IEP Individualized Education Program

THIS IEP WILL BE IMPLEMENTED DURING THE REGULAR SCHOOL TERM UNLESS NOTED IN GENERAL FACTORS

CHILD'S INFORMATION

MEETING INFORMATION

NAME: Emery Steel

ID NUMBER:

STREET:

GENDER: Female

CITY:

Tex

Edgewood

MEETING DATE:

STATE: OH

GRADE: 21

MEETING TYPE:
INITIAL IEP

ZIP:

ANNUAL REVIEW

DATE OF BIRTH: June 17, 2008

DISTRICT OF RESIDENCE:

Edgewood City Schools

11/15/2014

REVIEW OTHER THAN ANNUAL REVIEW

COUNTY OF RESIDENCE:

Butler

AMENDMENT
OTHER

DISTRICT OF SERVICE:

Edgewood
Will the child be 14 years old before the end of this IEP?
(Changes content of Sections 4 and 5)

YES
YES

Is the child a ward of the state?

NO

IEP TIME LINES

ETR COMPLETION DATE:

NO

NEXT ETR DUE DATE:

If yes, provide the name of the surrogate parent:

IEP EFFECTIVE DATES

START:

PARENTS' / GUARDIAN INFORMATION

NAME:

Lyra Steel

11/7/2014
11/6/2015
11/15/2014

END:

11/14/2015

NEXT IEP REVIEW:

11/14/2015

STREET:

IEP BY 3rd BIRTHDAY ?

CITY:

(If transitioning from EI services)

STATE: OH

ZIP:

HOME PHONE:

WORK PHONE:

IEP FORM STATUS

CELL PHONE:

EMAIL:

(Check when complete)

NAME: Jeremiah Steel

STREET:
CITY:

STATE: OH

HOME PHONE:

WORK PHONE:

CELL PHONE:

EMAIL:

ZIP:

OTHER INFORMATION:

YES

NO

1. FUTURE PLANNING
2. SPECIAL INSTRUCTIONAL FACTORS
3. PROFILE
4. POSTSECONDARY TRANSITION
5. POSTSECONDARY TRANSITION SERVICES
6. MEASURABLE ANNUAL GOALS
7. SPECIALLY DESIGNED SERVICES
8. TRANSPORTATION AS A RELATED SERVICE
9. NONACADEMIC AND EXTRA CURRICULAR
10. GENERAL FACTORS
11. LEAST RESTRICTIVE ENVIRONMENT
12. STATEWIDE AND DISTRICT TESTING
13. MEETING PARTICIPANTS
14. SIGNATURES

AMENDMENTS: (Complete only if amending the IEP)

IEP SECTION THE SCHOOL DISTRICT AND PARENTS HAVE AGREED
AMENDED TO MAKE THE FOLLOWING CHANGES TO THE IEP

PR-07 IEP FORM REVISED BY ODE: .":
, 20

DATE OF
AMENDMENT

PARTICIPANT & ROLE

PAGE 1 of 1

IEP

Individualized Education Program

CHILD'S NAME:

Emery Steel

FUTURE PLANNING

At this time, there are no concerns of the parent or student. The parents of Emery want to focus on her inattention and helping her reach her grade
level benchmark in reading comprehension, which this IEP is addressing.

SPECIAL INSTRUCTIONAL FACTORS

Items checked "YES" will be addressed in this IEP:

Does the child have behavior which impedes his/her learning or the learning of others?

YES

NO

Does the child have limited English proficiency?

YES

NO

Is the child blind or visually impaired?

YES

NO

Does the child have communication needs (required for deaf or hearing impaired )?

YES

NO

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

YES

NO

Does the child require specially designed physical education?

YES

NO

PROFILE

CHILD'S PROFILE:
Family: Emery resides with her parents, twin brother and older sister.
Strengths: Emery is a creative artistic child who enjoys sewing and gymnastics. Emery is a conscientious student, whom works hard to complete all
her assignments and always puts forth her best effort.
Educational: Emery attended the Little Red School House prior to Kindergarten. On 11/19/13, Emery was referred for an initial evaluation for a
suspected learning disability. She was subsequently identified as a student with a Specific Learning Disability in reading on 12/17/13. An IEP was
developed, but services were declined on two separate occasions by Emerys parents. On 1/15/14, Emery underwent a private cognitive evaluation
at The Affinity Center, Inc. According to the evaluation report, she was given the following DSM-V diagnoses: Attention-Deficit/Hyperactivity
Disorder, Combined Type; Specific Learning Disability with impairment in Reading. Emery is labeled as Specific Learning Disability because this
takes presedence over her Other Health Impairment diagnosis. In March, Emerys parents enrolled her in private tutoring with a tutor specializing in
Orton-Gillingham. Emery is currently in 2nd grade and receives all of her instruction in the general education classroom.
Medical Information: Emery has no food or environmental allergies. She passed the school vision and hearing screening on 10/7/14. Emery takes
Concerta for her ADHD.

PR-07 IEP FORM REVISED BY ODE: .":




PAGE 2 of 1

IEP

Individualized Education Program

CHILD'S NAME:

Emery Steel

POSTSECONDARY TRANSITION

FOR 14 YEARS AND OLDER

(or younger if appropriate)

A STATEMENT OF TRANSITION SERVICE NEEDS OF THE CHILD THAT FOCUSES ON THE CHILD'S COURSE OF STUDY

FOR 16 YEARS AND OLDER

(or younger if appropriate)

AGE APPROPRIATE TRANSITION ASSESSMENTS

Summarize the results of the age-appropriate transition assessment data in the space below, indicating the source of the assessment(s) and
the relevant information for transition planning

PR-07 IEP FORM REVISED BY ODE: .":




PAGE 3 of 1

IEP

Individualized Education Program

POSTSECONDARY TRANSITION SERVICES

CHILD'S NAME:

Emery Steel

POSTSECONDARY EDUCATION AND TRAINING (optional for 15 and younger)

MEASURABLE POSTSECONDARY GOAL:

COURSES OF STUDY:

TRANSITION SERVICE/ACTIVITY

NUMBERS OF ANNUAL GOAL(S)

PROJECTED BEGINNING
DATE

ANTICIPATED
DURATION

PERSON/AGENCY RESPONSIBLE

EMPLOYMENT (optional for 15 and younger)

MEASURABLE POSTSECONDARY GOAL:

COURSES OF STUDY:

TRANSITION SERVICE/ACTIVITY

PR-07 IEP FORM REVISED BY ODE: .":




NUMBERS OF ANNUAL GOAL(S)

PROJECTED BEGINNING ANTICIPATED

DATE
DURATION

PERSON/AGENCY RESPONSIBLE

PAGE 4 of 1

IEP

Individualized Education Program

CHILD'S NAME:

Emery Steel

INDEPENDENT LIVING (As appropriate)

MEASURABLE POSTSECONDARY GOAL:

COURSES OF STUDY:

TRANSITION SERVICE/ACTIVITY

NUMBERS OF ANNUAL GOAL(S)

PROJECTED BEGINNING
DATE

ANTICIPATED
DURATION

PERSON/AGENCY RESPONSIBLE

Target date for child to Graduate:

PR-07 IEP FORM REVISED BY ODE: .":




PAGE 5 of 1

IEP

Individualized Education Program

CHILD'S NAME:

Emery Steel

MEASURABLE ANNUAL GOALS

AREA: Reading Comprehension

NUMBER:

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Emery is currently at or above benchmark in her phonological awareness skills, oral reading fluency, sight word recognition, and reading accuracy. She is in the general education room and receives no interventions
currently, although she has a private tutor whom has helped her make significant gains in reading. Parents concerns are not included in the ETR and will be addressed at IEP meeting, and the statement regarding how the
disability affects this childs involvement and progress in the general education setting can be found in the profile section. Within the past 6 months Emery was assessed, in the area of oral reading fluency and reading
comprehension, using MAZE: CBM. She was above benchmark for oral reading fluency, but fell in the 10th percentile (below benchmark) compared to same grade peers, in reading comprehension. MAZE: CBM (reading
comprehension) requires students to read silently for three minutes and every seventh word is replaced with three words inside parenthesis: one correct and two to distract, Emerys score was one. Therefore, when Emery is
provided a second grade reading passage to silently read for 3 minutes, and every seventh word is replaced by three words in parenthesis (one correct and two to distract), she is currently able to select the correct answer
one time (compared to the second grade benchmark of 4).

MEASURABLE ANNUAL GOAL

METHOD(S)

When Emery is given the MAZE: CBM, in the general education classroom, at a second grade level, she will read the
passage silently for three minutes, and every seventh word is replaced by three words inside parenthesis: one correct
and two to distract, she will select the correct answer with a raw score of 4 (benchmark) 3 out of 4 trials by the end of
the IEP.

A, I

METHOD FOR MEASURING THE CHILD'S PROGRESS TOWARDS ANNUAL GOAL

a. Curriculum Based Assessment

e. Short-Cycle Assessments

i. Work Samples

b. Portfolios

f. Performance Assessments

j. Inventories

c. Observation

g. Checklists

k. Rubrics

d. Anecdotal Records

h. Running Records

MEASURABLE OBJECTIVES
NUM OBJECTIVE

.1

When Emery is given the MAZE: CBM, in the general education classroom, at a second grade level, she will read the passage silently for three minutes, and every seventh word is
replaced by three words in parenthesis: one correct and two to distract Emery will select the correct 2 times on 3 out of 4 trials by 2/6/15.

.2

When Emery is given the MAZE: CBM, in the general education classroom, at a second grade level, she will read the passage silently for three minutes, and every seventh word is
replaced by three words in parenthesis: one correct and two to distract Emery will select the correct 3 times on 3 out of 4 trials by 4/7/15.

.3

When Emery is given the MAZE: CBM, in the general education classroom, at a second grade level, she will read the passage silently for three minutes, and every seventh word is
replaced by three words in parenthesis: one correct and two to distract Emery will select the correct 4 times on 3 out of 4 trials by the end of the IEP.

.4
.5
.6
METHOD AND FREQUENCY FOR REPORTING THE CHILD'S PROGRESS TO PARENTS
Written report
Email

Reported every 8

weeks

Phone call
Journal entry

The child's progress will be reported to the child's parents each time report cards are issued

Other
Note: Progress Reports must be provided to parents of a child with a disability at least as often as report cards are issued to all children. If the district
provides interim reports to all children, progress reports must be provided to all parents of a child with a disability.

PR-07 IEP FORM REVISED BY ODE: .":




PAGE 6 of 1

IEP

Individualized Education Program

CHILD'S NAME:

Emery Steel

MEASURABLE ANNUAL GOALS

AREA: Behavior (Inattention)

NUMBER:

PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Emery has a medical diagnosis of ADHD and currently is taking Concerta for control of her symptoms. Emerys behavioral difficulties were evaluated at the end of 2014 using BOSS (Behavioral Observations of Students
in Schools) and the Conners 3rd edition- Teacher and Parent behavioral rating scores. The BOSS summary reported Emery was equally engaged in classroom activities compared with her peers. Teacher reports (noted in
ETR) state she always completes her work, is an active participant in class, and has a positive attitude. Emery currently has no interventions or accommodations. The ETR does not state concerns of the parents related to
this goal. Emerys Specific Learning disability affects her involvement and progress in the general curriculum because she is easily distracted and often needs instruction repeated and tasks broken down into more
manageable steps. According to Conners 3rd edition- Teacher and Parent behavioral rating scales (a standardized assessment), Emery scored within normal limits across hyperactivity/ impulsivity, conduct disorder and
global index total. However, her inattention score reported to be of moderate concern. Therefore, we would like to see Emerys concentration and attention focused on so she becomes less distracted by her surroundings.

MEASURABLE ANNUAL GOAL

METHOD(S)

In a general education setting Emery will follow multi-step instructions from start to finish with only one reminder from
the teacher in 4 out of 5 trials by the end of the IEP.

C,H

METHOD FOR MEASURING THE CHILD'S PROGRESS TOWARDS ANNUAL GOAL

a. Curriculum Based Assessment

e. Short-Cycle Assessments

i. Work Samples

b. Portfolios

f. Performance Assessments

j. Inventories

c. Observation

g. Checklists

k. Rubrics

d. Anecdotal Records

h. Running Records

MEASURABLE BENCHMARKS
NUM BENCHMARK

.1

DATE OF MASTERY

Emery will follow multi-step instructions, in a general education setting, all the way through with three or less
reminders in 4 out of 5 trials by 2/6/2015.

.2

Emery will follow multi-step instructions, in a general education setting, all the way through with two or less
reminders in 4 out of 5 trials by 5/18/2015.

.3

Emery will follow multi-step instructions, in a general education setting, all the way through with one reminder
in 4 out of 5 trials by the end of the IEP.

.4






.5
METHOD AND FREQUENCY FOR REPORTING THE CHILD'S PROGRESS TO PARENTS
Written report
Email

Reported every 8

weeks

Phone call
Journal entry

The child's progress will be reported to the child's parents each time report cards are issued

Other
Note: Interim Progress Reports must be provided to parents of a child with a disability at least as often as report cards are issued to all children. If the district
provides interim reports to all children, progress reports must be provided to all parents of a child with a disability.

PR-07 IEP FORM REVISED BY ODE: .":




PAGE  of 1

IEP

CHILD'S NAME:

Individualized Education Program

Emery Steel

DESCRIPTION(S) OF SPECIALLY DESIGNED SERVICES

TYPE OF SERVICE

GOAL(s)
ADDRESSED

PROVIDER TITLE

LOCATION OF SERVICES

SPECIALLY DESIGNED INSTRUCTION:

Emery will receive specially designed instruction, in reading comprehension, in a
direct large group setting. The instruction will be implemented through guided
practice, modeling, and scaffolding so she learn comprehension by making
connections, determining importance and summarize.

BEGIN:

11/15/14

END:

11/14/15

In direct small group instruction with corrective feedback, modeling, guided practice,
and repeated practice, Emery will be taught comprehension strategies such as: reading
questions first, highlighting important information, and filling out graphic organizers
with modeling.

BEGIN:

11/15/14

END: 11/14/15

Specially designed, direct large group instruction with intervention in breaking down
steps and redirection by self-monitoring, repeated practice and corrective feedback in
the area of behavior attention.

BEGIN:

11/15/14

END:

11/14/15

Language Arts Teacher: Mr. Combs

AMOUNT OF TIME:
1

FREQUENCY: Daily

Intervention Specialist: Mrs. Callahan Special Education Classroom

AMOUNT OF TIME:
2

45 Minutes

General Education Language Arts Room

15 Minutes

FREQUENCY:

3 times a week

Intervention Specialist: Mrs. Callahan Math General Education Room

AMOUNT OF TIME:

50 Minutes

FREQUENCY:

Weekly

RELATED SERVICES:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

ASSISTIVE TECHNOLOGY:

ACCOMMODATIONS:
Graphic organizers (summarize stories), lots of visual support, direct and small group instruction,
read- alouds (teach new vocabulary), think-alouds to teach inference, quite work areas, front of class
seat (surround by good role models), randomly select Emerys name to answer questions or place her
name in stores (increase attention), make eye contact with Emery when giving directions.

BEGIN: 11/15/14

PR-07 IEP FORM REVISED BY ODE: .":




END: 11/14/15

1 and 2

Intervention Specialist and General

Education Instructors

AMOUNT OF TIME:

Across all classroom settings

FREQUENCY:

PAGE  of 1

IEP

Individualized Education Program

BEGIN:

END:

CHILD'S NAME:

Emery Steel

AMOUNT OF TIME:

FREQUENCY:

MODIFICATIONS:
When short answer responses are required, after a reading, Emerys worksheets will provide her
with only two choices (one correct and one to distract), Emery must select one and write about that.
The intervention specialist will make all modified worksheets. Furthermore, Emery will be able to
use a filled out graphic organizer to assist her with comprehension questions on school assignments.

BEGIN:

END:

11/15/14

BEGIN:

11/14/15

END:

Intervention Specialist and General

Education Instructors

Across all classroom settings

AMOUNT OF TIME:

FREQUENCY:

AMOUNT OF TIME:

FREQUENCY:

SUPPORT FOR SCHOOL PERSONNEL:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

SERVICE(S) TO SUPPORT MEDICAL NEEDS:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

BEGIN:

END:

AMOUNT OF TIME:

FREQUENCY:

KEY:

OPTIONAL ENTRY

NOT REQUIRED

TRANSPORTATION AS A RELATED SERVICE

Does the child have needs related to their identified disability that require special transportation?
Does the child need accommodations or modifications for transportation?
If yes, check any transportation accommodations/modifications that are needed.

YES

NO

YES

NO

The bus driver will be notified of the child's behavioral and/or medical concerns
Specially Adapted Vehicle

Wheelchair lift

Bus Aide

Securement Systems

Car Seat

Harness

Other

Specify:

Does the child need transportation to and from provider services?

PR-07 IEP FORM REVISED BY ODE: .":




YES

NO

PAGE  of 1

IEP

Individualized Education Program

CHILD'S NAME: Emery Steel

NONACADEMIC AND EXTRACURRICULAR ACTIVITIES

In what ways will the child have the opportunity to participate in nonacademic/extracurricular activities with his/her nondisabled peers?

Describe
Emery is able to participate in extracurricular activities with her nondisabled peers. She can attend all her specials with the general education
population and she is able to participate in after school sports and clubs if she desires. Emery is already participating in gymnastics with
nondisabled peers.

If the child will not participate in non-academic/extracurricular activities, explain.

10

GENERAL FACTORS

HAS THE IEP TEAM CONSIDERED:

YES

NO

As appropriate, the results of performance on any state or district-wide assessments?

YES
YES
YES

NO

The academic, developmental, and functional needs of the child?

YES

NO

The strengths of the child?

The concerns of the parents for the education of the child?
The results of the initial or most recent evaluations of the child?

NO
NO

The need for extended school year (ESY) services

The team has determined that ESY services are not necessary.
The team has determined that ESY services are necessary for the following
Goals and Objectives or Benchmarks:
The team needs to collect further data before making a determination and
will meet again by:

PR-07 IEP FORM REVISED BY ODE: .":




PAGE  of 1

IEP

Individualized Education Program

11

LEAST RESTRICTIVE ENVIRONMENT

CHILD'S NAME: Emery Steel

Does this child attend the school (or for a preschool-age child, participate in the environment

he/she would attend if not disabled?

YES

NO

NO

If no, justify:

YES

Does this child receive all special education services with nondisabled peers?
If no, justify (justification may not be solely because of needed modifications in the general curriculum):

Based upon the information in the most recent ETR, Emery needs intensive intervention in reading comprehension. The team considered delivery
of services in the general education classroom and the specially designed instruction will help Emery achieve success in the general education
setting. The team has determined that supplementary aids and services will not be sufficient for the student to access or make adequate progress in
a general education classroom for language arts curriculum because Emery struggles with reading comprehension and is easily distracted. Emery
needs small group instruction in the special education room because there are fewer distractions so she can focus more on the comprehension tasks
at hand. Most of the time Emery will be in the general education class, just 15 minutes three times a week she will need to be pulled out to receive
more intensive interventions. Emery will participate in all classes with non-disabled peers.

12

STATEWIDE AND DISTRICT WIDE TESTING

For each subject tested in the child's grade, choose the method of assessment below. If "With Accommodations" is chosen for any subject,
provide a description of the Accommodations for each subject in the right column.
Alternate Assessment, if chosen, must apply to all tests taken.
Will the child participate in classroom, district wide and state wide assessments with accommodations?

AREA
READING

GRADE
2

CHILDREN WILL BE TESTED:

WITH ACCOMMODATIONS
MODIFIED ASSESSMENT

YES

NO

DETAIL OF ACCOMMODATIONS
Emery will be allowed to use a completed graphic organizer
that summarizes the story to assist her with comprehension
questions.

WITH ACCOMMODATIONS

WRITING

MODIFIED ASSESSMENT
WITH ACCOMMODATIONS

MATH

MODIFIED ASSESSMENT

SCIENCE

SOCIAL STUDIES

WITH ACCOMMODATIONS
MODIFIED ASSESSMENT

OTHER

PR-07 IEP FORM REVISED BY ODE: .":




WITH ACCOMMODATIONS
MODIFIED ASSESSMENT

Emery will be allowed to use a completed graphic organizer

that summarizes the story to assist her with comprehension
questions.
Emery will be allowed to use a completed graphic organizer
that summarizes the story to assist her with comprehension
questions.

WITH ACCOMMODATIONS
MODIFIED ASSESSMENT

PAGE 1 of 1

IEP

Individualized Education Program

CHILD'S NAME: Emery Steel

Is the child to be excused from the consequences of not passing the Ohio Graduation Test (OGT)?

YES

NO

The child is completing a curriculum that is significantly different than the curriculum completed by other
children required to take the test.

YES

NO

The child requires accommodations that are beyond the accommodations allowed for children taking state
wide assessments.

YES

NO

NO

NO

The child is excused from the consequences of not passing the OGT in the following subjects:
Reading
Mathematics
Writing
Social Studies
Science
Met Testing Participation Requirement?

Date complete:

Is the child participating in alternate assessment?

YES
YES

Justify the choice of alternate assessment and address why it is appropriate:

PR-07 IEP FORM REVISED BY ODE: .":




PAGE 1 of 1

IEP

Individualized Education Program

13

MEETING PARTICIPANTS

CHILD'S NAME: Emery Steel

THIS IEP MEETING WAS:

IEP EFFECTIVE DATES

Face-to-Face Meeting

START:

Video Conference
Telephone Conference/Conference Call
Other

11/15/14

END:

11/14/15

DATE OF NEXT IEP REVIEW:

11/14/15

IEP MEETING PARTICIPANTS

THE FOLLOWING PEOPLE ATTENDED AND PARTICIPATED IN THE MEETING TO DEVELOP THIS IEP

POSITION

NAME

Student*

Emery Steel

Parent

Lyra Steel

Parent

Jeremiah Steel

District Representative*

Ms. Prescott

Intervention Specialist*

Mrs. Callahan
Mr. Combs

General Education Teacher*

SIGNATURE

PEOPLE NOT IN ATTENDANCE WHO PROVIDED INFORMATION AND RECOMMENDATIONS

POSITION

NAME

SIGNATURE

DATE

IF THE REGULAR EDUCATION TEACHER, INTERVENTION SPECIALIST, DISTRICT REPRESENTATIVE OR PERSON KNOWLEDGABLE ABOUT THE
INSTRUCTIONAL IMPLICATIONS OF THE EVALUATION DATA HAVE SIGNED AS NOT IN ATTENDANCE AT THE IEP MEETING, A WRITTEN EXCUSE
MUST BE ON FILE*.

PR-07 IEP FORM REVISED BY ODE: .":




PAGE 1 of 1

IEP

Individualized Education Program

14

SIGNATURES

CHILD'S NAME: Emery Steel

INITIAL IEP
I give consent to initiate special education and related services specified in this IEP.*
I give consent to initiate special education and related services specified in this IEP except for **
AREA:
I do not give consent for special education and related services at this time.**
DATE:

PARENTS' SIGNATURE:

ANNUAL REVIEW/REVIEW OTHER THAN ANNUAL REVIEW (Not a Change of Placement)

I agree with the implementation of this IEP.*

I am signing to show my attendance/participation at the IEP team meeting but I do not agree with the following
special education and related services specified in this IEP.**
AREA:
Note: Not a Change of Placement does NOT require a parents' signature to implement the IEP.

PARENTS' SIGNATURE:

DATE:

ANNUAL REVIEW/REVIEW OTHER THAN ANNUAL REVIEW (Change of Placement)

I give consent for the change of placement as identified in this IEP.*
I do not give consent for the change of placement as identified in this IEP.**
I revoke consent for all special education and related services.**
PARENTS' SIGNATURE:

DATE:

* This IEP serves as prior written notice if there is agreement.

**If there is not agreement or consent is revoked, the district must provide prior written notice to the parents.

TRANSFER OF RIGHTS AT MAJORITY

By the child's 17th birthday, the child and the child's parents or surrogate parent received a copy of their procedural
safeguards notice and notice of the transfer of procedural safeguard rights under IDEA will take place on the child's
18th birthday.
CHILD'S SIGNATURE:
DATE:
PARENTS' SIGNATURE:

YES

NO

DATE:

PROCEDURAL SAFEGUARDS NOTICE

A copy of the Procedural Safeguards Notice was given to the parents at the IEP Meeting.

YES

NO

YES

NO

IF NO, DATE SENT TO PARENTS:

COPY OF THE IEP

A copy of the IEP was given to the parents at the IEP meeting.
IF NO, DATE SENT TO PARENTS:

PR-07 IEP FORM REVISED BY ODE: .":




PAGE 1 of 1

IEP

Individualized Education Program

15

CHILDREN WITH VISUAL IMPAIRMENTS

CHILD'S NAME:

This form shall be completed during the IEP meeting for each child who has a visual impairment, as defined by Ohio's Amended
Substitute House Bill Number 164, which requires a statement specifying one or more reading and writing media in which
instruction is appropriate to meet the child's educational needs. A copy of this completed form is part of, and must be attached to,
the child's IEP form.
1.Annual assessment of reading and writing skills was conducted with each child in all media considered appropriate.
YES
The results of these assessments are included in Present Levels of Development/Functioning/Performance on the
IEP and indicate both strengths and weaknesses.

NO

2.The IEP contains a requirement for instruction in Braille reading and writing when that medium is appropriate and is
indicated by adding Standard English Braille as a special service in Step 4, listing the date initiated and the
anticipated duration of services.

YES

NO

3.Instruction in Braille reading and writing was carefully considered for this child and pertinent literature describing the
educational benefits of instruction in Braille reading and writing was reviewed by the persons developing this
child's IEP.

YES

NO

4.The following visual condition(s) was taken into account and discussed in making the above decision:

YES

NO

Condition is degenerative and progressive loss is expected.

YES

NO

Condition is currently unpredictable in nature and will be reviewed if change in visual condition is noted.

YES

NO

Condition is temporary and expected to improve.

YES

NO

Condition is stable and will be monitored.

YES

NO

YES
YES
YES
YES
YES

NO
NO
NO
NO
NO

Annual goals provided

YES

NO

Short-term objectives provided

YES

NO

Date of initiation indicated

YES

NO

Frequency and duration of instructional sessions indicated

YES

NO

Level of competency to be achieved annually indicated

YES

NO

Objective determinants used to measure achievement provided

YES

NO

Documented visual acuity allowing the choice of larger type/regular type

YES

NO

Child is considered a pre-reader

YES

NO

Other

YES

NO

5.Indicate the appropriate instructional media

Standard English Braille
Large Print
Regular Print
Tape/auditory
Pre-reader
6.Complete if Braille reading and writing ARE appropriate at this time

7.Reasons Braille reading and writing ARE NOT appropriate this time

PR-07 IEP FORM REVISED BY ODE: .":