section o, part 6: student plans -...

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Section O, part 6: Student Plans

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Introduction to Student Plans MFNERC special education specialists have been given access to the program CLEVR. This is a cloud-‐hosted software application that allows cross collaboration between educators in the school. MFNERC special education team (SET) strongly recommends that schools consider using this program when developing their IEPs.

There are many different student plans available to schools and resource teachers. A small sample selection of these student plan templates are displayed on the following pages. The immediate first two templates are the ones selected by MFNERC’s special education specialists as the most efficient yet brief student plan format which resource teachers will find appropriate for student program planning needs.

Please remember to insert the school’s letterhead on the top of the template forms.

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Individualized Education Plan I To Be Implemented for School Year: __________________

I. Identifying Information Student Full Name: Student Resource Profile ID:

Name of Parent(s)/Guardian(s):

Date of Birth: Present Grade: School: First Nation:

Home Telephone: Other Phone Number: cell work (circle) Emergency Contact: Telephone:

Other Plan? YES NO (circle) Specify:

Date of IEP Written: Date of IEP Revision:

Agency Involvement? YES NO (circle)

If yes, Name of Agency: __________________________ Phone Number: Worker Name: __________________________________ Phone Number: Legal status:

Program (please check): Adapted □ Modified □ Individualized □ Accommodated □

II. IEP Involvement IEP Participants’ Names Position/Title Telephone

Signatures: Principal: Date:

Case Manager: Date:

Having read and participated in this Individualized Education Plan, I agree to the Special Education Program and Goals. Parent/Guardian Signature: _______________________________________________ Date: ____________________

III. Background Information

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School History (overview of pertinent information from cum file, attendance)

Prior Resource Involvement (summary of services)

Date original referral was made (yyyy-‐mm-‐dd): ___________________

Relevant Medical/Diagnostic Information

Language(s) Spoken

Supports to Assist in Implementation of IEP

(1) Domain: __________________________

Domains may include communication, social, academic, motor, cognitive, self-‐management (self-‐help), community, vocational, recreation/leisure, etc.

Current Level of Performance:

Strengths:

Student-‐Specific Outcome(s): (Student) will (specifically what) (under what conditions) (by what measurable criteria) by (expected date).

Performance Objectives

Strategies Materials/ Resources

Roles/Responsibilities (Classroom, Resource,

Home)

Evaluation

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(2) Domain: __________________________



Strengths:





Home)

Evaluation

(3) Domain: __________________________



Strengths:

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Home)

Evaluation

IV. Review

The entire program will be reviewed three times during academic school year. IEP review dates will occur two weeks before regular school reporting times.

Review 1 Date (yyyy-‐mm-‐dd): ______________________



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Individualized Education Plan II To Be Implemented for the School Year: _______________

Student Information

Name: Date of Birth: Grade Placement:

Parent/Guardian: Teacher:

Last Academic Assessment Date: Date Plan was Constructed:

Domain: Academic


Strengths:

Area Student-‐Specific Outcomes

Strategies/Resources To Be Used

Roles & Responsibilities

Evaluation & Review

Title/Name Signature Date (yyyy-‐mm-‐dd)

Parent

Classroom Teacher

Resource Teacher

Principal

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Individual Academic Program Student: _____________________________________________________

Date of Birth: _____________ Date of Report: ______________

School: _______________________________________________________

Teacher: ______________________________________________________

Resource Teacher: ___________________________________________

Funding/Program: ____________________________________________

Medical Information: Pertinent -‐-‐ Yes ___________ No ___________

Vision: Normal _____________ Problem ______________

Hearing: Normal _____________ Problem ______________

Support Services Speech/Language _______ Psychological ________ Counselling __________ Other _________________________________

(see resource file for information)

Student Strength & Weaknesses (Include informal & formal information)

Strengths: __________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Weaknesses: ________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Program Information Academic: __________ Social-‐Emotional: _________

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Attendance: _________ Work/Study Habits: ________

Area: __________________

Beginning Date: ____________ Review Date: _________

Current Level of Performance: ___________________________________________________________________________

___________________________________________________________________________

Objective: _______________________________________________________________

___________________________________________________________________________

Criteria for Success: ____________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Materials/Strategies: __________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Review: ___________________________________________________________________

___________________________________________________________________________

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Special Education Plan Adaptations Name: ___________________________________ Date: _______________

Subject(s): ________________________________________________________________

Learning Tools & Technology Devices Manipulatives Dark line paper

Raised line paper Large print materials

Braille written materials Calculator

Spell checker Personal FM system

Computer assisted technology Classroom FM system

Learning Environment

Alternative program site Special study area/individual work area (e.g., resource room, study carrel)

Seating arrangement Short-‐term Intervention

Special lighting

Taking Near rather than far copying Verbal notes on tape

Photocopied notes Student note taker

Key words and phrases only Point form notes

Word processor for notes Teacher’s copy of notes provided

Mind Map

Organization

Monitoring of student agenda/teacher initials homework

Put homework in separate special organizational binder

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Colour coding of notebooks Clean desk on regular schedule

Organizational mentor Individual/personal schedule

Outline provided for all special projects Extra set of texts at home

Special homework assignment sheet/contract Regular home contact (e.g., home/school journal, voice mail)

Human Resource Assistance Peer tutor Peer helper

Noon hour or after-‐school tutor Mentor

Sign or oral interpreter Scribe

Reader

Teaching & Learning Strategies Mnemonics (memory prompts) Reduced reading level materials

Strategy card (step-‐by-‐step direction) Simplified directions

Emphasize visual presentations Provide tactile/kinesthetic activities

Monitor attention (signal systems) Adjusted expectations for length of assignments

Frequent activity breaks Written directions read to student

Taped texts

Division of long assignments into parts

Homework/Study Strategies Test outline and preview provided Mentor

In-‐school study program Reduced number of assigned questions

Extra time for project completion Alternate format to written assignment

Reader or tutor to review notes Study broken into several short slots

Prioritize homework assignments

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Testing/Evaluation Scribe for designated tests Quiet, individual or small group setting

Adjusted test format (multiple, choice, true/false, etc.) in lieu of essay Access to computer

Oral testing Practice test provided or example given on tests

Provincial assessment accommodations (see provincial guidelines) Blank visual organizer provided with test

Frequent short quizzes in lieu of exam Extra time (usually time and a half/double time)

Evaluation of daily work only Word choices provided for fill-‐in-‐the-‐blank questions

Open book Teacher selects key questions

Evaluation of special projects only Spelling not counted in daily work or test situations

Written directions read to student Portfolio

Comments:

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Individual Education Plan (IEP) I. Identifying Information Student Name:

Date of Birth:

Present Grade Placement:

Address:

Name of Parent(s) / Guardian(s):

Telephone – Home: Telephone – Work:

School:

First Nation:

Present Classroom Teacher:

Nominal Role#:

Date Plan was Constructed:

Plan to be Implemented for School Year:

II. Program Planning Team Name Position/Title *Signature Date

Parent(s)/Guardian(s)

Special Education Coordinator

Principal

Resource Teacher

Classroom Teacher

Speech/Language Pathologist

Medical

Counsellor

Other

*signature indicates you understand the IEP

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III. Background Information Overall Current Level of Performance

Strengths

Programming Needs:

• System Needs • Learning Needs: (Social,

Academic, Personal/Emotional)

School History: (pertinent information from cum file, past schools attended)

Prior Resource Involvement

Relevant Medical/Diagnostic Information

Language Spoken

Agencies Actively Involved

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Domain: Social/Behavioural Current Level of Performance:

Student-‐Specific Outcome:


Instructional Strategies

Materials/Resources Roles / Responsibilities Date Started

Date Completed

Evaluation and Review

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Domain: Academic Current Level of Performance:





Date Completed


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Domain: Communication Current Level of Performance:





Date Completed


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Domain: Motor Current Level of Performance:





Date Completed


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Individual Education Plan

A. Student Information

School: _______________________________________ Date: ________________________

Student: ____________________________________ Birth Date: ___________________

Student Number: __________________ Gender: _____ Status: ________________

Band Name & Number: _____________________________________________________

Parent/Guardian: ___________________________________________________________

Address: ______________________________________________________________________

Phone: ___________________________

Child & Family Agency Involvement: YES NO (circle one)

Legal Status: ______________________________________________________________

Agency Name: _____________________________________________________________

Worker Name: _____________________________________________________________

Address: ____________________________________________________________________

Phone: ___________________________

B. Program

Adapted M I E (circle one) Grade Placement: _________

IEP Domains/Subjects: ________________________________________________________________

___________________________________________________________________________________________

Behaviour Intervention Plan: YES NO (circle one)

Health Care Plan: YES NO (circle one)

Other YES NO (circle one)

C. Signatures

Parent/Guardian: _____________________________________________

Classroom Teacher: __________________________________________

Principal: ______________________________________________________

Resource Teacher: ___________________________________________

Agency Personnel: ___________________________________________

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Case Manager: ______________________________________________

Special Services: ____________________________________________

D. Program Planning Team:

Name Position

E. Background Information a) Relevant Medical Information

b) First Language

c) What is the students’ attendance record?

d) Diagnostic Assessment Information

e) Describe, specifically the disabling conditions and/or recent exceptional

behaviours, which require special attention.

F. Domain: ____________________________________________________________


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Specific Outcome:

SMART – (Student) will (action) (what/how) (by what criteria) (where) (by what date) Performance Objectives Instructional Strategies/Resources Evaluation

G. Review:

Review Date: __________________________________

Review Date: __________________________________

Review Date: __________________________________

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Individual Education Plan [School Logo]

IEP for: _____________________________ DOB: __________________________

Status # ________________________ Grade: ________ Date:____________________

Academic Domain: Mathematics English Language Arts Social Studies

Science Other: ________________________________

Non-‐academic Domain: Social Communication Vocational

Cognitive Motor Self-‐management Recreation/Leisure

Other: _________________________________

Current Level of Academic Performance:

Below Grade Level At Grade Level Above Grade Level

Academic Issues Does not:

Understand the concepts Apply the concepts Remember the concepts

Behaviour Issues: No Yes (if yes, fill out BIP-‐attached)

Strengths:

Follows directions Completes assignments Asks for help when needed

Works cooperatively with peers Organized Displays positive attitude

Other: ________________________________________________________________

Student-‐Specific Outcomes:

Will advance: by ½ grade level by one grade level to grade placement level

By: mid quarter end of quarter Other: __________________________________________

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IEP Review Dates

#1 _____________________ #2 _____________________

Materials/Strategies/Accommodations: Domain: Flexible routine during class

Flexible timing for classes

Allows breaks during class

Preferential seating

Small group work/instruction

Individual work instruction

Special lighting

Adaptive special furniture

Noise buffers

Amplification equipment

Notes/Templates

Large print texts

Simplifying oral directions

Written directions

Transcriber for student

Allow extra time for tests

Allow extra time for assignments

Interpreting oral directions (i.e., ASL)

Quiet time out area

Signatures:

Teacher: ___________________________________________________________

Resource Teacher: ________________________________________________

Principal: __________________________________________________________

Parent: ____________________________________________________________

Template created by Jackie Sinclair, Ebb & Flow School

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Individual Education Plan (Level II) Student Name: ___________________________________________________

Grade: ________ School Year: __________________

Planning Team Name Position Signature Parents

Principal

Special Ed. Teacher

Resource Teacher

Classroom Teacher

Speech-‐Language

Occupational Therapist

Education Assistant

Other

Individual Education Plan (Level II) Student Name: ___________________________________________________________________________________

Student MET #: __________________________________________________________________________________

Date of Birth: ____________________________________________________________________________________

Parents/Guardians: _____________________________________________________________________________

Telephone #: ________________________________________________________________

Schools Attended: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Program(s):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Resource Coordinator: _____________________________________________

Special Education and Related Services:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Relevant Medical Information:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of Strength:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Areas of Need:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Long-‐Term Goals/Person Responsible (5-‐10)

1._______________________________________________________________

2._______________________________________________________________

3._______________________________________________________________

4._______________________________________________________________

5._______________________________________________________________

6._______________________________________________________________

7._______________________________________________________________

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8._______________________________________________________________

9._______________________________________________________________

10.______________________________________________________________

Parental Involvement/Expectations:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Assessed Levels of Performance: Behaviour:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Test Results:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Teacher Observation:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Long-‐Term Goal:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Short-‐term Objectives Related to Goal (2-‐3) 1.____________________________________________________________________

2.____________________________________________________________________

3.____________________________________________________________________

Review Date: __________________

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Assessment Used Result Observation

Work Samples

Teacher-‐Made Test

Student Log

Long-‐Term Goal:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Short-‐term Objectives Related to Goal:

1.___________________________________________________________________

2.___________________________________________________________________

3.___________________________________________________________________

Review Date: ________________


Work Samples


Student Log

Long-‐Term Goal:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


1.____________________________________________________________________

2.____________________________________________________________________

3.____________________________________________________________________

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Review Date: ________________


Work Samples


Student Log


Work Samples


Student Log

Long-‐Term Goal:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


1.____________________________________________________________________

2.____________________________________________________________________

3.____________________________________________________________________

Review Date: ________________


Work Samples


Student Log

Eight Intelligence Areas Is the student:

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§ Verbal/linguistic ___________________________________________________ § Logical/mathematical _____________________________________________ § Bodily/kinesthetic _________________________________________________ § Visual/spatial ______________________________________________________ § Interpersonal ______________________________________________________ § Intrapersonal ______________________________________________________ § Musical _____________________________________________________________ § Naturalist __________________________________________________________

Neurodevelopmental Constructs Does the student exhibit strong/weak signs of

§ Attention: alertness, mental effort, focus maintenance, facilitation, inhibition, pacing, self-‐monitoring

§ Temporal Sequential Ordering: sequential perception/memory, time management

§ Spatial Ordering: spatial awareness/perception, materials management § Memory: short-‐term, active, and long-‐term memory; memory access and

consolidation § Language: phonological processing, sentence comprehension, articulation and

fluency, semantic use, word retrieval, verbal elaboration § Neuro-‐motor Functions: gross, fine motor, grapho-‐motor functions § Social Cognition: communication, conversational technique, humour regulation,

self-‐marketing, collaboration, conflict resolution, political acumen § High Order Cognition: concept formation, critical thinking, creativity, problem

solving, reasoning, logical thinking

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Special Education Plan Accommodations Learning Tools and Technology Devices Description / Examples

Manipulatives

Raised line paper

Braille written materials

Computer assisted technology

Dark line paper

Large print materials

Calculator

Personal FM system

Classroom FM system

ASL

Learning Environment Description / Examples

Alternative program site

Seating arrangement

Special lighting

Special study area / work area

Teaching and Learning Strategies Description / Examples

Mnemonics (memory prompts)

Strategy card (step-‐by-‐step directions)

Emphasize visual presentations

Monitor attention (signal systems)

Frequent activity breaks

Taped texts

Division of long assignments into parts

Reduced reading level materials

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Teaching and Learning Strategies Description / Examples

Simplified directions

Provide tactile / kinesthetic activities

Adjusted expectations for length of assignments

Written directions read to student

Organization Description / Examples Monitoring of student agenda/teacher initials homework

Colour coding of notebooks

Organizational mentor

Outline provided for all special assignments

Special homework assignment sheet/contract

Put homework in separate special organizational binder

Clean desk on regular basis

Individual/personal schedule

Extra set of texts at home

Regular home contact (e.g., Home/school journal, voice mail)

Note Taking Description / Examples

Near rather than far copying

Photocopied notes

Key words and phrases only

Word processor for notes

Mind map

Verbal notes on tape

Student note taker

Point form notes

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Note Taking Description / Examples

Teacher’s copy of notes provided

Homework / Study Strategies Description / Examples

Test outline and preview provided

In school time for project completion

Extra time for project completion

Reader or tutor to review notes

Prioritize homework assignments

Mentor

Reduced number of assigned questions

Alternate format to written assignment

Study broken into several short slots

Testing / Evaluation Description / Examples

Scribe for designated tests

Adjusted test format in lieu of essay

Oral testing

Provincial assessment accommodations

Frequent short quizzes in lieu of exam

Evaluation of daily work only

Open book

Evaluation of special projects only

Written directions read to student

Quiet, individual or small group setting

Access to computer

Practice test provided or example given on tests

Blank visual organizer provided with test

Extra time

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Testing / Evaluation Description / Examples Word choices provided for fill-‐in-‐the-‐blank questions

Teacher selects key questions

Spelling not counted in daily work or test situations

Portfolio

Human Resource Assistance Description / Examples

Peer tutor

Noon hour or after-‐school tutor

Sign or oral interpreter

Reader

Peer helper

Mentor

Scribe

Developed by Tom Addison, Resource Teacher, Lake Manitoba

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Individual Education Plan (Level III) Student Name: ___________________________________________________

School Year: _______________

Identifying Information

Date of Birth: _____________________

Nominal Roll #: ___________________

Parent/Guardian: __________________________________________________

Case Manager(s): _________________________________________________

Planning Team Name Position Signature

Parents

Principal

Special Ed. Teacher

Resource Teacher

Speech-‐Language

Medical Services Branch

Child & Family Services

Occupational Therapist

Education Assistant

Background Information Present Situation (Why the plan is being developed and what are the behaviours and coping strategies that are contributing to the present situation.):

Home: Coping Strategies

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___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

School: Coping Strategies

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

General: Coping Strategies

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Traumatic History Impacting on Emotional / Behaviour Disorders:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Diagnostic Information Current Levels of Performance:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Summary of School Performance:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Summary of Home and Community Performance:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Student and System Needs System Needs:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Learning Needs:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Social:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Academic:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Personal/Emotional:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Student-‐Specific Outcomes: Emotional / Behavioural Outcomes

Safety:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Trust:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Friendship:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

BasicNeeds:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Educational Outcomes Educational Goals: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Grade ___ (level) Learning:

Educational Interventions:

Filling Gaps in ____________(subject area): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Methods:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Materials:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Strategies:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Identification of Safety and Shared¬ Service Goals 3 Safety Goals:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3 Shared-‐Service Goals:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Multi-‐system and School Interventions Safety Plan:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

System of Care:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Case Management Process:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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Behaviour Intervention Plan I (To accompany, in some instances, IEP)

School Year:____________

Critical Information Student: __________________________________________________________

Parents/Guardians: _________________________________________________________________________________

Agencies Involved: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Experience of student with agencies: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Experience of student at home:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Experience of student in community:

__________________________________________________________________________________________________________________________________________________________________________________________________________________

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__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other pertinent information:

Behaviours

In School/On Playgrounds In Home/In Community

_________________________________________ _________________________________________

_________________________________________ _________________________________________

_________________________________________ _________________________________________

_________________________________________ _________________________________________

Patterns and Triggers

Patterns (time, place, circumstance) Triggers (people, situation, verbal, mannerisms, behaviour

_________________________________________ _________________________________________

_________________________________________ _________________________________________

_________________________________________ _________________________________________

_________________________________________ _________________________________________

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Programming Needs System/School Learning Personal/Emotional Child Outcomes, Specific


Interventions

Proactive

Personal Needs Learning Needs

___________________________________________ ___________________________________________

___________________________________________ ___________________________________________

___________________________________________ ___________________________________________

___________________________________________ ___________________________________________

Reactive

Schools Home / Other

___________________________________________ ___________________________________________

___________________________________________ ___________________________________________

___________________________________________ ___________________________________________

___________________________________________ ___________________________________________ ***For every reactive intervention, there must be two proactive interventions.

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Implementation Who Does What When Supports Required by Caregivers

Materials / People

If there are problem, whom does the school call? Name Relationship to Student Contact Number


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Behavioural Intervention Plan II A. Student Information School: _________________________________________________ Date: ____________________________

Student: _________________________________________ Birth Date: ____________________________

Student Number: __________________ Gender: _____ Status: _______________________________

Band Name & Number: ______________________________________________________________________

Parent/Guardian: _____________________________________________________________________________

Address: _______________________________________________________ Phone: ______________________

Child & Family Agency Involvement: YES NO (circle one)

Legal Status: ___________________________________________________

Agency Name: __________________________________________________

Worker Name: __________________________________________________

Address: ___________________________________________________________________________________________

Phone: ___________________________________________

B. Program Adapted M I E (circle one) Grade Placement: _______

IEP Domains/Subjects: ________________________________________________________________

____________________________________________________________________________________________

Behaviour Intervention Plan: YES NO (circle one)

Health Care Plan: YES NO (circle one)

Other YES NO (circle one)

C. Signatures Parent/Guardian: ________________________________________________

Classroom Teacher: ______________________________________________

Principal: _________________________________________________________

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Resource Teacher: ________________________________________________

Agency Personnel: ________________________________________________

Case Manager: ____________________________________________________

Special Services: __________________________________________________

D. Program Planning Team Name Position

E. Background Information Relevant Medical Information

First Language

What is the students’ attendance record?

Diagnostic Assessment Information

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Describe, specifically the disabling conditions and/or recent exceptional behaviours, which require special attention.

School Home / Community

F. Background Information Summary of School Performance

Summary of Home and Community Performance

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Summary of Needs

System Needs

Learning Needs Social

Academic

Personal / Emotional

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Summary of Shared-‐Service & Educational Goals

Safety Goals (Goals that address system’s needs)

Shared-‐Service Goals (Goals that address personal/emotional & learning needs)

Educational Goals (Goals that address the student’s academic leaning needs)

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G. Domain: Emotional/Behavioural Emotional/Behavioural Outcome:

SMART – (Student) will (action) (what/how) (by what criteria) (where) (by what date)

Performance Objectives Instructional Strategies / Resources

Evaluation

Proactive Reactive

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H. Case Management Process

Name & Signature of Case Manager for School & Multi-‐

system

Position / Agency Role / Responsibility

I. Evaluation Process Review Date: __________________________________

Review Date: __________________________________

Review Date: __________________________________

J. Costs to Implement the School Component of Multi-‐system Education/Treatment Plan

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Special Education Case Conference Notes

Name: __________________________________________________________

SEP Number:__________________________________ Birthdate :______________________________

Telephone: _______________________ Address: ______________________________________________

Postal Code: ______________________

Date: ___________________

Diagnostic Information:

Medical:

Speech/Language/Communication:

Cognitive:

Self-‐Help: (Toileting, Dressing, Eating, etc.):

Fine/Gross Motor Skills:

Social Skills:

Attending Issues:

Sensory Issues:

Transitions:

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Likes/Dislikes:

Safety:

Behaviour Issues:

Conference Participants:

Name (Print) Title / Position Telephone # Fax #

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Individual Health Care Plan

School: __________________________________________________________________________________

Phone: ________________________________________________

Teacher: ____________________________________________________ Gr. Placement: __________

Student Information Name: ___________________________________________________ Birth Date: ______________________________

Address: _____________________________________________________________________________________________

Parent/Guardian: _______________________________________________

Phone: ____________________________________

Primary Caregiver (if other than guardian): ______________________________________________________

Phone: ______________

Back-‐up /Contact Person: _________________________________________________________

Phone: ________________________________________

Health Care Information Family Physician: _______________________________________________

Phone: ________________

Consulting Physician: ____________________________________________

Area of Expertise: ___________________________ Phone: ___________________________

Consulting Physician: _______________________________________________________________

Area of Expertise: ___________________________ Phone: ___________________________

Diagnosis: _______________________________________________________________________________________

Presenting Health Care Needs: ________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

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____________________________________________________________________________________________________

____________________________________________________________________________________________________

Plan Participants Name Role

Review Date: ______________________________________________

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Health Care Plan The Health/Nursing Care Plan was developed or recommended by:

_____________________________________________ Date: ____________________________

(Health Care Professional)

The Health Care Plan (check where appropriate):

is attached and/or is described below

Procedures (what, where, when, how, supplies/equipment)

Precautions

Emergency Procedures Contact Person: __________________________________________________

Phone: __________________________

Alternate: _______________________________________________________

Phone: _________________________

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If you see this: Do this:

Record of Personnel Training Primary Person trained: ________________________________________________________________

Date Trained: __________________________________________________________

Date recommended for retraining: ____________________________________

Back-‐up person(s) trained: ________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Training Provided by: ______________________________________________________________________

Level and description of training: __________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

____________________________________ _______________________

Signature of Trainer Date

____________________________________ _______________________

Signature of Principal Date

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Transition Plan

Name: DOB:

Address: City/Zip:

Phone: Today’s date:

Student #: Date Plan Initiated:

School: Teacher:

Grade: Year of Graduation/Completion:

Individual Transition Life Plan

Participants Student:______________________________________________________________

Coordinator: _________________________________________________________

Parent/Caregiver:____________________________________________________

Agency Rep:___________________________________________________________

Other: _________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Domains A) INSTRUCTION, may include, but not limited to:

self-‐advocacy skills pre-‐vocational education

vocational evaluation further instruction as it relates to adult services

B) COMMUNITY EXPERIENCES, may include, but not limited to:

participation, safety & consumerism recreation/leisure/fitness

citizenship/legal issues/self-‐advocacy transportation/mobility/accessibility

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C) EMPLOYMENT, may include, but not limited to:

career awareness work related skills/behaviours

job placement & employment summer employment

D) ADULT LIVING/DAILY LIVING SKILLS, may include, but not limited to:

self care/personal needs living options

household management income/finances

medical needs personal relationships

budgeting socialization and friendships

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Individual Transition Life Plan Student Name: ___________________________

Date: ______________________________

Domains A. _____ Instruction

B. _____ Community Experiences

C. _____Employment

D. _____ Adult Living/Daily Living Activities

Long-‐Term Goals _________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Objectives / Activities Responsible Person / Agency Target

Date Status Status

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Transition Plan Transition Planning for: _____________________________________________

Vision for the future: ________________________________________________

Record below the identified priority planning areas, long-‐term goals and objectives, what action will be taken and who will do this. The ‘What happened?’ section can be filled in at the next review meeting.

Priority planning area

What we decided as a

long-‐term goal

What we decided should be done now (short-‐term objective)

How will it be done?

Who will take action?

When will the action be

completed?

What happened?

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When planning, consider:

Community Participation, Independent Living Skills, Career Planning, Vocational Learning & Training, Employability Skills, Leisure & Recreation Activities, Communication Skills, Personal Well-‐being, Self-‐determination Skills, Social Skills, Transport & Mobility, needed information, services & accommodations.

Additional Notes:

Date of Meeting _____________________________ We will meet again on ___________________________

Completed by ______________________________ Signed ______________________________________________

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Section O, part 7: Record Keeping

section o, part 6: student plans -...

Documents