the school district of palm beach county ......exchange my child's confidential student...

PBSD 0659 (Rev. 2/10/2015) ORIGINAL - Student ESE Folder COPY - Parent/Guardian

THE SCHOOL DISTRICT OF PALM BEACH COUNTY DEPARTMENT OF EXCEPTIONAL STUDENT EDUCATION (ESE)

Individual Education Plan (IEP)

IEP Team Meeting Date IEP Initiation Date

IEP Anticipated Duration Date Reevaluation Due Date

Student ID # Birth Date Grade Gender Age

Student: First MI Last

Current School

SAC School

Primary Exceptionality

Parent

Address

City State Zip Code

Home Phone # Day Phone #

Primary language or mode of communication of parent/guardian if other than English

Yes No Not ApplicableInterpreter/Translator Provided:

If no, explain

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

Revision(s) Date Participant(s) and Roles IEP Section(s) Amended

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Additional Exceptionalities

E-mail Address


Exceptional Student Education Individual Education Plan (IEP)

Individual Education Plan (IEP) Team/SignaturesThe Individual Education Plan team makes the decisions about the student's program and placement. The following individuals were in attendance at the IEP meeting and participated in the development of the IEP. Signature on this IEP documents attendance, not agreement. The student's parent(s)/guardian, the student's special education teacher/provider, evaluation specialist, and a representative from the Local Education Agency are required members of this team. The General Education Teacher is required if the student is, or may be participating in the regular education environment. The IEP Team must invite the student if transition services are being planned or if the parents choose to have the student participate.

Parent/Guardian:

Parent/Guardian:

Student:

General Education Teacher:

Special Education Teacher Provider:

Evaluation Specialist:

Local Education Agency Representative:

Role or Title Print Names Signature

Written input received from the following excused members:

PROCEDURAL SAFEGUARDS NOTICE: I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides information about my rights, including the process for disagreeing with the IEP. The school has informed me of who I may contact if I need more information.

Signature of Parent/Guardian Date

waived explanation received explanation not in attendance; PBSD 1025 sent home onParent/Guardian

In accordance with FERPA, at 34 CFR §99.30 and IDEA requirements, I authorize the School District of Palm Beach County, Florida, to release and exchange my child's confidential student information to agencies of the State of Florida which would allow Palm Beach County Public Schools to receive Medicaid reimbursement for health related exceptional student services it provides to my child while at school. I understand my consent is voluntary and may be revoked at any time. My child will continue to receive services as per his/her IEP whether or not I give consent. In addition, I understand that I am not required to enroll in any public benefits or insurance program and that no out of pocket expense will be incurred for services provided as part of FAPE, and that there is no impact to my Medicaid benefits as a result of this school district's reimbursement for services.

DateSignature of Parent/Guardian

Your child may be eligible to participate in the John M. McKay Scholarship Program for Students with Disabilities. This is a parental choice program offering both private and public school choice options. For additional information visit the Florida Department of Education website at http://www.floridaschoolchoice.org or call 1-800-447-1636. You may also contact the local McKay Contact person at (561) 434-8626 or visit the District ESE website at http://www.palmbeachschools.org/ese

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Date

Yes No

Standard High School Diploma Certificate of CompletionI have been provided information and chose:

Initials

DateSignature of Parent/Guardian

N/A

(For students turning 14 and older only)



I. Special Considerations the IEP Team Must Consider Before Developing the IEPAny factors checked as "YES" must be addressed in the IEP.

In considering the following factors, if the IEP team determines that a student needs a particular device or service, including an intervention, accommodation, or program modification, the IEP must include a statement to that effect in the development of the IEP.

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Does the student's behavior impede his/her learning or the learning of others?If yes, the use of positive behavioral interventions, strategies and supports must be considered in the development of this IEP.

Does the student have limited English proficiency?If yes, the student's English Language Learner (ELL) needs are met through

Is the student blind or visually impaired?

If yes, the IEP must include a description of the instruction in Braille and the use of Braille unless the IEP team determines, after an evaluation of the student's reading and writing skills, needs, and appropriate reading and writing media (including an evaluation of the student's future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use of Braille is not appropriate for the student.

Does the student have communication needs?If yes, those needs must be addressed in this IEP

Is the student deaf or hard-of-hearing?

If yes, the IEP must include the student's language and communication needs, opportunities for direct communications with peers and professional personnel in the student's language and communication mode, academic level, and full range of needs, including opportunities for direct instruction in the student's language and communication mode; and assistive technology devices and services.

Does the student need assistive technology devices or services?If yes, the student's needs must be addressed in this IEP.

Other pertinent information (Limit 500 characters. Do not exceed text box - Attach additional information, if necessary)

Parent input was obtained through: attended meeting questionnaire (PBSD 0298) phone conference

The parents' concerns for enhancing the education of the student (Limit 500 characters. Do not exceed text box - Attach additional information, if necessary)

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Important MEDICAL information



II. Present Levels of Academic Achievement and Functional PerformanceInclude strengths of the student; academic, developmental, and functional needs; results of the initial or most recent evaluation; and results of the student's performance on statewide and districtwide assessment.

Statewide Assessment Data: FCAT FAA Not Applicable

Date:

Dev. Score:

Perf. Level:

Date:

Dev. Score:

Perf. Level:

Date:

Perf. Level:

Reading Math Writing

Limit 500 characters per text box. Do not exceed field boundaries - Attach additional information, if necessary.

Reading/Literacy or Emergent Literacy Skills for Pre-K

Written Language or Emergent Writing Skills for Pre-K

Mathematics or Emergent Math Skills for Pre-K

Social/Emotional Skills

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Communication Skills

Independent Functioning

Transition Information - Required tor ALL students turning age 14 through 22 (What are student's current strengths preferences and interests? Include areas of post-secondary education, employment and independent living.)

Transition Skills - Complete both Transition sections for students turning 16 through 22. (What are student's current skills in community experience, employment, and self-determination?)

How the Student's Disability Affects Involvement and Progress in the General Education Curriculum or Functioning in the Typical Learning Environment for Pre-K


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Complete when the student will be in the 8th grade or turning 14 years of age or older during the IEP year.

A. Not Applicable

Student's current courses of study needed to assist the student in reaching the transition goals and related objectives

Eligibility for graduation will be based upon meeting the course requirements for the following diploma option:

Standard Post-graduate Equivalency DiplomaSpecial Diploma Option 1 Special Diploma Option 2

Yes No Is there a need for instruction or information in the area of self-determination?

If yes, self-determination must be addressed through annual goals, short-term objectives/benchmarks, or services in the IEP.

Not ApplicableMeasurable Post Secondary GoalsB.Complete when the student will be turning 16 years of age or older during the IEP year.

Education/Training (required)

Employment (required)

Independent Living (if appropriate)

Interagency Responsibilities and/or Linkages for Transition ServicesInformation provided to parent List agency if current client

District designee for agency follow-up:


Not ApplicableTransfer of Rights at Age of MajorityC.Complete when the student will be turning 17 years of age during the IEP year.At least one year prior to the student's eighteenth birthday, the student was informed of his or her rights under Part B of the Individuals with Disabilities Education Act (IDEA 2004) that will transfer from the parent to the student on reaching the age of majority, which is eighteen years of age.

Yes No If yes, list date Student was informed: at meeting mailed home

Not Applicable

Yes No

A separate and distinct notice was provided closer to the time of the student's eighteenth birthday.

Complete when the student will be turning 18 years of age during the IEP year.

If yes, a notice of the transfer of rights will be sent home to the parent and student closer to the time of the student's eighteenth birthday. PBSD 2155

Goals and Short Term Objectives

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III. Transition Services

Certificate of CompletionStandard High School Diploma9th grade students in 2015 cohort only choose (entering 9th 2014-2015 or later):

Choose one

Career Goal (long term)

http://www.palmbeachschools.org/forms/documents/2155.pdf

http://www.palmbeachschools.org/forms/documents/0659_GO.pdf



Special Education Services/Specially Designed Instruction/Supplementary Aids and Services/Related Services

V.

A. Accommodations, Modifications, Aids & Services Initiation Duration Frequency Location

B. Special Education Services Initiation Duration Frequency Location

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Related Services Initiation Duration Frequency Location

C. Related Services No services needed at this time

List the related services that the student needs in order to benefit from or access his/her special education program.

Is special transportation required? Yes No If yes, enter bus code

BUS CODE KEY:

2 = Less Than 2 Miles From School, Requires Transportation

A = Medical EquipmentB = Medical ConditionC = Aide/Monitor RequiredD = Shortened School Day

Justification of Need

Transportation services for Special Needs Students form (PBSD 1848) MUST be submitted and supported on the IEP .

Yes No Has a formal evaluation to determine current levels of performance been recommended by the team and completed for this IEP year? If yes, enter date

Type of Evaluation (check all that apply)

Speech Language Occupational Therapy Physical Therapy Wheelchair Psycho-Educational

D. Extended School YearThe IEP team has determined that the student meets the criteria for ESY services.

Yes No Insufficient information available to determine ESY services

The Annual Goals and, when appropriate, Short-term Objectives from this IEP that are to be addressed in thestudent's ESY program are:

ESY Services Initiation Duration Frequency Location

School Personnel Needs Person Responsible Projected Date

The IEP team recommends the following training/support be provided to personnel listed below to assist with the implementation of the student's IEP:

E. Supports for School Personnel No supports needed at this time

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E = Other

Yes No Does student require being received by parent/guardian/designee at drop-off?



VI. Participation in State or District Assessments Not Applicable

The decision that a student will participate in the statewide alternate assessment is made by the IEP team and must meet the following criteria:

Does the student have a significant cognitive disability?Yes No

Is the student unable to master the grade level general state content standards even with appropriate and allowable instructional accommodations, assistive technology, and/or accessible instructional materials?

Yes No

Is the student participating in a curriculum based on State Standards Access Points for all academic areas (where applicable)?

Yes No

Does the student require extensive direct instruction in academics based on access points in order to acquire, generalize, and transfer skills across settings?

Yes No

If the IEP team determines that "yes" to all four of the questions accurately characterizes a student's current educational situation, then the Florida Alternate Assessment (FAA) must be used to provide a meaningful evaluation of the student's current academic achievement. If “yes” is not checked in all four areas, then the student must participate in the Florida Comprehensive Assessment Test (FCAT) with or without accommodations.

The ENNOBLES Act provides for the waiver of the FCAT requirement for graduation with a standard diploma for certain students with disabilities who have met all other requirements for graduation with a standard diploma, except for a passing score on the FCAT.

The IEP team has determined that the student will be assessed through:

General Statewide Assessment (FCAT)/ General District-wide Assessment without accommodations (Standard Administration)General Statewide Assessment (FCAT)/ General District-wide Assessment with accommodations as outlined in “For Students Participating In Assessment with Accommodations” below.Alternate Assessment

Explain why the general statewide assessment (FCAT)/General Districtwide Assessment is not appropriate

Explain why the alternate statewide assessment (FAA) is appropriate

PBSD 1998

For Students Participating In Assessment with AccommodationsAssessment accommodations may be used only if they do not alter the underlying content that is being measured by the assessment or negatively affect the assessment's reliability or validity. Only accommodations allowed by the individual test administration manuals may be implemented on standardized tests. PBSD 1996

Not Applicable

Schedule

Responding

Assistive Devices

Setting

Presentation

Other

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http://www.palmbeachschools.org/forms/documetns/1996.pdf



VII. Educational PlacementA. Least Restrictive Environment

To the maximum extent appropriate, special classes, separate schooling or other removal of students with disabilities from the general educational environment will occur only when the nature or severity of the disability is such that education in general education classes, even with the use of supplementary aids and services, cannot be achieved satisfactorily.

Provide an explanation of the extent, if any, to which the student will not participate with non-disabled students in the general education class.


The IEP team has determined that the student's IEP will be implemented in the following placement

Will the student be educated in the school he or she would attend if non-disabled?Yes No

If no, the student will be attending

B. Accessibility and IEP ImplementationThe IEP is accessible to each of the student's teachers who are responsible for implementation.

All persons responsible for IEP implementation were notified at the IEP meeting.

If no, how will the IEP team members be notified?

C. Prior Written NoticeDoes this IEP include a change of placement or change in the provision of a Free Appropriate Public Education (FAPE) from the previous IEP?

Yes No

NoYes

If yes, attach Prior Written Notice (PBSD 1723)PBSD 1723

VIII. Conference NotesLimit 500 characters per text box. Do not exceed field boundaries - Attach additional information, if necessary.

PBSD 1051

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