INDIVIDUALIZED EDUCATION PROGRAM (IEP) TEAM REPORT

Van Buren ISD

490 S Paw Paw St

Lawrence, MI 49064-9328

Phone: 2696748091

INDIVIDUALIZED EDUCATION PROGRAM (IEP) TEAM REPORT

Student's Address: 123 Love Lane, Hartford State: Michigan Zip Code: 49057 County: Van Buren County Resident District: 80000 (Van Buren ISD) Student Primary Language: English Language in the Home: English

Birthdate: 10/23/2000 Age: 13-10 Grade: Seventh grade PURPOSE

Purpose of IEP Team Meeting: Annual Review Additional Purpose: PARTICIPANTS

*

(the individual who can interpret the instructional implications of evaluation results)

NOTE: New language, Eval Team Rep is a required participant at every IEP.

These IEP Team members were absent, but submitted their input to the Team in writing: Input must be submitted prior to the IEP Team Meeting.

General Ed Teacher: School District Rep: Special Ed Provider: Special Ed Provider: Other/Title: Other/Title:

STUDENT PROFILE AND ELIGIBILITY

In determining both eligibility and need for special education programs/services, the IEP Team must consider each of the following:

Student Strengths

Identify 1-2 strengths prior to the IEP as a conversation starter. Parent Concerns

List any previously identified parent concerns prior to meeting. Confirm and ask parent if they have any additional concerns.

Current Evaluations (Include state and district assessments)

Provide a brief summary of any recent assessment(s) or evaluation information within past 12 months. Classroom assessments, state or district assessments, achievement testing, and summary of data from current evaluations can be listed in this section. Please do not copy entire ER information into this section.

If dismissing a service, this information may also be included here and must also be incorporated into the Notice section of the IEP.

Based on 1) Pam's current functioning, 2) the most recent evaluation findings and 3) any additional assessment information, does the IEP Team determine that this student has a disability that requires special education programs/services?

Yes, Pam is eligible for special education (Define below)

Primary Disability Qualifying Criteria Qualifying Criteria Specific Learning Disability Listening Comprehension

Secondary Disability Qualifying Criteria Qualifying Criteria

Check all boxes for participants who attended. Participants with * by title are mandatory.

Ancillary staff are only mandatory if providing direct/consultative services.

 Check to ensure accuracy of Disability with most recent ER. Areas cannot be added or removed without a REED. If student is not eligible, deselect all pages (Set Document > Sections) except the first and last pg.

Changes to student profile information need to be made in the SIS or by the district liaison.

Student Name: Pam Sample IEP Date: 09/20/2014

Secondary Transition Considerations

Transition Assessments Completed:

Assessments Student/Parent Input School Observation Data Date of Educational Plan:

Will a Student Transition Visions survey be completed? Yes No

Student Transition Visions survey is not required if the ESTR is given. Complete the last 2 pages of the ESTR.

preferences/vision:

Student’s Post-Secondary Vision and Transition Activities Career/Employment: As an adult, what kind of work do you want to do?

Career/Employment Assessment: Present level assessment related to this vision statement. Is there a need for activities or services for Career/Employment? Yes No

Type of Activity Explanation of activity/service

Responsible

Agency/Persons Expected Completion Date

Post-Secondary Education/Training: After leaving school, what additional education and training do you want? Post-Secondary Education/Training: Present level assessment related to this vision statement.

Is there a need for activities or services for Post-Secondary Education/Training? Yes No Type of Activity Explanation of

activity/service

Responsible

Agency/Persons Expected Completion Date Adult Living: As an adult, what kind of living arrangements would you like to have? Yes No

Type of Activity Explanation of activity/service

Responsible

Agency/Persons Expected Completion Date Adult Living Assessment: Present level assessment related to this vision statement.

Is there a need for activities or services for Adult Living? Yes No Type of Activity Explanation of

activity/service

Responsible

Agency/Persons Expected Completion Date Community Participation: As an adult, how do you want to be involved in your community?

Community Participation: Present level assessment related to this vision statement. Is there a need for activities or services for Community Participation? Yes No

Type of Activity Explanation of activity/service

Responsible

Agency/Persons Expected Completion Date

Course of Study

Describe how the student's course of study aligns with the postsecondary vision:

How does the students’ daily schedule impact their post-secondary goal? For example, if they’re interested in becoming a vet, are they enrolled in extra science classes? If they want to be a cosmetologist, is the student visiting/attending the Tech Center?

Check Only One:

Michigan Merit Curriculum leading to a high school diploma Is a Personal Curriculum on file?

(beginning with class of 2011). Yes No

Course of Study leading to:

Is Pam expected to graduate with a Regular Diploma during this IEP year? Yes No

NOTE: If box is checked “yes” include graduation information on Notice section of IEP using “Options Considered”. . Will Pam complete age eligibility for Special Education services? Yes No Will the student turn 26 yrs old this year? If box is checked “yes” include information on Notice section of IEP.

Anticipated graduation or completion date:

Community Agency Involvement

Was there a need to invite a community agency representative likely to provide current or future services?

Yes No If a need is present, agency rep must be listed on IEP invite. At age 16 and beyond, an agency rep should be invited unless parents refuse consent to invite, or if the student truly needs no outside agency support.

If Yes, did agency representative attend? Yes No

Please list any additional steps taken to ensure that the student has made connections with any appropriate outside programs and services:

If there is no need for agency involvement, explain why and include how you’ll connect student to agencies if/when need changes. If there is a need, yet agency did not attend, explain how you’ll connect the two.

Parental Rights and Age of Majority Check all that apply:

The student will be age 17 during this IEP and the student was informed of parental rights that he or she will receive at age 18.

The student has turned age 18 and the student and parent were informed of parental rights that were transferred to the student at age 18, including the right to invite a support person such as a parent, advocate, or friend.

The student has turned age 18 and there is a guardian established by court order.

The student has turned age 18 and a legally designated representative has been appointed.

Student Name: Pam Sample IEP Date: 09/20/2014

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Progress on most recent goals and objectives?

Refer back to last progress report and add statement of progress toward goals.

Area of Need Subarea of Need Data Sources and Description of Need Adverse Impact Goal? Reading

Date Modified:

Comprehension

List and explain how the student is progressing in the area (reading) and subarea of need (reading comprehension). How does this student compare with grade-level peers? Include data sources such as: curriculum based measures, universal screening, district assessments and routinely collected classroom data. “Tell the story” and explain why this student needs special education through specialized instruction, programming and/or services.

Explain how this student’s disability impacts performance in the general

education curriculum. What specifically about this student’s disability impedes participation? Check if goal is needed. If goal box is not checked then need must be addressed with an accommo-dation

The PLAAFP should

 clearly describe the need for special education programs/services and/or accommodations

 contain complete sentences with grammar and professional language

 correspond to either a goal or an accommodation; otherwise it should not be included  include a supporting statement regarding a state assessment if student is taking one The PLAAFP should not

 contain lengthy test report information  include dismissal of services

Student Name: Pam Sample IEP Date: 09/20/2014

SPECIAL FACTORS, SUPPLEMENTARY AIDS AND ASSESSMENTS

Supports and Modifications to the Environment, Behavior Training Needs, Social Interaction Supports for the Student, Health-Related Needs, Physical Needs, Transition aids and supports are provided to enable the student:

 To advance appropriately toward attaining the annual goals.

 To be involved and progress in the general education curriculum and to participate in extra-curricular and other nonacademic activities.

 To be educated and participate in activities with other students with disabilities and nondisabled students. Explain the extent, if any, to which the student will not participate with nondisabled students:

Simply describing how many special education classes the student has satisfies this requirement. Does Pam require supplementary aids and supports based on the following special factors?

A need for positive behavioral interventions, supports and other strategies

due to behavior that impedes the learning of self/others?

Yes

No

The language needs if this student is of limited English proficiency?

Yes

No

A need for Braille instruction?

Yes

No

The communication needs of this student?

Yes

No

The language/communication mode if this student is deaf or hard of hearing?

Yes

No

The requirement for assistive technology?

Yes

No

A need for accommodations on district assessments?

This is a new statement. If box is checked “yes” the accommodation table below will appear.

Yes

No

Does Pam require supplementary aids/program modifications/supports for any additional reasons?

Yes

No

Supplementary Aids/Program Modifications/Support for School

Personnel

Frequency/Timeline Location

List accommodation When? How often? Be specific.

“When or As Needed” should never be used.

Where? (examples located in insert statements)

Use a new box for each accommodation. After entering first accommodation, select “Save, Continue Editing” to add another box. These supplementary aids should align with assessment accommodations. Documentation of each accommodation provided is required.

STATE ASSESSMENTS

If box is checked “yes” the Accommodations and Alternate Assessment page will be added to the IEP.

Yes

No

To participate in the state assessment(s), will Pam require accommodations and/or

alternative assessments? If the student needs accommodations on standardized assessments, Yes No these accommodations should align with those needed daily in the classroom.

Does Pam need to take an alternate assessment instead of a particular state assessment?

Yes

No

Personal Care Services

Does the student have a chronic condition(s) that requires Personal Care Services (identified below) to enable her to accomplish Activities of Daily Living (ADL) in the area(s) checked here:

Yes

No

Time, Frequency, Conditions, Circumstances Location/Setting Eating/Feeding/Meal Preparation Respiratory Assistance Toileting/Maintenance Continence

Mobility/Positioning, Ambulation, Transferring

Bathing/Dressing/Grooming/Skin-Care/Personal Hygiene Assistance with Self-Administered Medications

Redirection & Intervention for Behavior

Health-Related Functions (via hands-on Assistance, Supervision, Cueing)

Intervention for Seizure Disorder

If selecting “yes”, must be medically necessary due to student’s disability. This page must be completed if student is receiving personal care services and a personal care log sheet is being completed.

If selecting “no” this page may be deleted from IEP. If page is not needed “Select Set Document > Sections” and uncheck this page.

Student Name: Pam Sample IEP Date: 5/29/2013

ACCOMMODATIONS AND ALTERNATE ASSESSMENT

For the listed state and district assessments, the IEP Team has determined that the following accommodations and/or alternative assessments are needed for Pam to participate:

Assessment Subtest Test Type Time/Schedule Setting Presentation Response

HINTS:

 The new Assessment drop down only includes available state assessment options. District assessments should be included on the Special Factors/Supplementary Aids/Assessments section of the IEP.

 Since Michigan is still determining what alternate assessment will be used long-term, a bank of insert statements have been provided that correspond with guidance from the MDE.

 Accommodations should match daily supplementary aids and services. For example, if a student needs extended time on standardized assessments, they should also be receiving extended time on tests during the school day.

Student Name: Pam Sample IEP Date: 09/20/2014

GOALS AND OBJECTIVES

Area of Need: Reading Subarea: Phonemic Awareness

 Curriculum Reference:Select “Curriculum Reference” from drop down and then choose “Select from

Curriculum” tool bar. Each curriculum populates a corresponding template, which changes and populates once the specific grade level and curriculum are selected. If no curriculum aligns with goal, please select “none”. Annual Goal:

 Must be observable and measurable

 What will it look like? Could you graph this goal to display progress? How will you know the student has made progress?

 Goals must be stand alone measurable and could be calculated even if objectives/benchmarks were removed.

Will a graph be used to report progress toward the annual goal and associated objectives/benchmarks? Yes No Short-Term Instructional Objectives/Benchmarks:

Objectives/Benchmarks Criteria Evaluations Schedule 1 Must have a least 2 short term objectives/

benchmarks for each goal. 2

Staff Responsible for Goal:List all staff who will be monitoring the goal Comments:

When will progress on goals and objectives be reported?

Every Grading Period Progress reports must be developed at each grading period. Other:

Hints:

 Goals must align with the student’s specific eligibility area of need and be fully supported and connected to the PLAAFP.

 Students who are eligible as OHI and EI should have at least 1 goal that addresses the behaviors or skills the student needs to be successful.

PARENT NOTIFICATION AND CONSENT

For billing the State for Medicaid School-Based Services

Student Name: Pam Sample Birth Date: 10/23/2000 Attending District: Van Buren

NOTIFICATION

If any of the services listed below are included on your child’s IEP (Individualized Education Program), and if your child was eligible for Medicaid at any time during the school year, we request your permission to bill the state Medicaid program to receive funding to help support the services your child received. Supported services include:

Speech/ Language Therapy, Occupational Therapy, Physical Therapy, Social Work Services, Psychological Services, Nursing Services, Orientation and Mobility, Assistive Technology Services, Case Management, Personal Care, Evaluations and Transportation.

Billing the state Medicaid program for your child’s School-Based Services does NOT affect your family’s Medicaid insurance benefits, and is at NO cost to your family, now or in the future.

We are simply asking your permission to claim funds reserved by the state to help schools provide the services listed on your child’s Special Education plan.

Billing the state’s Medicaid program requires that we release information to the state about your child. The information released could include date of birth, disability, gender, school, date of therapy, type of therapy, and progress reports. You will receive annual notification about information released in the Parent Handbook with Procedural Safeguards. Schools have released this information to the state program since 1993, but now need your permission because of changes in federal law.

You have the right to refuse consent to bill the state Medicaid system, and you have the right to revoke this consent at any time. If you check No below, the district will still provide the services but the district will not receive funding from the state Medicaid system for these services.

CONSENT

Yes, I understand, agree, and consent that the ISD and its local school districts may:

a. release Personally Identifiable Information (PII) about my child (including date of birth, disability, gender, school, date of therapy, type of therapy, progress reports to Michigan Medicaid and its billing agencies for Medicaid reimbursement of School-Based Services; and

b. bill my child’s Medicaid insurance for reimbursement of School-Based Services as described in my child’s plan.

I understand I may revoke this consent in writing at any time.

No, I do not give permission for the ISD and its local school districts to bill the state Medicaid system for reimbursement of School-Based Services provided to my child.

Parent/Guardian/Student Signature: Date:

This page should only be included if this is an initial IEP and the student is going to receive related services of OT, PT, Speech, Social Work, Audiological, Orientation and Mobility or personal care services. If this is an annual IEP and the student is receiving one of the related services listed above, you must check if Medicaid consent is already on file before including in the IEP. If consent is already on file DO NOT include this section.

Student Name: Pam Sample IEP Date: 09/20/2014

PROGRAMS AND SERVICES

Related Services with General Education and/or Special Education Programs

Direct Service: the primary mode of service is directly working with the student. There may be occasional consultation with others.

Consultative Service: the primary mode of service is working with the teacher(s) and others having daily contact with the student. Direct work with the student is occasional

Current IEP Year: From Date 09/20/2014 School Year: 2014-15 select from dropdown Grade: Sixth grade

To Date: 09/19/2015 School Year: 2015-16 select Grade: Seventh grade Related

Services

Start Date End Date Service Mode

Minutes Sessions Frequency Setting within Location Low Min. High Min. Low Number High Number

enter date enter date

check year

Direct Consultative

 Ancillary services and/or Teacher Consultant services written here. To include TC time, use the option that matches your endorsement area, not the student’s eligibility area. If student has no programs, TC time must be “Direct.” TC time may be “Consultative” if the student also has program time and a goal for the student was developed in collaboration with another service provider.

 For OT, PT, SW, SPL & O&M services if direct or consultative is selected there must be a goal. Programs Depart-

mentalized

Start Date End Date SE GE TotalFrequency Bldg/Location Low MinHigh Min Low Min High Min Min

Y N

 If you enter the SE Low Min and then select the lookup link for Bldg/Location, select the bldg and then select “Save, Continue Editing” and the GE High Min will auto calculate.

 Use separate lines to describe changes in program time due to trimester schedule changes or use a range if the span is not too broad.

 Never use zero for the SE Low Min.

 Regardless of your endorsement, the student’s program is Elementary or Secondary Resource Room (exception:

Self-contained Rooms).

Are you sure the student has no programs?

Does the student require a reduced day? Yes No If yes, then reduced day is allowed for:

Primary Setting Update this selection for current programming and be careful in your calculation. For questions regarding primary ed setting consult your District Liaison.

Student Name: Pam Sample IEP Date: 09/20/2014

OTHER CONSIDERATIONS

TRANSPORTATION PROVISIONS

Has the IEP Team determined that Pam requires special transportation?

No, transportation is not required or general education transportation is sufficient to meet Pam's needs. Yes, special transportation is required due to the following:

The recommended programs/services are not available in Pam's regular attendance area. The medical, health or developmental and/or behavioral needs of this student

necessitate special transportation.

Vehicle Type Stop Type Start Date End Date

Special Bus with Lift Curb to Curb 09/21/2014 09/19/2015

Describe other required transportation provisions not listed in the table above:

Start and End Dates for transportation are new fields. This data flows to a special transportation profile upon finalization.

EXTENDED SCHOOL YEAR Assurance that ESY was considered and discussed during the IEP. The IEP Team has considered the anticipated needs of this student including the need for extended school year (ESY) services

ESY services are needed

ANTICIPATED NEEDS AND OTHER COMMENTS Other Comments related to this IEP:

Student Name: Pam Sample IEP Date: 09/20/2014

NOTICE REGARDING PROVISION OF SPECIAL EDUCATION

STUDENT INFORMATION

Student: Pam Sample Date of IEP Team Meeting: 9/20/2014 Birthdate: 10/23/2000 Resident District: Van Buren ISD

Age: 12-7 Student Primary Language: English

Grade: Sixth grade Language in the Home: English PURPOSE

This notice is a result of the Individualized Education Program (IEP) Team meeting that was held on the date listed above for the following purpose(s):

Primary Purpose: Additional Purpose: NOTICE FOR PROVISION OF PROGRAMS AND SERVICES

You are receiving this notice because, based upon the most recent IEP Team meeting, Pam remains eligible for special education programs/services. Upon district signature, this notice and Pam's IEP constitute the district’s offer of a Free Appropriate Public Education (FAPE).

All programs/services/supplementary aids will start on: Make sure date is accurate The following person will assure implementation of this IEP:Select staff from dropdown

OPTIONS CONSIDERED

The IEP Team Report describes the assessment/evaluation procedures and data used during the IEP Team meeting. The following options were considered but not selected for the reason(s) indicated below:

Considered Options Reasons Not Selected An option considered is required. (Do not indicate

“None.”) List items/issues that were considered but not selected during the IEP.

Provide an evidence and data-based reason for the non-selection

Other relevant factors to the district’s proposal or refusal: (May list “none” here if there were no additional relevant factors) RESOURCES FOR PARENTS

The Michigan Department of Education - OSE/EIS: (517) 373-3324 Michigan Alliance for Families: (800) 552-4821

Michigan Protection & Advocacy Service: (800) 288-5923 Community Advocates/The Arc: (269) 342-9801

Advocacy Services for Kids (ASK): (269) 343-5896 Parent-to-Parent: (269) 345-8950

Citizen Mediation Service: (269) 982-7898 Dispute Resolution Kalamazoo: (269)552-3434

To Obtain a copy of the Procedural Safeguards for Parents/Students

Kalamazoo Regional Educational Service Agency (Kalamazoo RESA): (269) 250-9323 Van Buren Intermediate School District: (269) 674-8091

Michigan Department of Education: (517) 373-3324 that you received describes protections under the Individuals with Disabilities Education Act (IDEA). Information is also available from:

 MICHIGAN ALLIANCE FOR FAMILIES, 1819 South Wagner Road, PO Box 1406, Ann Arbor, MI 49106; 1-800-552-4821; www.michiganallianceforfamilies.org

 MICHIGAN DEPARTMENT OF EDUCATION, OFFICE OF SPECIAL EDUCATION AND EARLY INTERVENTION SERVICES, PO Box 30008, Lansing, MI 48909; 1-517-373-0923; www.michigan.gov/mde

 MICHIGAN PROTECTION AND ADVOCACY, 4095 Legacy Parkway, Suite 500, Lansing, MI 48911-4263; 1-800-288-5923; www.mpas.org

SIGNATURES DISTRICT COMMITMENT

The school district superintendent/designee assures that the least restrictive environment has been fully considered and assigns this student to the following: (Select one)

The resident district If student is attending a local district, select this box An operating district If student is attending a VBISD program, select this box Operating District:This only appears if “operating district” box was checked, enter VBISD. Building/Program: Enter bldg./program student will be attending

The resident district: (Select one)

Authorizes the operating district to conduct subsequent IEP Team meetings. Select “only” if student is going to a VBISD program

Will conduct subsequent IEP Team meetings. Operating District

Superintendent/Designee: Date: 9/20/2014

Resident District

Superintendent/Designee: Date:9/20/2014

This section will only appear if the “Purpose” of the IEP was selected as an Initial. PARENT/GUARDIAN/STUDENT

Parent consent is required for the initial provision of special education programs and/or services. I/We, as parent/guardian/student: (Select One)

Give consent to the initial provision of special education programs/services

Decline to give consent to the initial provision of special education programs/services

Parent/Guardian/Student: Date: 9/20/2014

 All signature pages must be scanned and uploaded to TIENET.

 The completed IEP must be provided (or sent) to the parent/guardian within 7 school days of the IEP meeting.

 If you make any changes to other pages within this IEP once you have completed this section, make sure you select this page again and select “Edit This Section > Save, Done Editing”. This will insure accurate data flow to the student’s profile upon finalization.

OFFICE USE ONLY