Mock IEP

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IEP Team Meeting Date (mm/dd/yy):04/30/2009

IEP Implementation Date (Projected Date when Services and Programs Will Begin):5/01/2009

Anticipated Duration of Services and Programs:04/29/2010

Date of Birth:4/24/2008



Anticipated Year of Graduation:2019

Local Education Agency (LEA):Girard School District

County of Residence:Erie County

Name and Address of Parent/Guardian/Surrogate:Phone (Home):814-555-1212

Jack and Rita JohnsonPhone (Work):814-555-1214

9400 West Lake Road

Lake City, PA 16423

Other Information:

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

Date of Revision(s)Participants/RolesIEP Section(s) Amended

IEP TEAM/SIGNATURESThe Individualized Education Program team makes the decisions about the students program and placement. The students parent(s), the students special education teacher, and a representative from the Local Education Agency are required members of this team. Signature on this IEP documents attendance, not agreement.

RolePrinted NameSignature

Parent/Guardian/SurrogateRita Johnson

Parent/Guardian/SurrogateJack Johnson


Regular Education Teacher**Mary Smith

Special Education TeacherJamie Snider

Local Ed Agency RepMary Ellen Rich

Career/Tech Ed Rep***

Community Agency Rep

Teacher of the Gifted****

*The IEP team must invite the student if transition services are being planned or if the parents choose to have the student participate.

**If the student is, or may be, participating in the regular education environment***As determined by the LEA as needed for transition services and other community services****A teacher of the gifted is required when writing an IEP for a student with a disability who also is gifted.

One individual listed above must be able to interpret the instructional implications of any evaluation results.

Written input received from the following members:

Transfer of Rights at Age of MajorityFor purposes of education, the age of majority is reached in Pennsylvania when the individual reaches 21 years of age. Likewise, for purposes of the Individuals with Disabilities Education Act, the age of majority is reached for students with disabilities when they reach 21 years of age.


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 whom I may contact if I need more information.

Signature of Parent/Guardian/Surrogate:


Is the student blind or visually impaired?YesThe 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 students reading and writing skills, needs, and appropriate reading and writing media (including an evaluation of the students 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.


Is the student deaf or hard of hearing?

YesThe IEP must include a communication plan to address the following: language and communication needs; opportunities for direct communications with peers and professional personnel in the students language and communication mode; academic level; full range of needs, including opportunities for direct instruction in the students language and communication mode; and assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The Communication Plan must be completed and is available at


Does the student have communication needs?

YesStudent needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)


Does the student need assistive technology devices and/or services?

YesStudent needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)


Does the student have limited English proficiency?

YesThe IEP team must address the students language needs and how those needs relate to the IEP.


Does the student exhibit behaviors that impede his/her learning or that of others?YesThe IEP team must develop a Positive Behavior Support Plan that is based on a functional assessment of behavior and that utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in the Present Levels section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially Designed Instruction sections of the IEP or in the Positive Behavior Support Plan if this is a separate document that is attached to the IEP. A Positive Behavior Support Plan and a Functional Behavioral Assessment form are available at


Other (specify):


Include the following information related to the student:

Present levels of academic achievement (e.g., most recent evaluation of the student, results of formative assessments, curriculum-based assessments, transition assessments, progress toward current goals)

Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress toward current goals)

Present levels related to current postsecondary transition goals if the students age is 14 or younger if determined appropriate by the IEP team (e.g., results of formative assessments, curriculum-based assessments, progress toward current goals)

Parental concerns for enhancing the education of the student

How the students disability affects involvement and progress in the general education curriculum


Academic, developmental, and functional needs related to students disabilityPresent levels of Academic Achievement: Jacob was assessed March 10, 2009 using Diagnostic Reading Assessment (DRA) and scored a nonfiction level 24. A level 24 is equivalent to a second grade level. This is up from a level 16 which was scored in January. This shows an increase from middle of first grade to the middle of second grade reading levels.

Jacob has just begun to use reading strategies to decode uncommon words. He is strongest in using the beginning sound and using it in conjunction with picture clues to decode the word. He has improved in decoding words, but is weakest at isolation of sounds and blending sounds together to form a word. This is consistent with the results of his WIATT II Word Reading scores. Jacob scored an 82 on this sub-test which indicates his is below average in comparison to his same age peers. This was also consistent with his Pseudo-word decoding score of 81. It demonstrates that Jacobs phonetic knowledge to sound out nonsense or unfamiliar words. This score is also below average in comparison to his same age peers. Jacob struggles with visual perception tasks in math such as: analyzing data and plotting them on a bar graph. He also has struggles with concepts such as: adding money and counting change. He has difficulty comprehending that even though a nickel is larger than a dime it is worth less monetarily.He scored an 81 on the numerical section of the WIATT-II. This score indicates that he is able to complete most basic addition and subtraction problems, but struggled when the problems moved into multi-digit or more abstract tasks. Jacobs working memory score on the WIATT-II was 68 and was placed in the extremely low range. Jacob was administered the Arithmetic subtest. The score indicates that Jacobs abilities in this area are significantly below those of his same age peers and he will likely have difficulty with tasks that require him to retain and retrieve information, particularly auditory information.

Jacob requires extended time to complete tasks during class. He has difficulty in retrieving information that has been retained from prior lesson or skill. If Jacob is rushed or does not understand the questions asked he will become frustrated and unable to answer any of the questions. Often times Jacob becomes frustrated because his pencil breaks during activities. Pencil pressure and control are difficult for him.Present levels of functional performance:

Jacob participates in class and interacts well with his classmates. He fits in socially with his peers and has many friends.

Jacob often has difficulty remaining in his seat during instruction and at times he becomes off-task during lesson introduction, he requires prompting to regain his focus and attention on the lesson. He works well independently, if he is confident that he knows and understands the requirements of the lesson or independent work. He often requires one on one reassurance and assistance from the teacher on independent seatwork. Parental Concerns for enhancing the education of the student:

Mrs. Johnson expressed a concern about Jacobs organizational skills. She reports that it requires Jacob several attempts to begin a homework assi