On-line Training

PLEASE NOTE: IEP forms may differ from county to county, however the information they require, by law, is the same. Use your county forms for this tutorial.

Tutorials for: (Click on desired tutorial)


Printed October 26, 2001


Date of Birth:   




Parent/Guardian:                                                        Natural      Guardian     LCI     FFH        Other _______



Home Phone:   

Work Phone:    

District of Residence:   


District of Attendance:  

School of Attendance:

School Type:

Primary Language:

Home Language:

Language of Instruction:


For non-English speakers, check those that apply:              ELL         FEP         EO           Migrant

Special Education Service Provider:

Grade Level:

Preschool Setting:

Social Security Number:



Ø      All lines to be completed thoroughly and accurately

o       Check with parents at IEP meeting to make sure information is accurate

Ø      CA – Chronological Age

Ø      May include multiple ethnicities (up to six)

Ø      LCI – Licensed Children’s Home    FFH – Foster Family Home

o       If not sure, ask the guardian

Ø      District of Residence is the district the student lives in – it may not be the district the student attends

Ø      District of Attendance is the district the student attends – this may be the county programs

Ø      School of Attendance is where the student attends school – this may not be where the service is provided

Ø      If unclear what school type is, check on a Pupil Data Form or call the MIS office

Ø      Primary Language is the language the student speaks the majority of the day

Ø      Home Language is the language the student’s parents speak to the student

Ø      Language of Instruction is the language used in the classroom

Ø      Language Designations (Should be determined by the school, not by the IEP team)

o       ELL – English Language Learner, used to be Limited English Proficient (LEP)   

o       FEP – Fluent English Proficient    

o       EO – is for students who have a non-English speaking family but can be appropriately served in an English Only educational setting due to very limited or no receptive or expressive language skills

o       Migrant is for students receiving Migrant Education services at school

Ø      Special Education Service Provider is the student’s primary service provider , or case manager

Ø      Preschool setting – see Pupil Data Form or call MIS office



This Meeting Date:

Purpose of Meeting:

Most Recent Triennial Date:
Administrative Placement  (not an annual IEP)

Date of Initial Placement:

*Initial IEP   (Referred by     parent     SST    other ____________)

Date of  This Placement:

*Annual IEP   (&    Triennial Assessment)

Next Annual Date:



Ø      All dates need to be month-day-year

Ø      Most Recent Triennial Date is the date at which the student’s continuing eligibility was determined following a complete assessment by the school psychologist and other educational specialists or the completion of a Triennial Review Worksheet

Ø      Date of Initial Placement is the date the student FIRST began receiving special education services of any kind, anywhere

Ø      Date of This Placement is the date this IEP takes affect

Ø      Next Annual Date is the date the NEXT annual IEP is to take place

Ø      Purpose of Meeting

o       Administrative Placement should be checked if the IEP is being completed to place a student in a new district, but is not taking the place of the annual IEP

o       Initial IEP should be checked if the IEP is the first one for the student

o       Annual IEP should be checked whenever all the IEP forms are updated, including goals

o       Also check Triennial Assessment if the IEP is being completed to determine eligibility following an assessment or completion of a Triennial Review Worksheet

o       Other would include discipline IEPs, transition IEPs, etc.





We the undersigned participated in the IEP meeting (All members must sign)















Ø      This section is for signatures

Ø      All members of the IEP must sign indicating that they participated in the IEP

Ø      Their signatures do not indicate approval of the IEP, just participation in its development

Ø      If you have a dissenting opinion regarding the placement of the student place an * by your name and attach your written dissention to the IEP. 





Section A:                                           Summary of IEP (complete at end of IEP meeting)

Services and Providers:

STAR Code:
(If 30, complete Alternate Assessment Data Form)

% of time outside regular class:

Extended Year Services:    Yes        No

Workability:    Yes        No

Transition Plan Attached:    Yes        No




Addendum Attached:     Yes     No          Date(s):


Ø      This section was included to ease in the completion of the Pupil Data Form or, in many instances, to allow the front page of the IEP to take the place of a Pupil Data Form

Ø      This section should be completed after the IEP meeting is done

Ø      When possible, the information should be taken from the appropriate sections of the completed IEP

o       Disability – Section C

o       Services and Providers – summarize the information from Section H, include names of the service providers

o       STAR Code, Alternate Assessment – Section F

§         Make sure to complete the Alternate Assessment Data Form if Code 30 is indicated

o       % of time outside regular class – Section I

o       Extended Year – check yes or no – Section H

o       Workability – check yes or no

o       Transition Plan Attached – check yes or no


Ø      When addendums are attached to the IEP, indicate this in the bottom section with the dates of the addendums




Section B:                                           Present Levels of Performance

Student with Functional Skills Based Curriculum

(Include current data from evaluations and district/state-wide assessments)

Area of Need



Self-Care, Independent Living


Functional Academics




Mobility, Motor Skills


Social, Emotional


Recreation, Leisure





Section B:                                           Present Levels of Performance

Student with Academic Skills Based Curriculum

(Include current data from evaluations and district/state-wide assessments)

Area of Need





Written Expression


Other Academic Areas




Cognitive/Adaptive Skills


Behavior (Social/Emotional)


Prevocational and/or Vocational Skills



Ø      The information on these pages should come directly from formal or informal assessments.  The purposes of these assessments are to determine the student’s present levels of educational performance and areas of need arising from the student’s specific disability so that approaches for ensuring the student’s involvement and progress in the general curriculum and any needed adaptations or modifications to that curriculum can be identified.

Ø      There are two Present Levels pages; one for students who are receiving a functional-skills based curriculum and one for students receiving an academic-skills based curriculum

Ø      Please fill out only the page that best fits the student

Ø      Complete only the sections that relate to the student’s areas of disability or those areas that were recently evaluated by individual testing, district-wide testing, or state-wide testing

Ø      Information presented should be descriptive and specific and should describe the reasons why the student meets or does not meet the eligibility requirements for special education services

Ø      This section should be a compilation of all evaluators and educators information; summaries of the results of everyone’s information

Ø      In the right hand column, check the areas that describe the student’s needs that will be addressed through the goals and objectives

Student Strengths:




Ø      Write a description of the student’s strengths as related to his or her academic program

Ø      Be specific…what is the student capable of, what growths has the student made

Ø      Relate the strengths to the previous year’s goals and objectives

Parent/Guardian Concerns




Ø      This section is for writing any information that the parent has regarding their student’s educational programming

Ø      It does not have to be negative comments only; it can be positive comments




Health issues, vision, hearing, and any other educationally relevant medical findings: (Vision and hearing test results needed for initial and re-evaluations)






Ø      Information gathered from school nurse, medical records, or parent

Ø      For Initial and Triennial evaluations, data on vision and hearing must be up to date

Ø      Include any diagnoses, medications, or other health information that affects the student’s schooling


Describe how the student’s disability affects involvement and progress in general curriculum.  For preschool children describe how the disability affects the student’s participation in appropriate activities:





Ø      Describe how the student’s disability affects his or her ability to progress and to participate in the general education curriculum

Ø      The information should be directly related to the student’s disabilities and the information presented in the rest of Section B

Ø      It should be a broad statement that specifies the student’s difficulties but allows for a variety of interventions

Ø      If desired, the statement could include possible examples of specific ways the disability affects the student’s involvement, but the examples should begin with a qualifying statement, such as “including but not limited to” or a similar phrase

Ø      The information written in this section should be individualized for each student; it should not be the same sentence written on every IEP



For initial placements, document the consideration of and prior use of regular education resources prior to special education placement:





Ø      For initial placements only, specifically describe all accommodations and modifications attempted within the general education setting before a recommendation for testing and placement was made



 What is written in all of the Present Levels Sections should directly lead to the types of special education services and supplementary aids and services that are recommended in the IEP, as well as the goals written for the student. *How well the present levels section is written can set the tone for the IEP, i.e. focused on student’s strengths and skills or focused on weaknesses and faults*



Section C:                                           Eligibility Determination


Student meets the eligibility criteria of one or more of the following:   YES   NO   (If yes, indicate [1] for primary, [2] for secondary)



Mentally Retarded


Hard of Hearing




Speech/Language Impaired


Visually Impaired


Emotionally Disturbed


Orthopedically Impaired


Other Health Impaired


Learning Disabled






Traumatic Brain Injury








Established Medical Condition


 Student requires special education:    YES   NO   




Ø      Indicate whether the student meets the eligibility criteria


Ø      If yes, put a “1” for the primary disability, and so on for additional disabilities


Ø      Disabilities checked must be directly related to information written in the Present Levels Section B

Ø      When appropriate, a child who meets more than one disability category including a low incidence disability should have the low incidence disability marked as primary

o       These include Visually Impaired, Hard of Hearing, Deaf-Blind, Deaf, and Orthopedically Impaired

Ø      Established Medical Condition is for infant and preschool students only (age 0-5)


Ø      Indicate whether or not the child requires special education due to the disability




Complete Only For Students Suspected of Having a Specific Learning Disability

(Complete after an initial evaluation, a re-evaluation, or a review of an independent or outside evaluation only)


Does a severe discrepancy exist between the intellectual ability and achievements in one or more of the following academic areas?
  YES    NO   If yes, indicate the academic area(s)


  Oral Expression                   

  Listening Comprehension

  Written Expression                  

  Basic Reading Skills

  Reading Comprehension                        

  Mathematics Calculation              

  Mathematics Reasoning                                                                                                                                                                                                                                                                                                     


Discrepancy due to psychological processing disorder in the following:



  Visual Processing   

  Auditory Processing    

  Sensory-Motor Skills  

  Cognitive Abilities, including association, conceptualization, and expression


Discrepancy determined by:      Standardized Test               Alternative Method:  Describe: _______________________


Yes     No      Discrepancy is the result of environmental, cultural, or economic disadvantages     


 Yes    No      Discrepancy can be corrected by regular or categorical services offered within the regular instructional program    


Yes     No      Disability is the result of visual, hearing, motor impairment, mental retardation, or emotional disturbance    



(Describe relevant behavior noted during the observation and how the behavior relates to student’s academic functioning)





Each team member must sign below to certify that the report reflects his/her conclusions.  Any participant who disagrees with the team’s decision must submit a separate statement presenting his/her conclusions. 

Yes  No     


Yes  No     








Ø      Information on this page must be related to results of psycho-educational assessments, not anecdotal information

Ø      An observation is to be completed for all evaluations of students with learning disabilities.  

o       State regulations indicates that “at least one team member other than the student’s regular teacher shall observe the student’s academic performance in the regular classroom setting” (§300.542)

o       This is to be a specific observation made by an IEP team member in a regular education setting for the purpose of meeting this requirement

§          Therefore, the specific date, location, and time of the observation should be listed in the spaces indicated

Ø      Each team member shall certify in writing whether the report reflects his or her conclusion.  If it does not reflect his or her conclusion, the team member must submit a separate statement presenting his or her conclusions.



Section D:                                                      Special Factors


(a) Is student blind or visually impaired?      

If yes, will instruction in Braille and in the use of Braille be provided?   


(b) Is student deaf or hard of hearing?       

If yes, are specialized communication strategies required?    

(c) Does student have a low incidence disability (DB, HOH, D, VI, or OI)?       


(d) Does the student require assistive technology devices and/or services to meet educational goals and objectives?


(e) Does the student engage in behaviors that are impeding the student’s learning or the learning of others?      

Does the student require a Behavior Intervention (Support) Plan (IDEA):           

Does the student require a Hughes Bill Positive Behavior Intervention Plan (CA):       


(f) Is the student identified as an English Language Learner (ELL) (Limited English Proficient LEP)?      

If yes, are linguistically appropriate goals addressed in the IEP?   

  Yes       No

  Yes       No


  Yes       No

  Yes       No


  Yes       No


  Yes       No


  Yes       No

  Yes       No

  Yes       No


  Yes       No

  Yes       No


From the above answers, as needed, (a) explain the appropriate visual media/medium for the student, (b) describe the student’s communication mode and opportunities for direct communication with adults and peers, (c) describe any Low Incidence specialized services, equipment and materials required for the student, (d) describe the assistive technology devices and/or services required, (e) describe any positive behavioral interventions, strategies, supports, and goals/objectives to address the behaviors, and/or (f) explain why linguistically appropriate goals are not needed:



Ø      If the student is blind or visually impaired, the IEP team must determine the appropriate medium/media to be used with the student.  The IEP should provide for instruction in Braille and the use of Braille unless the team determines, after an evaluation, that Braille instruction or use is not appropriate for the student.

Ø      If the student is deaf or hard of hearing, the IEP team must consider the student’s communication needs, opportunities for direct communication with peers and professional personnel in the student’s language/communication mode that meets all the student’s needs, is at his or her academic level, and meet the students needs for direct instruction.

Ø      If the student has a low incidence disability, indicate the specialized services, equipment and materials needed.

Ø      If the student requires assistive technology to meet the goals and objectives, describe the devices and/or services needed.  Do not name the specific devices.

Ø      If the student engages in behaviors that impede learning, the IEP must provide for positive behavioral interventions, strategies, and supports to address the behaviors.

o       Indicate which type of behavior plan, if any, the student requires

o       The Plan should then be attached to the IEP

Ø      If the student is an English Language Learner (or Limited English Proficient), the IEP team must consider the language needs of the student.  Indicate whether linguistically appropriate goals and objectives are required.  The answer should be Yes, unless there are extenuating circumstances, in which case, these should be described. 



Section E:                   Related Services, Supplementary Aids and Services, Program Modifications


Describe related services and supplementary aids and services to be provided to or on behalf of the student and the program modifications and supports for school personnel that will be provided to enable the student to advance toward attaining annual goals, be involved and progress in the general education curriculum and participate in extracurricular activities, and be educated and participate with other children with disabilities and with nondisabled children:



Ø      The term supplementary aids and services means aids, services, and other supports that are provided in regular education classes or other education-related settings to enable children with disabilities to be educated with nondisabled children to the maximum extent appropriate. 

Ø      If the student requires supplementary aids and/or services to meet the annual goals on the IEP, to progress in the general education curriculum, and to participate in extracurricular activities, these aids and/or services should be written in this section.

o       Aids and services that are already in use or new items that have been determined appropriate by the IEP team should be listed

o       The specific names of aids should not be listed, but the general type should be described

Ø      Examples of supplementary aids and services could include: adaptations in how information is presented and how the student is expected to perform or respond; adjustments in time allowed to complete schoolwork and quantity of work expected; alternative materials and classroom equipment; behavior interventions; assistive technology devices and services; and other innovative approaches in the regular classroom; modifications to the regular class curriculum; special education training for the regular teacher or other school personnel; use of computer-assisted devices; provision of notetakers; and use of a resource room

Ø      If school personnel require program modifications or supports in order for the student to meet the annual goals on the IEP, to progress in the general education curriculum, and to participate in extracurricular activities, these program modifications and supports should be written in this section.



Section F:                                           State or District-wide Assessment


List Specific Assessment and/or Content Areas


No Accommodations


Standard Accommodations


Non-Standard Accommodations or Modifications


Alternate Assessment






For each assessment/content area, describe the accommodations or modifications necessary for the student to participate in the assessment.  If the student is not participating in the assessment or is participating in the Alternate Assessment, explain why.





How will the student participate in the STAR assessment: (check only one)              


  10  To participate in full without accommodations

  11  To participate in full with standard accommodations

  12  To participate in full with non-standard accommodations

  20  To participate in part without accommodations


  21  To participate in part with standard accommodations

  22  To participate in part with non-standard accommodations

  30  To participate in alternate assessment

  40  Not to participate in the STAR program by parent exemption

  90  Not to participate at all in any statewide assessment program



Ø      List the specific assessments or the individual content areas of assessments in the left hand column.

Ø      Place a check in the appropriate boxes indicating the types of accommodations the student will need.

Ø      For their STAR participation, a small number of students may be determined by the IEP team to be appropriate for the Statewide Alternate Assessment instead of the SAT-9 assessment.  This should only be for students who are working on a functionally based (non-academic) educational program, which should be reflected in the Present Levels page that is completed for the student (Section B). 

Ø      Below the table, describe the types of accommodations the student will require or the reason why the IEP team feels the Alternate Assessment is appropriate.

Ø      Check the appropriate box to summarize the student’s STAR assessment participation. 

o       A code of 90 is for students who are either too young or too old to be required to participate in the STAR program, i.e., under 2nd grade or over 11th grade.



Section G:                                          Promotion, Graduation, Transition



Does the student require individualized promotion/retention standards?   Yes     No 


If yes, describe the individualized standards to be used in the area(s) of  reading proficiency (2nd & 3rd grade only); reading,

English/language arts, and math proficiency (4th through 9th grade only):




Ø      Promotion/Retention issues should be left in the general education arena as much as possible. 

Ø      If, due to the student’s disability, the student will not be able to meet the school’s board-adopted promotion standards, even with appropriate supports, then individualized promotion/retention standards can be developed by the IEP team

Ø      These standards should be developed prior to the beginning of the school year

Ø      The standards only need to address the specific areas of proficiency as indicated in California law for the student’s grade (as indicated on the IEP)




For Students Grade 7 and Higher:


At this time, the IEP team anticipates that the student will receive a diploma if the student completes all high school course requirements and credits, and passes all required state and district-wide tests.


At this time, the IEP team anticipates that the student will not be a candidate for a regular high school diploma but rather will be a candidate for a certificate of educational achievement/completion.


  Not able to determine at this time.



Ø      For a student in Grade 7 and higher, determine whether he or she is working towards a diploma or a letter of completion





For students at age 14, or younger if appropriate, see attached Individual Transition Plan (ITP) dated __________________.


On or before the student’s 17th birthday, he/she has been advised of rights at age of majority.       Yes       No  (explain)



Ø      Indicate the date of the ITP for students age 14 and above.


Ø      Prior the a student’s 17th birthday, advise of the rights he or she will have at the age of 18.




Section H:                                                                  Placement


Services considered by the IEP team (check all that apply):

General education      General education with accommodations       DIS/Related services        Resource services    

  Special class at home school       Special class within the home district        Special class outside of home district     

  Other ___________________________________


Explain the rationale for rejecting the services that will not be provided:



Ø      Indicate all the types of educational services that were considered at the IEP meeting


Ø      Explain briefly why certain services were rejected





Rationale for placement in other than general education classroom (check one or more):

          Not applicable

          Assessed needs require modified instruction or alternative curriculum not feasible within the general education classroom

          Intensive one-to-one and/or small group instruction is required based on assessed needs and learning style

          A high level of structure and supervision is required due to social, emotional, or behavior needs concurrent with other assessed learning needs




Ø      Check the ones that best fit the student’s needs, and/or add a rationale that is specific to the student

Ø      Information in other sections of the IEP should support the item that is checked




Rationale for placement in other than home school (check one or more):

          Not applicable

          Needs to be with peers who have similar learning needs/styles

          Student’s instructional/academic/behavioral needs necessitate a low pupil/adult ratio

          Student requires intensive special education and services which necessitates regionalized programming

          Student requires highly specialized instruction.

          Student requires specialized health care procedures.





Ø      Check the ones that best fit the student’s needs, and/or add a rationale that is specific to the student

Ø      Information in other sections of the IEP should support the item that is checked


Special Education Services



Start Date

End Date

Amount Per Day

Times per Week

Location of Services










Any member disagreeing with the placement will mark with an asterisk (*) by his or her name on the front page of this IEP and submit a dissenting statement to be attached to this IEP.




Ø      Under Special Education Services, write the service being offered, i.e. Resource Program, Special Day Class, Speech and Language, Adapted PE, Occupational Therapy, etc.

o A service may be written in twice if it is being offered in different locations or with different amounts of time, etc.

Ø      Under “Implementing Staff”, write the type of staff person to give the service, not the name of the person, i.e. SLP staff, RSP teacher and aide, etc. 

Ø      Under “Start Date”, write the date that each specific service is to begin

Ø      Under “End Date”, write the date that each specific service is to end; this may be the next annual IEP due date

Ø      Under “Amount Per Day” write the number of minutes, periods, or percent of the day the student will receive the service in that specific location

Ø      Under “Times per Week” write the number of times per week the service will be offered in that specific location

Ø      Under “Location of Services” write the specific educational setting the service will be provided, i.e. general education classroom, RSP room, Speech room, etc.  Do not write the name of the school.

Ø      A student may receive RSP services 15% of the day 5 times a week in the RSP room and 15% of the day 5 times a week in the general education classroom.  This information must be clearly indicated in this section of the IEP.




Is the student eligible for extended year services?      Yes       No 

If Yes, justify why and indicate the services to be provided :


Does the student require transportation services to meet his or her IEP goals?       Yes       No   

If Yes:        District Provided   or      County Provided   or     Other ___________________


Physical Education:






Specially Designed


Adapted P.E. (DIS)

Services provided by agencies other than the LEA:




Ø      Extended year services are for any student where “the interruption of the pupil’s educational programming may cause regression, when coupled with limited recoupment capacity, rendering it impossible or unlikely that the pupil will attain the level of self-sufficiency and independence … expected in view of his or her handicapping condition” (5 CCR 3043).  Each student’s individual need for extended year services should be addressed by the IEP team. 

Ø      Summer school is not necessarily the same as extended year services

Ø      The types of extended year services to be provided should be clearly indicated on the IEP

Ø       If a student requires transportation services to meet his or her goals and objectives, indicate who will be providing the transportation for the student.

Ø      In the “Services provided by agencies other than the LEA” section, you may indicate the types of services the student receives from other agencies, i.e. respite from Central Valley Regional Center, medication services from Mental Health, etc.  These are for services not included in the placement table and not the responsibility of the school district.



Section I:                                                        Participation


The student will participate with non-disabled children in the regular class and/or activities except for the following:

Percentage of time student is outside regular class for special education instruction or services:




Ø      Indicate the activities that the student will not be participating with non-disabled peers.  Include academic settings and non-academic settings.


Ø      Indicate the amount of time the student will be outside of the regular class for special education services.

Ø      Only instructional time should be indicated in this box.

Ø      For some students the amount in this box may be 0% if all of their special education services are received in the general education setting. 




Section J:                                                       Triennial Review


Is the student’s triennial evaluation due prior to the next scheduled IEP meeting?         Yes       No   

If yes, is a completed “Triennial Worksheet” attached to this IEP?          Yes       No    

If no, why not?



Ø      Determine when student’s triennial evaluation is due.  If it is prior to the next scheduled IEP meeting, discussion the completion of a Triennial Worksheet to determine what testing, if any, is required to determine continued eligibility.

o       Indicate why the Worksheet was not completed prior to the IEP meeting and indicate a timeline for the Worksheet’s or evaluation’s completion.

Ø      If a worksheet is already completed, attach it to the IEP.




Documented Efforts to Contact Parents


    Meeting scheduled with parents at a mutually agreed upon time and place.

    Notification of IEP sent to parents 10 or more days prior to meeting to ensure that parents had an opportunity to attend.

    Written notice sent to parent                     Date  __________________

    Follow-up contacts                                 Dates ________________________________________________________

    Parent unable to attend IEP meeting. 

    Copy of IEP and procedural safeguards to be sent home and explained to parent by __________________________.



Ø      The purpose of this section is to help document how the parents were notified of the IEP meeting and any follow-up contacts that were needed.

Ø      It is recommended that the parent be in attendance at ALL IEP’s, although we understand that this is not always possible.

Ø      If parents were unable to attend the IEP, be sure to indicate who will be responsible for presenting the information to the parents after the meeting is over.




Parent Certification And Signatures

These approvals are made voluntarily and I understand that they may be withdrawn at any time upon written request.


I was a member of and participated in the IEP team meeting.


I have approved the total IEP.


I disapprove those sections I have initialed, which are on page(s)_______. 

I understand that the sections I have approved will be implemented while negotiations continue.


I do not approve of this IEP for the following reasons:


A copy of the procedural safeguards was provided and explained to me. 

I also received information about the Community Advisory Committee.


For an initial evaluation or triennial evaluation, I received copies of all assessment reports.


IEP was interpreted by __________________________.

                                                 (interpreter’s signature)


Written translation of IEP requested:   Language: ______________________________


Please be advised that this school district maintains confidential records on your student which may not be limited to Individualized Education Plans and reports.

This confidential file is located at the ____________site.  You have the right to inspect and review these records.


Ø      Read to the parent the statement written at the top of this section.

Ø      If the parents were a member and participated in the IEP meeting, have them check the first box

Ø      If the parents approve of the entire IEP, have them check the second box

Ø      If the parents disapprove of some sections of the IEP, after all attempts to settle the disagreements have failed, have the parents initial the sections they disagree with and check the third box

Ø      If the parents disapprove of the entire IEP, after all attempts to settle the disagreements have failed, have the parents check the fourth box and indicate their reasons for disagreeing.

Ø      Parent must receive a copy of the Procedural Safeguards with every notice of an IEP meeting and should be given a copy of the Community Advisory Committee brochure or monthly flyer at each IEP meeting.  These should be explained to the parents, not just handed to them.  Have the parents check the fifth box indicating that these steps were taken.

Ø      For all initials and triennial evaluations, the parents must be given a copy of all assessment reports.  If the parents have received all reports, have then check the sixth box.  If they have not received all reports, indicate why not, when the reports will be given to the parents, and get parental permission for the delay. 

Ø      If the IEP was interpreted for the parent, check the seventh box and have the interpreter sign his or her name.

Ø      The eighth box is the location for indicating whether it has been requested that the IEP be translated and, if so, in what language.

§        For all non-English speaking parents, ask if they would like the IEP translated, and indicate their answer in this box

Ø      On the bottom of the page, indicate where the confidential records of the student are kept.




Section L:                                                       IEP Meeting Notes


Addendum to IEP     No      Yes    If yes, to be attached to IEP dated: ____________  (Add today’s date to front of original IEP)






If Addendum, include signatures.



Ø      This section is for writing any additional information that was not covered elsewhere on the IEP or for continuing from a section on the IEP where all of the information did not fit in the space provided.

Ø      It is also the page to complete when an addendum is needed to the IEP during the year.

Ø      Indicate whether the page is an addendum or not.

Ø      If it is, include the date of the annual IEP that the addendum is being attached to, put the date of the addendum on the front page of the annual IEP, and attach the addendum to the annual IEP.

Ø      Include signatures with all addendums.





Assessment Report


Ø      This report is to describe the results of formal testing completed with the student; if no formal testing was completed, then this page should not be completed

Ø      The report is to be completed by the person who did the testing, i.e. special education teacher, speech therapist, adapted physical education teacher, occupational therapist, etc.

Ø      It is to be completed when no other written report has been completed that includes the evaluator’s results, such as a multidisciplinary or Psychoeducational report.



Evaluator’s Name _______________  Title ____________ Date of Assessment _______ Purpose of Assessment _____________


Tests Administered

Scores Obtained

Description of Scores





Ø      Write the complete test name under “Test Administered”

Ø      Write the actual scores or score ranges under “Scores Obtained” (except for IQ scores)

Ø      Write a brief description of how the student did under “Description of Scores”; this may include the actual descriptive term for the score (average, etc.), the student’s areas of strengths and weaknesses, or more specific descriptions of the performance


Summary of Assessment Results: (include educationally relevant health, development, and medical findings if any)



Ø      This section is for a more specific summary of how the student did on the assessment. 

Ø      Be sure to include any relevant health, developmental, or medical findings


Validity of Assessment Results: (include behavior noted during observations and effects of environmental, cultural, or economic disadvantage, where appropriate)



Ø      This section should include a description of the student’s behavior during the assessment and any factors that may have affected the validity of the test scores


Does the student need special education and related services to address the area(s) assessed by this evaluator?   Yes   No   

If yes, why:



Ø      In your best judgment, determine whether the student needs special education services and explain why.


For a student with a learning disability, see Section C of the IEP.

For a student with a low incidence disability, see Section D of the IEP.





Method of Reporting to Parents Progress Towards Goals: Quarterly   Trimester   Semester   Other __________ (same as gen. ed. students)



Ø                 Indicate how often progress towards goals will be reported to parents

§                     State regulations indicate that a “pupil’s parents will be regularly informed, at least as often as parents are informed of their nondisabled pupil’s progress” [30 EC 56345 (a) (10)]




Curriculum Area:



Functional Skill Area:



Vocational Goal: 

Behavioral Goal: 

Linguistically Appropriate: 



Ø      Indicate the general education curricular area the goal is related to

§         This is mandatory for students with a functional skills based curriculum

§         It is recommended that all goals be aligned with the K-12 Academic Content Standards
for California Public Schools

Ø      Indicate the functional skill area the goal is related to

§         This is mandatory for students with a functional skills based curriculum

§         It is recommended that goals be aligned with the Alternate Curriculum Guide developed by SEACO

Ø      Indicate whether the goal meets the student’s vocational needs or behavioral needs

Ø      If the student is an English Language Learner, indicate whether the goal is linguistically appropriate for the student’s language needs



Measurable Annual Goal:                        





Every goal should contain the following seven elements:


1.                  The Student’s Name


2.                  Anticipated Date of Completion – Projected date when the teacher is anticipating the student will have completed the stated goal/objective and be ready to move to the next objective.  The goal date usually is one year from IEP meeting date.  Goal and benchmark date of completions should be as closely linked to report card reporting periods as possible .      


3.                  Observable Behavior – State a specific action or act that can be observed and measured by another person.  Should be related to the curricular area or functional area standard.




Observable Behaviors Not Observable Behaviors
  • Put in
  • Pick up
  • Eat
  • Scoop
  • Wipe
  • Press
  • Walk
  • Point to
  • Look at
  • Choose toy
  • Play appropriately
  • Sort by categories
  • Follow 2 step direction 
  • Add
  • Alphabetize
  • Answer in writing
  • Build
  • Circle
  • Complete in writing
  • Compute
  • Count 
  • Cut
  • Demonstrate
  • Describe orally
  • Discuss verbally
  • Explain orally
  • List in writing
  • Mark
  • Multiply
  • Name verbally
  • Read
  • Record in writing
  • Report orally
  • Spell orally
  • Subtract
  • Tell
  • Underline
  • Understand
  • Enjoy
  • Become familiar with
  • Prefer to
  • Participate in
  • Become aware of
  • Interact with
  • Grasp the meaning of
  • Indicate
  • Integrate with
  • Complete sequence
  • Know categories
  • Know routine
  • Identify
  • Experience
  • Think
  • Realize
  • Observe
  • Remember
  • Know
  • Learn
  • Comprehend
  • Distinguish



4.                  Conditions – State where, when, and under what circumstances the observable behavior will occur.  Not all objectives will necessarily have a condition listed.  The conditions may include the setting in which the behavior will occur, the materials to be used, the strategies implemented to teach the task, the prompting procedures to be used, or the instructions given to the student.  This component can be written in before the measurable behavior depending on individual preference.



Ø      when hand is placed on switch…

Ø      given one sip of liquid and full manual lip and jaw closure…

Ø      after hands are positioned on handrails…

Ø      with staff support at the wrists…

Ø      after right hand is placed on object…

Ø      when food filled spoon is brought to within 1” of mouth…

Ø      given contextual reading material at a 4.5 grade level…

Ø      given 40 math problems…

Ø      given stimulus pictures…

Ø      when listening to a 20-30 minute lecture by the teacher…

Ø      during lunch and freetime…

Ø      when asked content specific questions by teacher or peers…

Ø      on appointed days and times when instructed to do so…


Use of terms such as “minimal” or “moderate assist”, “physical prompt”, “full physical prompt”, or “appropriately” do not specify the actual conditions under which the student behavior is to be measured.  Be as specific as possible.



5.                  Criteria –   State the extent of achievement or standard of performance or degree of accuracy, which is required of the student.



                               - within 5 minutes                         - for 40% of trials

- 3 out of 4 trials                              - 2 times daily

- with 80% accuracy                             - 4 times weekly

- for 5 consecutive sessions              - for 3 minutes


If the criteria required from the student by the end of a year is less than 50%, it would be advisable to consider writing a more attainable goal/short-term objective.



6.                  Mastery –             State the level of achievement required of the student before proceeding to the next objective.  Mastery should be at a minimum 70% or higher level of success.  Mastery level indicates the period of time the student needs to demonstrate the criteria level before you will consider the objective/goal learned.



- 7 out of 10 trial days                  - for 5 consecutive weeks

- for 5 consecutive trial days     - 8 out of 10 trial days     

- 3 out of 4 trial sessions            - for a 3 week time period




7.                  Method of Measurement –             State the method of measurement – how you will measure if the goal has been mastered.



………as measured by data log

………as measured by data probes taken once weekly

………as measured by time sampling data

………as measured by using Instructional Plan Sheet with data collection

………as measured by anecdotal record

………as measured by student portfolio


Ø      Methods of measurement


Ø                  Formal Data Collection – data collected on standardized tests, assessment tools, data sheets or logs

Ø                  Instructional Plan Sheet with Data Collection – criterion referenced data, which can include frequency counts of skills and behaviors, which occur throughout the school day.  They may also be used to measure skills and behaviors specifically defined in IEP objectives. 

Ø                  Authentic Assessment/Portfolio Data Collection – actual samples of the student’s work, such as pictures drawn by the student.  These samples would be collected periodically to report progress.  Videotaping can be implemented as a means of following student’s progress (with parent permission)

Ø                  Anecdotal Notes and Logs – usually general in nature.  This information may be beneficial to have along with the criterion referenced data.





Person(s) Responsible: ___________________________ Baseline: _______________________

Enables student to be involved/progress in general curriculum and/or  Addresses other educational needs resulting from the disability



Ø      Person(s) Responsible – State the person(s) responsible for implementation of this specific goal and its benchmarks/objectives.  Keep in mind that the Special Education Teacher is always responsible for the implementation of the student’s complete IEP.


                                    … classroom staff, behavior aides, Speech/Language Specialist, etc.


Ø      Baseline – Summarize the student’s current skills levels with regards to this specific goal.  The baseline information should be related to formal or informal assessment of the student on the skills. 


Ø      Indicate whether this goal assists the student in accessing and progressing in the general curriculum and/or if the goal is addressing other needs of the student that are related to the disability but may not be directly related to the general curriculum



Benchmark / Short-Term Objective:



Ø      Baseline – Summarize the student’s current skills levels with regards to this specific benchmark or objective.  The baseline information should be related to formal or informal assessment of the student on the skills.  For some benchmarks or objectives this baseline may be the same as the overall goal’s baseline. 

Ø      Benchmark / Short-Term Objective

·         Benchmark: these are the same behaviors (skills) as the goal but the level of criteria or mastery are at differing levels

·         Short-Term Objective: these are different behaviors (skills) than the goal but lead to the student being able to complete the goal

·         Benchmark/short-term objectives should include the same components as the goal

·         It is okay to shorten the benchmark/short-term objective if some of the components are identical to the goal 

·         Make sure any changes are clearly delineated



Goal Progress:  Date:______________

Progress Code: ___

Is progress sufficient to meet annual goal?    Yes       No    

If not sufficient, enter reason code: __


Goal Progress:  Date:______________

Progress Code: ___

Is progress sufficient to meet annual goal?    Yes       No    

If not sufficient, enter reason code: __


Goal Progress:  Date:______________

Progress Code: ___

Is progress sufficient to meet annual goal?    Yes       No    

If not sufficient, enter reason code: __


ANNUAL GOAL REVIEW:  Date________________

Progress Code: ___

If goal not met, enter reason code: ___


Progress Codes:  1) No Progress; 2)  Partial Progress = 1%-49% of goal met; 3) Substantial Progress = 50% - 99% of goal met; 4) Goal Met or Exceeded

Reason Codes:  1) More time needed; 2) Excessive absences or tardies; 3) Assignments not completed; 4)  Need to review or revise goal; 5) Other



Ø      This is the area for indicating progress on the GOAL throughout the school year. 

Ø      Indicate the date that the goal progress is being measured

Ø      Enter a “Progress Code” as listed at the bottom of the page

·        Remember that the progress is on how the goal is being met, not the benchmarks/objectives

Ø      Indicate whether or not there is sufficient progress towards the goal for the student to meet the goal by the annual date

·        If not, indicate a “Reason Code” from the bottom of the page

Ø      At the Annual Review IEP, complete the last box

·        Enter the date of the review

·        Enter the progress code from the bottom of the page

·        If the goal was not met, enter the reason code from the bottom of the page


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