INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name: Clark Shurtleff

INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Students Name:

School Age

Clark Shurtleff

IEP Team Meeting Date (mm/dd/yy):

09/10/2015

IEP Implementation Date (Projected Date when Services and Programs Will Begin):
Anticipated Duration of Services and Programs:
Date of Birth:
15 years 00
Age:
months
Grade: Ninth grade

09/17/2015

09/16/2015

09/05/2000

Anticipated Year of Graduation:

2019

Local Education Agency (LEA):

County of Residence:

Myers Campus
Philadelphia County

Name and Address of Parent/Guardian/Surrogate:

Guardian: James Shurtleff

Phone (Home):
20 South 39 Street
th

Phone (Work):

203-974-3196
215-549-4459

Philadelphia, PA 19104

Other Information:

Most Recent Evaluation: 9/12/14

Primary Disability: Specific Learning Disability in the areas of Math Computation, and Math
Problem Solving.
Type of Support: Itinerant
Related Services: Counseling (social skills training) 1100 minutes per IEP term

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

Date of Revision(s)

Page 1 of 37

Participants/Roles

IEP Section(s) Amended

April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name: Clark Shurtleff

Page 2 of 37

April 2014

IEP TEAM/SIGNATURES
The Individualized Education Program team makes the decisions about the students program and placement. The students parent(s), the students 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

Parent/Guardian/Surrogate

James Shurtleff

Student*

Clark Shutleff

Regular Education Teacher**

Charles Jackson

Regular Education Teacher**

Devon Buchanan

Regular Education Teacher**

Eupha McCrary

Regular Education Teacher**

Regular Education Teacher**

Gloria Lee
James Sadler

Regular Education Teacher**

Margaret Ambrose

Special Education Teacher

Laura Agosto

Local Ed Agency Rep

Tifanie Pierce

Signature

Career/Tech Ed Rep***
Community Agency Rep
Teacher of the Gifted****

*
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:
Ms. McCrary - 9th grade Literature, Ms.Tremaine- Literacy Support for 9th grade Literature,
Mrs. Young- 8th grade Case manager, Ms. Agosto-9th grade Case Manager
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 SBAPthe cost of certain
special education and related services described in my childs 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 childs 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 childs 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 familys 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 students reading and writing skills, needs, and appropriate reading and writing media (including an
evaluation of the students 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 students language and communication mode; academic
level; full range of needs, including opportunities for direct instruction in the students 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?

Yes
The IEP team must address the students language needs and how those needs relate to the IEP.
x

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 students 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 students disability affects involvement and progress in the general education curriculum
Strengths
Academic, developmental, and functional needs related to students disability
Present Levels of Academic Achievement:
INTRODUCTION:
Clark is a 15 year old, 9th grade student, who attends Millbrooke Charter Myers Campus.
Clark began
attending Myers campus in 8th grade and previously attended Millbrooke Charter Cleveland
Campus. According to Clarks recent evaluation completed 9/12/14, he is currently eligible for
special education services under the primary category of Specific Learning Disability in the
areas of Math Computation and Math Problem Solving. Clark is currently receiving counseling
(social skills training) as a related service; 1100 minutes per IEP term.

Evaluation Summary:
Clarks recent re-evaluation report, 9/12/14 was completed by Millbrooke Charter School
Myers Campus.
Clarks cognitive functioning was assessed using the Wechsler Abbreviated Scale of
Intelligence, Second Edition (WASI-II). The Wechsler Abbreviated Scale of Intelligence, Second
Edition (WASI-II) is an
individually administered clinical instrument that evaluates intellectual ability.
The WASI-II provides composite scores that estimate intellectual functioning in two areas
(i.e., Verbal
Comprehension and Perceptual Reasoning) and a composite score that estimates overall
intellectual ability. The Percentile Rank is an estimate of how well Clark performed in
comparison to students his same age. The following scores were obtained.
Test/Subtest
Full Scale IQ
Verbal Comprehension
-Vocabulary
-Similarities
Perceptual Reasoning
-Block Design
-Matrix Reasoning

Score
88
90
43
44
90
42
46

Percentile
21
25
--25
---

Rank Classification
Low Average
Average
Average
Average
Average
Below Average
Average

Clark achieved a Full Scale IQ score of 88 indicating that he is presently functioning within
the Low
Average range of intelligence at the 21st percentile compared with other children his age.
Clark scored in the average in his verbal comprehension, vocabulary, similarities, perceptual
reasoning and matrix reasoning abilities. This indicates that Clark is functioning at a level
that is comparable to his
peers. He performed within the upper limit of the Below Average range in his ability to
visually process
information and use two-color cubes to construct replicas of two-dimensional, geometric
patterns.
Given his history of processing speed difficulties and based on the results of the current
evaluation, it is
likely that Clarks's visual abilities are stronger than this score suggests.
The Differential Ability Scales Second Edition (DAS-II) School-Age version was administered
to obtain an estimate of Clarks current Automatic or low-level processing skills. These skills
are important for the
ability to process information quickly and efficiently without conscious thought or effort.
Automatic

processing is used for both recall and rapid processing of information. Results are reported
below.
Area/Subtest
Standard Score
Percentile Rank
Classification
Working Memory
76
5
Low
-Recall of Sequential Order
28
1
Very
Low
-Recall of Digits Backward
42
21
Below
Average
Processing Speed
77
6
Low
-Speed of Information Proc.
38
12
Below
Average
-Rapid Naming
35
10
Low
Processing Speed (Gs) is the ability to quickly and automatically perform cognitive tasks
while maintaining
focused attention. It is linked to academic achievement in reading and math. Clarks overall
performance in this area ranged from the Below Average to the Very Low range. On these
subtests, Clark demonstrated difficulty fluently identifying numbers, colors, and objects. This
indicates that Clark processes information and performs tasks at rate slower than his same
age peers. This indicates that in the classroom he will benefit from accommodations such as
wait time when asked to answer questions orally and extended time when completing written
assignments.
Working Memory (Gsm) is the ability to hold information in immediate awareness and then
use it within a
matter of a few seconds. It is linked to both reading and math achievement and impacts an
individuals
ability to follow directions and complete academic tasks. Clark was required on these
subtests to recall a string of numbers backward and recall verbal and visual information after
reordering it. He performed
similarly on both tasks, displaying skills below expected for his age. This indicates that he
may benefit
from accommodations such as checking for understanding, guided notes and review of
information during class instruction.
The Wechsler Individual Achievement Test-3rd Edition (WIAT-III) was administered to provide
standardized data regarding Clarks achievement in reading and mathematics. His
achievement scores in these areas are presented and discussed below. The scores below

represent Clarks achievement when compared to her same grade peers. Grade norms were
used due to his being retained in third grade.
Area/Subtest
GLE
Reading
--Oral Reading Fluency
5.7
-Oral Reading Accuracy
---Oral Reading Rate
--Mathematics
--Math Problem Solving
2.6
Numerical Operations
4.7

Standard Score

Percentile Rank

Classification

83

13

Below Average

84

14

Below Average

74

Below Average

88

21

Average

70

13

Below Average

64

Extremely Low

78

Below Average

WIAT-III Results
Reading
Reading Comprehension
On the Reading Comprehension subtest, Clark was required to read three grade level
passages and answer questions about them. On this subtest, he scored within the Average
range, suggesting that he is achieving similarly to his same age peers. On this subtest it was
noted that Clark frequently required repetition, but was able to arrive at the correct answer
on most items that were repeated. Teachers should check for understanding in the classroom
and simplify directions to support Clark in the classroom.
On the Oral Reading Fluency subtest, Clark was required to read two passages out load to the
evaluator. On this subtest he scored within the upper limit of the Below Average range. While
his rate was good, he made a number of errors such as skipping words or slightly
mispronouncing words. Overall, his skills are slightly below expected for someone his same
age.
Mathematics
Numerical Operations
Clarks overall performance on the Numerical Operations subtest was within the Below
Average range. In terms of his computation skills, Clark was proficient with addition,
subtraction, multiplication, and
simple addition with fractions. He had difficulty with long division, subtraction with
regrouping, and

multi-step problems. In the classroom, Clark benefits from the use of a calculator.
Math Problem-Solving
Clarks performance on the Math Problem-solving subtest was within the Extremely Low
range. In this area, Clark was proficient with basic pattern completion, reading basic graphs,
and counting money. He had difficulty with more complex graphs, word problems using
fractions, reading a calendar, reading an analog clock, and word problems with subtraction.
He appears to have great difficulty applying his math knowledge to word problems when
compared to his same age peers. In order to support Clark in the classroom, teachers should
break problems down into smaller and more manageable steps, they should also check for
understanding and allow for Clark to use manipulatives to make problems for visual for him.
Academic Achievement:
Clarks academic progress was assessed with the Woodcock Reading Millbrooke Tests
(WRMT-III) and the Key Math 3 Diagnostic Assessment from 09/02/2015-09/08/2015. The
results of his assessment are below.
Woodcock Reading Millbrooke Tests (WRMT-III)

Test
Letter Identification
Phonological Awareness
Word Identification
Word Attack
Word Comprehension
Passage Comprehension
Listening Comprehension
Oral Reading Fluency

Standard Score
--74
70
67
68
80
71

GLE
--4.8
3.2
3.4
3.4
5.4
3.1

Overall, the reading assessment indicates that Clark is below grade level. The assessment
indicates that listening comprehension is a relative strength for Clark. While he has made
progress over the past year in reading, Clark would still benefit from accommodations such
as checks for understanding, simplified directions, and participation in a reading intervention
class. Clarks needs with reading comprehension will affect his ability to process and solve
word problems and multi-step algebraic problems in math.

Key Math 3 Diagnostic Assessment

Test
Numeration
Algebra
Geometry
Measurement

Raw Score
20
15
13
16

GLE
4.0
3.8
2.2
3.4

Data Analysis & Probability

15

3.4

Basic Concepts

79

3.4

Mental Computation & Estimation

Addition and Subtraction
Multiplication and Division

18
19
8

4.5
4.0
4.2

Operations

45

4.1

Foundations of Problem Solving

Applied Problem Solving
Applications

16
13
29

5.0
3.0
3.9

Clark continues to struggle with basic math skills as well as multi-step problems. Clark would
benefit
from accommodations such as checks for understanding, breaking down of problems into
smaller steps,
emphasizing quality over quantity, and continued participation in math intervention
programming.
Overall Clark struggled to maintain focus and stay on task during both the reading and the
mathematics the assessments. This could have contributed to the results.
Assessment Summary:
Reading: On the Fountas and Pinnell research-based literacy assessment, administered on
09/08/2015 Clark read independently at a Level S (5.00)99% accuracy, a fluency rating of 2,
8/10 comprehension, and 132 wcpm. Clarks instructional level is currently Level T (GLE
5.33) with 98% accuracy, a fluency rating of 2, and 8/10 comprehension.
Math: On a 4th GLE Math problem solving assessment (multi-step algebraic and word
problems), administered on 09/07/2015, Clark scored a 1 out of 10 for 10% accuracy.
On a 6th GLE Math computation assessment (consisting of addition, subtraction,
multiplication, division, and fractions), administered on 09/07/2015, Clark scored 18 digits
correct. Given 25 5th GLE computation problems consisting of addition, subtraction,
multiplication, division, and fractions Clark scored 23 digits correct.
Current Grades:
Current grades for 2015-2016 school year Grades with an * indicate grades that are below

Millbrooke ; Millbrooke =76 or above)

Subject
Literature 9
Composition 9
Algebra 1
African-American History
Physical Education
Trans Math
Physical Science
Leveled Literacy Intervention

RP1
*53
*73
96
*69
-*55
*36
87

Report card summary- 2014-2015 school year (Grades with an * indicate grades that are

below Millbrooke ; Millbrooke =76 or above)

Subject
Q1
Art
79
Social Skills
100
Literature 8
83
Composition 8
76
Reading Comprehension 7-9 -General Math
76
PE
100
Science 8
88
Technology
--

Q2
78
100
78
77
90
85
100
76
--

SEM1
79
100
81
77
90
81
100
82
--

Q3
85
89
76
85
-77
-77
86

Q4
77
91
*64
*67
-80
-77
87

SEM2
81
90
70
76
-79
-77
87

State Testing:

PSSA Scores
Math
4/2015-Below Basic
3/2014-Below Basic
4/2013-Basic
Reading
3/2014-Below Basic
4/2013-Below Basic
Progress Toward Previous IEP Goals
According to the Fountas and Pinnell test, Clark is currently reading at a level R
(equivalent to a 4th grade reading level) with 99% accuracy, and satisfactory
comprehension (7/10). Clark will read at a level U (equivalent to a 5.67 grade
reading level) with 98% accuracy and satisfactory comprehension in 3 out of 4
trials (7/10) as measured by a research-based literacy assessment (Fountas and

Pinnell).
As of June 2015 Clark has made significant progress in this area. Clark was given an F&P
reading assessment at level W (GLE 6.33) and read 94 wcpm with 96% accuracy and 7/10
comprehension. Clark has mastered this goal.
Clark's score on the Basic Math Computation assessment was 30 correct digits per
minute, where the goal for this level is 39 digits per minute (75th percentile).
Given 25 grade-level computation problems consisting of addition, subtraction,
multiplication, division, and fractions, Clark will receive a score of at least 45
digits per minute correct on 3 of 4 trials over a period of at least 6 weeks.
Clark was given 6 minutes to solve math calculation problems. He solved 24 digits correct a
decrease when compared to RP3. He was able to add and subtract problems with whole
numbers. He attempted more problems with fractions. He will continue to develop his math
skills in his math intervention class.
Clark's score on the Basic Math and Application assessment was 42% accurate at
4th grade GLE. Clark will increase his ability to solve instructional level multi-step
algebraic calculations and word problems at the 6th GLE with at least 80%
accuracy in 3 out of 4 trials as measured by progress monitoring probes given
once every six weeks.
Clark was given a math application probe at the 6th GLE with the use of a calculator. He
earned a 60%.
Clark improved his ability to solve word problems involving fractions. He needs to continue to
develop his overall math problem solving skills. He will continue to develop in this area.
Clark socializes with his peers approximately 30% of the time as measured by
class observations; Clark is not currently involved in any non-academic afterschool
activities. Clark will increase his
socialization with peers through school related and/or community activities by
initiating conversations with others, responding appropriately to peers and
classmates, working collaboratively in small groups or with a partner, engaging in
non-academic activities/clubs/programs as measured by teacher reports and
observations completed twice per report period.
Clark has made significant progress in this area. Clark was observed in two settings and was
observed socializing with his peers 87% of the time. During class, Clark has been vocal
during group work and has been asking questions to teachers and peers when needed. He
will continue to be monitored in this area.
Clark demonstrates ready to learn behaviors during class approximately 45% of
the time based on
observations. Clark will display ready to learn behaviors during class by attending
to the
speaker,working to his ability level, participating in class, asking for help needed,

working with peers

when directed, with 80% accuracy in 3 out of 4 trials as measured by teacher
reports and observations conducted twice per report period.
Clark is making progress with this goal. According to observations, he was on task for an
average of 91% off the time. Clark has become more focused in class in effort to avoid
summer school (according to him). He copied notes, participated, and read aloud. His off task
behaviors included looking around the room. He will continue to be monitored in this area.

Present Level of Functional Performance:

Millbrooke Charter School utilizes a merit/demerit system for behavior management. Students
receive merits
for performing good behavior/actions. Students, in turn, receive demerits for performing
undesirable
behaviors such as disrespect, tardiness, disruptiveness, etc.
Current School year Disciplinary and Attendance Records (2015-2016)

Disciplinary Records
0- Filled Demerit Cards
0- Filled Merit Cards
0- Rent-a-Cards
0-Level 2 Violations

Attendance Records
00000-

Unexcused Absences
Excused Absences
Unexcused Tardy
Excused Tardy
Early Dismissal

Teacher Reports
Ms. McCrary (9th grade literature), Mrs. Young (8th grade case manager), and Ms. Tremaine
(student supports
for 9th grade literature), and Ms. Agosto (9th grade case manager) completed the Teacher Input
Form to
provide information about his academic strengths and weaknesses as well as his social and
educational needs.
In 9th grade literature, Ms. McCrary reported that Clark's strengths in class are his willingness
and

determination. He is always willing to redo an assignment or the stay after to work on an

assignment. Ms.
McCrary reported that written expression is a significant weakness. She noted that Clark
comprehends the
readings, but that it is difficult for him to write out his analysis. She also reported that task
initiation
and homework completion are areas of significant weakness. She added that Clark does not
regularly complete the homework and that often times he needs a separate set of directions.
Overall, she said that Clark's difficulties in academic functioning are minor problems. In terms of
classroom/school behaviors Ms. McCrary wrote that Clark is often late to class, but that overall
Clark presents minor problems in his
classroom/school behaviors. In regards to peer interactions, she noticed that Clark struggles to
interact
fully with other students. Additionally, Ms. McCrary reported that office hours, extended time, one
on one
instruction, and small group learning were all successful in helping Clark with her class.
Ms. Tremaine provided push-in support for Ms. McCrary's 9th grade literature class last year. She
reported
that Clark's strengths include his kind and positive demeanor, and the effort he shows towards
his academic
success. Ms. Tremaine noted written expression, word attack/decoding, reading fluency,
grammar, and reading
comprehension as areas of significant struggle for Clark. He struggled with understanding
prompts for
writing assignments and had difficulty summarizing in class reading assignments. She described
his writing
skills as basic and said that he had trouble elaborating his thoughts and including details. In
terms
of academic behavior, Ms. Tremaine noted that task initiation, classwork completion, following
instructions, and independent work were areas of significant weakness for Clark. Often times, she
said that
Clark needed encouragement to start and continue assignments. Often his answers reflected a
basic level of
understanding and he needed constant prompting and rephrasing of the questions in order to
understand. She
also noticed that Clark regularly did other assignments for weren't for that day.With regards to
Clarks
school behavior, Ms. Tremaine reported that areas of significant weakness for Clark were
participation,
motivation, volunteering in class, asking questions, and seeking teacher assistance. She wrote
that Clark
is quiet and non-disruptive. She said that sometimes he gets frustrated by the activities of other

students
and that he seems to get overwhelmed if he isn't doing the assignment correctly. In terms of peer
interactions, Ms. Tremaine noted that Clark struggles to initiate interactions. She clarified this
saying
that he will interact with other students, but will rarely ask for help from them. Accommodations
that Ms.
Tremaine reported as successful included: limited text and direction towards key lines to find the
answers in, giving time frames for during class check ins, and preferential seating in order to
monitor his progress
on classwork.
Mrs. Young reported that Clark is well behaved, quiet and respectful of his peers and
teachers. Academically, Mrs. Young reported that areas of significant weakness for Clark include:
mental
math skills, spelling skills, written expression, vocabulary usage, work attack/decoding, grammar,
reading
comprehension, and word problems. Although Clark has made progress with is reading, writing,
and math
skills, she said that he continues to struggle and need support in those areas. When reading Clark
struggles with using effective decoding strategies, learned in his reading intervention classes,
and instead
asks the teacher to tell him the unfamiliar word. When tackling math problems, Clark struggles
with basic
math operations without the use of a calculator. However, Mrs. Young noted that Clark has made
progress
with his ability to attempt and solve problems involving fractions, but still continues to struggle
with
word problems. She noted that task initiation is a significant area of weakness for Clark, and that
he often needs prompts to start tasks within an appropriate amount of time. She reported that at
times he
appears to be daydreaming and stating instead of starting right away. As an area of strength,
Mrs. Young
said Clark often asks questions in class and participates when he feels confident. With regards to
peer
interactions, Mrs. Young reported that Clark has significantly improved over the course of the
year. He has
become more social and interacts appropriately with his peers when instructed. Accommodations
that Mrs.
Young noted as successful for Clark included: homework folder for organization, check ins,
mandatory office
hours, re-teaching concepts in small groups, and modeling or coaching appropriate peer
interactions.

Ms. Agosto observed that Clark is quiet, respectful, and kind to his teachers and peers. His
strengths
include making connections and his determination to try. She reported that mental math skills,
applied math
skills, basic math skills, and word problems are areas of significant weakness in math for Clark.
Often,
she noted, he confuses positives/negatives and struggles with multiplication/division. Moreover,
she wrote
that multi-step math problems are particularly difficult for Clark if not broken down into smaller
pieces
or steps. With regards to reading and writing skills, she noted that written expression, word
attack/decoding, and reading comprehension continue to be areas of significant weakness for
Clark. As a
result, she saw that it is hard for him to keep up with in class notes and annotations
Clarks current reading and math needs affect his performance in history and science as well. He
struggles to read and comprehend the texts in both his history and science classes. His current
grades in both of these classes, 69% in history and 36% in science, reflect the effect that his
reading needs have upon his success in those classes. Clarks current math level also affects his
ability to fully engage with the material in his science class. In terms of classroom behaviors, she
reported that Clark struggles to stay on task (during both direct instruction and independent
work). Additionally, Clark's organizational skills need further development. Since his organization
is currently an area of significant weakness, Ms. Agosto believes that this significantly
contributes with Clark's struggle to complete homework. Also, she noted that while Clark
participates when
he feels confident, he struggles to ask questions when he needs help. With regards to peer
interactions, Ms.
Agosto reported that initiating interactions with other students is an area of significant weakness
and that
Clark benefits from prompting. Finally, Ms. Agosto wrote that the following accommodations were
successful
with Clark: multiple ways of presenting directions, breaking down directions into steps/chunks,
prompting/check ins to stay on task, and a homework folder for organization.

Present Levels Related to Current Postsecondary Transition Goals:

Clark completed the ONet online Career Survey on September 10, 2015 in order to provide
information about his skills and possible career interests. The results of the survey indicate that
Clark would do well in fields in the following areas:
Artistic- These fields deal with the artistic side of things such as acting, music, art and design.
People

who are artistic most likely like creativity in their work and enjoy work that can be done without a
set of
rules.
Investigative- These fields deal with ideas and thinking rather than physical activity of leading
people.
People who are investigative like searching for facts and figuring out problems.
The results of the survey align with Clark's current interests and are consistent with his previous
goals. Although Clark stated that he is unsure of the career field that he would like to pursue,
while reviewing the results of the survey, he became excited to learn that he earned a higher
score in the artistic area of interests. He seemed to show interests in architecture, fine arts, and
acting. He revealed that he likes to draw and to act, but that unlike most who score in the artistic
field section he does like following rules. He further elaborated on
his interests in the Fine Arts saying that he has been thinking about voice acting and going to
acting school. When discussing how much preparation he was interested in partaking in towards
a career, Clark indicated that a medium level of preparation was appealing to him. This means
that he is interested in entering a vocational or technical training program after high school.
When asked about his thoughts towards college,
Clark responded that he hadn't given it much thought and didn't necessarily see himself in a
traditional
college setting.
In terms of his living arrangement after high school, Clark stated that he would like to have an
apartment by himself.
In order to reach his transitional goals Clark will need to work on the following employment skills:
efficient completion, accurate completion, asking for help, clarifying directions, and appropriate
interactions with others. Clark will also need to learn to practice the following skills: interacting
appropriately with his peers and participating in class. With the help of his case manager Clark
will begin to look for ways to develop his acting skills. Additionally, Clark will benefit from
increasing his reading comprehension, math calculation, and math problem solving in an effort to
increase his success rate at the post-secondary level.
During the IEP Meeting Mr. Shurtleff completed a transition input form. He said that he saw Clark
having a
full time job as an adult. With regards to post-secondary education Mr. Shurtleff said that it
depends on what
aligns to Clark's career goals. Finally he stated that after graduation he believes Clark can and
will
live independently if that is what he would like to do. He said that whatever Clark chooses for his
living
situation after high school will be what happens.

At this time the IEP team has decided that it is not necessary to involve any outside agencies.

Parental Concerns for Enhancing the Education of the Student:

Parent input was discussed during the IEP meeting. Mr. Shurtleff reported that he is content with
Clark's
progress thus far and has observed some of his social gains. He supports Clark's current career
and
independent living goals and wants him to achieve all academic and personal goals that he sets
for himself.
How the students disability affects involvement and progress in the general education curriculum:
Clark's diagnosis of Specific Learning Disability affects his involvement in the general education
curriculum. His deficits in reading and math requires both using a specially designed instruction
and
accommodations and modifications made to the curriculum in order to achieve success and
continue to
demonstrate growth. Clark receives reading support with a Special Education Teacher, a researchbased
Reading Intervention, small group math support as needed within the classroom setting, and
social skills
training/counseling (1100 minutes per IEP term).

Strengths
Academic:
Math calculations
Single step math problem solving
Recalling/retelling details
Drawing conclusions
Using context clues
Word Attack
Reading Fluency
Responding in writing to text
Behavioral:
Attendance
Following rules
Accepting criticism
Following directions

Complying with directives

Peer relationships
Academic, developmental, and functional needs related to students disability:
Academic:
Math problem solving (solving equations with variables, multiple steps)- (addressed in goals and
SDI
sections)
Reading Comprehension - making inferences (addressed in goals and SDI sections)
Basic Math Skills (addressed in goals and SDI sections)
Behavioral:
Working to ability level (addressed in goals and SDI sections)
Participation (addressed in goals and SDI sections)
Peer relationships (addressed in goals and SDI sections)
Functioning independently (addressed in goals and SDI sections)
Ability to remain on task (addressed in goals and SDI sections)

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 students 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 students 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 students needs taking into account the students 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:
Not applicable at this time.

Postsecondary Education and Training Goal:

Measurable Annual Goal

Clark has the goal of attending a vocational program to pursue training and education that aligns with his
interests in the areas of Fine Arts.

Yes/No
(Document in Section V)
Yes

Courses of Study:
Literature, Composition, Science, Math, PE/Tech, Reading Intervention, Math Intervention, History
Service/Activity

Location

Frequency

Projected
Beginning Date

Anticipated
Duration

Person(s)/Agency
Responsible

Clark will be given the opportunity

to increase his reading
comprehension and math skills
through intensive reading and math
support.

Academic Support
Classroom

weekly

9/17/2015

9/16/2016

Special
Education/Regular
Education Teacher

Across All Settings

Per IEP term

9/17/2015

9/16/2016

Special
Education/Regular
Education Teacher

Across All Settings

Per IEP term

9/17/2015

9/16/2016

Special
Education/Regular
Education Teacher

Across All Settings

daily

9/17/2015

9/16/2016

Clark will receive reading and math

intervention on a weekly basis.
Credit Accrual: Clark will be given
the opportunity to achieve
Millbrooke in all classes.
Teachers and case managers
will provide support for
Clark with supports such as
check ins/grade conferencing,
office hours, etc.
College Visit: Clark will be given
the opportunity to visit at least 1
college campus over the course of
the IEP term. While visiting the
campus, Clark will collect
information related to admission
criteria and majors offered.
Millbrooke staff will provide
the guidelines for the
college visit.
Clark will be given the opportunity
to practice the following skills:
interacting appropriately with his
peers, and participating in class.
Teachers and case managers will
provide Clark with support

Special
Education/Regular
Education Teacher

regarding participation,
confidence, to help him attain his
goal.
Employment Goal:
Upon completion of high school, Clark has the goal to pursue a career in Fine Arts.

Measurable Annual Goal

Yes/No
(Document in Section V)
Yes

Courses of Study:
Literature, Composition, Science, Math, PE/Tech, Reading Intervention, Math Intervention, History
Service/Activity

Location

Frequency

Projected
Beginning Date

Anticipated
Duration

Person(s)/Agency
Responsible

Community

Per IEP term

9/17/2015

9/16/2016

Job/Transition
Coordinator

Across All Settings

daily

9/17/2015

9/16/2016

Special
Education/Regular
Education Teacher

Career Fair: Clark will be given the

opportunity to attend Millbrooke 's
annual Career Fair.
With support from his
teachers and staff, Clark
will ask questions to
panelists in his field of
interests to gain information
about different career fields.
Clark will be given the opportunity
to work on the following
employment skills: efficient
completion,
accurate completion, asking
for help, clarifying
directions, and appropriate
interactions with others.
Teachers and staff at Millbrooke
will support Clark with time
management, organization, and
socialization skills in order
to attain this goal.

Independent Living Goal, if appropriate:

Clark has the goal of living independently in an apartment by himself after high school.

Measurable Annual Goal

Yes/No
(Document in Section V)
Yes

Courses of Study:
Literature, Composition, Science, Math, PE/Tech, Reading Intervention, Math Intervention, History
Service/Activity

Location

Frequency

Projected
Beginning Date

Anticipated
Duration

Person(s)/Agency
Responsible

Clark will be given the opportunity

to increase his reading
comprehension and math skills
through intensive reading and math
support.

Academic Support
Classroom

weekly

9/17/2015

9/16/2016

Special
Education/Regular
Education Teacher

Clark will receive reading and math

intervention on a weekly basis.
Clark will be given the opportunity
to increase his socialization skills
(appropriate interactions with
peers, asking for help when
needed, and collaborating
effectively).

Across All Settings

daily

9/17/2015

9/16/2016

Special
Education/Regular
Education Teacher

Teachers and staff at Millbrooke

will support Clark with practicing
social skills in order
to attain this goal.

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
No statewide assessment is administered at this students 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
Extended time
Algebra 1
x
Small-group setting
Simplified directions
Read aloud test directions
Use of calculator
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

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 students gifted program may be listed
under Goals or Short Term Objectives.
MEASURABLE ANNUAL GOAL
Include: Condition, Name, Behavior, and Criteria
(Refer to Annotated IEP for description of these
components)

Describe HOW the

students progress toward
meeting this goal will be
measured

Given 7.00 grade level reading materials, Clark

will be given the opportunity to read with 98%
accuracy in 3 out of 4 trials, moving from a
baseline of 5.33 GLE with 98% accuracy, as
measured by a research-based literacy assessment
(Fountas and Pinnell) completed once per report
period.

Criterion-Referenced
Tests; Performance Based
Assessment

Report Period (quarterly)

Given 7.00 grade level reading materials, Clark

will be given the opportunity to demonstrate at
least 70% comprehension in 3 out of 4 trials,
moving from a baseline of 5.3 GLE with 80%
comprehension, as measured by a research-based
literacy assessment (Fountas and Pinnell)
completed once per report period.

Criterion-Referenced
Tests; Performance Based
Assessment

Report Period (quarterly)

When provided with embedded opportunities in

the inclusive setting, Clark will increase his
socialization with peers through school related
and/or community activities by working
collaboratively in small groups or with a
partner with at least 80% accuracy, moving from a
baseline of 60% of the time, as measured by
teacher reports and observations completed twice
per report period.

Data Collection from

Teacher Reports; Teacher
Obeservation

Report Period (quarterly)

Clark will be given the opportunity to solve

5th grade level multi-step algebraic calculations
and word problems with at least 30% accuracy,
moving from a baseline of 10% accuracy on a 4th
grade level assessment, in 3 out of 4 trials as

Criterion-Referenced
Tests; Performance Based
Assessment

Report Period (quarterly)

Describe WHEN periodic

reports on progress will be
provided to parents

Report of Progress

measured by progress monitoring probes given

once every six weeks.

Clark will be given the opportunity to solve 25 6th

grade level computation
problems consisting of addition,
subtraction, multiplication, division, and
fractions, with at least 35 digits per minute
correct, moving from a baseline of 18 digits
correct on a 6th grade level, on 3 of 4 trials over a
period of at least 6 weeks.

Criterion-Referenced
Tests; Performance Based
Assessment

Report Period (quarterly)

When provided with embedded opportunities in

the inclusive setting, Clark will be given the
opportunity to display ready to learn behaviors
during class by working to his ability
level, raising his hand and asking and
answering questions, functioning
independently by completing tasks without
additional prompts (as needed),
and attending to the speaker at least 80% of
the time, moving from a baseline of 77% of the
time, in 3 out of 4 trials as measured by
teacher reports and observations conducted twice
per report period.

Data Collection;
From Teacher Reports;
Teacher
Observation

Report Period (quarterly)

When given a task or assignment during class

Clark will be given the opportunity to begin
working on the task or ask
a clarifying question about the task within
1 minute at least 50% of the time, moving from a
baseline of beginning a task or asking a
clarifying question about the task within 1
minute approximately 30% of the time, in 3 out
of 4 trials as measured by observations
conducted twice per report period.

Data Collection;
From Teacher Reports;
Teacher
Observation

Report Period (quarterly)

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

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
Due to Clarks current math
skills level, he will
participate in a math
intervention class.
Due to Clarks current
reading level, he will
participate in a reading
intervention class.
Due to Clarks current math
level, he will require all
homework and classwork to
be modified to meet his
present level of academic
skill.
Due to Clarks current
reading level, he will
require all homework and
classwork to be modified to
meet his present level of
academic skill.
Due to Clarks current
classroom behavior needs,
he will require directions to
be clear and succinct,
avoiding extraneous words
and digressions. When
possible, limit the number
of steps or requests made.
State multi-step directions
in the sequence in which
they are to be completed.

Location

Frequency

Projected Beginning Date

Anticipated Duration

Academic Support
Classroom

weekly

9/17/15

9/16/16

Academic Support
Classroom

weekly

9/17/15

9/16/16

Across All Settings

daily

9/17/15

9/16/16

Across All Settings

daily

9/17/15

9/16/16

Across All Settings

daily

9/17/15

9/16/16

Due to Clarks current

behavioral needs, he may
have difficulty recalling
oral directions given to the
class. As a result, it will be
important to monitor his
understanding after
group directions are given.
During oral presentation,
write important
information on the board.
Also, provide written
directions that accompany
oral directions.
Due to Clarks current
behavioral needs,
assignments and tasks
should be broken down into
smaller more manageable
steps with frequent checkins in order to maintain
Clarks level of focus and to
allow teachers to closely
monitor his progress
towards completing the
task at hand.
Due to Clarks current
levels of academic
functioning, he will be
allowed extra time to
complete all assignments,
tests, and tasks. Teachers
should also consider ways
to modify tasks that
emphasize quality of work
produced rather than
volume and speed of work
completed.

Across All Settings

daily

9/17/15

9/16/16

Across All Settings

daily

9/17/15

9/16/16

Across All Settings

daily

9/17/15

9/16/16

Due to Clarks current math

level, reword mathematical
vocabulary daily in simpler
terms to compensate for
the Clarks lack of
knowledge (e.g. reduce
means to state a fraction in
terms using smaller
numbers). It may be
necessary to provide
concrete examples for
some abstract terms. Clark
would also benefit from
the use of a calculator at
times so he can focus on
Problems should be broken
down into a step-by-step
manner as assuring
completion of each step
will be beneficial to Clarks
growth in math. Create
visual representations
of word problems
(drawing the problem,
providing examples of
methods to compute the
problem). Additionally,
operational signs on
worksheets and assessments
should be highlighted in
order to clearly direct
Clarks attention to the sign
and the corresponding
operation he needs to
perform.

Across All Settings

daily

9/17/15

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

9/16/16

Service
Social Skills Training Small
Group
Social Skills Training Small
Group

Location

Frequency
1,100 minutes per
IEP term

Projected Beginning Date

Anticipated Duration

9/17/15

6/24/16

1,100 minutes per IEP term

8/24/16

9/16/16

Myers Campus
Myers Campus

C. SUPPORTS FOR SCHOOL PERSONNEL List the staff to receive the supports and the supports needed to implement the students IEP.
School Personnel to
Receive Support

Regular Education
Teacher

Special Education
Teacher

School Staff

Support
On-going support
and communication
between general
education teachers
and special
education
department
On-going
communication
between parent and
Millbrooke Charter
School
On-going
communication
between parent and
Millbrooke Charter
School's special
education
department

Location

Frequency

Projected Beginning
Date

Anticipated Duration

Across All Settings

Daily

9/17/15

9/16/16

Across All Settings

Daily

9/17/15

9/16/16

Across All Settings

Daily

9/17/15

9/16/16

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

Clark does not qualify as a gifted student.

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:
Student is not eligible for Extended Year Services at this time. Clark has not received ESY services in the past and is able to recoup
information after lapses in school session.

The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the students 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 disabilities in the regular education class:
Clark will participate in the regular education class with the specially designed instruction and
accommodations and/or modifications necessary to promote academic and social-emotional gains. Clark
will receive counseling services (1100 minutes per IEP term) outside the regular education class. Clark
will receive push in support and a research based reading and math intervention programming.
Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
Clark will participate in the general education curriculum for all academic subjects with the specially
designed instruction and accommodations and/or modifications necessary to promote academic and
social-emotional gains. Clark will receive research based reading and math intervention programming.

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
B. Type of Support
1. Amount of special education supports
Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day
x

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

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April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
C. Location of students program
Name of School District where the IEP will be implemented:

Myers Campus

Name of School Building where the IEP will be implemented:

Myers Campus

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

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

Special education supports and services required in the students IEP cannot be provided in the neighborhood school
x

Other. Please explain:

Parent selected charter school

Page 36 of 37

April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students 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 students 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

Total hours the student

spends in the regular
classroom per day

Total hours in a typical

school day
(including lunch, recess
& study periods)

(Hours inside regular

classroom hours in
school day) x 100 = %
(Column 1 Column 2) x
100 = %

Section A: The percentage of

time student spends inside the
regular classroom:

5.50

6.9

(5.50 6.90) x 100

80% of the day

Percentage Category
Using the calculation result select the appropriate percentage category

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) _________________________
Approved Private School (Residential)
_________________________
Other Private Facility (Non Residential)
_________________________
Other Private Facility (Residential)
________________________
Other Public Facility (Residential)
________________________

Other Public Facility (Non Residential) _________________________

Hospital/Homebound
_________________________
Correctional Facility
_________________________
Out of State Facility
_________________________
Instruction Conducted in the Home
_________________________

EXAMPLES for Section A: How to Calculate PennDataEducational Environment Percentages

Example 1

Column 1

Column 2

Calculation

Indicate Percentage

Total hours the student spends in the

regular classroom per day

Total hours in a typical school day

(including lunch, recess & study
periods)

(Hours inside regular classroom hours in school day)

x 100 = %
(Column 1 Column 2) x 100 = %

Section A: The percentage of time student

spends inside the regular classroom:

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
60% of the day
(3 5) x 100 = 60%
(Inside 79-40% of Day)
Example 3
1
5
20% of the day
(1 5) x 100 = 20%
(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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April 2014