INDIVIDUALIZED EDUCATION PLAN (IEP)

SECTION A. PERSONAL INFORMATION

LEARNER/PARENT INFORMATION: DIFFICULTIES (select most relevant) MEETING INFORMATION
Date of Meeting
Learner: Kelvin Clyde Valdez ☐ Difficulty in Seeing Date of Last IEP
Birthdate: January 10, 2019 ☐ Difficulty in Hearing (?)
LRN: Difficulty in Communicating
Sex: M PURPOSE OF MEETING:
Grade Level: ☐ Difficulty in Mobility Walking
☐ Interim
Current School: ☐ Difficulty in Displaying Interpersonal
IEP Initial
Address of School: Behaviors Difficulty in Performing
IEP
Mother Tongue Spoken: Tagalog, Bisaya Address: Adaptive Skills
Ramon Nena Village Forestal ☐ Term IEP
☐ Difficulty in Basic Skills and
Learner’s Phone (if there is): ☐ IEP Following 3Yr Reevaluation
Applying knowledge
☐ Revision to IEP Date
Parent/Guardian/ Caregiver: Meriam ☐ Difficulty in in Remembering/
☐ Exit Graduation
Valdez, Cesar Valdez Jr. Concentrating ☐ IEP Revision Without a Meeting
Work & Workplace: Housewife, Soldier ☐ Others (please specify) At the request of: ☐ Parent
Landline/Mobile/Cell Phone: School IEP Review Date
Email ☐ Medical Diagnosis (If yes, please specify COMMENTS:

IEP TEAM MEMBERS IN ATTENDANCE

Parent/Guardian/ Caregiver: School Psychologist:
*Learners: Guidance Counselor/Designate:
Principal / School Head: School Nurse:
Other (name and role): Therapist/Pathologist/Specialist:
Special Education Teacher: Speech/Language Interpreter:
** Regular Education./ Receiving Teacher:
*Learner must be invited when the transition is discussed
**The IEP Team must include at least one regular education teacher of the learner (if the learners is or may be participating in the regular
education environment)

Signature over Printed Name of Parent/ Guardian/Caregiver

ATLEAST ONE YEAR PRIOR TO REACHING AGE 18, LEARNER MUST BE INFORMED OF THEIR RIGHTS UNDER THE LAW AND ADVISED THAT
THESE RIGHTS WILL BE ENJOEYED AT AGE 18
Not Applicable (learner will not be 18 within one year)
 ☐ The learner has been informed of his/her rights under the law and advised of the transfer of rights at age 18
Distribution: _ Learner’s Folder
Parent/ Guardian/ Caregiver Ed Special Education/ Receiving Teacher
LEARNER:
DATE:
I. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Results of initial or most recent evaluation and results of school and division assessments:

Portage Guide to Early Education

LANGUAGE
- his language has delays or is not appropriate to his age
COGNITIVE
- almost all of the expected behavior was achieved in the ages 3-4
MOTOR
- the starting behavior for the age level 5-6, resulted in the child being observed hasn’t able to do
and mastered so far, the following behaviors and the rest behavior followed
SELF-HELP
- the child hasn’t mastered the behavior according to his age

Description of academic, developmental and/or functional strengths:

LANGUAGE
- can answer yes/no question with affirmative or negative reply
- can combine noun or adjectives and noun in two-word phrase (ball chair;my ball)
- can combine noun and verb in two-word phrase (daddy go)
- can use word for bathroom need; can combines verb or noun with “there” and “here” in 2-word utterance (chair here)

COGNITIVE
- can name big and little objects; points to 10 body parts when asked
- points to boy and girl on verbal command; tells if object is heavy or light
- puts together 2 parts of shape to make whole

MOTOR
- runs changing direction
- walks balance beam
- jumps forward 10 times without falling
- jumps over string 2 inches off the floor

SELF-HELP
- can perfectly do like hold a drinks from cup with one hand
 - puts hands in water and pats wet hands-on face in limitation
- sits on potty or infant toilet seat for 5 minutes
- puts hats on head and takes it off
- pull off socks

Description of academic, developmental and/or functional needs:

The child can’t:

LANGUAGE
- define words
- tell the opposites
- answer “what happened if … “
- use yesterday and tomorrow meaningfully
- ask meaning of new or unfamiliar words

COGNITIVE
- copy diamond shape
- complete simple maze
- name days of the week in order
- add and subtract combinations to three
- tell month and day of birthday

MOTOR
- climb up step ladders or steps ten feet high to slide
- hit nail with hammer
- dribble ball with direction
- color remaining within lines 95%
- cut picture from magazine or catalog without being more than ¼ from edge

SELF-HELP
- lace shoes
- tie shoes
- do weekly household upon request
- select appropriate clothing for temperature and occasion
- stop at curb, look both ways, and cross street without verbal reminder

Parental concerns regarding their child’s evaluation:

NONE
Impact of the disability on involvement and progress in the general education curriculum (for preschool, how the disability affects participation in
appropriate activities):

Kelvin had difficulties in communicating, remembering, and concentrating. This led to his delays in learning.

II. CONSIDERATION OF SPECIAL FACTORS

a. Does the learner have difficulty relating with people which impedes his/her learning or the learning of others ☐ NO YES
b. If yeas, consider the appropriateness of developing a Behavior Intervention Plan
Behavior Intervention Plan Developed? NO ☐ YES
Refer to Behavior Intervention Plan for additional information

Does the learner have difficulty in Moving/Walking

If yes, consider the mobility needs as related to the IEP and describe how

Does the learner have difficulty in seeing or with blindness/visual impairment? NO ☐ YES
If yes, provide instruction in Braille and the use of Braille, unless the IEP Team determines that
instruction in Braile is not appropriate for the learner after an evaluation of the learner’s reading
writing skills, needs, and

appropriate reading and writing media, including evaluation of future instruction in Braille or the use
of Braille. Describe below.

Does the learner have difficulty in communicating? ☐ NO YES

If yes, consider the communication needs and describe below.

Does the learner have difficulty in concentrating/paying attention? NO ☐ YES

If yes, consider the attention span needs and describe below.

Does the learner have difficulty in remembering/understanding? NO ☐ YES

If yes, consider the understanding needs and describe below.

Does the learner have difficulty in hearing or is the learner deaf or hard of hearing? NO ☐ YES
If yes, consider and describe the learner’s language and communication needs, opportunities for
direct communication with peers and professional personnel in the learner’s language and
communication mode, academic level and full range of needs, including opportunities for direct
instruction in the learner’s language and
communication mode. Describe communication needs below.

Does the learner need assistive technology devices or services? NO ☐ YES

 If yes, describe the type of assistive technology and how it is used. If no, describe how the
learner’s needs are being met in deficit areas.

Does the learner require alternative format for instructional materials? NO ☐ YES
If yes, specify format(s) of materials required below.
☐ Braille ☐ Large Type ☐ Auditory ☐ Electronic text
SECTION B: DIFFICULTIES, BARRIERS, AND ENABLING SUPPORTS
DIFFICULTY ENVIRONMENTAL BARRIERS ENVIRONMENTAL ACCOMMODATIONS
(enter all areas of (describe each factor FACILITATORS (describe (list items, staff resources,
difficulty) restricting each and
participation) factor enabling infrastructure changes
participation in required to
response to barriers) enable participation)
DIFFICULTY IN COMMUNICATING - Use of correct words and
sentence
Selection of Barriers and Qualifiers for Environmental Barriers and Facilitators (taken from ICF)
DIFFICULTIES (select all Qualifier for Environmental Barriers Qualifier for Environmental Facilities
relevant categories)
 Seeing .0 No barrier +1 Mild facilitator
 Hearing .1 Mild barrier +2 Moderate facilitator
 Communicating .2 Moderate barrier +3 Substantial facilitator
 Moving/ Walking .3 Severe barrier +4 Complete facilitator
 Concentrating/ Paying attention .4 Complete barrier +8 Facilitator, not specified
 Remembering/ Understanding .5 Barrier, not specified +9 Not applicable
.9 Not applicable
SECTION C: LEARNER GOALS
To support identification of learner goals, also confirm:
 To what opportunities are available at the school to support learner goals?
 What are the student interest areas?
  What disability-specific skills does the learner need to develop to support their participation/ attainment of goals?

Goals (eg- skills to improve participation in education or daily living skills. Goals should be SMART (Strategic, Measurable,
Achievable, Realistic and Time-bound)
INTEREST GOAL INTERVENTIONS TIMELINE INDIVIDUALS REMARKS PROGRESS/
RESOPINSIBLE NEXT STEPS
SECTION D: LEARNER TRANSITION
This section is for learners exiting the school environment and transitioning into work.
INTEREST WORK OPPORTUNITIES INTERVENTION/ INDIVIDUALS REMARKS
TRANISTION SKILLS RESPONSIBILITY

Signatures:

Guardian Principal Special Education Teacher

General Education Teacher School Psychologist Guidance Counselor

School Nurse Therapist/ Specialist/ Speech/ Language

Pathologist Interpreter