Form 6c - IEP (without Transition) Page 1 August 2008 (Rev.

10/2013)
PURPOSE: The IEP is designed to clearly communicate to the parents, the student, and providers the type and amount of special education and any necessary related services or
supports that will be made available to the student. The most recent evaluation report is used to develop the IEP. The IEP is individualized to reflect the unique needs of the student and
how these needs will be addressed to permit the student to be included and progress in the general education curriculum.

INDIVIDUALIZED EDUCATION PROGRAM

Student name: Sam Jones Student ID No.: X Date of IEP meeting: 8/13/14
Birthdate: 01/09/03 Age: 11 Grade: 5 IEP annual review date:
Eligibility category: OHI Date of most recent eval:
Race/Ethnicity: Caucasian Primary language: English Reevaluation due date:
District: Resident School: Serving School (if different):
Parent(s) name(s): LiSA Primary language at home: English
Parent interpreter needed? Yes No Surrogate parent: Yes No If yes, name:
Primary staff contact name: Title:

PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
POINTS THAT MUST BE
CONSIDERED IN
DEVELOPING THE IEP (refer
to WAC 392-172A-03110):
Results of the most current
evaluation, and the academic,
developmental, and functional
needs of the student.
Positive behavioral supports and
interventions, if the students
behavior impedes the students
learning or that of others.
Language needs of students with
limited English proficiency as
they relate to the childs IEP.
Supports for blind/visually
impaired students, include
Braille instruction.
Communication needs of the
student, including the needs for
deaf and hard of hearing
students.
Assistive technology devices and
services.
Supplementary aids/services,
program modifications, and
support for school personnel.
Present levels of academic achievement:
Sam is a smiley, enthusiastic fifth grader. She is compassionate towards those around her, enjoys reading and drawing,
and is adept at telling stories. Sams home language is English and she is able to verbally communicate effectively with
peers and adults. Sam has a diagnosis of Down Syndrome, and receives services under the category of Other Health
Impairments.
Sam takes the WAAS rather than the MSP. She passed her individualized goals for the 3rd grade 2013 WAAS for
Reading and Math.

Math:
Sams RIT score on the MAP test was a 152 in fall 2013 and a 145 in winter. Both scores place Sam in the first percentile for
her age group.
Sam can skip count by 5s to 80. She can count by 2 to 12. She can count by 10 to 180. She cannot count by 25.
Sam is able to count groups of pennies, nickels, dimes, and quarters by themselves. She does not count quarters.
She can count up to 4 nickels with pennies, or 5 dimes with pennies. She needs prompts to switch what to count by
when adding dimes and nickels. She does, however, understand the value of each coin, and can switch between counting
each one fairly fluidly. Cardinality is often a struggle, but Sam does not hesitate to recount if she is unsure.
When telling time on an analog clock, Sam can consistently name the minutes to the five minute interval. She needs
prompts when naming the hour, especially if the minutes are past 40 (ex.: will call 3:45 "4:45")
Sam can add +1, +2, and +3 to numerals 1 to 10 with 90% accuracy by counting up or using touch math.
Sam is able to subtract 0, 1, and 2. She needs prompts when subtracting -3.
Sam is able to do single step story problems that result in addition or subtraction equations she is familiar with (+1,
+2, +3 or -1, -2, -3. She understands basic key words that cue her to the operation.
When Sam is given a mixed set of addition and subtraction problems, her accuracy rate significantly decreases. She
will get confused or does not check the sign, and tries the opposite sign. This is not the case with story problems. She
pays attention to the key words and chooses the correct operation. Her accuracy improves when she moves to a direct
modeling strategy, but she does not do so readily.
Form 6c - IEP (without Transition) Page 2 August 2008 (Rev. 10/2013)

Reading:
Sams RIT score on the Map test was a 156 in fall 2013 and a 160 in winter. Both scores plase Sam in the first percentile for her
age group.
Sam is a great participant in a small group System 44 reading class. She enjoys learning new information about units
studies: Children who Change the World, Sports Stories, and Animal Friends or Foes. Sam is highly engaged in
reading class and small group discussions. She contributes to our discussions, helps her partner, and works hard and
consistently on her guided independent work. Sam loves to read, and when reading a story at her decoding level, or
when reading a guided reading passage that she has practiced, reads with natural intonation and expression. She looks
at the pictures as she reads to enhance her understanding and enjoyment of the story. She is now using the pictures to
help her figure out tricky words. She is also using her own background knowledge to figure out unknown words.
Sam decodes passages on the Brigance assessment at the lower 2nd grade level passages with 98% accuracy. At
the upper 2nd grade level, she reads with 92% accuracy. At the lower 3rd grade level, she reads with 90% accuracy.
Sam's reading level has improved by 1.5 years over the last year! This time last year, Sam read at level D (upper
kindergarten) and comprehended at a rate of 75%. At this time, Sam is reading independently at level J, beginning
2nd grade level. Her comprehension is 75% for direct recall, 50% for inferential questions.
In classroom observations, Sam reads with approximately 90% fluency, which often improves after a short warm-up.
She reads at a steady pace and uses appropriate intonation as she reads aloud. She is able to sound out words when
prompted but uses mainly visual cues and does not cue on meaning. She focuses primarily on decoding and does not
immediately engage with comprehension questions, such as predictions and inferences. However, when given questions
asking her to recall a detail from the text, Sam can answer with 100% accuracy. Sam would benefit from direct
instruction and scaffolding around attending to details in the text that would support her to make inferences.

Writing:
Sam is able to produce a high volume of writing on a given topic when she is passionate about it, though her
handwriting and fine motor skills slow her down slightly. She is not attempting to use punctuation throughout her
writing at this time. She is able to write on nearly any topic, using a variety of sentence structures, but uses adjectives
infrequently and ordinarily only describes items by their color or name. Sam would benefit from development of
descriptive vocabulary and supporting her to make intentional observations of the descriptions in her books.

Present levels of functional performance (i.e. communication, motor, social, behavior, life/adaptive skills, etc.):
Sam is functioning easily in the classroom setting. She is able to communicate fluently, asks for things when she needs
them, and gets along well with her peers. She has minor challenges with fine motor, specifically with her hand
dexterity. This is noted in her handwriting primarily, but is also present when she tries to count coins by picking them
up.
Sam walks, runs, climbs, and jumps without difficulty. She wears arch supports to relieve occasional pain in her feet.
Although previously raised as a concern, Sam seems to be responding well to social cues and is well-liked.
Sam struggles with using a combination to open her locker independently.



Effect of the disability on the students involvement and progress in the general education curriculum (or for preschool children, as
Form 6c - IEP (without Transition) Page 3 August 2008 (Rev. 10/2013)
appropriate, how the disability affects the childs participation in appropriate activities):
In correspondence with the many markers of Down Syndrome, Sam has a measured IQ of 86, placing her in the category of mildly delayed. This
contributes to her need for academic supports and creates a need for academic scaffolding in order to access grade-level content.



CONSIDERATION OF SPECIAL FACTORS:
1. Does this student require special
transportation?
Yes No
If yes, describe (if not addressed on the service matrix):

2. Does this student require Extended School
Year (ESY) services?
Yes No
Will be determined by
the IEP team by:
If ESY is determined by the IEP team to be necessary, complete and
attach the ESY addendum.
Date:
3. Does the students behavior negatively impact
his/her learning or the learning of others?
Yes No
If yes, consider the students need for positive behavioral supports/
interventions, a Functional Behavioral Assessment, and/or a
Behavioral Intervention Plan.
4. Does this student require the use of aversive
interventions?
Yes No If yes, complete and attach the Aversive Intervention Plan addendum.
5. Are there any other factors not already
addressed (such as medical concerns or other
issues), or other adaptations needed?
Yes No
If yes, describe:
Sam wears eyeglasses for distance vision, but is able to see very
well when she wears them.

Form 6c - IEP (without Transition) Page 4 August 2008 (Rev. 10/2013)

PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet each of the students educational needs that result
from the students disability to enable the student to be involved and make progress in the general education curriculum. In order to be measurable, the goal should include a baseline,
a target, and a unit of measure. For students who will be assessed through the WAAS Portfolio this year, the IEP team should use the Measurable Annual Goal(s) with Short-term
Objectives/Benchmarks page (see next page).

MEASURABLE ANNUAL GOAL(S)
Goal
#
Measurable Annual Goal
Method/Criteria for
Evaluating Progress
(if not addressed in a
separate document)
Progress Notes (if not maintained separately)
POINTS TO
CONSIDER:
Date Date Date Date Measurable
annual goals stem
from the
recommendations
for specially
designed
instruction in the
evaluation report.
Measurable
annual goals must
relate to the
general education
curriculum or, for
preschool
students,
participation in
appropriate
activities.
Measurable
annual goals must
also address other
educational needs
that result from
the students
disability.
The IEP must
include a
description of
how the district
will measure the
students progress
and when
progress will be
reported to
parents
(concurrent with
the issuance of
report cards).
11/1/14 1/31/15 3/1/14 6/15/14
1

By 12/18/14, when given a set of mixed
addition and subtraction problems using
numbers 1-20 written both vertically and
horizontally, Sam will identify the
correct operation and solve using
drawings or Touch Math, improving
accuracy from 70% to 90%, as measured
by a curriculum based measure.
Sam will eb assessed
using a curriculum
based measure and data
will be tracked on a
data collection sheet.

2

By 12/18/14, when given a text at TC
level J, Sam will use context clues to
answer inferential questions about
implied meaning in a text and provide
reasoning for her inferences, improving
accuracy from 25% to 100% as measured
by teacher observation
Inferential questions
are provided in the TC
reading assessments
(typically questions
number 3 and 4)

Copy additional pages as necessary

Form 6c - IEP (without Transition) Page 5 August 2008 (Rev. 10/2013)
PURPOSE: IEPs must include a statement of measurable annual goals, including academic and functional goals, designed to meet each of the students educational needs that result
from the students disability to enable the student to be involved and make progress in the general education curriculum. For students who take alternate assessments aligned to
alternate achievement standards (WAAS Portfolio), benchmarks or short-term objectives in the areas being assessed must also be included. In order to be measurable, the goal should
include a baseline, a target, and a unit of measure.

MEASURABLE ANNUAL GOAL(S) WITH SHORT-TERM OBJECTIVES/BENCHMARKS

Goal
#
Measurable Annual Goal
Method/Criteria for
Evaluating Progress
(if not addressed in a
separate document)
Progress Notes (if not maintained separately)
POINTS TO
CONSIDER:
Date Date Date Date
Measurable annual
goals stem from the
recommendations
for specially
designed instruction
in the evaluation
report.
Measurable annual
goals must relate to
the general
education
curriculum or, for
preschool students,
participation in
appropriate
activities.
Measurable annual
goals must also
address other
educational needs
that result from the
students disability.
The IEP must
include a description
of how the district
will measure the
students progress
and when progress
will be reported to
parents (concurrent
with the issuance of
report cards).


Benchmarks or Short-Term Objectives




Copy additional pages as necessary

Form 6c - IEP (without Transition) Page 6 August 2008 (Rev. 10/2013)

PURPOSE: The purpose of the report of student progress is to inform the parents and the student of the students progress toward meeting the measurable annual goal(s) and to
specify how and when parents will be informed.

REPORT OF STUDENT PROGRESS:
POINTS TO CONSIDER:
Parents should be provided periodic reports on the students progress (such as through the
use of quarterly or other periodic reports, concurrent with the issuance of report cards).
State how the students progress toward meeting the annual goal(s) will be measured (if not already addressed on measurable annual goal page(s)):
See above.
State how the parents will be periodically informed of the students progress toward meeting the annual goal(s):
Sam will receive progress reports from the Special Education teacher on a quarterly basis.

PARTICIPATION IN STATE AND DISTRICTWIDE ASSESSMENTS OF STUDENT ACHIEVEMENT
State Assessment The student will participate in the following state assessment(s) during this IEP year:
POINTS TO CONSIDER:
The IEP team makes the
determination of what type of
assessment the student will take
and what administrative
modifications and individual
accommodations are necessary.
Accommodations provided on
state and districtwide
assessments should be those
that are provided as part of the
regular instructional program.
Parents and students should be
informed that any assessment
other than the regular state
assessment (with or without
accommodations) leads to a
Certificate of Individual
Achievement (CIA), rather than
a Certificate of Academic
Achievement (CAA).
For further information
regarding the state assessment
system, allowable
accommodations, and
graduation requirements, please
refer to OSPIs website
(www.k12.wa.us/assessment).

Reading Math Writing Science
Regular State Assessment
Regular State Assessment with Accommodations
Alternate Assessment (WAAS Portfolio - requires benchmarks/objs.)
Other:
Districtwide Assessment The student will participate in the following districtwide assessment(s) this school year:
WAAS, MAP
Accommodations List any individual accommodations in the administration of the state or districtwide
assessments that are necessary for the student to participate:
Sam may use a whisper phone to read questions aloud to herself.
Sam may have questions read to her in Writing, Math, and Science ONLY.
Sam may use manipulatives for math assessments.
Sam may test in a small group setting.
Sam may take frequent breaks.
Sam may have extended test-taking time
Sam may have someone scribe for her.
Sam may type her test responses.
If the student: (a) will not participate in the regular state assessment (with or without accommodations) or (b) is unable
to participate in a regular districtwide assessment, explain why the student cannot participate in the regular assessment
and why the selected assessment option is appropriate:
N/A
Form 6c - IEP (without Transition) Page 7 August 2008 (Rev. 10/2013)

PURPOSE: The purpose of this page is to document the modifications and/or accommodations that the student requires, based on the students assessed needs, in order to advance
appropriately toward attaining the identified annual goals, to be involved and make progress in the general education curriculum, and to be educated with non-disabled peers to the
maximum extent appropriate.

ACCOMMODATIONS, MODIFICATIONS, AND ASSISTIVE TECHNOLOGY
Subject
(codes below)
Accommodations/Modifications Needed
Subject
(codes below)
Accommodations/Modifications Needed
POINTS TO
CONSIDER:
The IEP team
makes the
determination of
what
modifications and
individual
accommodations
are necessary for
the student.
Copies of this
page should be
provided to the
general education
teacher(s) or other
staff who will be
responsible for
making these
accommodations.
Accommodations
provided on state
and districtwide
assessments (as
noted on the
previous page)
should be those
that are provided
as part of the
regular
instructional
program.
Presentation Setting
Use large print/Braille/recorded books A Provide individualized/small group instruction
Alter format of materials (highlight, type, spacing, color-code etc.) A Read class materials orally
Low-vision devices (magnifiers, Closed Circuit TV, etc.) Provide study outlines/guides/graphic organizers
Sign Language ASL or SEE Modify/repeat/model directions
Shortened assignments Take test in separate location
Preview test procedures Preferential seating
Limited multiple choice Other:
A Rephrase test questions and/or directions Response
Provide test/quiz study guide Utilize oral responses to assignments/tests
Provide extra credit options Text-to-Speech (Kurzweil, WYNN, Text Help, etc.)
Simplify test wording A Allow dictation to a scribe
A Read class materials orally A Allow use of a calculator
A Assign peer tutor/note taker Allow use of tape recorder
Other: A Spelling and grammar devices
Timing/Scheduling A Speech-to-text software
A Prior notice of tests/quizzes Hands-on assignments
A Extra time to complete assignments Other:

Modify students schedule (describe below): Other

A Provide desktop list of tasks
Provide homework lists
Behavior plan/contract
A Extra time on tests/quizzes Provide daily assignment list
A Allow breaks (during work, between tasks, during testing, etc.) Modified grading
Other: Other:
Assistive Technology
A Describe: Use of keyboard to type responses
A Describe: Use of iPad (or dictionary) to support accurate spelling
a. All subjects
b. Reading
c. English
d. Spelling
e. Math
f. Science
g. Social Studies
h. History
i. Health
j. Economics
k. Physical Education
l. Music/Art
m. Vocational
n. Lunch/Recess
o. Library

p. Extracurricular Activities
q. Other:

Form 6c - IEP (without Transition) Page 8 August 2008 (Rev. 10/2013)

PURPOSE: The information on this page is a summary of the students program/services, including when services will begin, where they will be provided, who will be responsible for
providing them, and when they will end.

SUMMARY OF SERVICES MATRIX

Service
Initiation
Date
Frequency
(i.e. minutes per week)
Location of
Service
(setting)
Duration
Staff Responsible for
Delivering Service
POINTS TO
CONSIDER:
If the position
responsible for
delivering the
specially designed
instruction is
anyone other than
a certificated
special education
teacher or related
service provider,
then the
certificated
special education
teacher/related
service provider
must design and
supervise the
instruction, and
monitor and
evaluate the
students
progress.
For definitions of
special education,
related services,
and
supplementary
aids and services,
refer to WAC
392-172A-01020
through -01200.

Special Education (specially designed instruction):
MATH 9/1/2014
30 minutes / 3
times weekly
Resource room Special Education teacher
READING 9/1/2014
45 minutes / 5
times weekl
Resource room Special Education teacher
WRITTEN LANGUAGE 9/1/2014
15 minutes / 5
times weekly
Resource room Special Education teacher
Related Services (i.e. speech, motor, counseling, vision/hearing, transportation, interpreting services, orientation/mobility, parent training, etc.):
COMMUNICATION 9/1/2014
25 minutes / 7
times monthly
Speech office SLP




Supplementary Aids and Services (allows student to be educated with non-disabled peers to the maximum extent in general education or other
educational setting):



Program Modifications or Supports for School Personnel (i.e. staff development/training, technical assistance, etc.):




Form 6c - IEP (without Transition) Page 9 August 2008 (Rev. 10/2013)

PURPOSE: The purpose of this page is to document the extent to which the student will be involved and progress in the general curriculum, participate in extracurricular and
nonacademic activities and be educated and participate with other special education students and non-disabled students.

LEAST RESTRICTIVE ENVIRONMENT:
Students ages 3 to 5 Choose one:
POINTS TO CONSIDER:
Children should be
educated with non-
disabled peers to the
maximum extent
appropriate.
The IEP Team, including
the parent(s), is
responsible for
determining the
educational placement of
the child.
Job placements and
community-based
instruction are considered
to be general education
settings, unless only
disabled individuals are
present (such as in a
sheltered workshop).
For additional information
on LRE for students ages 3
to 5 and ages 6 and above,
refer to the LRE
Calculator.

A Regular Early Childhood (REC) program
means a program outside the childs home
that includes at least 50% children without
disabilities.

If the child attends a REC program, check the
appropriate box from the first four choices. If
the child does not attend a REC program,
check the appropriate box from the five
remaining options.

In a REC program:

REC Program 10 hours per week &:
Special education services with non-
disabled peers
Special education services elsewhere

REC Program <10 hours per week &:
Special education services with non-
disabled peers
Special education services elsewhere

Not in a REC program:

Separate class
In separate day school (public
or private)
Residential facility (public or
private)
Home
Service provider location
Students ages 6 and above Choose one:
A. 1650
= Total minutes per week of building
instructional time available for this student
(excluding lunch)
In general ed. setting 80 to 100% of the time
In general ed. setting 40 to 79% of the time
In general ed. setting 0 to 39% of the time
In separate day school (public or private)
Residential facility (public or private)
Correctional facility
Homebound/hospital
Home-school/parentally-placed private school
B. 433.75
= Total of those minutes in A. above in which
this student is in a special education setting
(excluding lunch)
73.8%
= Percent of time spent in a general education
setting (A minus B divided by A)
An explanation of the extent, if any, to which
the student will not participate with
nondisabled students in the general education
class, and in nonacademic and extracurricular
activities, including a description of any
adaptations needed for participation in
physical education:


Form 6c - IEP (without Transition) Page 10 August 2008 (Rev. 10/2013)


PARTICIPANTS IN IEP MEETING (Signatures are used to document participation in the meeting and do not constitute
agreement or disagreement):





POINTS TO CONSIDER:
IEP team membership is described
in WAC 392-172A-03095.
School district must give prior
written notice when proposing or
refusing to initiate or change the
identification, evaluation,
educational placement, or
provision of FAPE.
A required team member may be
excused from attending an IEP
meeting with the agreement/
consent of the parent(s) and the
district, depending upon whether
that members area is being
discussed or modified at the
meeting. See WAC 392-172A-
03095 (5) for additional related
requirements.
The IEP must include the districts
procedures for notifying parents
regarding the use of restraint or
isolation. Districts must also
provide parents with a copy of the
districts policy on the use of
isolation and restraint.
Parent/Guardian Name/Title

Parent/Guardian Name/Title

Student Name/Title

Special Education Teacher Name/Title

General Education Teacher Name/Title


District Representative

Name/Title



Other individuals who should be informed of his/her responsibilities in implementing the IEP (bus driver, librarian, etc.):


The district has procedures for notifying parents regarding the use of restraint or isolation. A copy of those procedures is attached to this IEP.


*Note: Before providing initial special education services to a student, the district must obtain informed written parental consent.
(See model form 3)