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STATE OF NEVADA INDIVIDUALIZED EDUCATIONAL PROGRAM (IEP)

INFORMATION
STUDENT/PARENT INFORMATION ELIGIBILITY CATEGORY MEETING INFORMATION
Students Sex: Select Gender DATE OF MEETING_
Autism Spectrum Disorder
DATE OF LAST IEP MEETING_
Birthdate. Grade^ Student ID #_
Student Primary Language Deaf/Blind PURPOSE OF MEETING
Student English Proficiency Status: Select LEP Status Developmental Delay n Interim IEP

Federal Placement Code: Select Placement Code Emotional Disturbance Initial IEP

Federal Student Ethnicity Code: Select Ethnicity Code Health Impairment AnnualIEP

Address^. II Hearing Impairment/Deaf IEP Following 3-Yr Reevaluation

Student PhoneL m Intellectual Disability Revision To IEP Dated

II Multiple Impairment Exit Select Exit Code

Parent/Guardian/Surrogate:.
II Orthopedic Impairment II IEP Revision Without A Meeting:
Parent Phone (Home)_ (Work)
Optional: Celj_ Email. II Specific Learning Disability At the request of: |_(Parent or |_| School District

Primary Language Spoken at Home. II Speech/Language Impairment n Other_

Interpreter or Other Accommodations NeededSelect Y or N II Traumatic Brain Injury IEP SERVICES WILL BEGIN_
Emergency Contact/Phone Number. n Visual Impairment/Blind ANTICIPATED
DURATION OF SERVICES_
Current School_ Zoned SchooL ELIGIBILITY DATE
IEP REVIEW DATE.
ANTICIPATED 3-YR COMMENTS_
REEVALUATION_
IEP PARTICIPATION
Parent/Guardian/Surrogate*. Speech/Language TherapisVPathologist/Specialist.
Student**. School Nurse
LEA Representative*. InterpreteL
Special Education Teacher*. Other (name and role).
Regular Education Teacher"*. Other (name and role)_
School Psychologist. and

*Required participant.
" Student must be invited when transition is discussed (beginning at age 14 or younger if appropriate).
***The IEP team must include at least one regular education teacher of the student (if the student is, or may be, participating in the regular education environment).

PROCEDURAL SAFEGUARDS
II I have received a statement of procedural safeguards under the Individuals with Disabilities Education Act (IDEA) and these rights have been explained to me in my primary language.

Parent Signature.

AT LEAST ONE YEAR PRIOR TO REACHING AGE 18, STUDENTS MUST BE INFORMED OF THEIR RIGHTS UNDER IDEA AND ADVISED THAT THESE RIGHTS WILL TRANSFER TO THEM AT AGE 18.

Not applicable. Student will not be 18 within one year, and the student's next annual IEP meeting will occur no later than the student's 17th birthday.

The student has been informed of his/her rights under IDEA and advised of the transfer of these rights at age 18.
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PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Consider results of the initial evaluation or most recent reevaluation, and the academic, developmental, and functional needs of the student, which may include the following areas:
academic achievement, language/communication skills, social/emotional/behavior skills, cognitive abilities, health, motor skills, adaptive skills, pre-vocational skills, vocational skills, and other skills as
appropriate. For students who are 16 or older, or will turn 16 when this IEP is in effect, also consider the results of age appropriate transition assessments related to training/education, employment,
and independent living skills (as appropriate).

ASSESSMENTS CONDUCTED ASSESSMENT RESULTS EFFECT ON STUDENTS INVOLVEMENT AND PROGRESS IN GENERAL EDUCATION
CURRICULUM OR, FOR EARLY CHILDHOOD STUDENTS, INVOLVEMENT IN
DEVELOPMENTAL ACTIVITIES

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STRENGTHS, CONCERNS, INTERESTS AND PREFERENCES

STATEMENT OF STUDENT STRENGTHS

STATEMENT OF PARENT EDUCATIONAL CONCERNS

STATEMENT OF STUDENT'S PREFERENCES AND INTERESTS (required if transition services will be discussed, beginning at age 14 or younger if appropriate)

If student was not in attendance, describe the steps taken to ensure that the student's preferences and interests were considered:

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CONSIDERATION OF SPECIAL FACTORS

1. Does the student's behavior impede the student's learning or the learning of others? |_| No. |_| Yes.
If YES, IEP committee must provide positive behavioral strategies, supports and interventions, or other strategies, supports and interventions to address that
behavior.
n Addressed in IEP.

2. Does the student require assistive technology devices and services? II No. II Yes.
If YES, IEP committee must determine nature and extent of devices and services.
Addressed in IEP.

3. Does the student have limited English proficiency? |_| No. |_| Yes.
If YES, IEP committee'must consider the following (check box if IEP committee considered the item):
Language needs of the student as those needs relate to the student's IEP.

4. Is the student blind or visually impaired? |_| No. I_| Yes.

If YES, IEP committee must evaluate reading and writing skills, needs, and appropriate reading and writing media (including an evaluation of the child's future needs for
instruction in Braille or use of Braille) and must provide for instruction in Braille and use of Braille unless determined not appropriate for the student.
Braille instruction and use of Braille is not appropriate for student. I I Braille instruction and use of Braille is addressed in IEP.

5. Is the student deaf or hard of hearing? II No. II Yes.

If YES, IEP committee must consider the student's language and communication needs and consider the following (check box if IEP committee considered the
item):

I[ The related services and program options that provide the student with an appropriate and equal opportunity for communication access.
The student's primary communication mode.
The availability to the student of a sufficient number of age, cognitive, academic and language peers of similar abilities.
The availability to the student of adult models who are deaf or hearing impaired and who use the student's primary communication mode.
The availability of special education teachers, interpreters and other special education personnel who are proficient in the student's primary communication mode.
The provision of academic instruction, school services and direct access to all components of the educational process, including, without limitation, advanced
placement courses,'career and technical education courses, recess, lunch, extracurricular activities and athletic activities.
The preferences of the parent or guardian of the student concerning the best feasible services, placement and content of the student's IEP.
The appropriate assistive technology necessary to provide the student with an appropriate and equal opportunity for communication access.

6. Does the student have a Specific Learning Disability and Dyslexia? |_| No. |_| Yes.
If YES, the IEP committee must consider the following instructional approaches (check box if IEP committee considered the item):

D Explicit, direct instruction that is systematic, sequential and cumulative and follows a logical plan of presenting the alphabetic principle that targets the specific needs of
the student.
D Individualized instruction to meet the specific needs of the student in an appropriate setting that uses intensive, highly-concentrated instruction methods and materials
that maximize student engagement.
D Meaning-based instruction directed at purposeful reading and writing, with an emphasis on comprehension and composition.
D Multisensory instruction that incorporates the simultaneous use of two or more sensory pathways during teacher presentations and student practice.

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TRANSITION

DIPLOMA OPTION SELECTED FOR GRADUATION (Diploma option must be declared at age 14 and reviewed annually.)
Standard or Advanced High School Diploma. Must complete all applicable credit Adjusted High School Diploma. Must complete IEP requirements.
requirements and pass the High School Proficiency Examination (with permissible accommodations as needed).

STUDENTS VISION FOR THE FUTURE

A short statement that directly quotes what the student wants for the future.

STATEMENT OF TRANSITION SERVICES: COURSE OF STUDY

Beginning at age 14 or younger if determined appropriate by the IEP team, describe the focus of the student's course of study.

STATEMENT OF MEASURABLE POSTSECONDARY GOALS

Beginning not later than the first IEP to be in effect when the student is 16, describe measurable postsecondary goals in the following areas:

Training/Education

n Employment

Independent Living Skills (As Appropriate)

Other

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TRANSITION (continued)
STATEMENT OF TRANSITION SERVICES: COORDINATED ACTIVITIES
Beginning not later than the first IEP to be in effect when the student is 16, develop a statement of needed transition services, including strategies or activities, for the student.

Instruction

Any Other Agency Involvement (Optional):

Related Services

Any Other Agency Involvement (Optional):

Community Experiences

Any Other Agency Involvement (Optional):

Employment and Other Post-SchooI Adult Living Objectives

Any Other Agency Involvement (Optional):

Acquisition of Daily Living Skills and Functional Vocational Evaluation (if appropriate)

Any Other Agency Involvement (Optional):

Other

Any Other Agency Involvement (Optional):

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IEP GOALS, INCLUDING ACADEMIC AND FUNCTIONAL GOALS, AND BENCHMARKS OR SHORT-TERM OBJECTIVES

MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
1. Satisfactory Progress Being Made (continue)

Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates: 2. Unsatisfactory Progress Being Made
(need to review?revise)

lucation |_| Employment ]_| Independent Living Skills |_[Other 3. Goal Met (note date)

Date Date Date

Check here if this goal will be addressed during Extended School Year Services (ESY)

Progress Progress Progress Progress

#_)

#_)

#_)

#_)

MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
2. Satisfactory Progress Being Made (continue)

Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates: 2. Unsatisfactory Progress Being Made
(need to review/revise)

fucation |_| Employment |_| Independent Living Skills |_[Other 3. Goal Met (note date)

Check here if this goal will be addressed during Extended School Year Services (ESY)

Progress Progress Progress Progress

#_)

#_)

#_)

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IEP GOALS, INCLUDING ACADEMIC AND FUNCTIONAL GOALS, AND BENCHMARKS OR SHORT-TERM OBJECTIVES

MEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
3. Satisfactory Progress Being Made (continue)

Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates: 2. Unsatisfactory Progress Being Made
(need to review/revise)

jTraining/Education |_| Employment |_| Independent Living Skills |_[Other 3. Goal Met (note date)

Date Date Date Date

Check here if this goal will be addressed during Extended School Year Services (ESY)

Progress Progress Progress Progress

#_)

#_)

#_)

#_)

IVIEASURABLE ANNUAL GOAL (including how progress toward the annual goal will be measured) PROGRESS REPORT
4. Satisfactory Progress Being Made (continue)

Check here if this goal supports the student's postsecondary goal(s) and identify the goal(s) to which it relates: 2. Unsatisfactory Progress Being Made
(need to review/revise)

jTraining/Education |_| Employment |_| Independent Living Skills |_[Other 3. Goal Met (note date)

Date
Check here if this goal will be addressed during Extended School Year Services (ESY)

Progress Progress Progress Progress

#_)

#_)

#_)

#_)

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METHOD FOR REPORTING PROGRESS

METHOD FOR REPORTING THE STUDENT'S PROGRESS TOWARD MEETING ANNUAL GOALS (check all PROJECTED FREQUENCY OF REPORTS
methods that will be used)
n IEP Goals Pages Doistrict Report Card m Quarterly Semester
II Specialized Progress Report II Parent Conferences II Trimester Othej_

Other.

SPECIAL EDUCATION SERVICES

SPECIALLY DESIGNED INSTRUCTION BEGINNING FREQUENCY LOCATION
AND OF SERVICES OF
ENDING SERVICES
DATES

SUPPLEMENTARY AIDS AND SERVICES

Includes aids, services, and other supports provided in regular education classes, other education-related settings, and in extracurricular and nonacademic settings to enable
students with disabilities to be educated with nondisabled students to the maximum extent appropriate.

BEGINNING AND FREQUENCY OF LOCATION OF

MODIFICATION, ACCOMMODATION, OR SUPPORT FOR STUDENT OR PERSONNEL ENDING DATES SERVICES SERVICES
Provide specific description(s) below.

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RELATED SERVICES
RELATED SERVICE SERVICE TYPE AND/OR BEGINNING FREQUENCY LOCATION
DESCRIPTION AND ENDING OF SERVICES OF
A - Assessment DATES SERVICES
C - Consultative
D - Direct

Select Related Service Select Service Type Description:

Select Related Service Select Service Type Description:
Select Related Service Select Service Type Description:
Select Related Service Select Service Type Description:
Select Related Service Select Service Type Description:
Select Related Service Select Service Type Description:

PARTICIPATION IN STATEWIDE AND/OR DISTRICT-WIDE ASSESSMENTS

Indicate how the student will participate If the student will participate in an alternate assessment, explain If the student will participate in a
in statewide or district-wide why the student cannot participate in the regular assessment, and regular assessment, does the student
assessments. why the particular alternate assessment selected is appropriate require accommodations?

State Criterion-Referenced Test ] No DYCS

(CRT) DYCS DN/A D Alternate If YES, list on "Accommodation(s) for the
Nevada Proficiency Examination Program"
(attach form).

End of Course Exams ]No DYes

DYes DN/A If YES, list on "Accommodation(s) for the
Nevada Proficiency Examination Program"
(attach form).

College and Career Readiness Assessment DNO DYes

]Yes DN/A If YES, list on "Accommodation(s) for the
Nevada Proficiency Examination Program"
(attach form).

Other (List): lo I_|Yes ListAccommodation(s):

F]Yes DN/A

EXTENDED SCHOOL YEAR SERVICES

Does the student require extended school year services?
]No DYCS If YES, IEP goals and benchmarks/short-term objectives and/or related services to be implemented in ESY must be identified.
If need for ESY is to be determined at a later date, indicate date by which IEP decision will be madei.

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PLACEMENT
PLACEMENT CONSIDERATIONS PERCENTAGE OF TIME
IN REGULAR EDUCATION ENVIRONMENT
Qse/ecfecf D Rejected Regular class with supplementary aids and services (no removal)
nSe/ecteof D Rejected Regular class and special education class (e.g., resource) combination

D
The student will spend _ % of his or her school day in the
IIse/ecfed Rejected Self-contained program regular education environment.

IIse/ected Rejected Special School

Qse/ected Rejected Residential
Qse/ected D Rejected Hospital
Qse/ectec/ Rejected Home
JSe/ecfed D Rejected Other

JUSTIFICATION FOR PLACEMENT INVOLVING REMOVAL FROM REGULAR EDUCATION ENVIRONMENTS*

Explain why the IEP goals and objectives cannot be implemented in regular education environments, including the reasons why the team rejected a less restrictive placement.
Include an explanation of any harmful effects on the learning of this or other students which affected the placement selection.

*Regular education environments include academic classes (which might include field trips linked to the curriculum), nonacademic settings (such as recess), and extracurricular activities (for
example, sports, after-school clubs, band, etc.).

IEP IMPLEMENTATION

I agree with the components of this IEP. I understand that its provisions will be implemented as soon as possible after the IEP goes into effect.

As the parent, I disagree with all or part of this IEP. I understand that the school district must provide me with written notice of any intent to implement this IEP. If I wish to prevent the implementation of this IEP, I mus|
submit a written request for a due process hearing to the local school district superintendent.

Parent Signature.

A copy of this IEP was provided to the student's parent on : -by_

(date) (name) (title)

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