6/06 MICHIGAN COUNTY EDUCATIONAL SERVICE AGENCY Birthplace ______Individualized Education Program Team (IEPT) Report DPT______

Student Information IEP Date Initial / most recent Prior IEP Date Birthdate Gender Grade reevaluation IEP M F Student’s Last Name First Name Initial Ethnic Group Student’s ID Email Address Number

Student’s Home Address City Zip Code Home Telephone (989) Parent/ Guardian/Surrogate Last Name First Relationship to Native Language / Mode of Interpreter Needed? Name Student Communication Parent: Student: Yes No Parent/Guardian/Surrogate Address (if different) City Zip Code Work Telephone Pager / Cell

Resident District Operating District Attending Building

Purpose Purpose(s) of this Individualized Educational Program (IEP) Team meeting are to discuss (check all that apply): Initial Review/Revise IEP Reevaluation Transition Other, Eligibility specify

Parent Contact The parent(s)/guardian(s)/surrogate(s) were contacted to arrange a mutually agreeable time and place for the IEP Team meeting and to explain the purpose of the meeting and the roles of each participant. Additional contacts should be documented and attached to this IEP form. By Method of Dat Results Contact e By Method of Dat Results Contact e

IEP Team Meeting Participants in Attendance Check the box indicating the IEP Team member who can explain the instructional implications of evaluation results. Check the circle indicating the IEP Team member who has observed the student suspected of having a learning disability. Participant signatures are required to verify a determination regarding a suspected learning disability under R340.1713. 34CFR§300.344(b) requires the school to invite students to participate in the IEP team meeting if the meeting will include consideration of transition needs of or services. Participants who disagree with the IEP Team’s determination shall indicate the reason on a dissenting report.

Student General Education Teacher

Parent(s)/Guardian(s)/Surrogate(s) Special Education Teacher/Provider O

MET Representative Special Education Teacher/Provider O

Resident District Representative Adult Service Agency Representative

Operating District Representative Other

Eligibility for Special Education

This IEP Team determined this student to be: ELIGIBLE INELIGIBLE (go to signature page) Autism Spectrum Disorder (R340.1715) Hearing Impairment (R340.1707) Severe Multiple Impairment (R340.1714) Cognitive Impairment (R340.1705) Learning Disability (R340.1713) Speech and Language Impairment (R340.1710) 6/06 Student Name: ______Page 3

Early Childhood Developmental Delay (R340.1711) Other Health Impairment (R340.1709a) Traumatic Brain Injury (R340.1716) Emotional Impairment (R340.1706) Physical Impairment (R340.1709) Visual Impairment (R340.1708) Deaf-Blindness (R340.1717) Will no longer receive services after______due to graduation or reaching age 26

Educational Setting: Sp. Ed. <21% Sp.Ed. 21-60 % Sp.Ed. > 60 %

Time Time Time Time convened recessed reconvened adjourned

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Attendance Not Necessary: The Parent and the LEA or ESA agree that the attendance of a member listed below is not necessary because the member’s area of curriculum or related service is not being modified or discussed in the meeting.

Excusal Prior to the IEP Team Meeting: A member of the IEP Team may be excused from attending an IEP meeting, in whole or in part, when the meeting involves a modification to or discussion of the member’s area of the curriculum or related service, if: 1) The parent and the local educational agency consent to the excusal; and 2) The member submits, in writing to the parent and the IEP Team, input into the development of the IEP Team Report prior to the meeting. A parent’s agreement shall be in writing.

Student Profile and Eligibility Consider (check) each of the following and comment as appropriate. Student’s progress on the current IEP annual goals and objectives

Initial evaluation or most recent reevaluation of the

A Student

Parent input and

Student’s anticipated needs or

Placement Considerations and Accommodations Least Restrictive Environment The student will : Fully participate with students who are nondisabled in the general education setting except for the time spent in separate special education programs/services provided outside of the general education classroom as specified in this IEP. Yes No (explain): Be fully involved in and progress in the general education curriculum. Yes No (explain): Have the same opportunity as general education students to participate in nonacademic and extracurricular activities. Yes No (explain):

Consideration of Special Factors – Consider (check) each of the following. Needs in any of the following require a statement in the comments below. Positive behavior intervention, supports and strategies for the student whose behavior impedes learning Language needs for the student with limited English proficiency Braille instruction for the student who is blind or visually impaired Communication and language needs for the student who is deaf or hearing impaired The communication needs of the student The need for assistive technology devices or services Comments : 6/06 Student Name: ______Page 4

Supplementary Aids / Services / Personnel Supports

The IEP Team has considered supplementary aids, services, and personnel supports that will be provided for the student. Describe service(s) needed, if any, below. (If none, check here. ) Supplementary Aids / Services / Personnel Supports Amount of Time / Frequency/ Conditions Location

All supplementary aids/services and supports listed above will begin on the initiation date of the IEP and continue for one calendar year, following the approved school district calendar. Note exceptions to beginning and ending dates and locations given above. Specify month/day/year:

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Vocational and Transition Considerations The student is younger than age 13 and vocational/transition services are not (Proceed to next needed at this time. section)

Course of Study Addressing Post-school Transition Needs for Post-Secondary Adult Activities (Required to consider the following for any student who will reach age 16 during this IEP; optional to consider at age 13 or younger if determined appropriate by the IEP Team and reviewed at each subsequent IEP.) Check one:

General and/or special education classes leading to a diploma

Course of study leading to a certificate of completion

Describe how the student’s courses of study align with the student’s post-secondary goals:

______

______

Needed Transition Activities/Services Related to Present Level of Academic and Functional Performance Address by Age 16 within this IEP Year. Recommended beginning at age 13 and annually thereafter if determined by the IEP Team. See attached Transition Page.

Parental Rights and Age of Majority (check all applicable):

If the student will be age 17 during this IEP, the student was informed of parental rights that will transfer to him/her at age 18.

If the student has turned age 18, the student and parent were informed of the parental rights that transferred to the student at age 18 including the right to invite a support person(s) such as a parent, other family member, advocate, or friend.

The student has turned age 18 and there is a guardian established by court order. The guardian is: ______

The student has turned age 18 and has appointed a legally designated representative (e.g., power-of-attorney, trustee). The representative is: ______6/06 Student Name: ______Page 5

Additional Comments

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State- and District-wide Assessment The student will participate in the Michigan Educational Assessment System and district-wide/NAEP assessments as follows:

Section 1: MEAP, ELPA and MI-Access Grades/Ages Assessed (“Ages” as of December 1 and for ungraded programs only)

Directions: Check the one that applies to this IEP. State Assessments are NOT administered at the grade level covered by this IEP. State Assessments ARE administered at the grade level covered by this IEP. (If checked, continue below.)

Content Area Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8 Grade 9 Grade 11 Age 9 Age 10 Age 11 Age 12 Age 13 Age 14 Age 15 Age 17 English Language Arts X X X X X X X Mathematics X X X X X X X Science X X X Social Studies X X X

Michigan Educational Assessment Program (MEAP) * e s

l e d b r r a o a t c r d o S n

p a d t e e S R - v

n o e r o g p e N l

p l e A o r Is the a C e

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assessment s a t o If YES, for each content area, indicate if the student needs any assessment n f S o

appropriate i

r MEAP / MME accommodation(s) and which specific accommodations are needed. t a o for the w f d o

Content Area l l o student? w a o

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Assessed If NO, state the reason why the specific MME/MEAP assessment is not l l Check the s m a n appropriate for the student and indicate what alternate assessment will be o o s i appropriate c t n administered to the student. c a o A box below. i d t o a d m o m m o c m c o A c s c e A r o c

YES NO Y S N Y N Y N No accommodations needed English Accommodations:______Language Arts (Grades 3-8 6/06 Student Name: ______Page 6

and 11) Reason(s) not appropriate: ______

Appropriate assessment is: ______No accommodations needed Mathematics (Grades 3-8 Accommodations:______and 11) Reason(s) not appropriate: ______

Appropriate assessment is: ______No accommodations needed Science (Grades 5, 8 Accommodations:______and 11) Reason(s) not appropriate: ______

Appropriate assessment is: ______No accommodations needed Social Studies (Grades 6, 9 Accommodations:______and 11) Reason(s) not appropriate: ______

Appropriate assessment is: ______

*Scores received, using a non-standard assessment accommodation, are not eligible for the Michigan Merit Award, nor will the student be counted as assessed for No Child Left Behind (NCLB) participation rates.

English Language Proficiency Assessment (ELPA) Directions: Check the one that applies to this IEP.

The student IS NOT an English Language Learner, therefore the ELPA will NOT be administered. The student IS an English Language Learner and has been in the United States for ______number of years. Therefore, the student will participate in the EPLA.

Requires reading assessments using tests written in English, for any student who has attended school in the US (excluding Puerto Rico) for three or more consecutive years, with LEA discretion to use tests in another language for up to two additional years. States also must annually assess English proficiency for all LEP students beginning with the 2002-03 school year. 6/06 Student Name: ______Page 7

MI-Access, Michigan’s Alternative Assessment Program

MI-Access Type of If YES, why is the alternative assessment identified appropriate for the student Are the Assessment Is the Assessment and and accommodations assessment Content Area standard as per current appropriate? indicate if the student needs any assessment accommodation(s) and what Assessed specifically is needed. guidelines? YES NO YES NO* This assessment appropriately measures the student’s ability. Participation Other reason(s) why appropriate:______

Accommodations:______This assessment appropriately measures the student’s ability. Supported Other reason(s) why appropriate:______Independence Accommodations:______Functional This assessment appropriately measures the student’s ability. Independence: Other reason(s) why appropriate:______English Language Arts Accommodations:______Functional This assessment appropriately measures the student’s ability. Independence: Other reason(s) why appropriate:______Mathematics Accommodations:______The State does not currently have a Science assessment developed. Indicate Functional how the student will be assessed in Science: ______Independence: Science Accommodations:______

The State does not currently have a Social Studies assessment developed. Functional Indicate how the student will be assessed in Social Studies: ______Independence: Social Studies Accommodations:______*Scores received, using a non-standard assessment accommodation, are not eligible for the Michigan Merit Award, nor will the student be counted as assessed for NCLB participation rates No Child Left Behind (NCLB).

Section 2: District-wide Assessment Directions: Check the one that applies to this IEP. District-wide Assessments are NOT administered at the grade level covered by this IEP. District-wide Assessments ARE administered at the grade level covered by this IEP. (If checked, complete this section.)

District-wide Assessment: Is the assessment If YES, for each content area, indicate if the student needs any assessment accommodation(s) and List each assessment appropriate for what specifically is needed. that is administered the student? If NO, state the reason why the specific district-wide assessment is not appropriate for the student district-wide and indicate what alternate assessment the student will be administered. YES NO

Section 3: National Assessment of Educational Performance (NAEP) Directions: Check the one that applies to this IEP.

The NAEP Assessments are NOT administered at the grade level covered by this IEP. The NAEP Assessments ARE administered at the grade level covered by this IEP and this student was selected as part of the sample. (If checked, continue below.) The NAEP Assessments ARE administered at the grade level covered by this IEP, but our school was NOT selected in the sample. (If checked, nothing else is needed.)

If YES, for each content area, indicate if the student needs any assessment accommodation(s) and Is the assessment what specifically is needed. NAEP Assessments appropriate for If NO, state the reason why the specific NAEP assessment is not appropriate for the student. If the the student? student is participating in MI-Access for the NAEP content areas being assessed, an alternate assessment does NOT need to be administered. YES NO 6/06 Student Name: ______Page 8

Special Education Programs/Services

Program Placement: Is the chosen categorical program departmentalized? (R340.1749 c) No Yes Is there a need for a teacher with a particular endorsement? No Yes, specify: ______

Autism Program (R340.1758) Moderate Cognitive Impairment Program (R340.1739) Early Childhood Special Education Program (R340.1754) Physical Impairment or Other Health Impairment Program (R340.1744 ) Emotional Impairment Program (R340.1741) Severe Cognitive Impairment Program (R340.1738) Hearing Impairment Program (R340.1742) Severe Language Impairment Program (R340.1756) Learning Disability Program (R340.1747) Severe Multiple Impairment Program (R340.1748) Mild Cognitive Impairment Program (R340.1740) Visual Impairment Program (R340.1743)

Amount of Time/Frequency: (Min/Hour/Period) per Location Initiation/Duration* (Day/Week/Month) pe r pe r

Resource Program: Is the chosen program departmentalized? (R340.1749c) No Yes R340.1749(a) (elementary) R340.1749(b) (secondary) Amount of Time/Frequency: (Min/Hour/Period) per Location Initiation/Duration* (Day/Week/Month)

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Resource Room Only: Is a Teacher Consultant with endorsement matching the student’s disability needed? No Yes

Related Services Type of Services and Amount of Time and Location Initiation/Duration* Rule Number (R340.____) Frequency (Min/Hour) per (Day/Week/Month) Speech and Language- 1745 Early Childhood Services- 1755 Occupational Therapy- 1701b(d) Physical Therapy- 1701b(g) Teacher Consultant- 1749 Psychological Services- 34 CFR § 300.24 School Social Worker- 34 CFR § 300.24 Other- 1701c (a)

* All programs and services listed above will begin on the initiation date of the IEP and continue for one calendar year, following the approved school district calendar. Note any exceptions to the beginning and ending dates/locations above. Extended school year (ESY) services must be provided only if the IEP Team determines on an individual basis that ESY services are necessary for provision of FAPE. Describe ESY services:

6/06 Student Name: ______Page 9

Transportation: Is specialized No Yes, transportation required? specifics:

Total hours/week in General Total hours/week in Special Total School Hours per Education Education Week

Nonpublic School Pupils: Identify programs/services offered by the district but not provided because the parent elected to enroll the child in a nonpublic school.

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Resident District Commitment Resident district superintendent/ designee: (Check all that apply) Agrees with the IEP and its implementation Disagrees with this IEP and requests mediation Authorizes the non-resident operating district to conduct subsequent Disagrees with this IEP and requests a due IEPT meetings process hearing Agrees that the student is not eligible for special education

Resident District Superintendent or Dat Designee e

Operating District Commitment The superintendent/designee (Check all that apply) Agrees to provide the IEP program(s) and/or service(s) Disagrees with the IEP and requests mediation Agrees to conduct subsequent IEPT meetings Disagrees with this IEP and requests a due process hearing Agrees that the student is not eligible for special education

Operating District Superintendent or Dat Designee e

Adult Providing IEP Consent Adult providing IEP consent: I have been informed of all procedural safeguards and sources to obtain assistance, and : Understand the contents of this IEP Disagree but will allow implementation of this IEP Agree with the IEP and its implementation Disagrees with this IEP and request mediation Agrees that the student is not eligible for special Disagrees with this IEP and request an impartial due process education hearing

Adult Providing Dat Consent e

Operating District Notice Requirements

The superintendent or designee of the operating district assures that: a) to the maximum extent appropriate, a person who has a disability, including a person who is assigned to a public or private institution or other care facility, is educated with persons who do not have disabilities. b) placement of a person who has a disability in special classes, separate schools, or the removal of a person who has a disability from the general education environment occurs only when the nature or severity of the disability is such that education in a regular class using supplementary aids and services cannot be satisfactorily achieved. 6/06 Student Name: ______Page 10 c) the placement for the student with a disability is as close as possible to his or her home. d) unless the IEP of a student with a disability requires some other arrangement, the student is educated in the school that he or she would attend if nondisabled. e) in selecting the least restrictive environment, consideration shall be given to any potentially harmful effects to the student or the quality of services that the student needs. f) a child with a disability will not be removed from education in age-appropriate general education classrooms solely because of needed accommodations in the general curriculum.

Implementation Site______Staff responsible for implementation: ______

Beginning Date: ______Ending Date:______(month/day/year) (month/day/year)

Signed:______Date:______Superintendent or Designee (month/day/year)

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