Jackson County School District IEP Checklist Revised July 10, 2012

Student Name: ______Current Eligibility Date: ______School ______Date of Annual IEP: ______Eligibility Category: ______Reviewed By: ______Date Reviewed: ______(PLP) W-1: Must also list the source of information Needs Adequate Improvement How disability affects involvement & progress in the general curriculum Detailed description current performance reading & math Results of initial or most recent reevaluation Strengths of the student Concerns of parent for enhancing education of the student Description of student’s social, behavior, and/or emotional skills Form W-2: List area List modifications or accommodations Check district wide or state Beginning and ending dates Frequency of services Physical Location of Services List Area Support for personnel Beginning and ending dates Frequency of services Physical Location of Services MUST include an EXPLANATION of nonparticipation in general ed. services, including nonacademic and extracurricular activities: Form W-3a: This form is to be used only for SCD students. Measurable annual goal Short-term instructional objective(s) Check if objective is a transition activity Method(s) Report of progress Beginning/ending dates of services Frequency Progress toward annual goal Physical location of services Reason for not meeting goal Form W-3b: This form is to be used for Non SCD Students. Goal # Measurable Annual Goals: Method of measurement Area Date: Progress toward annual goal, Reason Goal # Beginning/Ending Dates of Services Physical location of Services Frequency Check if goal is a transition activity Progress/Reason Form W-4: Type of Assessment Grade Level EXPLAIN why the student cannot take the grade/course level assessment or grade/course level assessment with accommodations, and then EXPLAIN why the student’s disability requires the administration of a grade/course level alternate assessment and indicate the subject and grade/course level alternate assessment the student will take. HIGH SCHOOL: Signature of Parent and Date that the MS assessment system has been explained to the parent. Form W-5: Criteria met for SCD: Services Beginning/Ending Date Physical Location Amount of Time Frequency Graduation Options have been reviewed with the parent Graduation options determined appropriate for the child. Consideration of Special Factors Method of informing Parents/Guardians of Progress (all three should be checked) Frequency of Notification: (Check every 9 weeks and other (4 ½ weeks) LRE Classification must be checked Form W-6: Check criterion used in determining eligibility: (Must be checked) Check meets or does not meet criteria for ESY service Committee Members Present Date of Meeting Date copy is given to the parent/guardian If IEP is conducted via alternate means of technology Names and positions of excused IEP Team Members If student meets ESY criterion: Annual goals or short-term objectives Method(s), Physical location of services, Report of Progress Types of Services # of weeks, # of Days, Amount of time per day, Beginning/ending dates Committee Members Present must be completed Form W-7: Must be completed for each student beginning at age 8. Identify assessment utilized Post-secondary goal (s) Course of study aligned with Post-secondary goal (s) Check yes if service area is needed after high school, check no if not needed Linkages: list interagency that is responsible for providing or paying for needed services Form W-8: Evaluation: Indicate plan Initial Placement/Out of State: Need Parent Signature Names of Annual IEP members (does not require signatures) Names and position of excused IEP team member(s) (Documentation included) Date of Meeting Conducted via alternate means of technology Date copy of the IEP is given to the parent/guardian Projected date of review/revision of the IEP OTHER: Parent Response Form Notice of Committee Meeting Form BIP/FBA Progress Monitoring