INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Student’s Name:

INDIVIDUALIZED EDUCATION PROGRAM (IEP) School Age

Student’s Name: Vinny Smith

IEP Team Meeting Date (mm/dd/yy): 05/04/21
IEP Implementation Date (Projected Date when Services and Programs Will Begin): 05/05/21
Anticipated Duration of Services and Programs: 05/04/22
Date of Birth: 07/09/2017
Age: 3
Grade: Pre-K
Anticipated Year of Graduation: 2034
Local Education Agency (LEA): Steubenville City School District
County of Residence: Steubenville City
Name and Address of Parent/Guardian/Surrogate: Phone (Home): (555)555-5555
Jane Smith Phone (Work): (444)444-4444
1234 Somestreet Ave
Steubenville, OH 43052

Vinny’s parents are no longer married, mom and children live with grandmother and father has
Other Information:
visitation rights.

The LEA and parent have agreed to make the following changes to the IEP without convening an IEP meeting, as documented by:
N/A

Date of Revision(s) Participants/Roles IEP Section(s) Amended

Page 1 of 23 April 2014

 IEP TEAM/SIGNATURES

The Individualized Education Program team makes the decisions about the student’s program and placement. The student’s parent(s), the student’s special
education teacher, and a representative from the Local Education Agency are required members of this team. Signature on this IEP documents attendance, not
agreement.

Role Printed Name Signature

Parent/Guardian/Surrogate Jane Smith
Parent/Guardian/Surrogate N/A
Student* N/A
Regular Education Teacher** Britany Fuller
Special Education Teacher Marcelle SaintJean
Local Ed Agency Rep N/A
Career/Tech Ed Rep*** N/A
Community Agency Rep N/A
Teacher of the Gifted**** N/A
Speech Therapist Angela Smith
Principal Mrs. Saccoccia

* The IEP team must invite the student if transition services are being planned or if the parents choose to have the student participate.
** If the student is, or may be, participating in the regular education environment
*** As determined by the LEA as needed for transition services and other community services
**** A teacher of the gifted is required when writing an IEP for a student with a disability who also is gifted.
One individual listed above must be able to interpret the instructional implications of any evaluation results.

Written input received from the following members:

N/A

Transfer of Rights at Age of Majority

For purposes of education, the age of majority is reached in Pennsylvania when the individual reaches 21 years of age. Likewise, for purposes of the Individuals
with Disabilities Education Act, the age of majority is reached for students with disabilities when they reach 21 years of age.

PROCEDURAL SAFEGUARDS NOTICE

I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides information about my rights,
including the process for disagreeing with the IEP. The school has informed me whom I may contact if I need more information.

Signature of Parent/Guardian/Surrogate:

MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

(Applicable only to parents who have consented to the release of billing information to Medical Assistance programs)

I understand that the school may charge the School-Based Access Program (“SBAP”)—or any program that replaces or supplements the SBAP—the cost of certain
special education and related services described in my child’s IEP.  To make these charges to the SBAP, the school will release to the administrator of that
program the name, age, and address of my child, verification of Medicaid eligibility for my child, a copy of my child’s IEP, a description of the services
provided and the times and dates during which such services were provided to my child, and the identity of the provider of such services.   I understand that
such information will not be disclosed, and such charges will not be made, unless I consent to the disclosure. I acknowledge that I have provided written
consent to disclose such information.

I understand that my consent is ongoing from year-to-year unless and until I withdraw it. I can withdraw my consent in writing, or orally if I am unable to
write, at any time.  My refusal to consent or my withdrawal of consent will not relieve the school of the obligation to provide, at no cost to me or my family,
any service or program to which my child is entitled under the Individuals with Disabilities Education Act (“IDEA”) or that is necessary to enable my child to
receive a free appropriate public education as described in my child’s IEP. 

I understand that the school cannot—

Require me or my family to sign up for or enroll in any public benefits or insurance program, such as Medicaid, as a condition of receiving a free appropriate
public education for my child;

Require me or my family to incur any expense for the provision of a free appropriate public education to my child, including co-payments and deductibles,
unless it agrees to pay such expenses on my or my family’s behalf;

Cause a decrease in available lifetime coverage or any other insured benefit;

Cause me or my family to pay for services that would otherwise be covered by a public benefits or insurance program and that are required for my child
outside the time that he or she is in school;

Risk the loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.
I. SPECIAL CONSIDERATIONS THE IEP TEAM MUST CONSIDER BEFORE DEVELOPING THE IEP. ANY FACTORS CHECKED AS “YES” MUST BE ADDRESSED IN THE IEP.

Is the student blind or visually impaired?

Yes The IEP must include a description of the instruction in Braille and the use of Braille unless the IEP team determines, after an
evaluation of the student’s reading and writing skills, needs, and appropriate reading and writing media (including an
evaluation of the student’s future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use of
Braille is not appropriate for the student.
X No

Is the student deaf or hard of hearing?

Yes The IEP must include a communication plan to address the following: language and communication needs; opportunities for
direct communications with peers and professional personnel in the student’s language and communication mode; academic
level; full range of needs, including opportunities for direct instruction in the student’s language and communication mode;
and assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The
Communication Plan must be completed and is available at www.pattan.net

X No

Does the student have communication needs?

Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)

X No

Does the student need assistive technology devices and/or services?

Yes Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)

X No

Does the student have limited English proficiency?

X Yes The IEP team must address the student’s language needs and how those needs relate to the IEP.

No
 Does the student exhibit behaviors that impede his/her learning or that of others?
Yes The IEP team must develop a Positive Behavior Support Plan that is based on a functional assessment of behavior and that
utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in the Present Levels
section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially Designed Instruction
sections of the IEP or in the Positive Behavior Support Plan if this is a separate document that is attached to the IEP. A
Positive Behavior Support Plan and a Functional Behavioral Assessment form are available at www.pattan.net

X No

Other (specify):

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Include the following information related to the student:

 Present levels of academic achievement (e.g., most recent evaluation of the student, results of formative assessments, curriculum-based
assessments, transition assessments, progress toward current goals)
 Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress
toward current goals)
 Present levels related to current postsecondary transition goals if the student’s age is 14 or younger if determined appropriate by the IEP team
(e.g., results of formative assessments, curriculum-based assessments, progress toward current goals)
 Parental concerns for enhancing the education of the student
 How the student’s disability affects involvement and progress in the general education curriculum
 Strengths
 Academic, developmental, and functional needs related to student’s disability

Summary
Vinny is a three-year-old male attending East Garfield Elementary in Steubenville Ohio. She was evaluated on April 22 nd, 2021 and found to
have developmental delay. In this report, Vinny’s assessment results, areas of needs, and strengths are discussed and listed to develop a
plan for academic support.

Present level of academic achievement:

Literacy: When Vinny was assessed with the Brigance Inventory of Early Development III, his results show that he was not at the
appropriate grade level for Language Development. Vinny performed at an age equivalent level of 2 years and 7 months. He had a raw
score of 8/170 and a composite score of 82. From the assessment results it is clear that Vinny shows little understanding of books and text,
and letter recognition. He could not identify more than a few letters in the alphabet and could not recite the entire alphabet. He was able
to successfully able to identify the letters V and O. And letter A when it was capitalized. He could not blend words together, identify
rhymes or segment words. Vinny was not able to ask question about a story, nor could he identify the front and back of a book.
Mathematics: When assessed with the Brigance, Vinny performed at an age equivalent to a 2 year and 9 months. He had a raw score of
10/101 and a composite score of 87. Vinny can rote count to 4 and understood the concept of giving just one and one more. He could not
compare different amounts or sort objects by sort by tow attributes. Vinny could not match quantities with numerals, read numerals above
five, or solve word problems.

Present level of Functional performance:

Behavior: Vinny is always pleasant and is easy to redirect if needed. Vinny is kind to other and eager to help. He shares well and works
well in any group setting. However, Vinny often opts for working independently. When Vinny becomes frustrated, he puts his head down
and will not continue the task. He does not require prompting or reminders to remain on task often. If Vinny does need reminders or
prompting, he quickly complies and returns to the task at hand. Vinny remains in his designated area and completes his tasks given.

Communication: when assessed for receptive language with the Brigance, Vinny performed at the age equivalent of a 1 year and 8 months.
Receiving a raw score of 38 and a composite score of 78. Vinny demonstrated receptive language skills entailing short commands like
responding to the word give and putting a block into a box when asked to do so. Vinny demonstrated an understanding of animal words by
making the correct sound of those animals. When asked to point to named body parts, Vinny followed instruction well and was able to
identify the named body parts. Vinny can understand verbal concept like open/close, forward/backward, and away from/toward. But
struggles with understanding in/out, bottom top and behind/in front of. Vinny can follow one-step, two-step, and three-step instruction.

Social Skills: When assessed for social emotional development using the Brigance, Vinny performed at an age equivalent of a 4 year and 0
months, receiving a raw score of 32 and a composite score of 96. Vinny demonstrates a healthy relationship with adults. He shows
affection and behaves in a warm and caring manner, is respectful, responds to directions, shares his feelings, and asks for guidance when
needed. However, Vinny does not share information about himself, or his thoughts and ideas. Vinny shows signs of attachment to a single
playmate even temporarily, but he does not have any special or best friends. Vinny is beginning to be aware of his own good and bad
behavior, as well as the good and bad behavior of others. He demonstrates that he is satisfied with himself and is not overly critical of his
performance. However, Vinny does not remain focused on what is being asked of him.

Gross and Fine Motor Skills: When assessed for physical development in the gross motor domain, Vinny performed at an equivalent of 1
year and 11 months, receiving a raw score of 30/63 and a composite score 81. Vinny can successfully stand on one foot for one second. He
can jump off the floor with both feet, walk up the stairs with one hand held, and walk down the stairs with one hand held. However, Vinny
still cannot hop two hops on one foot, walk up or down the stairs with alternating feet with one hand on the railing. Vinny is able to throw
a playground ball with both hands from an overhead position and catch a thrown playground ball with hands and chest. However, he
cannot catch a thrown tennis ball with both hands. When assessed for physical development in the fine motor skill domain, Vinny
performed at an age equivalent of 0 year and 9 months. He received a raw score of 13/107 and a composite score of <55. Vinny can
successfully put objects, such as blocks into a container, grasp, and release objects, unwrap objects and imitate scribbles. However, Vinny
cannot squeak a toy with his hand or take objects out of a container. Vinny is able to successfully draw a vertical and horizontal line. He is
still not able to draw a circle, plus sign, x, or a square. Vinny still cannot print the first letter of his first name.

Adaptive Skills: When assessed for adaptive skills using the Brigance, Vinny performed at an age equivalent of 2 years and 7 months,
receiving a raw score of 28/48 and a composite score of 88. He is able to ask for food when he is hungry, hold a cup with one hand, place a
spoon in his mouth without turning the spoon upside down. Vinny can remove his own socks if his shoes are removed, if the shoelaces are
undone for him, Vinny can remove his shoes. However, Vinny does not put on his shoes on the correct foot 90% of the time.

Present level related to current postsecondary transition goals:

 Transition services are not appropriate at this time.

How the student’s disability affects involvement and progress in the general education curriculum:
Vinny’s speech delay makes it difficult to accurately measure his academic strengths. It is possible that Vinny can counter higher than 6
but he only whispers when counting.

Strengths (per the information above):

-Vinny can identify three letters.
-Vinny can rote count to 4.
-Vinny is kind to his peers and to adults.
-Vinny is respectful to adults and peers.
-Vinny shows early receptive skills like responding with the correct animal sound when a picture of an animal is shown.
-Vinny can walk up and down the stairs with one hand held.
-Vinny can feed and dress himself independently.

Academic, developmental, and functional needs related to student’s disability:

The literacy assessment of the Brigance demonstrated that Vinny has little letter recognition. He was only able to identify 3 out of the 26
letters and was unable to recite the alphabet. This weakness of this foundational element impacts his ability to advance in his literacy
skills like writing his name, decoding words, and writing. Vinny needs to learn his letters so that he can be successful in literacy.
Physical Development:
The Fine-Motor Skills Assessment of the Brigance demonstrated that Vinny cannot squeak a toy with his hands and upon observation, Vinny
still hold a crayon in a fist. While he is able to draw a vertical and a horizontal line, Vinny cannot draw a circle or any other shapes. Vinny
cannot write any letters in his name. A weakness in this foundation impacts his ability to write and will eventually affect his ability to
meet grade-level writing standards.

III. TRANSITION SERVICES – This is required for students age 14 or younger if determined appropriate by the IEP team. If the student does not attend the
IEP meeting, the school must take other steps to ensure that the student’s preferences and interests are considered. Transition services are a coordinated
set of activities for a student with a disability that is designed to be within a results oriented process, that is focused on improving the academic and
functional achievement of the student with a disability to facilitate the student’s movement from school to post school activities, including postsecondary
education, vocational education, integrated employment (including supported employment), continuing and adult education, adult services, independent
living, or community participation that is based on the individual student’s needs taking into account the student’s strengths, preferences, and interests.

POST SCHOOL GOALS – Based on age appropriate assessment, define and project the appropriate measurable postsecondary goals that address education
and training, employment, and as needed, independent living. Under each area, list the services/activities and courses of study that support that goal.
Include for each service/activity the location, frequency, projected beginning date, anticipated duration, and person/agency responsible.

For students in Career and Technology Centers, CIP Code:

N/A
Postsecondary Education and Training Goal:
Measurable Annual Goal
N/A Yes/No
(Document in Section V)

Courses of Study:
N/A

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible

Employment Goal: N/A

Measurable Annual Goal
Yes/No
(Document in Section V)
Courses of Study:
N/A

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible
Independent Living Goal, if appropriate: N/A
Measurable Annual Goal
Yes/No
(Document in Section V)

Courses of Study: N/A

Projected Anticipated Person(s)/Agency

Service/Activity Location Frequency
Beginning Date Duration Responsible

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Instructions for IEP Teams:
Please select the appropriate assessment option. Information on available testing accommodations may be found in the Accommodations Guidelines
available on www.education.state.pa.us.

State Assessments

Not Assessed
X No statewide assessment is administered at this student’s grade level.
X No English proficiency assessment administered because the student is not an English Language Learner.

PSSA (Math administered in grades 3-8; Science administered in grades 4 and 8; Reading administered in grades 3-8; Writing administered in grades 5
and 8; and ELA*)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Math
Science
Reading
Writing
ELA*
*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.

Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11 th grade)
 Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1
Literature
Biology

Keystone Project Based Assessment (Available when student is unable to demonstrate proficiency on a Keystone Exam or Keystone Exam
module.)
Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1
Literature
Biology

Validated Local Assessment (Available when selected as option by LEA)

Without With
Tested Subject Accommodations Accommodations Accommodations to be Provided
Algebra 1
Literature
Biology

PASA (Administered in grades 3-8, 11 for Reading and Math; Grades 4, 8, 11 for Science)
Student will participate in the PASA.

Explain why the student cannot participate in the PSSA or the Keystone Exam for Reading/Literature, Math/Algebra 1,
Science/Biology, and Composition (The Composition exam will be available for the 2016-17 school year):

Explain why the PASA is appropriate:

Choose how the student’s performance on the PASA will be documented.

Videotape (preferred method)

Written narrative notes (requires prior approval in accordance with PDE

guidance)

ACCESS for ELLs (Administered in grades K-12)

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to
 Accommodations Accommodations Participate Participate in Selected Domains
Listening
Reading
Writing
Speaking

Alternate ACCESS for ELLs (Administered in grades 1-12)

Student will participate in the Alternate ACCESS for ELLs.

Explain why the student cannot participate in the ACCESS for ELLs:

Explain why the Alternate ACCESS for ELLs is appropriate:

Domains Without With Unable to Accommodations to be Provided or Rationale for Inability to

Accommodations Accommodations Participate Participate in Selected Domains
Listening
Reading
Writing
Speaking

Local Assessments

X Local assessment is not administered at this student’s grade level; OR

Student will participate in local assessments without accommodations; OR

Student will participate in local assessments with the following accommodations; OR

The student will take a local alternate assessment.

Explain why the student cannot participate in the local regular assessment:
Explain why the local alternate assessment is appropriate:
V. GOALS AND OBJECTIVES – Include, as appropriate, academic and functional goals. Use as many copies of this page as needed to plan appropriately.
Specially designed instruction may be listed with each goal/objective or listed in Section VI.

Short term learning outcomes are required for students who are gifted. The short term learning outcomes related to the student’s gifted program may be
listed under Goals or Short Term Objectives.

MEASURABLE ANNUAL GOAL Describe HOW the

Describe WHEN periodic
Include: Condition, Name, Behavior, and Criteria student’s progress toward
reports on progress will be Report of Progress
(Refer to Annotated IEP for description of these meeting this goal will be
provided to parents
components) measured

Presented with the written form of the 26 letters Once a week the special Progress will be sent
of the alphabet, Vinny will identify the letters education teacher will quarterly to parents with
with 80% accuracy for 4 consecutive progress present Vinny the 26 report cards.
monitoring sessions. letters of the alphabet.
The teacher will record
the letters that Vinny was
able to correctly identify
and record the number of
letters he identified.
When presented with 15 objects, Vinny will count Once a week the special Progress will be sent
the objects in numeric order with 80% accuracy education teacher will quarterly to parents with
for 4 consecutive progress monitoring sessions. present Vinny with a report cards.
group of 15 objects and
instruct him to count
them in numeric order.
The teacher will record
that Vinny was able to
count in numerical order.
When given a laminated lined paper with his first Once a week the special Progress will be sent
name written on it, Vinny will trace his name with education teacher will quarterly to parents with
80% accuracy for 4 consecutive progress present Vinny with report cards.
monitoring sessions laminated piece of paper
and a marker and instruct
him to trace and write his
name. The teacher will
record the letters Vinny
can write correctly in his
first name.

SHORT TERM OBJECTIVES – Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).
Short term objectives / Benchmarks

N/A
VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS – Include, as appropriate, for nonacademic
and extracurricular services and activities.

A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)

 SDI may be listed with each goal or as part of the table below.
 Include supplementary aids and services as appropriate.
 For a student who has a disability and is gifted, SDI also should include adaptations, accommodations, or modifications to the general
education curriculum, as appropriate for a student with a disability.

Modifications and SDI Location Frequency Projected Beginning Date Anticipated Duration
SDI for Goal 1:
The general education
teacher or the special
education will give Vinny
explicit and direct
instruction while working
one-on-one with Vinny. The
teacher will use letter card
and use guided practice. General Education
4 times per week 05/05/2021 05/0521-05/04/22
The teacher will first Classroom
identify the letter by saying
it out loud, repeat the
letter name with Vinny and
finally instruct Vinny to say
the letter independently.
Verbal praise reinforcement
will be provided
continuously.
SDI for Goal 1: General Education 4 times per week 05/05/2021 05/0521-05/04/22
Using direct and explicit Classroom
instruction, the general
education teacher or the
special education will use
physical alphabet letters
with Vinny. With the
physical manipulatives, the
teacher will name the
letter, then say the letter
with Vinny and instruct
Vinny to name the letter
independently. The teacher
will give verbal praise as a
reinforcement and record
Vinny’s response.
SDI for Goal 2:
The general education
teacher or the special
education teacher will use
direct and explicit
instruction to teach the
numbers to Vinny. Using a
dry erase board, the
teacher will write the
General Education
number on the dry erase 4 times per week 05/05/2021 05/0521-05/04/22
Classroom
board. Then the teacher
will say the number out
loud, then repeat the
number with Vinny and
finally ask him to
independently identify the
letter. Verbal
reinforcement will be used
continuously.
SDI for Goal 2:
With direct and explicit
instruction, the special
education or the general
education teacher will use
number matching cards to
practice naming numbers.
When Vinny pulls out a card General Education
4 times per week 05/05/21 05/0521-05/04/22
from the deck the teacher Classroom
will first identify the
number, then say the
number with Vinny and
finally ask Vinny to identify
the number independently.
Verbal reinforcement will
be provided continuously.
SDI for Goal 3: General Education 4 times per week 05/05/21 05/0521-05/04/22
Using direct and explicit Classroom
instruction, the special
education or the general
education teacher will
provide Vinny with a
laminated board with his
name already printed on it
and a marker. The teacher
will trace the letters of
Vinny’s name on the paper,
then with physical
guidance, help Vinny write
his name and finally, allow
Vinny to write his name
independently. The teacher
will record every letter
Vinny can write
independently in his name.
A sticker chart will be used
for reinforcement.
SDI for Goal 3:
With direct and explicit
instruction, Vinny will
engage in independent
practice. Given a white
board and dry erase
marker, Vinny will practice
General Education
writing his name 4 times per week 05/05/21 05/0521-05/04/22
Classroom
independently. The general
education teacher or
special education teacher
will monitor Vinny’s writing
attempts and progress. A
sticker chart will be used
for reinforcement.

B. RELATED SERVICES – List the services that the student needs in order to benefit from his/her special education program.

Service Location Frequency Projected Beginning Date Anticipated Duration

Speech and Language Speech and Language Room 30 minutes every week 05/05/21 05/0521-05/04/22

C. SUPPORTS FOR SCHOOL PERSONNEL – List the staff to receive the supports and the supports needed to implement the student’s IEP.

School Personnel to Support Location Frequency Projected Beginning Anticipated Duration

Receive Support Date
D. GIFTED SUPPORT SERVICES FOR A STUDENT IDENTIFIED AS GIFTED WHO ALSO IS IDENTIFIED AS A STUDENT WITH A DISABILITY – Support services are
required to assist a gifted student to benefit from gifted education (e.g., psychological services, parent counseling and education, counseling services,
transportation to and from gifted programs to classrooms in buildings operated by the school district).

Support Service N/A

Support Service N/A
Support Service N/A

E. EXTENDED SCHOOL YEAR (ESY) – The IEP team has considered and discussed ESY services, and determined that:

Student IS eligible for ESY based on the following information or data reviewed by the IEP team:

OR

X As of the date of this IEP, student is NOT eligible for ESY based on the following information or data reviewed by the IEP team:

Vinny will be evaluated for ESY during the 2021-2022 school year’s winter break. Ten days before the winter holiday break and ten
days after, Vinny will be assessed. If any regression in his progress occurs or recoupment during the break, a decision for an ESY
placement will be discussed and made by March 2022. The assessments will look for any regression that affects his social,
functional, academic performance.

The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the student’s ESY Program are:

If the IEP team has determined ESY is appropriate, complete the following:

ESY Service to be Provided Location Frequency Projected Beginning Date Anticipated Duration
VII. EDUCATIONAL PLACEMENT

A. QUESTIONS FOR IEP TEAM – The following questions must be reviewed and discussed by the IEP team prior to providing the explanations regarding
participation with students without disabilities.

It is the responsibility of each public agency to ensure that, to the maximum extent appropriate, students with disabilities, including those in public
or private institutions or other care facilities, are educated with students who are not disabled. Special classes, separate schooling or other removal
of students with disabilities from the general educational environment occurs only when the nature or severity of the disability is such that education
in general education classes, EVEN WITH the use of supplementary aids and services, cannot be achieved satisfactorily.

 What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the supplementary
aids and services will or will not enable the student to make progress on the goals and objectives (if applicable) in this IEP in the general
education class.

 What benefits are provided in the general education class with supplementary aids and services versus the benefits provided in the special
education class?

 What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the other students in the
class, even with supplementary aids and services?

 To what extent, if any, will the student participate with nondisabled peers in extracurricular activities or other nonacademic activities?

Explanation of the extent, if any, to which the student will not participate with students without disabili ties in the regular education class:
Academically, Vinny is performing at an age equivalent of a 2 year and 9 months. Although there is an
age gap between his developmental age and chronological age, it is not a big enough gap for him to
need placement or more time out of the regular education classroom. Vinny will continue to participate
in the regular education classroom and will only need to be pulled out for the specified services he
requires.

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
Vinny is performing academically and functionally at the age equivalent of a 2 year and 9 months.
Though he is partaking in the regular education classroom, his special needs indicate that he requires
support services to ensure his success in the general classroom education curriculum.
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name:

B. Type of Support

1. Amount of special education supports

X Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day

Supplemental: Special education supports and services provided by special education personnel for more than 20% of the day but less than
80% of the school day

Full-Time: Special education supports and services provided by special education personnel for 80% or more of the school day

2. Type of special education supports

Autistic Support

Blind-Visually Impaired Support

Deaf and Hard of Hearing Support

Emotional Support

X Learning Support

Life Skills Support

Multiple Disabilities Support

Physical Support

Speech and Language Support

Page 21 of 23 April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name:

C. Location of student’s program

Name of School District where the IEP will be implemented: Jefferson County School District

Name of School Building where the IEP will be implemented: East Garfield Elementary School

Is this school the student’s neighborhood school (i.e., the school the student would attend if he/she did not have an IEP)?
X Yes

No. If the answer is “no,” select the reason why not.

Special education supports and services required in the student’s IEP cannot be provided in the neighborhood school

Other. Please explain:

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student’s Name:

VIII. PENNDATA REPORTING: Educational Environment (Complete either Section A or B; Select only one Educational Environment)
To calculate the percentage of time inside the regular classroom, divide the number of hours the student spends inside the regular classroom by the total number of hours in the school day (including
lunch, recess, study periods). The result is then multiplied by 100.
SECTION A: For Students Educated in Regular School Buildings with Non Disabled Peers – Indicate the Percentage of time INSIDE the regular classroom for this student:
Time spent outside the regular classroom receiving services unrelated to the student’s disability (e.g., time receiving ESL services) should be considered time inside the regular classroom.
Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as college campuses or vocational sites, should be counted as time
spent inside the regular classroom.
Calculation for this Student:
Column 1 Column 2 Calculation Indicate Percentage Percentage Category
Total hours the student Total hours in a typical (Hours inside regular Section A: The percentage of
school day classroom ÷ hours in Using the calculation result – select the appropriate percentage category
spends in the regular time student spends inside the
(including lunch, recess school day) x 100 = %
classroom per day & study periods) (Column 1 ÷ Column 2) regular classroom:
x 100 = %

5.95 6 (5.95 ÷ 6) x 100=% ___99__% of the day X INSIDE the Regular Classroom 80% or More of the Day
INSIDE the Regular Classroom 79-40% of the Day
INSIDE the Regular Classroom Less Than 40% of the Day

SECTION B: This section required only for Students Educated OUTSIDE Regular School Buildings for more than 50% of the day – select and indicate the Name of School or
Facility on the line corresponding with the appropriate selection: (If a student spends less than 50% of the day in one of these locations, the IEP team must do the calculation
in Section A)
Approved Private School (Non Residential) _________________________ Other Public Facility (Non Residential) _________________________
Approved Private School (Residential) _________________________ Hospital/Homebound _________________________
Other Private Facility (Non Residential) _________________________ Correctional Facility _________________________
Other Private Facility (Residential) ________________________ Out of State Facility _________________________
Other Public Facility (Residential) ________________________ Instruction Conducted in the Home _________________________

EXAMPLES for Section A: How to Calculate PennData–Educational Environment Percentages

Column 1 Column 2 Calculation Indicate Percentage

Total hours the student spends in the Total hours in a typical school (Hours inside regular classroom ÷ hours in school day) Section A: The percentage of time student
day (including lunch, recess & x 100 = % spends inside the regular classroom:
regular classroom per day
study periods) (Column 1 ÷ Column 2) x 100 = %

Example 1 5.5 6.5 (5.5  6.5) x 100 = 85% 85% of the day
(Inside 80% or More of Day)
Example 2 3 5 (3 5) x 100 = 60% 60% of the day
(Inside 79-40% of Day)
Example 3 1 5 (1 5) x 100 = 20% 20% of the day
(Inside less than 40% of Day)
For help in understanding this form, an annotated IEP is available on the PaTTAN website at www.pattan.net Type “Annotated Forms” in the Search feature on the website. If you do not have access
to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.

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