPECIAL TRANSPORTATION
TRANSPORTATION RECOMMENDATION TO ADDRESS NEEDS OF THE STUDENT RELATING TO HIS/HER DISABILITY

NYC DOE Community School

SUMMARY
STUDENT INFORMATION

Student Name: Jane Doe

NYC ID: 555555
DOB: 7/7/2000
Gender: Female
Parents Language(s) Spoken/Mode Communication: English
IEP INFORMATION

Date of IEP Meeting: 05/21/2015

IEP Amendment:
Yes
No
Reconvene of IEP Meeting:

Yes

No

INSTRUCTIONAL/FUNCTIONAL LEVELS

Reading:4th Grade
Math:3rd Grade
SUMMARY OF RECOMMENDATIONS

Classification of Disability: Other Health Impairment

Recommended Services:
Special Education Programs

Special Education Teacher Support Services [SETSS]

Integrated Co-Teaching Services
Integrated Co-Teaching Services
Integrated Co-Teaching Services
Special Education Teacher Support Services [SETSS]
Related Services

English
English
English
English
English

Counseling Services

English

12-Month Services:

The student will participate in the same State and district-wide assessments of student achievement that are administered
to general education students.
Does Jane Doe have a Behavioral Intervention Plan? No
Recommended for Specialized Transportation:
None

Student needs specialized transportation

School Type: NYC DOE Community School

Medical Alert: The student has
medical conditions and/or
behavior and/or

physical limitations which affect her

learning,

participation in school activities.

The student requires

medical and/or

health care treatment(s) or procedure(s) during the school day.

PROMOTION CRITERIA
CURRENT YEAR

Standard

Modified

Multiple Criteria and Modification of Achievement of

Performance Standards

English Language Arts ("ELA") The student Jane

Math The student Jane Doe must meet 50 % of

Doe must meet 50 % of the 6 grade

Standards must be the 6 grade
Standards must be mastered as evidenced
mastered as evidenced by student work, teacher
by student work, teacher observation, assessments/grades,
observation, assessments/grades, and attendance.
and attendance.
NEXT YEAR

Standard

Modified

Multiple Criteria and Modification of Achievement of

Performance Standards

PROMOTION CRITERIA

English Language Arts ("ELA") The student Jane

Math The student Jane Doe must meet 50 % of

Doe must meet 50 % of the 7 grade

Standards must be the 7 grade
Standards must be mastered as evidenced
mastered as evidenced by student work, teacher
by student work, teacher observation, assessments/grades,
observation, assessments/grades, and attendance.
and attendance.
Parent Concerns:
OTHER OPTIONS CONSIDERED

Special Education Teacher Support Services

Integrated Co-teaching
Counseling Services
Reason(s) for Rejection: Jane Doe McCall's needs can be met with special education teacher support services in the
general education classroom.

ATTENDANCE PAGE

PLEASE NOTE THAT YOUR SIGNATURE REFLECTS YOUR PARTICIPATION AT THE CONFERENCE AND DOES
NOT NECESSARILY INDICATE AGREEMENT WITH THE INDIVIDUALIZED EDUCATION PROGRAM.
ROLE (INDICATE IF BILINGUAL)
NAME
SIGNATURE