Individualized Education Program (IEP) Performance Template

Part I: Community, District, School, and Classroom Factors

Complete this portion of the IPE Template document using the following link:

After completing the e-doc portion, submit the PDF you receive into the digital classroom.

Part II: Demographic, Environment, and Academic Factors

Complete this portion of the IEP Template document using the following link:

After completing the e-doc portion, submit the PDF you receive into the digital classroom.

In order to submit this assignment, you must:

1. Complete each section of Standard 1.

Note: Closing your internet browser before the signing process is completed will result in a loss of your work. If you will be completing this document in multiple sittings, it is highly recommended to save and back up your work on another document.  When you are ready to make your final submission, copy and paste your responses into this document. The data from this electronic document will not be saved until you complete the signing process.

2. Complete the signing process by entering your name, selecting “Click to Sign,” and entering your email address. 

· An initial email will be sent to you to confirm your email address. 

· A completed copy of the document will be emailed to you within minutes of confirming your email address.

3. After completing the e-doc portion, submit the PDF you receive into the digital classroom.

Special Education Department

Individualized Education Program (IEP)

Student Name: Student Data/Cover Sheet (Form A-1)IEP Meeting Date:

Demographic Information
Student Number:	Student (Pseudo) Name:	Birthdate:	Gender:	Grade:
Student Address: 3500 West Camelback Road	Home Phone: Do not complete
City, State, Zip: Phoenix, Arizona 85017
Parent 1 (Pseudo) Name:	Parent 1 Relationship:
Parent 1 Address: Do not complete.	Home Phone: Do not complete.
City, State, Zip: Do not complete.	Work Phone: Do not complete.
Parent 1 Email: Do not complete.
Parent 2 (Pseudo) Name:	Parent 2 Relationship:
Parent 2 Address: Do not complete.	Home Phone: Do not complete.
City, State, Zip: Do not complete.	Work Phone: Do not complete.
Parent 2 Email: Do not complete.
Primary Language of Home:	Primary Language Survey Date: Primary Language Survey Results:	Language of Instruction:
Home District: Attendance District:	Service Coordinator:
Home School:	Attending School:
Vision Screened On:	Results:	Hearing Screened On:	Results:
Meeting Date:	Anticipated Duration of IEP: From: To:	Re-evaluation Due: Current Evaluation:
Special Education Primary Category 1:
Special Education Eligibility Category 2:
Special Education Eligibility Category 3:
For Students with SLD only, the following area(s) of eligibility was/were previously determined:
Level of Services: (A)
Type of Meeting:
Date Meeting Notice Sent to the Parent(s):	Date Procedural Safeguards given to the Parent(s):

This page will not need to be completed because it is a signature page.

Special Education Department

Individualized Education Program (IEP)

Student (Pseudo) Name:Student Data/Cover Sheet (Form A-2)IEP Meeting Date:

Student ID: DOB:

The following persons participated in the conference and/or the development of the IEP. Additionally, parents have been given a copy of their rights regarding the student’s placement in special education and understand that they have the right to request a review of their child’s IEP at any time.

Position/Relation to Student Participant Date (MM/DD/YY)

If during the IEP year the student turns 16, if the student is not present at the IEP meeting, the service coordinator must review the IEP with the student and obtain the student’s signature and the date of this review.

Special Education Department

Individualized Education Program (IEP)

Student (Pseudo) Name:Student Data/Cover Sheet (Form B)IEP Meeting Date:

Student ID: DOB:

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE (PLAAFP)

Section 1: Current IEP Information

Summarize special education services the student is receiving:

Section 2: Evaluation Information

Areas of Eligibility:

Special Education Primary Category:

Special Education Eligibility Category 2:

Special Education Eligibility Category 3:

For students with SLD only, the following area(s) of eligibility was previously determined:

State and District Assessment Scores:

Section 3: Present Level of Academic Achievement and Functional Performance

A. Cognitive (academic performance in content areas, e.g., ELA/Reading/Writing, Math, Science, Social Studies, Technology and Fine Arts, as applicable)

B. Physical (gross motor, fine motor, vision, and hearing)

C. Oral Language and Communication

D. Social and Emotional Behavior

E. Adaptive

Current Classroom-Based Data:

Family’s Input on Student’s Current Performance:

Summary of Work Habits:

Section 4: Summary of Educational Needs and General Accommodations

Special Education Department

Individualized Education Program (IEP)

Student (Pseudo) Name:Considerations Form (Form C) IEP Meeting Date:

Student ID DOB:

ADDITIONAL DOCUMENTATION/CONSIDERATION OF SPECIAL FACTORS

	Considered Not Needed	Included
Individual Transition Plan	☐	☐
Statement of Transfer of Parental Rights at Age of Majority	☐	☐
Statement of Positive Behavior Interventions, Strategies, and Supports Considered for a Student Whose Behavior Impedes his or her Learning, or That of Others	☐	☐
Statement of Language Needs in the Case of a Child with Limited English Proficiency	☐	☐
Statement of Provisions of Instruction in Braille and User of Braille for a Visually Impaired Child	☐	☐
Statement of the Language of Needs, Opportunities for Direct Communication with Peers in the Child’s Language, and Communication Mode	☐	☐
Statement of Required Assistive Technology Devices and Services	☐	☐
Statement of Communication Needs for a Child with a Disability	☐	☐

Special Education Department

Individualized Education Program (IEP)

Student (Pseudo) Name:Accommodations (Form F)IEP Meeting Date:

Student ID: DOB:

ASSESSMENTS

(Rationales for the accommodations that are being chosen specific to assessments.)

Rationale:

State Assessments

Standard Accommodation(s):

District Assessments

Standard Accommodation(s):

CURRENT STATE STANDARDIZED TEST (i.e., AIMS, PSSA) RESULTS

Testing Area	Test Results	Grade	Semester	Year
Reading
Writing
Math
Science

LEAST RESTRICTIVE ENVIRONMENT (LRE)

Provide an explanation of the extent, if any, to which the student will NOT participate with non-disabled students in the general curricular, extracurricular, nonacademic activities, and program options. §300.347(a) (4):

Consider any potential harmful effects of this placement for the child or on the quality of services that he or she needs §300.552 (a-b):

Reason for different services at school:

OR, if the above LRE information does not apply to this student, explain why: