INDIVIDUALIZED EDUCATION PROGRAM (IEP)

SAU or CDS Site: School

Date IEP Sent to Parent:

1. CHILD INFORMATION

Child’s Name: Student X Annual Date of IEP Meeting: 5/10/2017

Date of Birth: Age: 12 Effective Date of IEP: 5/20/2017

School/Program: Grade: 5th Date of Next Annual IEP Meeting: 5/9/2018

Parent/Guardian name: Date of Re-Evaluation: 5/9/2019
Child’s Address: Date(s) of Amended IEP:
City, State, ZIP: Case Manager: Ross G.

State Agency Client? ☐ YES ☒ NO

2. DISABILITY
☐ Autism ☐ Deaf- Blindness ☐ Deafness ☐ Developmental Delay (3-5)
☐ Developmental Delay (Kindergarten) ☐ Emotional Disturbance ☐ Hearing Impairment ☒ Intellectual Disability

☐ Visual Impairment (including Blindness) ☐ Other Health Impairment ☐ Orthopedic Impairment ☐ Speech or Language Impairment

☐ Specific Learning Disability ☐ Traumatic Brain Injury ☐ Multiple Disability (list concomitant disabilities)

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3. CONSIDERATIONS – INCLUDING SPECIAL FACTORS

A. Concerns of the parents for enhancing the education of their child (MUSER IX.3.C.(1)(b)):
Student X’s parents are concerned with the fact that X can’t make friends. They are worried about his education and want to see him like coming to school.

B. Does the child exhibit behavior that impedes the ☒ Yes ☐ No C. Does the child have limited English ☒ Yes ☒ No
child's learning or that of others? proficiency?(MUSER IX.3.C.(2)(b))
(MUSER IX.3.C.(2)(a))
Does the child have language needs due to limited ☐ Yes ☒ No
☒ Yes ☐ No English proficiency which must be addressed in the
Does the child need positive behavioral
IEP?
interventions and supports and other
strategies to address the behavior?
If yes, where is this addressed in the IEP?
If yes, where is this addressed in the IEP? Section
7 accommodations, present level, goals
D. If the child is blind or visually impaired, does the ☐ Yes ☒ No E. Does the child have communication needs? ☐ Yes ☐ No
child require instruction in Braille and the use of (MUSER IX.3.C.(2)(d))
Braille? (MUSER IX.3.C.(2)(c))
Is the child deaf or hard of hearing? ☐ Yes ☒ No
Does the child have a print disability that requires ☐ Yes ☒ No
accessible educational materials (AEM) to If yes, where is this addressed in the IEP?
access the curriculum? (MUSER IX.3.C.(2)(c)) Goals, accommodations
If yes, what type of accessible educational
materials (AEM) does the child require?

If yes, where is this addressed in the IEP?

F. Does the child need assistive technology devices ☐ Yes ☒ G. Does the child have academic needs? ☒ Yes ☐ No
No and services? (MUSER IX.3.C.(2)(e))
If yes, where is this addressed in the IEP?
If yes, where is this addressed in the IEP?
Goals and accommodations ☒ Yes ☐ No
Does the child have functional/developmental needs?
If yes, where is this addressed in the IEP?
Goals and accommodations

SECONDARY TRANSITION
Is the child in 9th grade or above? ☐ Yes ☒ No If yes, Section 10 should be completed before completing the
remainder of the IEP.
Is the child 16 or older? ☐ Yes ☒ No If yes, Section 10 should be completed before completing the
remainder of the IEP.

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4. RESULTS OF ALL INITIAL EVALUATIONS OR MOST RECENT EVALUATION OF THE CHILD.

Results of evaluations:
KTEA Kaufman Test of Educational Achievement September 2016 (85-110 is average)

Standard Scores 95% Confidence Interval Percentile rank

Reading Composite 79 81-93% 6th
Reading Comprehension 80 75-85 9th
Letter/Word Recognition 78 72-83 7th
Reading fluency 78 72-83 7th
Standard Scores 95% Confidence Interval Percentile Rank
Writing Composite 77 71-83 6th
Written Expression 72 62-82 3
Spelling 81 76-86 10
Standard Scores 95% Confidence Interval Percentile Rank
Math Composite 92 81-93% 22
Math Concepts & applications 90 78-98% 21
Math Computation 98 81-93% 22

Gallistel Ellis Test of Decoding 2016: Phonic Structures: Closed Syllables with single consonants 80%, blends and Digraphs 65%, Silent e words with soft c and
g 72%, vowel teams and vowel-r 73%, multi-syllable and irregular words 65%, nonsense syllables 58%. Due to the low score with nonsense syllables STUDENT
X relies on sight memory rather than truly understanding how to decode syllable types.

Intellectual testing Wechsler Intelligence Scale for Children WISC IV 2016 indicates intact cognitive functioning with a general abilities index of 87,
19th percentile. STUDENT X performs in the average range for verbal comprehension 92 and visual spatial 100, with low average range for fluid
reasoning 89, working memory 88, and processing speed 86. STUDENT X continues to exhibit deficits in verbal and visual memory as well as
attention/concentration tasks requiring these skills. He performs in the low average range for verbal memory 82 and visual memory 85, with low
attention/concentration 79 and general memory index 85. STUDENT X has difficulty with tasks requiring rote memorization, recall of previously
presented information and material that is presented visually for later consideration.

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5. FOR CHILDREN AGES 3-5 ONLY (CDS) DO NOT PRINT FOR K-12 CHILDREN
DEVELOPMENTAL PERFORMANCE (MUSER IX.3.C.(1)(c))
Developmental performance (ages 3 to 5) refers to how the child is performing developmentally (comparable to same age/grade peers) in physical, cognitive,
communicative, social, emotional and/or adaptive areas. Performance must be addressed in either academic or functional performance in A or B below.

6. FOR K-12 ONLY DO NOT PRINT FOR CHILDREN AGE 3-5

MEASURABLE ANNUAL GOAL(S) (MUSER IX.3.A.(1)(b)&(c))
A. Academic Performance - Academic performance refers to a child’s ability to perform age appropriate (comparable to same age/grade peers) tasks and
demonstrate appropriate skills in reading, writing, listening, speaking, and mathematical problem solving in the school environment.

Strengths: Student X has strengths in mathematics, specifically when solving problems. He is a student who “sees” numbers and doesn’t often need to figure
it out on paper.

Needs:

Decoding
 Difficulty with decoding and has poor word recognition
 Difficulty with applying grade-level phonics and word analysis skills to decode unfamiliar words
Fluency
 Difficulty with fluent reading, automatic word recognition and lacks skills to sound out unfamiliar words
Comprehension
 Difficulty with reading comprehension, cannot perform reading tasks at grade level
 Difficulty with monitoring his reading for meaning
Writing
 Difficulty with written expression, writing paragraphs, organization and logical sequence

Present Levels of Academic Performance (MUSER IX.3.A.(1)(a)(i)&(ii)):

Student E is a 12th grade student who is decoding at a 2rd grade level. He is reading fluently at a 2rd grade level and comprehension
is also two years below grade level.

Student X does not have the skills to decode unfamiliar words; he is a dysfluent reader who often makes frequent mistakes, he has poor
word recognition, will often skip words, and substitute similar-appearing words.

Student X is not a fluent reader. He is able to read 96 words per minute when given a 3rd grade reading passage and is currently
working on increasing his ability to read sentences/paragraph’s fluently. Student X is currently able to read 96 words a minute with 6
errors when given a 3rd grade passage.

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Student X’s comprehension is affected due to his inability to explain the meaning of the story and draw inferences. When in class, if he
is called on to answer questions he does not do so willingly. Informal testing identified that he is able to answer on average 50% of the
comprehension questions. He has been working hard to identify the who, what, when, where, why and how of each passage that he is
reading. He has increased his ability to identify the main idea from a single sentence level to 2 sentences.

Student X is a 5th grade student performing at a 3rd grade level in writing.

With the use of graphic organizers student X is able to respond to most parts of the prompt and organize his information in a clear
manner. He is able to use linking words and phrases at a 3rd grade level when connecting opinion and reasons. His development of the
topic is limited and he is not able to expand on his ideas beyond the 3rd grade writing rubric. Some of his sentence structures are
grammatically awkward, but when guided he writes in complete sentences.

How the child’s disability affects the child’s involvement and progress in the general education curriculum.
Student X’s processing difficulties, weak memory, and deficits in reading development skills specifically in decoding, fluency
and comprehension are making it difficult for him to participate in tasks and activities that are on grade level.
Measurable Goal (MUSER IX.3.A.(1)(b)&(c)) Progress:

By 5/10/2018, given specially designed instruction and multiple opportunities to practice, student
X will know and be able to apply 4th grade-level phonics and word analysis skills in decoding
unfamiliar multi-syllabic words, with at least 80% accuracy, as measured by informal assessments,
teacher observation records, and progress monitoring data. (CCSS:RL 4.4)

Objective(s) required? ☐ Yes ☒ No

By date, given service, child’s name will skill as measured by evidence.

Measurable Goal (MUSER IX.3.A.(1)(b)&(c)) Progress:

By 5/10/2017, given specially designed instruction in guided reading and fluency, X will read
with sufficient accuracy, rate and expression to support comprehension and use context (syntax,
visual and meaning) to confirm or self-correct word recognition and understanding, rereading as
necessary with 95% accuracy as measured by formal and informal reading assessments such as
teacher running records. (CCSS: ELA Literacy RF 4.4).

Objective(s) required? ☐ Yes ☐ No

By date, given service, child’s name will skill as measured by evidence.

Measurable Goal (MUSER IX.3.A.(1)(b)&(c)) Progress:

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By 5/10, 2017, given small group instruction and instructional level literature passages, student
X will read closely to determine what the text says explicitly and make logical inferences from
it citing specific textual evidence with 85 % accuracy as measured by teacher observation
records,
formal and informal reading assessments, and progress monitoring. (CCSS: ELA 4 RL. 1. 4 RI.1)
.

Objective(s) required? ☐ Yes ☐ No

By date, given service, child’s name will skill as measured by evidence.

Measurable Goal (MUSER IX.3.A.(1)(b)&(c)) Progress:

By June 10, 2017, given small group instruction and the use of graphic organizers, rubrics and
other tools, X will be able to produce a piece of writing that is clear and coherent in which the
development, organization and style are appropriate to task purpose and audience in 4 of 5
opportunities presented as measured by completion of informal writing assignments, teacher
observation records, student work samples, and progress monitoring. (CCSS: ELA 4.W.4)

Objective(s) required? ☐ Yes ☐ No

By date, given service, child’s name will skill as measured by evidence.

B. Functional/Developmental Performance – Functional/developmental performance refers to how the child is managing daily activities in cognitive,
communicative, motor, adaptive, social/emotional and sensory areas.

Strengths:
Student X is an extremely inquisitive young man. He likes to explore, especially when he can explore outside searching for
frogs and other small creatures! Student X has lots of knowledge to share and will provide information when he is in a relaxed
state and feels he trusts those around him.
Needs:
 Difficulty attending to or accurately interpreting social/cues poor perception of social nuances
 Difficulty starting conversations, entering and participating in groups, connecting with people, and practicing basic social skills
 Difficulty expressing concerns, needs, or thoughts in words.

Present Levels of Functional/Developmental Performance (MUSER IX.3.A.(1)(a)(i)&(ii)):

Functional Behavior

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Student X has difficulty meeting the expectations of the classroom 80% of the day.

During language arts Student X has difficulty closing his computer when prompted. He doesn’t respond to questions when he is called
on in front of the group. Daily, Student X has difficulty returning to class after lunch. While waiting for the bus, X has difficulty with
personal space and boundaries. X has difficulty independently completing his math and language arts homework assignments daily.

Student X exhibits challenging behaviors in the regular education setting 75% of the day

Once frustrated X’s behaviors quickly escalate and he either runs out of the classroom or, on occasion, must be removed. His
outbursts may be affecting his peer relations, as his classmates have expressed a reluctance to interact with him. He has been
increasingly reluctant to participate in working with the resource room teacher.

Speech/Language: Student X presents with weaknesses in expressive language skills, which impact his ability to participate in
classroom discussions and work collaboratively with peers. His difficulty sequencing his thoughts impacts his ability to express his
knowledge effectively when compared with same-aged peers.

How the child’s disability affects the child’s involvement and progress in the general education curriculum.
Student X’s lagging skills and unsolved problems negatively impact his ability to participate in the general education curriculum.
Additionally, X is resistant to participating in any classroom activities involving reading and writing, is having difficulty accessing the
general education curriculum in these realms, and has been increasingly reluctant to attend school.

Measurable Goal (MUSER IX.3.A.(1)(b)&(c)) Progress:

By May 10,2018, given Direct Specialized Instruction, and the opportunity to participate in
problem solving discussions Student X will state a concern identifying the who, what, where or
when, and describe the problem to the collaborating adult 80% of the time as measured by
evidence tracked on the Problem Solving Plan tracking sheet.

Objective(s) required? ☐ Yes ☒ No

By date, given service, child’s name will skill as measured by evidence.

Measurable Goal (MUSER IX.3.A.(1)(b)&(c)) Progress:

By May 10, 2018, given Direct Specialized instruction ,and the opportunity to participate in
problem solving discussions Student X will demonstrate an improved capacity to communicate
about the factors that are making it difficult to for him to reliably participate in classroom activities
involving reading, writing , and verbal give and take 80% of the time as measured by the agreed
upon solution and Problem Solving Plan.

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Objective(s) required? ☐ Yes ☒ No

By date, given service, child’s name will skill as measured by evidence.

Measurable Goal (MUSER IX.3.A.(1)(b)&(c)) Progress:

By May 10, 2018, given Speech and language Services, Student X will improve his pragmatic
language skills in order to functionally communicate with adults and peers up to 80% as measured
by a reduction in challenging behaviors and an increase in meaningful communication .
Objective(s) required? ☐ Yes ☒ No

By date, given service, child’s name will skill as measured by evidence.

FOR ALL CHILDREN

Progress on goals will be reported 3_ times per academic year, using the following codes: (locally determined) Add the

description below of progress codes for annual goal(s)

1. Exceeds
2. Met
3. Partially Met
4.
5.
6.

7. SUPPLEMENTARY AIDS, SERVICES, MODIFICATIONS AND/OR SUPPORTS (MUSER IX.3.A.(1)(d) & (g))

In addition to ongoing classroom supports and services, supplemental aids, and modifications, a statement of any individual appropriate accommodations that are
necessary to measure the academic achievement and functional performance of the child on State and district-wide and classroom assessments. (MUSER IX.3.A.(1)(f)
(i))
A. Statement of supplementary aids, modifications,
accommodations, services, and/or supports for SAU Duration
Location Frequency
personnel Beginning/Ending Date

Access to Problem Solving ☒ Classroom instruction Regular and Special Ed Ongoing 5/20/18-5/9-2019
Check sheet ☒ Classroom Assessment Settings
☐ District-wide Assessment
☐ State Assessment
Think time when faced with ☒ Classroom instruction Regular and Special Ed Ongoing 5/20/18-5/9-2019
difficult situations ☒ Classroom Assessment Settings
☐ District-wide Assessment
☐ State Assessment

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☐ Classroom instruction
☐ Classroom Assessment
☐ District-wide Assessment
☐ State Assessment
☐ Other
☐ Other
B. Alternate Assessments
If the IEP Team determines that the child shall take an alternate assessment on a particular State or district-wide assessment of child achievement, a statement of why
the child cannot participate in the regular assessment and why the particular alternate assessment selected is appropriate for the child. (MUSER IX.3.A.(1)(f)(ii)
(I)&(II))
Student X will participate in state and local assessments. NA on Alternate Assessment

8. SPECIAL EDUCATION AND RELATED SERVICES (MUSER IX.3.A.(1)(d) & IX.3.A.(1)(g))

Duration
Special Education Services Position Responsible Location Frequency
Beginning/End Date
Specially Designed Instruction Special Education Special Education 60 minutes daily 5/20/18-5/9-2019
Teacher
Speech and Language Services
Consultation
Tutorial Instruction
Extended School Year Services
Duration
Related Services Position Responsible Location Frequency
Beginning/End Date
Speech and Language Services SPL/Therapist Special Education 60 minutes weekly 5/20/18-5/9/2019
Occupational Therapy
Physical Therapy
Social Work Services
Transportation
Other

9. LEAST RESTRICTIVE ENVIRONMENT

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FOR CHILDREN AGES 3-5 ONLY (CDS)

What percentage of time is this child with non-disabled children? An explanation of the extent, if any, to which the
General Education Special Education child will not participate with non-disabled children
More than or equal to 10 hours Less than 10 hours Total # of hours: in the regular class and in extracurricular and other
☐ ☐ nonacademic activities: (MUSER IX.3.A.(1)(e))

FOR K-12 ONLY

What percentage of time is this An explanation of the extent, if any, to which the child will not participate with non-disabled children in the
child with non-disabled children? regular class and in extracurricular and other nonacademic activities: (MUSER IX.3.A.(1)(e))
80% Student X will receive instruction in the resource setting for 20% of his day.

If your child’s IEP does not require a Post-Secondary Transition Plan (Section 10) this will be the LAST page of your child’s IEP.

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10. POST-SECONDARY TRANSITION PLAN - This section must be completed for each IEP, during but not later than 9 th grade or age 16, whichever comes
first and updated annually. (MUSER IX.3(A)(1)(h)).

A. Projected Date of Graduation/Program Completion:

IDEA 300.102(a)(3)(i)-(iii) limitation to FAPE - NOTE: Graduation with a regular diploma will permanently end entitlement to a free and appropriate public
education (FAPE) under the federal Individuals with Disabilities Education Act and Maine’s Unified Special Education Regulations. Therefore, after graduation
this child will no longer be entitled to receive special education and related services.

B. Transition Assessments Completed:

C. In the case of a child not attending the meeting, document efforts made (prior to the IEP meeting) to obtain the child’s preferences
and interests:

D. Measurable Post-Secondary Goals (MUSER IX.3(A)(1)(h)(i) - Measurable post-secondary goals must be based on current age-
appropriate transition assessments.

Education/Training Goal

After graduation, child’s name, will education/training goal.

Employment Goal

After graduation, child’s name, will employment goal.

Independent Living Skill Goal (when appropriate):

After graduation, child’s name, will independent living skill.

E. Planned Course of Study (MUSER IX.3.(A)(l)(h)(ii))

The class schedule must be multi-year (through exit), specific and individualized, and directly linked to the postsecondary goals. The planned course of study
must address all post-school goals that are identified for the child.

F. Transition Services and Activities: (MUSER IX.3(A)(l)(h)(ii)) – Describe the activities provided by the adults in the school and in the community that
will enable and promote the child’s progress toward meeting annual and post-secondary goals. Include special education, general education, related
services, services from other agencies, and services provided by families, as appropriate for the child’s needs. Transition services must be specific and
individualized.

Education/Instruction and Related Services:

Career/Employment and Other Post-Secondary Adult Living Objectives:

Community Experiences:

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If Appropriate, Daily Living Skills and/or Functional Vocational Evaluation:

G. Agencies responsible to provide and/or pay for services. (MUSER IX.3.E.(1)(2))

What agency linkages, if any, have been made? Written parental consent must be obtained prior to inviting to an IEP meeting any agency or organization that is
likely to be responsible for providing or paying for transition services.

11. Age of Majority

If the child will turn 17 during the course of this IEP period, child and parent(s) have been informed of the transfer of rights at the age of majority (18). IDEA
300.320(c)-Transfer of rights at age of majority. ☐ YES Date: ☐ N/A

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