Monroe County Community School Corporation

Case Conference Summary/IEP/ITP

Date 3/3/08

Student Name Derek Black DOB 3/2/96 Sex Male Re-eval Date 3/3/11

Home School/Attending School Marlin Elementary / Marlin Elementary Grade 5.8 ID# 123456789

Student Resides with: Phone Caseworker/Agency Representative Phone

Robert and Betty Black Home 999 - 8899 Home

Parent/Guardian Name Name

254 Clarizz Blvd. Work 999 - 7788 Work

Street Address Street Address

Bloomington, IN 47401 Emergency 999 - 6677 Emergency

City/Zip City/Zip

Legal Guardian: ✔ Natural Parents

  Adoptive Parents  DFC
 Natural Mother  Adoptive Mother  Court
 Natural Father  Adoptive Father  Other __________________________________________

Purpose of Case Conference:


✔ Initial Conference  Annual Case Review  Transition
 Declassification/Reclassification  Causal Relationship  Move in
 IEP Review

Case Conference Committee Members (Indicate role)

Melissa Baker Sara Campbell Hazel Competent, M. Ed.

Chairperson Special Education Teacher

Derek Black Anne Smith

Student General Education Teacher

Robert Black Betty Black

Parent
Student Performance Derek Black

Evaluation procedures, assessments, records or reports utilized to help determine eligibility for special education services.

Cognitive:
On the WISC-III, Derek performed in the average range.

Impact on involvement in general education curriculum: None- Derek should be able to perform at regular grade level.

Achievement: Evaluation Data: Woodcock Johnson III, Test of Written Spelling-3, and TOWL

Reading: Strengths Decoding (word attack)

Weaknesses Comprehension, spelling, letter ID

Impact on involvement in general education curriculum: Failing in language arts; Derek needs specialized instruction in addition to general education.

Math: Strengths Calculation, applied problems

Weaknesses No apparent weaknesses at this time.

Impact on involvement in general education curriculum: No apparent impact.

Social Emotional: Strengths N/A

Weaknesses N/A

Impact on involvement in general education curriculum: N/A

Communication: Strengths N/A

Weaknesses N/A

Impact on involvement in general education curriculum: N/A

Adaptive Behavior: Strengths N/A

Weaknesses N/A

Impact on involvement in general education curriculum: N/A

Behavior: Strengths No physical violence/behavior, manages personal behavior according to parents.

Weaknesses Inattentive in class, difficulty staying engaged on task, unfocused

Impact on involvement in general education curriculum: Derek needs more academic and classroom structure that limits distraction in the general education classroom.

Other: Strengths N/A

Weaknesses N/A

Impact on involvement in general education curriculum: N/A

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401

(812)349-4756 or (812)349-4757 - FAX=(812)330-7811

Case Conference Summary Page 2

Derek Black

Student input (strengths, interests, concerns): Derek says he enjoys math, but does not like language arts or attending school. He also expressed frustration in being retained when he was in third

grade.

Parent input (strengths, interests, concerns): Parents are concerned that Derek is not focused and is hyperactive. They also worry that his academic difficulties will increase if he receives no help. His

mother says he is "pretty good" about managing his personal care.

The following health data was discussed

 no known problems  frequent absences/tardies: days present _____ days absent _____
 on medication (specify)  physical concern (specify)

 seizure activity  wears glasses/contacts/hearing aid/prosthesis (circle)

 health plan 
✔ Past hearing difficulti
other ___________________

Special Factors

1. Does behavior impede student learning or the learning of others? Yes ✔ No If YES, team must develop and attach intervention plan
2. Does the student have limited English proficiency? Yes ✔ No If YES, team must consider language needs
3. Is the student blind or visually impaired? Yes ✔ No If YES, team must consider appropriate reading and writing media.
4. Is the student deaf or hard of hearing? Yes ✔ No If YES, team must consider communication needs.
5. Does the student require assistive technology devices or services? Yes ✔ No If YES, see accommodations and/or related services
6. Should the student be considered for an assistive technology evaluation? Yes ✔ No If YES, appropriate referral forms must be completed
7. “Other” Request assessment in hearing

Based on the case conference committee’s discussion of the data noted above:

✔
 The student is eligible for special education services as defined in Indiana Code

 The student is not eligible for special education services as defined in Indiana Code

___ Autism
___ Hearing Impairment
___ Orthopedic Impairment
Disability Category(ies)
1 = primary disability 2 = secondary disability
___ Communication Disorder ___ Dual Sensory Impairment ___ Developmentally Delayed ___ Emotional Handicap
1 Learning Disability
___ ___ Mild Mental Handicap ___ Moderate Mental Handicap ___ Severe Mental Handicap
___ Other Health Impairment ___ Traumatic Brain Injury ___ Visual Impairment

Does the student require an alternative curriculum? Yes ✔ No If YES, explain non-participation in general education curriculum

Can student participate in non-academic and extra curricular activities? ✔ Yes No If NO, explain

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401

(812)349-4756 or (812)349-4757 - FAX=(812)330-7811

Case Conference Summary Page 3

 Individualized Transition Plan

Name: Derek Black Social Security Number

School Anticipated final year of school

Initial
Plan Date Review Date Review Date Review Date Review Date Review Date

1. Projected Post-School Outcomes:

Post-Secondary Education

Vocational Training

Community Living

Continuing/Adult Ed.

Integrated/Supported Employment

Community Participation

2. Statement of student’s interests and preferences:

3. This student is working toward:  Credit - diploma  Non-credit - certificate of completion  GED

4. Ongoing Adult Services:  NO  YES - what information was given? Date given:

5. I have been informed that at the age of eighteen all rights accorded parents under special education legislation are transferred to the student and are concurrent with the parents’.
(Must be completed if student is 17 at the time of conference.)

Student Signature/Date Parent Signature/Date

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)349-7811

Transition Plan Page 1

Derek Black
6. Statement of Needed Transition Services: (A “ statement of needed transition services” describes services the student needs to gain the skills and connections necessary to
achieve his or her desired goals):

Transition Services Needed? IEP must contain goals/ Coordinated Sequential Set of Person Responsible/Agency
objectives related to all Activities/objectives Linkages
YES - See goal/objectives areas marked YES
NO - Explain
Instruction  YES

 NO

Related Services  YES

 NO

Community Experience  YES

 NO

Employment/Functional  YES
Vocational Evaluation
 NO

Daily Living  YES

 NO

Residential  YES

 NO

Other (eg: medical, financial)  YES

 NO

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)349-7811

Transition Plan Page 2

 Goals and Objectives

Student’s Name Derek Black Identified Need: Reading comprehension

Annual Goal Having been read a late 3rd grade level story, Derek will retell the story correctly, remembering 8 out of 10 key points (see the teacher's rubric) once a week for three consecutive wee

Measurable, Short-term Instructional Objectives Person(s) Responsible Procedures of Progress Comments

Including Objective Criteria to be reviewed annually (By Title) Evaluation
Having been read a late 3rd grade level story, Derek will retell the story Spec. ed. B
correctly, remembering 2 out of 10 key points (see teacher's rubric) once a
week for three consecutive weeks.
Having been read a late 3rd grade level story, Derek will retell the story Spec. ed. B
correctly, remembering 4 out of 10 key points (see teacher's rubric) once a
week for three consecutive weeks.
Having been read a late 3rd grade level story, Derek will retell the story Spec. ed. B
correctly, remembering 6 out of 10 key points (see teacher's rubric) once a
week for three consecutive weeks.

Person(s) Responsible Procedures for Evaluation Progress

General Education Teacher Gen. Ed A. Observation i. Objective Met

Special Education Teacher Spec. Ed. B. Written/Oral Response ii. Progress made, but objective not yet met

Parent Parent C. Performance iii. Little or no progress

Occupational Therapist OT D. Criterion Referenced Test iv. Met, but not maintained

Physical Therapist PT E. Student Self Assessment v. Other (specify)

Speech/Language Pathologist SLP F. Other (specify):

Hearing Impairment Specialist HI

Vision Impairment Specialist VI

 Progress will be reported on the goals form  Other (Specify)


✔ Progress toward annual goals will be provided at time of report cards; or
 Other (Specify)

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)330-7811
IEP Page 1
 Goals and Objectives

Student’s Name Derek Black Identified Need: Reading fluency

Annual Goal Given a random reading passage of 200 words at the late 3rd grade level, Derek will correctly read 80% of the words once a week for three consecutive weeks.

Measurable, Short-term Instructional Objectives Person(s) Responsible Procedures of Progress Comments

Including Objective Criteria to be reviewed annually (By Title) Evaluation
Given a random reading passage of 50 words at the late 3rd grade level, Spec. ed. B
Derek will correctly read 80% of the words once a week for three
consecutive weeks.
Given a random reading passage of 100 words at the late 3rd grade level, Spec. ed. B
Derek will correctly read 80% of the words once a week for three
consecutive weeks.
Given a random reading passage of 150 words at the late 3rd grade level, Spec. ed. B
Derek will correctly read 80% of the words once a week for three
consecutive weeks.

Person(s) Responsible Procedures for Evaluation Progress

General Education Teacher Gen. Ed A. Observation i. Objective Met

Special Education Teacher Spec. Ed. B. Written/Oral Response ii. Progress made, but objective not yet met

Parent Parent C. Performance iii. Little or no progress

Occupational Therapist OT D. Criterion Referenced Test iv. Met, but not maintained

Physical Therapist PT E. Student Self Assessment v. Other (specify)

Speech/Language Pathologist SLP F. Other (specify):

Hearing Impairment Specialist HI

Vision Impairment Specialist VI

 Progress will be reported on the goals form  Other (Specify)


✔ Progress toward annual goals will be provided at time of report cards; or
 Other (Specify)

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)330-7811
IEP Page 1
 Goals and Objectives

Student’s Name Derek Black Identified Need: Spelling

Annual Goal Given a selection of 20 words from a pool of 100 words at the late 3rd grade level, Derek will correctly spell 80% of the words on three consecutive weekly spelling tests.

Measurable, Short-term Instructional Objectives Person(s) Responsible Procedures of Progress Comments

Including Objective Criteria to be reviewed annually (By Title) Evaluation
Given a selection of 5 words from a pool of 100 words at the late 3rd grade Spec. ed. B
level, Derek will correctly spell 80% of the words on three consecutive
weekly spelling tests.
Given a selection of 10 words from a pool of 100 words at the late 3rd grade Spec. ed. B
level, Derek will correctly spell 80% of the words on three consecutive
weekly spelling tests.
Given a selection of 15 words from a pool of 100 words at the late 3rd Spec. ed. B
grade level, Derek will correctly spell 80% of the words on three
consecutive weekly spelling tests.

Person(s) Responsible Procedures for Evaluation Progress

General Education Teacher Gen. Ed A. Observation i. Objective Met

Special Education Teacher Spec. Ed. B. Written/Oral Response ii. Progress made, but objective not yet met

Parent Parent C. Performance iii. Little or no progress

Occupational Therapist OT D. Criterion Referenced Test iv. Met, but not maintained

Physical Therapist PT E. Student Self Assessment v. Other (specify)

Speech/Language Pathologist SLP F. Other (specify):

Hearing Impairment Specialist HI

Vision Impairment Specialist VI

 Progress will be reported on the goals form  Other (Specify)


✔ Progress toward annual goals will be provided at time of report cards; or
 Other (Specify)

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)330-7811
IEP Page 1
 Goals and Objectives

Student’s Name Derek Black Identified Need:

Annual Goal

Measurable, Short-term Instructional Objectives Person(s) Responsible Procedures of Progress Comments

Including Objective Criteria to be reviewed annually (By Title) Evaluation

Person(s) Responsible Procedures for Evaluation Progress

General Education Teacher Gen. Ed A. Observation i. Objective Met

Special Education Teacher Spec. Ed. B. Written/Oral Response ii. Progress made, but objective not yet met

Parent Parent C. Performance iii. Little or no progress

Occupational Therapist OT D. Criterion Referenced Test iv. Met, but not maintained

Physical Therapist PT E. Student Self Assessment v. Other (specify)

Speech/Language Pathologist SLP F. Other (specify):

Hearing Impairment Specialist HI

Vision Impairment Specialist VI

 Progress will be reported on the goals form  Other (Specify)

 Progress toward annual goals will be provided at time of report cards; or
 Other (Specify)

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)330-7811
IEP Page 1
 Goals and Objectives

Student’s Name Derek Black Identified Need:

Annual Goal

Measurable, Short-term Instructional Objectives Person(s) Responsible Procedures of Progress Comments

Including Objective Criteria to be reviewed annually (By Title) Evaluation

Person(s) Responsible Procedures for Evaluation Progress

General Education Teacher Gen. Ed A. Observation i. Objective Met

Special Education Teacher Spec. Ed. B. Written/Oral Response ii. Progress made, but objective not yet met

Parent Parent C. Performance iii. Little or no progress

Occupational Therapist OT D. Criterion Referenced Test iv. Met, but not maintained

Physical Therapist PT E. Student Self Assessment v. Other (specify)

Speech/Language Pathologist SLP F. Other (specify):

Hearing Impairment Specialist HI

Vision Impairment Specialist VI

 Progress will be reported on the goals form  Other (Specify)

 Progress toward annual goals will be provided at time of report cards; or
 Other (Specify)

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)330-7811
IEP Page 1
 Goals and Objectives

Student’s Name Derek Black Identified Need:

Annual Goal

Measurable, Short-term Instructional Objectives Person(s) Responsible Procedures of Progress Comments

Including Objective Criteria to be reviewed annually (By Title) Evaluation

Person(s) Responsible Procedures for Evaluation Progress

General Education Teacher Gen. Ed A. Observation i. Objective Met

Special Education Teacher Spec. Ed. B. Written/Oral Response ii. Progress made, but objective not yet met

Parent Parent C. Performance iii. Little or no progress

Occupational Therapist OT D. Criterion Referenced Test iv. Met, but not maintained

Physical Therapist PT E. Student Self Assessment v. Other (specify)

Speech/Language Pathologist SLP F. Other (specify):

Hearing Impairment Specialist HI

Vision Impairment Specialist VI

 Progress will be reported on the goals form  Other (Specify)

 Progress toward annual goals will be provided at time of report cards; or
 Other (Specify)

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)330-7811
IEP Page 1
 Goals and Objectives

Student’s Name Derek Black Identified Need:

Annual Goal

Measurable, Short-term Instructional Objectives Person(s) Responsible Procedures of Progress Comments

Including Objective Criteria to be reviewed annually (By Title) Evaluation

Person(s) Responsible Procedures for Evaluation Progress

General Education Teacher Gen. Ed A. Observation i. Objective Met

Special Education Teacher Spec. Ed. B. Written/Oral Response ii. Progress made, but objective not yet met

Parent Parent C. Performance iii. Little or no progress

Occupational Therapist OT D. Criterion Referenced Test iv. Met, but not maintained

Physical Therapist PT E. Student Self Assessment v. Other (specify)

Speech/Language Pathologist SLP F. Other (specify):

Hearing Impairment Specialist HI

Vision Impairment Specialist VI

 Progress will be reported on the goals form  Other (Specify)

 Progress toward annual goals will be provided at time of report cards; or
 Other (Specify)

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)330-7811
IEP Page 1
 Derek Black

Special Education Services/Least Restrictive Environment Any potentially harmful effects of the recommendations must be considered.

Services considered and rejected (indicate reasons)

Full-time and part-time special education placement were considered, but the committee found full-time placement too restrictive.

Services recommended (indicate reasons; location, frequency and length)

Committee recommends part-time services in a resource setting for five days a week, one hour each day.

Related Services (Note intensity, frequency and location of services)

_____Occupational therapy for a minimum of _____ minutes each  week  month

_____ direct, integrated in classroom & community
_____consultation _____ other (specify)________________

_____Physical therapy for a minimum of _____ minutes each  week  month

_____ direct, integrated in classroom & community
_____consultation _____ other (specify)________________

Social Worker Transportation: Attach Transportation Form.

Other

Supplementary aids and services/and/or other factors relevant to proposed services:

N/A

3/10/08 3/10/09
Date for Initiation of Services (on or about): , ending date (on or about) following regular school calendar.

Teacher of Record: Sara Campbell

Other Teachers of Record for Secondary Disabilities None

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)330-7811
Case Conference Summary Page 4
Derek Black
2008-2009
Recommended Participation in Statewide or District standardized testing for the _______________ school year.

Indiana MCCSC
This student is not in a standardized testing mandated grade level.
This student will fully participate in the standardized testing program without accommodations.
This student will not participate in the standardized testing program (Specify reasons below).
✔ ✔ This student will fully participate in the standardized testing program with accommodations (Specify below).
This student will participate in the standardized testing program for diagnostic purposes.
This student will be subject to remediation.
This student will be subject to retesting.
This student will need the following testing accommodations (Specify):
Additional time on all standardized tests; all areas by reading will be read orally to student.

This student’s essential skills will be tested using an alternate assessment (Specify, including why the statewide or district assessment is not appropriate and
how the student will be assessed):

Is extended school year recommended? YES ✔ NO

If yes, committee must document the degree of regression; amount of time for recoupment; and the extraordinary, irretrievable educational, emotional or vocational reversals.

If yes, describe the nature of the interventions, include interventions parents can provide to meet student’s needs.

Name(s) of person(s) who will submit a written opinion.

NA

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)330-7811
Case Conference Summary 5
Student Name: Derek Black

School: Marlin Elementary

Parent Permission for Special Education Services

You have the right to request a case conference and/or revoke your written permission for services at any time. If you are prepared to decide at this time, please sign on one of
the lines below.

I/we agree with the services recommended and give permission for the plan to be implemented:

Parent Signature Date Student Signature (If 18) Date

I/we do not agree with the services recommended.

Parent Signature Date Student Signature (If 18) Date

Parental Rights have been explained and provided:

Parent Initials

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)330-7811
Case Conference Summary 6
 Modifications/Accommodations/Supports to Meet Educational Needs
Derek Black
Pacing Assignments Social Interaction Supports
✔ Allow more time ✔ Give directions in small, distinct Peer/cross age tutoring
Vary activity often steps (written/picture/verbal) Structure activities to create opportunities
Allow breaks Use written backup for oral directions of social interaction
Avoid timed/pressure situations Read or tape record directions to Focus on social process rather than
Other: student activity/end product
Adjust difficulty level Partial participation
Environment Shorten assignment/fewer items on Cooperative learning groups
✔ Preferential seating page Other:
Planned seating: Bus Classroom Reduce paper and pencil tasks
Lunchroom Auditorium ✔ Give extra cues or prompts Motivation and Reinforcement
Alter physical room arrangement Allow student to record/type or Verbal
Define areas concretely dictate assignment Non-verbal
✔ Reduce/minimize distractions: Avoid penalizing for spelling errors/ ✔ Positive reinforcement
✔ Visual Auditory sloppy papers/penmanship Concrete reinforcement
Spatial Movement Student should use cursive/printing Planned motivating sequences of activities
Provide opportunity for separate seating Other: Reinforce initiation
Teach positive rules for use of space ✔ Offer choices
Other: Self Management/Follow Through Use strengths/interests often
Visual daily schedule Reinforce approximation
Presentation of Subject Matter Calendars Response cost
Teach to student’s learning style ✔ Daily/Weekly assignment sheets Other:
Visual Auditory Model Check often for understanding/review
Tactile Multi Experiential Learning Request parent reinforcement
Review prior to presenting new materials ✔ Have student repeat directions
Individual/small group instruction Encourage use of notebook with
Utilize alternate specialized curriculum dividers, or file folders, for organization
Tape lectures/discussions for replay Use student sheets to organize
Utilize manipulatives material
Emphasize critical information Design/write/use long term
Pre-teach vocabulary assignment timelines
Make/use vocabulary files Plan for generalization
Oral reading on voluntary basis only Develop organized routine
✔ Provide study guides/outlines Schedule regular communication/
Encourage feedback from student to check for learning reports between home and school
Other: Other:

Materials Student Assessment

Arrangement of material on page Oral/taped responses Short answer
Taped tests and/or other class materials Taped responses Multiple choice
Highlighted tests/study guides ✔ Read test to student Modify time frame
Notetaking assistance: carbonless or xerox copy of notes of Shorten length ✔ Extend time frame
regular students, copy of notes from board provided Consider individual progress over time
Large print/graph paper/lined paper Consider effort
Special Equipment: Alternative assessment
Word processor Calculator Test administered by:
Computer Math facts sheet Other:

Monroe County Community School Corporation - 315 North Drive - Bloomington, IN 47401
(812)349-4756 or (812)349-4757 -- FAX (812)330-7811
Case Conference Summary 7