Individualized Education Program (IEP) Performance Template

Susie Irwin
Table of Contents
Table of Contents......................................................................................................2
Standard 1: Contextual Factors: School and Community Demographics, Classroom Demographics,
Building Trust Relationships, and Classroom Management.....................................3
Standard 2: Individualized Education Plan – Part 1..................................................4
Standard 3: Individualized Education Plan - Part 2.................................................13
Standard 4: Preparation for IEP Meeting................................................................18
Standard 5: Implementation, Communication, and Progress Reporting.................20
Standard 6: Revised IEP..........................................................................................22
Standard 7: Reflection of the IEP Process...............................................................23
 Standard 1: Contextual Factors: School and Community Demographics, Classroom
Demographics, Building Trust Relationships, and Classroom Management

The IEP Performance Standards is the process for preparing and implementing the IEP
process. This template will be used to address specific standards and go through the process
of creating an IEP for a student in your placement.

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

Complete this portion of the IPE Template document using the following link:
Standard 1, Part I
After completing the e-doc portion, submit the PDF you receive into the Learning Management System (LMS).

Part II: Demographic, Environment, and Academic Factors

Complete this portion of the IEP Template document using the following link:
Standard 1, Part II
After completing the e-doc portion, submit the PDF you receive into the Learning Management System (LMS).

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 Learning Management System
(LMS).
Standard 2: Individualized Education Plan – Part 1
Base the IEP on the student you are following throughout your student teaching placement.
All identifiable student information should be replaced with pseudonyms for confidentiality. In
addition, some information has been marked "Do not complete"’ due to confidentiality
concerns.
The present level of academic achievement and functional performance (PLAAFP) will guide
 the development of the IEP. Teachers must describe student strengths, interests, and needs
within the PLAAFP. Assessment scores and a description of how the student is performing in
relationship to typically developing peers will provide the rationale for the development of
IEP goals, services, testing accommodations, and supplementary aides and services. It is
important that all sections of the IEP align with the PLAAFP.

Special Education Department

Individualized Education Program (IEP)
Student Name:
Demographic Information Tyler White
Student
Student Number: Student (Pseudo) Birthdate: Gender: Grade: Data/Cover Sheet
Name: 08/06/2015 M K
(Form A-1) IEP
Beau Zhang
Meeting
Student Address: Home Phone: Date:8/17/2021
3500 West Camelback Road Do not complete
City, State, Zip:
Phoenix, Arizona 85017
Parent 1 (Pseudo) Name: Parent 1 Relationship:
Bob White Father
Parent 1 Address: Home Phone:
Do not complete. Do not complete.
City, State, Zip: Work Phone:
Do not complete. Do not complete.
Parent 1 Email:
Do not complete.
Parent 2 (Pseudo) Name: Parent 2 Relationship:
Sally White Mother
Parent 2 Address: Home Phone:
Do not complete. Do not complete.
City, State, Zip: Work Phone:
Do not complete. Do not complete.
Parent 2 Email:
Do not complete.
Primary Language of Home: Primary Language Survey Date:11/10/2019 Language of Instruction:
English Primary Language Survey Results: English
11/10/2019
Home District: Fulton County Service Coordinator: Susie Irwin
Attendance District: Johns Creek Susie Irwin
Home School: Wilson Creek Attending School: Medlock Bridge
Vision Screened On: Results: Hearing Screened On: Results:
Meeting Date:8/17/2021 Anticipated Duration of Re-evaluation Due:8/16/2021
IEP:08/16/2022 Current Evaluation:
From: 08/16/2021 To: 08/16/2022
Special Education Primary Category 1: Autism

Special Education Eligibility Category 2: Speech/Language Impairment

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: Annual Review

Date Meeting Notice Sent to the Date Procedural Safeguards given to the
Parent(s): 08/12/2021 Parent(s): 08/12/2021
 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: Tyler White Student Data/Cover Sheet (Form B)

IEP Meeting Date:08/16/2021

Student ID: 123-23-4567 DOB:08/06/2015

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE (PLAAFP)

Section 1: Current IEP Information

Summarize special education services the student is receiving:

Tyler will receive instruction in the special education setting KSE classroom where he will receive 1,755 minutes of
instruction weekly for reading, math, ELA, Science, Social Studies, Behavior Support and Health. He will also
receive speech and language services in the special education setting for 60 minutes weekly. He will attend lunch
and recess daily with non-disabled peers in the general education setting for 300 minutes weekly as well as attend
Music 45 minutes per week. Tyler will receive Related Services for Occupational Therapy 60 minutes a week, and
Adaptive PE for 90 minutes a week, as well as receive Adaptive Art instruction.

Section 2: Evaluation Information

Areas of Eligibility:

Special Education Primary Category: Autism

Special Education Eligibility Category 2: Speech/Language Impairment
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

ACADEMIC: He is emerging in nesting objects inside one another. He does not find an object hidden under one of
two cups, select the hand hiding the toy, attend to a learning task or story in a small group for 5 minutes, pull a
cloth to obtain an object, identify sources of common actions, Tyler demonstrates echolalia and delayed echolalia,
which often impedes his ability to grasp novel directions and concepts. He will repeat familiar scenes/lines from
favored cartoons such as Peppa Pig and Daniel Tiger. When given a direction or asked a question, he will most
often repeat what has been said to him rather than answering the questions. This is more prevalent with verbal
questioning alone rather than questions with a visual cue or prompt. Sometimes repeated questioning is needed to
gain attention and elicit an answer. Tyler is not showing interest in noticing or playing with rhyming words in
songs, stories, or poems. He is not able to state his name, age, or gender when asked.
EMOTIONAL/SOCIAL/BEHAVIORAL: He is emerging appropriately communicating a range of positive and
negative emotions, expressing enthusiasm for work or play, using objects in make-believe play, and engaging in
adult role-playing and imitation. He does not respond positively to adult praise, rewards, or promise of rewards,
respond positively when adult initiate social contact, allow others to participate in his activities, show awareness of
the presence of other children, enjoy playing
with other children, initiate social contact with peers in play, imitate the play activities of other children, respond
differently to familiar and unfamiliar children, using the same materials, without disturbing the other child’s play,
follow directions related to his daily routine, imitate others and change his behavior based on what others are doing,
show pride in accomplishments, state his first name, use words for social contact, use a personal pronoun or his
name to refer to himself, or state his age. Although this has improved with Tyler learning the classroom routine and
having a very structured learning environment, it is difficult for Tyler to maintained joint attention once established.
He requires multiple verbal prompts to redirect his attention. He has difficulty transitioning to the correct area when
split from his brother, as he is interested in where his brother is going. Currently, this only happens during 2 small
group instructional lessons. Tyler has difficulty complying with many simple verbal directions, such as ’come here’
if his attention is directed elsewhere and needs several verbal prompts and/or physical redirection to comply. He is
not able to state his name, age, or gender when asked.

PHYSICAL (FINE/GROSS MOTOR):He is emerging in kicking a ball forward without falling and imitating
circular markings. He does not throw a ball 5 feet forward with direction, imitate the bilateral movements of an
adult, use pads of fingertips to grasp pencil, fasten clothing without assistance, wiggle his thumb in bending,
circular, and back-and-forth movements, and trace designs with curved edges. Tyler is not yet able to lace a card,
copy a cross, cut across paper or manage buttons. Tyler shows tendencies to respond negatively to loud noises.

Gross Motor: Tyler is able to throw a ball 5 feet with direction, in 4/5 trials He throws the ball down and bounces it
to his partner instead of throwing it in the air straight across. Upon completion of an Adapted PE evaluation, Tyler
qualifies for Adapted PE for his kindergarten year. He had difficulty following directions as well as completing
examiners task as given.

Fine Motor: Classroom - Tyler is still not producing a square with 4 distinct corners. He does not use an age-
appropriate grasp when working with larger crayons or markers.

Current Classroom-Based Data:

ACADEMIC: Per teacher report and standardized testing, Tyler attends to one activity for 3 or more minutes.
Tyler shows curiosity about environmental objects and events. He is able to recognize and name basic shapes. He can
recognize his name from that of his classmates. He is able to identify most letters, upper and lowercase. Tyler can identify and
sort big and little items with 100% accuracy in 3+ consecutive data sessions. He is able to identify numerals 1-10 consistently,
demonstrate 1:1 correspondence up to 10 and give requested #of objects to 10. He understands the concept of ’more’.

COMMUNICATION/SPEECH LANGUAGE: Tyler demonstrated strengths in self-directed play with a toy piggy bank at the
end of the second evaluation session, at- tempted to sing the song that corresponds with the toy when activated, using one-
word utterances, and inconsistently producing phrases (“Thank you” and “See you later”).

He is using 3–4-word sentences given a cue consistently. He is starting to respond to simple what questions, and he can follow
some routine 1 step directions. Tyler’s articulation, voice and fluency skills were informally assessed through the use of an
informal language sample and examiner observations. Because Tyler had difficulty with compliance, a cursory oral-motor
examination was completed to assess his face, lips, tongue, teeth, and jaw for functional speech production. Based on the
brief oral-motor assessment, Tyler’s oral and facial structures were deemed adequate for speech production. His speech was
100 percent intelligible to the average listener. His articulation skills fell in the average range and were deemed effective for
communicating successfully with peers and adults in school. Tyler’s voice was deemed normal for intensity, resonance, and
pitch. His voice production skills were within functioning limits for effective communication with peers and adults in the
educational setting. Tyler produced minimal spontaneous phrases but frequently produced single words during the evaluation
sessions. Words and phrases produced by Tyler within the informal sample were smooth. No repetitions, prolongations,
blocks, or physical concomitants were noted in his speech production. Tyler’s fluency skills fell within the average range of
performance and were effective for communicating with peers and adults in the educational setting.

Within the PLS-5 and DAYC-2 Communication Domain, Tyler demonstrated the greatest strengths in identifying body parts
and things you wear, understanding the verbs “drink” and “sleep” in context, engaging in pretend play, responding to “where”
questions by going to get the object asked for, pointing to five or more familiar persons, animals or toys, following directions
about placing an item “in” or “on” another, pointing to 15 or more pictures of common objects when they are named, using 10
to 15 words spontaneously, producing three or more two-word phrases, naming eight or more pictures of familiar objects,
using at least 50 different words in spontaneous speech, using a representational gestures, producing syllable strings with
inflection similar to adult speech, imitating words, producing different types of consonant-vowel combinations, initiating a
turn-taking game or social routine and using gestures and vocalizations to request objects.

He is using 3–4-word sentences given a cue consistently. He is starting to respond to simple what questions, and he can follow
some routine 1 step directions.

EMOTIONAL/SOCIAL/BEHAVIORAL: Per teacher report and standardized testing, Tyler plays independently in the
company of peers, and he expresses ownership or possession. Tyler has learned the routine of the classroom and is able to use
a three-picture visual schedule appropriately for 5+ transitions per day in 3+ consecutive data sessions. He plays appropriately
with a variety of toys. He plays and works alongside others but needs support to initiate interactions.

PHYSICAL (FINE/GROSS MOTOR):Per parent report and standardized testing, Tyler bends over and touches the floor with
both hands, he walks downstairs without assistance, alternating feet, he walks forward 2 or more steps on a line on the floor,
alternating feet, he holds paper with one hand while drawing with the other hand, he strings 4 large beads, he copies a circle,
and he stacks 8 cubes vertically. The Peabody Developmental Motor Scale-2 was administered on 12/2/2019. On the Grasping
subtest, he scored a standard score of 3 (1st percentile). On the Visual Motor Integration Subtest, he scored a standard score of
6 (9th percentile). The scores yield a Fine Motor (FMQ) of 67 (1st percentile).

The Sensory Processing Measure was administered as a way of obtaining a complete picture of the student’s sensory
functioning in the home environment. School environment is not assessed at this time due to Tyler is does not attend
preschool at this time. Scores indicate Typical Performance in the areas of Social (T-score=56) Vision (T-score=56), Hearing
(T- score=55), Touch (T- score=58), Body Awareness (T-score=50), Balance/Motion (T-score=50), Planning/Ideas (T-
score=52) and Total Sensory (T- score=56).

Tyler can secure small pellets with a pincer grasp and used a mature three finger grasp to secure small blocks. He can secure
multiple blocks in one hand and build a tower of 8 blocks. He shows emerging skill to imitate simple 3-4 block structures.
Tyler
can use two hands together to fold paper, string small beads and produce snips with scissors. Tyler can
use a fisted grasp to imitate a vertical stroke and a horizontal stroke. He can copy a single closed circle.
He shows emerging skill to copy a cross.

Gross Motor: - Tyler is able to navigate the school environment independently. He climbs on the
playground equipment safely. Tyler is able to run, changing directions 3 times on teacher’s signals.

Fine Motor: Classroom - Classroom data shows that Tyler can cut through a 6“ bolded line with 100%
accuracy in 4 consecutive data sessions. He is able to copy a cross with 80% accuracy in 3+ data sessions
and is emerging on copying a square.

Family’s Input on Student’s Current Performance:

Parents’ main concern is with Tyler’s delays in communication skills.

Summary of Work Habits:

STRENGTHS: Tyler demonstrated strengths in self-directed play with a toy piggy bank at the end of the
second evaluation session, at- tempted to sing the song that corresponds with the toy when activated,
using one-word utterances, and inconsistently producing phrases (“Thank you” and “See you later”). He
is using 3–4-word sentences given a cue consistently. He is starting to respond to simple what questions,
and he can follow some routine 1 step directions. Tyler’s articulation, voice and fluency skills were
informally assessed using an informal language sample and examiner observations. Because Tyler
had difficulty with compliance, a cursory oral-motor examination was completed to assess his face, lips,
tongue, teeth, and jaw for functional speech production. Tyler’s oral and facial structures were deemed
adequate for speech production. His speech was 100 percent intelligible to the average listener. His
articulation skills fell in the average range and were deemed effective for communicating successfully
with peers and adults in school. Tyler’s voice was deemed normal for intensity, resonance, and pitch. His
voice production skills were within functioning limits for effective communication with peers and adults
in the educational setting. Tyler produced minimal spontaneous phrases but frequently produced single
words during the evaluation sessions. Words and phrases produced by Tyler within the informal sample
were smooth. No repetitions, prolongations, blocks, or physical concomitants were noted in his speech
production. Tyler’s fluency skills fell within the average range of performance and were effective for
communicating with peers and adults in the educational setting. Tyler demonstrated the greatest strengths
in identifying body parts and things you wear, understanding the verbs “drink” and “sleep” in context,
engaging in pretend play, responding to “where” questions by going to get the object asked for, pointing
to five
or more familiar persons, animals or toys, following directions about placing an item “in” or “on”
another, pointing to 15 or more pictures of common objects when they are named, using 10 to 15 words
spontaneously, producing three or more two- word phrases, naming eight or more pictures of familiar
objects, using at least 50 different words in spontaneous speech, using a representational gestures,
producing syllable strings with inflection similar to adult speech, imitating words, producing different
types of consonant-vowel combinations, initiating a turn-taking game or social routine and using gestures
and vocalizations to request objects. He is using 3–4-word sentences given a cue consistently. He is
starting to respond to simple what questions, and he can follow some routine 1 step directions.

WEAKNESSES: Tyler demonstrated the greatest needs in the following areas: understanding pronouns,
following commands without gestural cues, engaging in symbolic play, recognizing action in pictures,
understanding use of objects, understanding spatial concepts, understanding quantitative concepts,
making inferences, understanding analogies, answering yes/no questions, carrying out two-step
© 2019. Grand Canyon University. All Rights Reserved.
directions, understanding at least three possessives, understanding negative, understanding “big” and
“little,” responding to “who” and “whose” questions, following directions that include spatial concepts
(“beside” “under” “in front of” and “behind,), demonstrating joint attention, naming objects in
photographs and pictures, using words more often than gestures to communicate, using words for a
variety of pragmatic language functions, using different word combinations, combining three or four
words in spontaneous speech, using a variety of nouns, verbs, modifiers and pronouns in spontaneous
speech, producing a four- or five-word sentence, using present progressive verbs, whispering, describing
what he is doing, asking ”what“ or ”where“ questions, using five or more regular plurals, changing his
speech depending on the listener, giving his full name on request, answering ”What happens if“ questions
(hypothetical questions) and using five or more contractions.

Section 4: Summary of Educational Needs and General Accommodations

Special Education Department

Individualized Education Program (IEP)
Student (Pseudo) Name: Tyler White Considerations Form (Form C)

IEP Meeting Date:08/16/2021

Student ID 123-45-678 DOB : 08/06/2021

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 ☒ ☐

© 2019. Grand Canyon University. All Rights Reserved. Page 10 of 29

© 2019. Grand Canyon University. All Rights Reserved. Page 11 of 29
 Special Education Department
Individualized Education Program (IEP)
Student (Pseudo) Name: Tyler White Accommodations (Form F) IEP Meeting Date:
08/16/2021

Student ID: 123-45-678 DOB: 08/06/2015

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

A recent speech and language evaluation revealed that Tyler has receptive and expressive language
delays. His voice, articulation and fluency skills fell in the average range of performance. According to
the developmental evaluation from November 2019, Tyler has significant developmental delays in the
areas of personal/social, motor, and cognitive skills.

State Assessments
11/13/19 Battelle Developmental Inventory-2nd Edition Developmental Profile 3 The results indicate
significant develop- mental delays in the areas of social, motor, and cognitive skills.

Tyler was evaluated by Asia Gifford, Psy.D., Licensed Clinical Psychologist, on October 22, 2019.
Following is a brief summary of results. Please refer to Dr. Gifford’s psychological evaluation report for
further details. The Autism Diagnostic Observation Schedule (ADOS-2) was administered. Results of the
ADOS-2 indicate that he is showing symptoms of autism spectrum disorder. Tyler reportedly said three
recognizable words during the evaluation and one phrase which was scripted. His vocalizations almost
never appeared to be directed to others. He used poorly modulated eye contact, used no social overtures,
and struggled to request for activities to continue. Tyler engaged in unusual hand mannerisms including
odd posturing. He engaged in stereotyped interests and had difficulty with transitioning and putting away
toys as wanted.

The Autism Diagnostic Interview - Revised (ADI-R) and the Autism Spectrum Rating Scales were
completed. The pattern of scores on the ASRS indicate that Tyler has symptoms directly related to the
DSM-5 diagnostic criteria (DSM-5 Scale T-
Score=73; 99%; Very Elevated range), and he is exhibiting many of the associated features characteristic
of autism spectrum disorder (Total T-Score=67; 96%; Elevated range).
Dr. Gifford indicated that Tyler meets the criteria for Autism Spectrum Disorder Level 2 (needs
substantial support). It was noted that he has difficulty using appropriate non-verbal communication for
social contact, engages in unusual behaviors, has difficulty relating to children, has difficulty related to
adults, engages in stereotypical behaviors, and has difficulty tolerating changes in routine.

According to results of the Adaptive Behavior Assessment System, Third Edition (ABAS-3), the General
Adaptive Compos- ite standard score of 81 (10th percentile) falls in the Below Average range compared
to his same age peers. The Conceptual Domain standard score of 81 (10th percentile) also falls in the
Below Average range. The Social Domain standard score of 70 (2nd percentile) falls in the Low range
and is an area of weakness for Tyler. The Practical Domain standard score of 91 (27th percentile) falls in
the Average range and is an area of relative strength for him. It was noted that Tyler demonstrated
strengths in home living and health and safety skills.

© 2019. Grand Canyon University. All Rights Reserved. Page 12 of 29

Standard Accommodation(s):

Chunk assignment/scaffolding
1 or 2 step instructions
Check for understanding
Clarify instructions/directions
Extra time for responses
Provide warning prior to calling on student
Repeat directions
Visual aids (pictures, flash cards, etc.)
Provide sensory breaks as needed

District Assessments
The only district assessment used in kindergarten is GKids. It is a one-on-one observational assessment.

Standard Accommodation(s):

Chunk assignment/scaffolding
1 or 2 step instructions
Check for understanding
Clarify instructions/directions
Extra time for responses
Provide warning prior to calling on student
Repeat directions
Visual aids (pictures, flash cards, etc.)
Provide sensory breaks as needed

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

Testing Area Test Results Grade Semester Year

Reading 75% K Fall 2021
Writing 15% K Fall 2021
Math 23% K Fall 2021
Science N/A

LEAST RESTRICTIVE ENVIRONMENT (LRE)

© 2019. Grand Canyon University. All Rights Reserved. Page 13 of 29

 Tyler is in the LRE with his placement within the kindergarten special education classroom.
With his lack of social skills, academic goals, and communication skills he would not be able
to function at the academic level needed in a general education classroom. Tyler’s delays in
receptive and expressive language skills negatively impact his ability to communicate
effectively with peers and adults in the educational setting.

His delays in personal/social skills negatively impact his ability to interact appropriately with
peers and adults, his delays in motor skills negatively impact his ability to play with peers
and draw and write, and his delays in cognitive skills negatively impact his ability to be
successful in a typical preschool.

Assessment results indicate that Tyler may have difficulty engaging in successful or
appropriate behavior across a variety of settings, including interacting with others,
performing age-appropriate tasks, and performing school-related tasks. He may experience
deficits in social skills, communication, and interests and activities that adversely impact his
x
ability to respond appropriately to everyday settings and situations.

© 2019. Grand Canyon University. All Rights Reserved. Page 14 of 29

 Standard 3: Individualized Education Plan - Part 2

Special Education Department

Individualized Education Program (IEP)
Student (Pseudo) Name: Tyler White Student Goals and
Performance Objectives IEP Meeting Date: 08/16/2021

Student ID: 123-45-678 Progress Report DOB: 08/06/2015

Skill Area: Math

Standard:

Annual Goal: Tyler will improve his Comparison skills in Math, from not being able to identify
larger shapes, to being able to identify larger numerical quantities/amounts.

Baseline Level of Mastery: 5 out of 10 attempts. As identified in short term objectives to

include, but not limited to work samples, benchmark assessments, data collection, and/or annotated
observations.
Service Provider(s) for this goal: Special Education Teacher

Skill Area: Sensory/Motor

Standard:

Annual Goal: Tyler will improve his fine motor and visual motor skills
from needing assistance to hold a pencil with an age-appropriate grasp and
forming beginning prewriting designs to independently assuming an age-
appropriate grasp and writing his first name legibly.

Baseline Level of Mastery: 5 out of 10 attempts. As identified in short term objectives to include,
but not limited to work samples, benchmark assessments, data collection, and/or annotated observations.

Service Provider(s) for this goal: Special Education Teacher

Skill Area: Reading

Standard:

Annual Goal: Tyler will improve his reading skills from reading 5 kindergarten level sight
words, to reading 10 kindergarten level sight words.

© 2019. Grand Canyon University. All Rights Reserved. Page 15 of 29

 Baseline Level of Mastery: Reading 20 kindergarten level sight words. As identified in short term
objectives. To include, but not limited to work samples, benchmark assessments, data collection, and/or
annotated observations.

Service Provider(s) for this goal: Special Education Teacher

Skill Area:
Standard:

Annual Goal:

Baseline Level of Mastery:

Service Provider(s) for this goal:

© 2019. Grand Canyon University. All Rights Reserved. Page 16 of 29

 Special Education Department
Individualized Education Program (IEP)
Student (Pseudo) Name: Tyler White Accommodations (Form E) IEP Meeting Date:
08/16/2021

Student ID 123-45678 DOB:08/6/2015

ACCOMODATIONS

Date Given to General Education Teacher: Erin Smith Service Coordinator: Susie Irwin

Accommodations Type Location

Repeated Directions 1 A
Visual Aids 3 A
Additional Time to Respond 3 A
Chunk assignment/scaffolding 1 A
1 or 2 step instructions 3 A/O
Check for understanding 1 A
Provide warning prior to calling on student 1 A
Repeat directions 3 A/O
Provide sensory breaks as needed 3 A
LEGEND FOR TYPE AND LOCATION FIELDS
Type:
1 = Class work/assignments 2 = Assessments/tests 3 = Both class work/assignments/assessments
Location:
A = All Subjects B = Language Arts/English C = Reading D = Spelling E = Math
F = Science G = Social Studies H = Health I = Electives J = Physical Education
K = Lunch L = Transition / Vocation M = Library N = Title 1 O = Special/Exploratory

Family Communication
How will the family be informed of their child’s academic progress and the extent to which that progress
is sufficient to enable the child to achieve annual goals by the end of the year?
Parents will be notified by email and written notice sent home in the communication folder.

IEP Team Consideration for Extended School Year

Consideration for eligibility:

x Severity of disability

x Delays or interruptions in service

x Critical point of instruction/ emerging skills

Summary of ESY Consideration:

Eligible for ESY: Yes

© 2019. Grand Canyon University. All Rights Reserved. Page 17 of 29

Written explanation as to why ESY is or is not needed: ESY is not a consideration at this time because
this is the first IEP meeting for Tyler at Medlock. The team will meet in March 2022 to re-examine if
Tyler will need ESY.

© 2019. Grand Canyon University. All Rights Reserved. Page 18 of 29

 Special Education Department
Individualized Education Program (IEP)
Student (Pseudo) Name: Tyler White Services and Environment (Form I) IEP Meeting Date:
08/16/2021

Student ID: 123-45-678 DOB: 08/06/2015

SPECIAL EDUCATION SERVICES TO BE PROVIDED

Special education services necessary to meet special education goals and objectives during the school
calendar year.
The child is in need of specially designed instruction in the following areas:
Special Instructional
Education Setting/ Start Date Frequency Provider Duration/ End
Services Location Date
Autism- General 08/17/2021 45.0 min,3.0 Paraprofessional 08/17/2021-
Supportive Education times/week 08/16/2022
Instruction
Seech/Languag Speech 08/17/2021 30.0 min, 2.0 Speech 08/17/2021-
e Impairment- Education times/week Language 08/16/2022
Separate Class Pathologist
Autism- Special 08/17/2021 1755.0 min, Special 08/17/2021-
Separate Class Education 1.0 times/ Education 08/16/2022
week Teacher
Occupational Special 08/17/2021 30.0 min, 2.0 Occupational 08/17/2021-
Therapy-Pull- Education times/week Therapist 08/16/2022
Out
Special Special 08/17/2021 60.0 min, 5.0 Related Service 08/17/2021-
Education Education times/week Provider 08/16/2022
Transportation
Orientation and Special 08/17/2021 45.0 min, 2.0 Special 08/17/2021-
Mobility-Pull- Education times/week Education 08/16/2022
Out
Clarification: The stated services will be provided to Tyler as per this IEP.

EDUCATIONALLY RELEVANT RELATED SERVICES

Special Instructional
Education Setting/ Start Date Frequency Provider Duration/ End
Services Location Date

Clarification:

EDUCATIONALLY RELEVANT SUPPLEMENTARY AIDS/ASSISTIVE TECHNOLOGY and

SERVICES for STUDENTS

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 .
Special Instructional
Education Setting/ Start Date Frequency Provider Duration/ End
Services Location Date

Clarification:

SUPPORTS FOR SCHOOL PERSONNEL

Special Instructional
Education Setting/ Start Date Frequency Provider Duration/ End
Services Location Date

Clarification:

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 Standard 4: Preparation for IEP Meeting
The IEP team must cover mandated topics during the IEP meeting. Topics that must be
addressed during the IEP include, but are not limited to, an introduction of team members,
clarifying the type of meeting (initial, review, amendment/addendum to current IEP), the
required components of the IEP, the procedural safeguards, and prior written notice.

IEP Meeting Planning

Required Participants/Roles:
Special Education Teacher
General Education Teacher
Tyler’s Parents
Speech Pathologist
IST Administrator
Occupational Therapist

Required Agenda Outline:

IEP MEETING AGENDA
I. Introductions
Special Education Teacher-Susie Irwin
Parents- Bob and Sally Zhang
OT-
II. Review the purpose of the meeting and the agenda
III. Present levels of academic achievement and functional performance
A. Strengths
B. Statements about how the student is performing in the home, classroom, community

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 C. Statement about how the disability affects the student’s progress in the general
curriculum
D. Evaluation data, parent reports, progress reports, test results
E. Needs
IV. Create measurable annual goals and objectives; determine how the goals will be
measured.
V. Services
A. How will the student reach the goals? What special education services and supports
would help the student be successful? (include time and frequency, and
accommodations)
B. Who is responsible for the services?
C. Where will the services be provided and why? (placement and LRE)
VI. Progress reporting to parents
A. Frequency
B. Method
VII. Other items, as needed
A. Testing protocol
B. Transfer of rights
C. Behavior support plan
D. Extended school year
E. Transition
F. Graduation planning
VIII. Accountability: next steps, meeting notes, meeting decisions
IX. Closing

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 Plan for Conflicts:
I will work at establishing good relationships with the parents of my students with open and
honest communication. I will be prepared for IEP meeting and will present the information
without any personal opinions or bias. I will, as well as the other educational members of the
team use current and accurate data to support the recommendations. If a recommendation is
not what the parents expected or do not understand why their child needs it, I will refer to data
to support the accommodation, goals, or placement for the student. IEP meetings can be
stressful for parents and as a teacher I need to be aware of that and make sure to keep an eye
on the emotional reading of the meeting and present the parents with accurate information
supported by data to provide the best support for their child.

Mock IEP Introduction Video

Now that you have outlined the IEP meeting agenda, you are prepared to conduct the meeting. In order
to prepare for running your first official IEP meeting, record yourself as if you were conducting the IEP
meeting. Your video should not exceed 15 minutes in length.
Focus your practice on the meeting introduction. Include the following components within your
recording:
 An introduction of all parties represented and their roles
 Reason for the meeting (initial IEP or IEP review)
 Meeting norms so all parties are heard and respected
 Review of the PLAAFP including the discussion of test results, present levels, goals, services,
Least Restrictive Environment (LRE) statement, Extended School Year (ESY) services,
procedural safeguards, and prior written notice (PWN).
Conclude your video by providing an explanation of how you would actively listen to and address the
needs of families and other stakeholders throughout the meeting.
After recording yourself, review and reflect upon the video below.

Mock IEP Introduction Video Link:

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 Video Recording Link: If you are submitting your video to OneDrive, note it here.

Reflection:

An Individualized Educational Plan (IEP) is required for every student who obtains any exceptional
services and special education via educational laws. The procedure of creating IEP requires the parents,
the children, administrators, special education teachers, general education teachers, and other district
personnel to come together and work with each other to support the needs of the individual student.
The process is not complete upon the implementation of the IEP because as the student progresses,
they might need to develop and or expand on a plan of action to improve the student’s educational
weaknesses, downfalls, behavior, classroom accommodations and other needs. An IEP is vital with
ensuring that every child with disabilities and other exceptionalities are receiving a quality education.
Overall, this IEP provides support for Tyler’s individual needs as a student in a kindergarten special
education program. This is the first IEP meeting for Tyler since this is his first year at Medlock. There
may be changes that need to be addressed in January 2022 before the annual review such as his
eligibility for ESY. Accommodations may be required if Tyler is eligible to push into the general
education class for academics, especially in the area of reading.

Standard 5: Implementation, Communication, and Progress Reporting

Accountability of Free Appropriate Public Education (FAPE) is mandated by the Individuals with
Disabilities Education Act of 2004 (IDEA). IEP teams must have a plan to document the provision of
services as written in the IEP. Appropriate and accurate data must also be collected to document
quarterly progression toward mastery of IEP goals. Teams must have a plan for on-going data
collection, communication, and presentation of data to the parents/guardians during quarterly
progress reports and annual IEP review meetings.

Accommodations Progress and Communication Plan

Complete the Accommodations Table below, demonstrating how you plan to ensure all
accommodations are being met in the general education setting (if applicable). If the student is not in a
general education classroom, indicate how the student will receive accommodations in content specific
areas based on his or her PLAAFP and IEP goals.

On the Accommodations Table, note the dates when you will obtain progress reports from the general
education teacher or related services staff so that you can gather data on progress (if applicable). If no
general education teachers are reporting, indicate the dates of your (special education teacher)

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 reporting.

In addition, use the Accommodations Table to gather data on the student’s progress for the first
Quarterly Progress Report.

NOTE: Only two dates are included on the Accommodations Table for the purpose of this assignment.
You may not gather data on both dates in the duration of your placement, but dates should be noted.

Accommodations Table

Goal 1: Tyler will improve his reading skills from reading 10 kindergarten level sight words, to reading 20
kindergarten level sight words.
Implemented Accommodations: Person(s) Responsible:
Visual aids for learning kindergarten level sight words. Susie Irwin
1 or 2 step instructions
Extra time for responses
Provide sensory breaks as needed
Clarify instructions/directions

Quarterly Progress Report 1 Date: 09/23/2021

Data Results: Tyler is able to read 15 out of 20 kindergarten level sights words during three attempts.

Quarterly Progress Report 2 Date:

Data Results:

Goal 2: Tyler will improve his Comparison skills in Math, from not being able to identify larger shapes, to
being able to identify larger numerical quantities/amounts.
Implemented Accommodations: Person(s) Responsible:
Visual aids and repeated directions. Susie Irwin
Tyler is given additional time to respond to questions.
1 or 2 step instructions
Provide sensory breaks as needed
Clarify instructions/directions

Quarterly Progress Report 1 Date:09/23/2021

Data Results: Tyler is able to identify 2 dimensional shapes correctly 5 out of 10 attempts. Tyler is able to successfully
sort objects into larger quantities 5 out of 10 attempts.

Quarterly Progress Report 2 Date:

Data Results:

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Accommodations Summary:
With the accommodations that are in place for Tyler the data is showing that he is progressing to mastery of his
annual goals. Increasing the amount of time, he has to respond is working to allow Tyler to process the question
being asked. The use of visual aids helped Tyler to make stronger connections with the academic material. He is
able to retain the information and apply it when asked questions or to demonstrate a skill, such as sorting larger
quantities. According to the current data from the progress reports, the current accommodations for math could
amended and removed. Tyler continues to clarification for instructions and redirection when he is off task. The
accommodations used in his reading goal are showing based on the data that Tyler is retaining kindergarten level
sight words at a faster rate then was stated in the IEP annual goal.

Communication Plan for General Education Teachers and Related Services Staff:
The district has put into place a new program to monitor and collect data that uses a form similar to a quarterly
progress report. Special education teachers can input the students data along with the stated goal it supports and
receive a graphed report that shows clearly where a student is on their path to mastering their goals. This report is
completed at four-week intervals and is sent home to Tyler’s parents. Others that contribute to monitoring Tyler’s
progress are the speech therapist, adaptive PE teacher, adaptive art teacher, and the occupational therapist. action
plan that outlines how you plan to share the student’s progress information with the necessary faculty and staff. The
IEP team meets on a regular to monitor Tyler’s progress and the team members give their data to Tyler’s special
education teacher for her to input into the system as well as place hard copies into Tyler’s data binder.

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 Standard 6: Revised IEP
IEP teams are expected to regularly analyze and document students’ progress on their IEP
goals throughout the year. This includes identifying when there are changes affecting the
student and presenting evidence of attempts to meet student needs when there is a lack of
progress. To address times when information, services, or goals need to be changed or added
to an existing IEP, the Individuals with Disabilities Education Act of 2004 (IDEA) describes
the regulations and procedures for changing an IEP using an amendment or addendum. An
amendment is used to change something already in the IEP. An addendum is used to add
something new to the IEP, such as goals, services, or accommodations.

After reflecting on your completed Standard 5 content, create a progress report addendum and/or
amendment (based on changes needed) to be added to the initial IEP, or describe why neither an
addendum nor amendment are not needed.

Data Collection and IEP Modifications

Stakeholders involved in special education must be aware of the student progress monitoring
process, keeping the goal of mastering IEP goals, and presenting evidence of attempts to meet
said goals in mind. It is vital to keep a record of new information affecting student needs,
including a lack of progress when an IEP is in effect, using an IEP amendment or addendum.
An amendment is a change to the IEP and an addendum is the addition of goals or services and
accommodations to the IEP.

IEP Modification Need

Data has shown that over the past four weeks Tyler has acquired more that the goal of 10
kindergarten level sight words. Tyler is able to sort larger quantities of items and has met the
goal for the academic area of math. Therefore, his goal for reading can be amended or
removed. In addition to new district standards, he has been placed into a kindergarten adaptive
art rather than attending the general education art class. Because of this new placement an
accommodation needs to be added to his current IEP.

Family Communication Plan

Tyler’s parents have a very active role in the entire IEP process. Communication is sent home on a
weekly rate with a data repot that shows using a graph of where Tyler is on meeting the annual goals in
the IEP. The district has put into place a new program to monitor and collect data that uses a form
similar to a quarterly progress report. Eamila is the preferred method of communication and Tyler’s
parents receive weekly communication from his special education teacher.

Standard 7: Reflection of the IEP Process

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 Reflection is an important part of professional practice. Professional special education
teachers plan and frequently reflect on their delivery of services, instruction, data collection
procedures, and individual student progress. Identification of practices that have worked, and
those that have not, can help the special education teacher adjust instruction and services to
better meet the needs of students.

Continued Learning
After completing the Individualized Education Program (IEP) Performance Template, reflect
upon three best practices you have learned from this student teaching experience in 50-150
words.

1.Using accurate data from multiple sources. Not limiting the data used in an IEP helps to provide a
better picture of exactly what the student’s strengths and areas of weakness are. Collect direct feedback
about the student's strengths and needs from special education support staff, parents, and teachers. Each
year, supplement current levels with progress monitoring data and progress reports.

2.Ensure that the student’s parent are active participants in their child’s IEP. Create a welcoming
environment where parents understand what is being discussed and know that their concerns are being
not only heard but addressed. Make sure that not only the entire team has all of the information prior to
the meeting but that the parents do as well.

3. Write specific statements using clear language on academic and functional needs as well as
goals. The language used in an IEP must be concise and not leave room for interpretation.

Improved Practice
Based on your experience of developing and delivering your Individualized Education
Program (IEP) Performance Template, list three implications for your future teaching practices
in 50-150 words. Consider concepts you want to take with you into your own classroom, such
as how you will establish and maintain organization in order to facilitate the IEP process in
your classroom.

1.Data collection is the foundation of any IEP. If data is not accurate, unbiased, and
collected at regular intervals. Without that information creating an IEP that works for and supports the
needs of the student simply cannot be done accurately.

2.There are parents that do not take an active role in their child’s IEP process. As a teacher one cannot
force them to comply or take an active role. That being said one can make sure that parents are
informed, invited, and made to feel welcome throughout the entire meeting.

3. Language used in an IEP must be direct, understandable, and clear. When writing goals either
academic or social emotional these objectives are designed to assist students in participating in the
general education curriculum. IEP objectives must be both realistic and measurable and to ensure that
using Specific, Measurable, Attainable, Results-oriented, and Time-bound (SMART) goals is an
approach that will serve one well.

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