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MANATEE COUNTY SCHOOLS

EdVantage

NOTICE OF CONFERENCE
IEP/TIEP

PST/CST

ESOL

D504

Name:
Student Number:
DOB:
Age:
Address:
Phone:
Dear Parent/Legal Guardian:
Parent Conference
Developing, amending, or updating your child's IEP
Q Reviewing the results of your child's evaluation/reevaluation
Discussing the possible discontinuation of one or more ESE programs or dismissal from all ESE programs
Identify Transitional Service needs of the student (14 and15)
Consideration of Post Secondary Goals and Transition Services (16 and older)

Date:_

O t h e r (Specify):
The meeting is scheduled on

at
Date

the meeting will be held at


Time

Location

The following participants have been invited to attend unless non-attendance (NA) and/or excusal (E) is requested:
NA E Position

NA E Position

Parent/Legal Guardian
Student -

Invited

Excused

Principal/Designee (LEA)
Interpreter of Instructional Implications of Evaluations

Teacher
ESE
n Regular Education Teacher

Parent Response to Request for Non-Attendance/Excusal:

n
n
.n
.n
n
.n
n

The school district requests that the IEP team member(s) indicated above with "no need for participation" (NA) and/or with "request
excusal" (E) need not participate in this meeting because:
their area of the curriculum or related services is not being modified or discussed
and/or
t h e school district is requesting they be excused from the meeting and their written input provided prior to the meeting.D
Please check and sign:

I am in agreement with the school district with this/these IEP team member(s) not attending the meeting.

If there is an exception to your agreement, please indicate participants (by title) who should be required to attend:
Parent Signature

LEA Signature

Parent Response to Notice of Meeting:


I will attend on the above date and time.
You may invite other persons who have knowledge or special expertise about your child.
I plan to bring
Name
Role
I need a sign language interpreter
I need an interpreter of my native language of:

I wish to attend but on another date or time

I am unable to attend, but do give my permission for the meeting to proceed without me. (Please return Parent Planning Notes)

Comments:
Parent Signature

Date

As a parent(s)/Guardian(s) of a child with disability, you have certain protections under the Procedural Safeguards of the Individuals with Disabilities Education Act. A copy of
the Procedural Safeguards will be mailed with the annual IEP meeting notice, otherwise Procedural Safeguards will be provided at the meeting. You may also view and/or
download the entire document from the Manatee County Schools website at http://www.schools.manatee.k12.fl.us/3130ESE1/exceptional_student_education or from the
Florida Department of Education website at www.fldoe.org/ese/pdf/procedural.odf. Further explanation of rights and copies may be obtained from the ESE Department 7 5 1 6550 or contact
at
Name

Record of Attempts:

MCSD ESE Form 9/09


MIS 41-00403

Position

1.
2.
3.
4.

Date:
Date:
Date:
Date

Page 1 of 2

Phone #

Tvoe:
Tvpe:
Tvoe:
Tvoe:

Result:
Result:
Result:
Result:

Notice of Conference
Distribution ( ) Student File ( ) Parent /Legal Guardi;in/Surrogate

Meeting Date

M a n a t e e County Schools

EdVantage

REPORT O F C O N F E R E N C E
IEP/TIEP

Revision

Reevaluation

Student:
Date of Birth:
| Aqe'
Case Status/Reason For Conference:

1 Grade:Pre-K

DPS/RTI

HCST

DESOL

D504

Student Number:
School:

QOther
1 Date:
"

Decision/Recommendations:

Person(s) Responsible for Implementation of Decision/Recommendations:

MCSD ESE Form

Report of C o n f e r e n c e

Date of M e e t i n g .

Revision Date.

Grade:_
School:

M A N A T E E C O U N T Y SCHOOLS
R E V I E W O F E L I G I B 1 L T Y AND C O N S E N T F O R P L A C E M E N T

Student:
Grade:
Parent/Legal Guardian:
Address:
" ~

Race:

Student U:
Sex:F

Date of Birth:
Language:
(Home)

Phone:

Date:
(Cell)

COMMITTEE MEMBERS

Principal/Designee:
ESE Administrator/Designee:
ESE Teacher:
Parent:
Other:

Guidance Counselor:
Evaluation Specialist:
Regular Education Teacher:
Speech/Language Pathologist:
Other:

ELIGIBILITY RECOMMENDATIONS
The Child Study Team/IEP committee, which reviewed educational information about this student met on

to consider

MOST R E C E N T EVALUATIONS:
Name

Description

Date

Please Check Eligibility Recommendations:


n
Meets initial eligibility criteria for
IEP will be developed:
I I at this meeting
__] at a separate meeting within 30 calendar days of eligibility.
Does not meet initial eligibility criteria for an Exceptional Student Education program at this time, based Response to Intervention,
review o f evaluation data, and consideration o f need for specifically designed instruction and services.
Is already enrolled in
and meets/does not meet (circle one) current criteria for

Is recommended for discontinuation from


eligibility for

program(s) and continues


program(s).

I I Is an in-state/out-of-state (circle one) transfer student and meets eligibility criteria for permanent placement in
Is recommended for dismissal from Exceptional Student Education based on the IEP/EP team meeting, which reviewed reevaluation
data indicating the student will be successful in the general curriculum without ESE support.

Other factors relevant to this proposal may:


ELIGIBILITY REVIEW
(Eligibility is based on ESE Administrator/Designee review o f evaluation data and the staffing committee's recommendations)
I I Compliance Reviewed by ESE Administrator/Specialist
PLACEMENT RECEOMMENDATIONS
I f your child is eligible for ESE, the district proposes to place your child as indicated on the Individual Education Plan, in order to meet the
child's educational needs. A l l o f the following placement options were considered. Final recommendation is indicated by checks:

Regular Class (80-100%)


Other placements did not:
I I Provide least restrictive environment

Resource Room (40-79%)


[J
Provide the appropriate program

Separate Class (39% or less)


I I Other (specify)
I I Special day School
I I Individual instruction in a home or hospital
__] Other (specify)
PARENT CONSENT FOR INITIAL
PLACEMENT
Consent for placement is required for the first time the student is placed in an ESE program. 1 understand that Parent/Guardian consent is
required only before initial placement. We the undersigned parent(s)/guardian(s) of above named student:
1) __] agree to his/her placement; 2) f__ Do not agree to his/her placement in the Exceptional Student Education Program.
Parent/Guardian Signature
Date
As parent(s)/guardian(s), you have certain protections under the attached Procedural Safeguards of the Individuals with Disabilities
Education Act. Further explanation of rights and copies may be obtained from the ESE Department 751-6550.

MCSD ESE Form

Review o f Eligibility and Consent for Placement

Plan Date

Revision Date

MANATEE COUNTY SCHOOLS

EdV^Ultage
f>>fi>ie iJui ^lulrnii;,- [ tarn. Di/an j * J .tihirir.

Student:
PARENT PLANNING NOTES FOR THE IEP/TIEP
Your participation in the development of the IEP/TIEP is very important for your child and your child's teachers. Please respond to the
areas below related to your child's need for special education services. Please return these notes to your child's teacher prior to the
IEP/TIEP meeting if possible, or bring them with you to the meeting.
I. Describe your child's:

Strengths:

Learning needs:

Social relationships with adults and other children/students:

Ability to be independent at school and at home:

Communication skills:

II. List things that have helped your child be successful in learning (for example, repeating directions, providing extra time,
keeping you informed about academic and behavior progress, etc.):
III. If your child is 14 years old or older, describe your child's needs in the following areas:
Instruction/Training

Employment

Independent Living

Community Experiences

Information about your Procedural Safeguards and Parent Planning Notes are enclosed with your written meeting notice. A printed
copy of the full Procedural Safeguards document will be provided at your child's IEP meeting. You may also view and/or download
the entire document from the Manatee County Schools website at www.manateeschools.net,
http://www.schools.manatee.k12.fl.us/3130ESE1/exceptional_student_education or from the Florida Department of Education website
at www.fldoe.org/ese/pdf/procedural.pdf. If you would like additional information about your procedural safeguards contact one of the
school/district contacts listed above.
Parents of eligible students (Note: only students with disabilities) may choose to request a McKay Scholarship to (1) keep their child in
the same school; (2) enroll their child in another public school within the same district; (3) enroll their child in another public school in an
adjacent district; (4) enroll their child in a participating private school and receive a scholarship. Information is available on the
Department of Education's website at www.floridaschoolchoice.org or telephone the hotline at 1-800-447-1636.

MCSD ESE Form 9/09


MIS 41-00403

Page 2 of 2

Notice of Conference
Distribution ( ) Student File ( ) Parent /Legal Guardian/Surrogate

Meeting Date

Current Grade
OR
Anticipated G r a d e _
For School Year
School A t t e n d i n g

M A N A T E E C O U N T Y SCHOOLS
EXCEPTIONAL STUDENT EDUCATION
INDIVIDUAL EDUCATIONAL PLAN
I E P Plan Date:

Student Name:

Student #:

Address:

T h r e e - y e a r Reevaluation T r a n s i t i o n IEP
Initial Placement Date:
3-Yr. Reevaluation Date:

Date o f B i r t h :
Phone:

EXCEPTIONALITIES:

DESIRED SCHOOL OR POST-SCHOOL OUTCOME:


GRADUATION RECOMMENDATIONS:
Diploma Type: QStandard fJSpecial Option 1 __Special Option 2
C O U R S E O F S T U D Y (For students 14 years and older also consider: programs and courses of study, extra curricular activities, postsecondary
education, continuing and adult education, vocational training, employment, adult services, and community living.)

Self-Determination (For a student whose IEP is developed or revised by age 16, specify how the student will be instructed and/or provided
information in self determination to assist the student to be able to actively and effectively participate in the IEP meetings and self advocate, i f
appropriate.)

I N S T R U C T I O N A L S T R U C T U R E : Place a check in those domains in which the student demonstrates a need and the IEP team will develop
present level of performance statements, measurable annual goals, and short term objectives or benchmarks (See attached IEP Goal Pages).
D O M A I N S : __Curriculum and Learning QSocial/Emotional [""[independent Functioning I iHealth Care I [Communication __Transition
G E N E R A L F A C T O R S : (Briefly describe each of the following general factors)
Strengths of the student:
Results of the initial or most recent evaluation:

Parent's concern for enhancing their child's education:


Results of the student's performance on any general, state, or district wide assessment: Year:
Reading: SSS (
) Level(
) Math: SSS (
) Level (
) Writing: (
Other:

IEP SPECIAL CONSIDERATIONS:


A. Is the student Blind or Visually Impaired? f l N o
__Yes - Team must address the need for Braille/Braille instruction based on the student's current and future reading and writing skills
and needs to be included in the development of the IEP.
__Yes - Team does not need to address the need for Braille/Braille instruction based on the student's current and future reading and writing skills
and needs.
B. Is the student Deaf or Hearing Impaired? __ No
__Yes - Team must address the student's language and communication needs, opportunities for direct communication with peers and
professionals in the student's language and communication mode, academic level, and full range of needs including opportunities for
direct instruction in the child's language and communication mode in the development of the IEP.
C. Does the student exhibit behaviors that impede his/her learning or that of others?
I~~) No CJYes - Team must develop strategies including positive behavior interventions and supports in the IEP.
D. Does the student have limited English proficiency?
I I No __Yes - Team must address the language needs of the student in the development of the IEP.
E. Does the student have Communication Needs?
I I No __|Yes - Team must address the communication needs of the student in the development of the IEP.
F. Does the student require Assistive Technology Devices and Services?
I I No I I Yes - Team must address the student's assistive technology needs in the development of the IEP.
E X T E N D E D S C H O O L Y E A R : Answer E A C H question below. Ask whether student needs ESY based on one or more of the seven criteria.
(Checking "yes" for any one question below indicates a need for ESY.
__Yes __No Regression/Recoupment
__ Yes [_No Degree of Progress
__Yes __No Interfering Behaviors
__Yes __No Nature/Severity of Disability
__Yes I iNo Special Circumstances
__Yes I |No Emerging Skills Breakthrough
L~_ Yes __No Critical Point of Instruction [_Yes __No Other (explain)
Student __is __is not recommended for ESY services. (If yes, complete E S Y Addendum.)
T Y P E O F P H Y S I C A L E D U C A T I O N : Student to Receive: fjRegular __Adapted f j N / A (Pre-K/Off Sites) __Medical Diagnosis
PERTINENT MEDICAL INFORMATION:
M C S D ESE F O R M 9/09

Individual Education Plan

MIS -41-00413

Distribution: ( )ESE File ( ) Parent/Legal Guardian/Surrogate

PAGE 1 o f 2

Plan Date

Revision Date

Manatee County Schools


EXCEPTIONAL STUDENT EDUCATION
INDIVIDUAL EDUCATIONAL PLAN
P R O G R A M A C C O M M O D A T I O N S / M O D I F I C A T I O N S AND D O C U M E N T A T I O N O F IEP R E C E I P T
Initiation Date:
Duration Date:
Frequency:
Location:
Note: The above initiation date, duration date, frequency and location apply to each accommodation/modification unless
otherwise specified below.
ENVIRONMENTAL ACCOMMODATIONS/MODIFICATIONS

Initiation Date

Duration Date

Frequency

Location

INSTRUCTIONAL ACCOMMODATIONS/MODIFICATIONS

Initiation Date

Duration Date

Frequency

Location

SOCIAL/EMOTIONAL B E H A V I O R A L ACCOMMODATIONS/
MODIFICATIONS

Initiation Date

Duration Date

Frequency

Location

COMMUNICATION

Initiation Date

Duration Date

Frequency

Location

INDEPENDENT FUNCTIONING

Initiation Date

Duration Date

Frequency

Location

EVALUATION

Initiation Date

Duration Date

Frequency

Location

IMPLEMENTATON
__Yes - The IEP is accessible to each of the student's teachers who are responsible for implementation.
__Yes - Each teacher/therapist/service provider of the student will be informed by the student's case manager of the specific responsibilities related
to implementing the IEP.

MCSD ESE Form

Accommodations/Modifications and Documentation of IEP Receipt

Plan Date

Revision Date

Manatee County Schools


E X C E P T I O N A L STUDENT EDUCATION
INDIVIDUAL EDUCATIONAL PLAN
P R E S E N T L E V E L S O F E D U C A T I O N A L AND F U N C T I O N A L P E R F O R M A N C E
(Describe the levels o f achievement and functioning for each domain)

Student Name:
Check Domain/
Transition Area:

Plan Date:
Domain:
C]A Curriculum & Learning
1 IB Social/Emotional
C. Independent Functioning
D . HealthCare
1 |E, Communication

Transition
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Activity Area:
No
I . Instruction (Academic)
No
2. Community Experience
No
3. Employment
No
4. Post School - Adult Living
5. Daily Living Skills
No
6. Functional/Vocational Evaluation
No
No
7. Related Services

Present Level of Educational Performance


Specify the domain. Identify the sources of information about the student; the student's strength's how the student's disability affects involvement
and progress in the general curriculum or for prekindergarten children with disabilities' how the disability affects the child's participation in
appropriate activities' and the priority educational needs that result from the disability.
Based on: (Recent assessments, student records, staff & student input

Effects of Disability

Priority Needs/Remediation Statement

For each domain, describe what unique educational needs, difficulties or challenges the student has accessing the general education
curriculum.:

For each domain, describe the impact of those needs, difficulties or challenges on the student's participation in the general curriculum as a
result of the disability:

For each domain/transition area, describe what the student is able to do:

M C S D ESE Form

Present Levels o f Educational and Functional Performance

Plan Date

Revision Date

Manatee County Schools

SIGNATURE PAGE

Student:
Date o f Birth:

Student Number:
Age:

Grade:

Date:

School:

P A R T I C I P A N T S I G N A T U R E S (Signature indicates participation; include title where appropriate).


Parent/Guardian:

Parent/Guardian:

Parent/Guardian: Please read the attached "Parent Rights - Procedural Safeguards for Exceptional
Students." Parents o f a child with a disability have protection under the procedural safeguards. For
assistance and further understanding o f your rights, please call the Exceptional Student Education
Department 751-6550.
Procedural Safeguards (check all that apply): __ Received __ Reviewed __Waived I iMailed
Student:

Principal/Designee:

L E A Representative:

Counselor:

Psychologist:

Speech/Language Therapist:

ESE Teacher:

Evaluator:

Classroom Teacher:

Nurse:

Occupational Therapist:

Agency Representative:

Physical Therapist:

Other:

Vision Therapist:

Other:

Social Worker:

Other:

Please Check the following have been reviewed and received: __ Medicaid _ J McKay Letter

M C S D ESE Form

Signature Page

Plan Date:

Revision Date:

Manatee County Schools


EXCEPTIONAL STUDENT EDUCATION
INDIVIDUAL EDUCATIONAL PLAN
M E A S U R A B L E A N N U A L G O A L S AND S H O R T T E R M I N S T R U C T I O N A L O B J E C T I V E S
(Additional pages as needed)

Student Name:

Plan Date:

Annual goals and short-term objectives must relate to meeting the student's needs resulting from the student's disability in ways that enable the
student to be involved in and progress in the general curriculum; and to meeting each of the student's other educational needs resulting from the
student's disability.
R E P O R T T O P A R E N T O N P R O G R E S S O F A N N U A L G O A L S : The IEP Committee has determined that the parent will be informed of the
student's progress toward meeting annual goals through the following methods: (Check all that apply)
__Annual Goal Progress Report __Report Card __Interim IEP Review [_Parent Conference [_Other (Specify):
Progress in regular education courses, as appropriate, is reported on the student's report card.
Domain:

C u r r i c u l u m and L e a r n i n g

Social/Emotional

independent Functioning

Health C a r e C J C o m m u n i c a t i o n

Transition: i n s t r u c t i o n C o m m u n i t y E m p l o y m e n t P o s t School -Adult L i v i n g D a i l y L i v i n g F u n c t i o n a l / V o c a t i o n a l E v a l R e l a t e d Services

Goal: (MAGs must include behavior, conditions, and criterion)

P e r s o n ( s ) R e s p o n s i b l e for G o a l :

Objectrve/Benchmark:
1.

2.

5.
Domain:

C u r r i c u l u m and L e a r n i n g S o c i a l / E m o t i o n a l i n d e p e n d e n t Functioning H e a l t h C a r e C o m m u n i c a t i o n

Transition: i n s t r u c t i o n C o m m u n i t y E m p l o y m e n t P o s t School -Adult L i v i n g D a i l y L i v i n g F u n c t i o n a U V o c a t i o n a l E v a l R e l a t e d Services


Goal:

(MAGs must include behavior, conditions, and criterion)

P e r s o n ( s ) R e s p o n s i b l e for G o a l :

Objective/Benchmark:
1.

2.

3.

Domain: C u r r i c u l u m and L e a r n i n g S o c i a l / E m o t i o n a l i n d e p e n d e n t Functioning H e a l t h C a r e C o m m u n i c a t i o n


Transition: i n s t r u c t i o n C o m m u n i t y E m p l o y m e n t P o s t School -Adult L i v i n g D a i l y L i v i n g F u n c t i o n a l A ' o c a t i o n a l E v a l R e l a t e d Services
Goal:

(MAGs must include behavior, conditions, and criterion)

P e r s o n ( s ) R e s p o n s i b l e for G o a l :

Objective/Benchmark:
1.

2.

3.

MSCD ESE Form

Measurable Annual Goals and Short Term Instructional Objectives

Plan Date

Revision Date

Manatee County Schools


E X C E P T I O N A L STUDENT EDUCATION
M E A S U R A B L E POST-SECONDARY IEP/TIEP GOALS

Student Name:

Student #

Method for Obtaining Student's Needs, Preferences, and Interests:


Student input obtained from:

Birth Date:

Age:_

Other:
Other

Parent input obtained from:


Agency input obtained from:

Other

Students ages 16 and older require measurable post-secondary goals based on transition assessments. Annual goals, or short term objectives or
benchmarks must also be developed to reasonably enable the student to meet the measurable post-secondary goals.
Post-Secondary Education/Training goal & Employment goal (goals can be written individually or combined into one goal)

A) Measurable Annual Goal for Education/ Training:

Position Responsible:

Or Short Term Objectives OR Benchmarks

B) Measurable Annual Goal for Employment:

Position Responsible:

Or Short Term Objectives OR Benchmarks

Post Secondary Independent living goal (When appropriate) (Can be written individually or combined with above Post Secondary goals)

C) Measurable Annual Goal for Independent Living:

Position Responsible:_

Or Short Term Objectives OR Benchmarks

The Post Secondary Goals above arc based on the following age appropriate transition assessment (s):
Student is a client of
IEP team recommends a referral to the following agencies: I f so, Consent for Mutual Exchange of Information must be obtained each time invited
1 1 No Referral is being recommended at this time
1" 1 Division of Vocational Rehabilitation
| | Division of Blind Services
1 I Community College/Slate College, specify:
l~l Technical Institute, specify:
1 1 Division of Hearing Impaired
Other
1 1 Agency for Persons with Disabilities
Responsibilities and / or linkages for Transition Services: A person's signature below indicates willingness to provide for the support, services, or
skills that relate to this transition plan.
Agency Represented

Responsibilities

Signature of Agency Representative

Other:

Responsibilities

Signature

If a participating agency responsible for transition services fails to provide the services stated above, then the IEP Team shall reconvene to discuss
alternative strategies.
M S C D ESE Form

Measurable Post-Secondary Goals

Plan Date

Revision Date:

Manatee County Schools


Exceptional Student Education
Informed Notice of Change of Placement and / or
Free Appropriate Public Education ( F A P E )
Student Name:

Date:

Dear:
(Name of Parent / Adult Student)
Your child's individual education plan (IEP) or program was revised to include a change in
placement or FAPE, and a copy of the IEP, with procedural safeguards is provided. Under federal
and state requirements, you must be informed of the following information.
Action proposed or refused:

Why the action is proposed or refused:

Options considered and reason why certain options were rejected:

Evaluation procedures, tests, records, or reports used as a basis for the proposal or refusal
included:

Other factors relevant to the proposal or refusal included:

As parent(s) / guardian(s) of a child with a disability, you have certain protections under the
attached Procedural Safeguards of the Individuals with Disabilities Education Act. For a gifted
student, you have protections under the Procedural Safeguards under Rule 6A-6.03313, FAC.
Further explanation of rights and copies may be obtained from the ESE Department (751-6550)
or :
at

Name

Position

MCSD ESE Form Informed Notice of Change of Placement/FAPE Form Plan Date

Phone Number & Extension


Revision Date

MANATEE COUNTY SCHOOLS


E X C E P T I O N A L STUDENT EDUCATION
I N F O R M E D N O T I C E O F C H A N G E IN P L A C E M E N T F O R STUDENTS W I T H
DISABILITIES GRADUATING WITH A REGULAR DIPLOMA
Name o f Student:

Date:

Dear:
The federal regulations for the Individuals with Disabilities Education Act ( I D E A ) at CFR
8.3000.122(a)(3)(iii) state that, "Graduation from high schools with a regular diploma constitutes a change
o f placement requiring written prior notices in accordance with 8.300.503*.
has met the requirements o f the regular diploma and is
expected to graduate on

. The School District o f Manatee County proposes that

exceptional student services provided by the district will be terminated upon graduation with a regular
diploma. This proposal is based on a review that determined the criteria for a regular diploma as specified
in the district's Pupil Progression Plan which includes: required high school credits, grade point average
and passing the Florida Comprehensive Assessment Test (FCAT) has been met.
The option to provide a free appropriate public education (FAPE) was considered, however, this option was
rejected because the student has met all requirements for graduation with a regular high school diploma.
Other factors relevant to this proposal: _ ] N o n e OR _ _ Specify any

You have specific rights concerning this decision in the attachment, "Procedural safeguards". Should you
want additional information or to view the full document, please contact the ESE Department (751-6550)
or:
at
Name & Position

Phone Number & Extension

You may also view and / or download the entire document from the Manatee County Schools website at
http://www.schools.manatee.k 12.fl.us/3130ESE1 /exceptional student education or from the Florida
Department o f Education website at www.fldoe.org/ese/pdf/procedural.pdf.
Sincerely,

Name & Title

[^Attachment Procedural Safeguards __|In Conference __US Mail on


Distribution: __ESE Folder

MCSD ESE Form

__Parent / Legal Guardian / Student

Notice of Change in Placement Regular Diploma Plan Date

[_Principal

Revision Date