Special education presentation

School District Identifying Information

Student Name:      

Date of Birth:       Local ID #:      

Disability Classification: FORMDROPDOWN

Projected date IEP is to be implemented:      

Projected date of annual review:      

PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL NEEDS

Documentation of student's current performance and academic, developmental and functional needs

Evaluation Results (including for school-age students, performance on State and district-wide assessments)

Academic Achievement, Functional Performance and Learning Characteristics

Levels of knowledge and development in subject and skill areas including activities of daily living, level of intellectual functioning, adaptive behavior, expected rate of progress in acquiring skills and information, and learning style:

Student strengths, preferences, interests:

Academic, developmental and functional needs of the student, including consideration of student needs that are of concern to the parent:

Social Development

The degree (extent) and quality of the student's relationships with peers and adults; feelings about self; and social adjustment to school and community environments:

Student strengths:

Social development needs of the student, including consideration of student needs that are of concern to the parent:

Physical Development

The degree (extent) and quality of the student’s motor and sensory development, health, vitality and physical skills or limitations which pertain to the learning process:

Student strengths:

Physical development needs of the student, including consideration of student needs that are of concern to the parent:

Management Needs

The nature (type) and degree (extent) to which environmental and human or material resources are needed to address needs identified above:      

Effect of Student Needs on Involvement and Progress in the General Education Curriculum or, for a Preschool Student, Effect of Student Needs on Participation in Appropriate Activities

Student Needs Relating to Special Factors

Based on the identification of the student's needs, the Committee must consider whether the student needs a particular device or service to address the special factors as indicated below, and if so, the appropriate section of the IEP must identify the particular device or service(s) needed.

Does the student need strategies, including positive behavioral interventions, supports and other strategies to address behaviors that impede the student's learning or that of others? FORMCHECKBOX Yes FORMCHECKBOX No

Does the student need a behavioral intervention plan? FORMCHECKBOX No FORMCHECKBOX Yes:      

For a student with limited English proficiency, does he/she need a special education service to address his/her language needs as they relate to the IEP?

FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not Applicable

For a student who is blind or visually impaired, does he/she need instruction in Braille and the use of Braille? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not Applicable

Does the student need a particular device or service to address his/her communication needs? FORMCHECKBOX Yes FORMCHECKBOX No

In the case of a student who is deaf or hard of hearing, does the student need a particular device or service in consideration of 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?

FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not Applicable

Does the student need an assistive technology device and/or service? FORMCHECKBOX Yes FORMCHECKBOX No

If yes, does the Committee recommend that the device(s) be used in the student's home? FORMCHECKBOX Yes FORMCHECKBOX No

Beginning not later than the first IEP to be in effect when the student is age 15 (and at a younger age if determined appropriate)

MEASURABLE POSTSECONDARY GOALS

long-term goals for living, working and learning as an adult

Education/Training:      

Employment:      

Independent Living Skills (when appropriate):      

TRANSITION NEEDS

In consideration of present levels of performance, transition service needs of the student that focus on the student's courses of study, taking into account the student’s strengths, preferences and interests as they relate to transition from school to post-school activities:      

MEASURABLE ANNUAL GOALS

The following goals are recommended to enable the student to be involved in and progress in the general education curriculum, address other educational needs that result from the student's disability, and prepare the student to meet his/her postsecondary goals.

Annual Goals

What the student will be expected to achieve by the end of the year in which the IEP is in effect

Criteria

Measure to determine if goal has been achieved

Method

How progress will be measured

Schedule

When progress will

be measured

REPORTING PROGRESS TO PARENTS

Identify when periodic reports on the student's progress toward meeting the annual goals will be provided to the student's parents:      

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MEASURABLE ANNUAL GOALS

The following goals are recommended to enable the student to be involved in and progress in the general education curriculum or, for a preschool child, in appropriate activities, address other educational needs that result from the student's disability, and, for a school-age student, prepare the student to meet his/her postsecondary goals.

Annual Goal

What the student will be expected to achieve by the end of the year in which the IEP is in effect

Criteria

Measure to determine if goal has been achieved

Method

How progress will be measured

Schedule

When progress will

be measured

Short-term Instructional Objectives and/or Benchmarks (intermediate steps between the student’s present level of performance and the measurable annual goal):

Annual Goal

Criteria

Method

Schedule

Short-term Instructional Objectives and/or Benchmarks (intermediate steps between the student’s present level of performance and the measurable annual goal):

Annual Goal

Criteria

Method

Schedule

Short-term Instructional Objectives and/or Benchmarks (intermediate steps between the student’s present level of performance and the measurable annual goal):

(Duplicate table/rows as needed)

REPORTING PROGRESS TO PARENTS

Identify when periodic reports on the student's progress toward meeting the annual goals will be provided to the student's parents:      

RECOMMENDED SPECIAL EDUCATION PROGRAMS AND SERVICES

Special Education Program/Services

Service Delivery Recommendations*

Frequency

How often provided

Duration

Length of session

Location

Where service will be provided

Projected Beginning/ Service Date(s)

Special Education Program:

FORMDROPDOWN FORMDROPDOWN      

FORMDROPDOWN FORMDROPDOWN      

FORMDROPDOWN FORMDROPDOWN      

FORMDROPDOWN FORMDROPDOWN      

Related Services:

FORMDROPDOWN

FORMDROPDOWN

FORMDROPDOWN

FORMDROPDOWN

Supplementary Aids and Services/Program Modifications/Accommodations:

Assistive Technology Devices and/or Services:

Supports for School Personnel on Behalf of the Student:

* Identify, if applicable, class size (maximum student-to-staff ratio), language if other than English, group or individual services, direct and/or indirect consultant teacher services or other service delivery recommendations.

12-Month Service and/or Program – Student is eligible to receive special education services and/or program during July/August: FORMCHECKBOX No FORMCHECKBOX Yes

If yes:

FORMCHECKBOX Student will receive the same special education program/services as recommended above.

OR

FORMCHECKBOX Student will receive the following special education program/services:

Special Education Program/Services

Service Delivery Recommendations

Frequency

Duration

Location

Projected Beginning/ Service Date(s)

Name of school/agency provider of services during July and August:      

For a preschool student, reason(s) the child requires services during July and August:      

Testing Accommodations (to be completed for preschool children only if there is an assessment program for nondisabled preschool children):

Individual testing accommodations, specific to the student’s disability and needs, to be used consistently by the student in the recommended educational program and in the administration of district-wide assessments of student achievement and, in accordance with Department policy, State assessments of student achievement

Testing Accommodation

Conditions*

Implementation Recommendations**

FORMCHECKBOX None

FORMDROPDOWN

FORMDROPDOWN

FORMDROPDOWN

FORMDROPDOWN

*Conditions – Test Characteristics: Describe the type, length, purpose of the test upon which the use of testing accommodations is conditioned, if applicable.

**Implementation Recommendations: Identify the amount of extended time, type of setting, etc., specific to the testing accommodations, if applicable.

Beginning not later than the first IEP to be in effect when the student is age 15 (and at a younger age, if determined appropriate).

COORDINATED SET OF TRANSITION ACTIVITIES

Needed activities to facilitate the student’s movement from school to

post-school activities

Service/Activity

School District/

Agency Responsible

Instruction

Related Services

Community Experiences

Development of Employment and Other Post-school Adult Living Objectives

Acquisition of Daily Living Skills (if applicable)

Functional Vocational Assessment (if applicable)

PARTICIPATION IN STATE AND DISTRICT-WIDE ASSESSMENTS

(To be completed for preschool students only if there is an assessment program for nondisabled preschool students)

FORMCHECKBOX The student will participate in the same State and district-wide assessments of student achievement that are administered to general education students.

FORMCHECKBOX The student will participate in an alternate assessment on a particular State or district-wide assessment of student achievement.

Identify the alternate assessment:      

Statement of why the student cannot participate in the regular assessment and why the particular alternate assessment selected is appropriate for the student:      

PARTICIPATION WITH STUDENTS WITHOUT DISABILITIES

Removal from the general education environment occurs only when the nature or severity of the disability is such that, even with the use of supplementary aids and services, education cannot be satisfactorily achieved.

For the preschool student:

Explain the extent, if any, to which the student will not participate in appropriate activities with age-appropriate nondisabled peers (e.g., percent of the school day and/or specify particular activities):      

For the school-age student:

Explain the extent, if any, to which the student will not participate in regular class, extracurricular and other nonacademic activities (e.g., percent of the school day and/or specify particular activities):      

If the student is not participating in a regular physical education program, identify the extent to which the student will participate in specially-designed instruction in physical education, including adapted physical education:      

Exemption from language other than English diploma requirement: FORMCHECKBOX No FORMCHECKBOX Yes – The Committee has determined that the student's disability adversely affects his/her ability to learn a language and recommends the student be exempt from the language other than English requirement.

SPECIAL TRANSPORTATION

Transportation recommendation to address needs of the student relating to his/her disability

FORMCHECKBOX None.

FORMCHECKBOX Student needs special transportation accommodations/services as follows:

FORMDROPDOWN      

FORMDROPDOWN      

FORMDROPDOWN      

FORMDROPDOWN      

FORMDROPDOWN      

FORMCHECKBOX Student needs transportation to and from special classes or programs at another site:      

PLACEMENT RECOMMENDATION

THIS IEP INCLUDES:

FORMCHECKBOX Transitions

FORMCHECKBOX Interim Service Plan

NEW YORK CITY

BOARD OF EDUCATION

INDIVIDUALIZED EDUCATION PROGRAM

CONFERENCE INFORMATION

CSE Case#   -     

Home District:    Service District:   

Date:   /  /    

Type:      

STUDENT INFORMATION *Age as of the date of the conference

Name:      

NYC ID#    -   -   

Date of Birth   /  /    

Gender FORMDROPDOWN

Address:      

Age:      

Phone: (   )    -    

English LAB      

Year     

Spanish LAB      

Year     

Grade FORMDROPDOWN

Language(s) Spoken/Mode of Communication FORMDROPDOWN

Primary Agency with whom student is involved      

Name of Contact       FORMTEXT      

Phone: (   )    -    

Agency Case#      

PARENT/GUARDIAN INFORMATION Relationship to Student

Name:      

FORMDROPDOWN

Address:      

Phone (Home): (   )    -    

Phone (Work): (   )    -    

Interpreter Required FORMCHECKBOX Yes FORMCHECKBOX No

Preferred Language/ Mode of Communication FORMDROPDOWN

SPECIAL MEDICAL/PHYSICAL ALERTS (Refer to Health & Physical Development Page for additional details.)

The student has FORMCHECKBOX medical conditions and/or FORMCHECKBOX physical limitations which affect his/her FORMCHECKBOX learning FORMCHECKBOX behavior and/or FORMCHECKBOX participation in school activities.

The student requires FORMCHECKBOX medication and/or FORMCHECKBOX health care treatment(s) or procedure(s) during the school day.

Other alerts:      

SUMMARY OF RECOMMENDATIONS Eligibility FORMCHECKBOX Yes FORMCHECKBOX No

Recommended Services Classification of Disability FORMDROPDOWN

FORMDROPDOWN      

Staffing Ratio

FORMDROPDOWN

Twelve Month School Year FORMCHECKBOX Yes FORMCHECKBOX No Recommended Services for the Twelve Month School Year

FORMDROPDOWN      

Staffing Ratio

FORMDROPDOWN

Other Recommendations (Check all that apply) *Details are provided in relevant sections of IEP

FORMCHECKBOX Program Accessibility

FORMCHECKBOX Adaptive Phys. Ed.*

FORMCHECKBOX Bilingual Instruction

FORMCHECKBOX Related Services

FORMCHECKBOX Assistive Technology

FORMCHECKBOX Monolingual Services with ESL

FORMCHECKBOX Monolingual Services without ESL

FORMCHECKBOX Special Education Transportation – Comment      

Students who are blind or visually impaired:

Students who are deaf or hard of hearing

Braille instruction needed FORMCHECKBOX Yes FORMCHECKBOX No

Language of Instruction      

Mode of Communication      

Copy for FORMCHECKBOX CSE FORMCHECKBOX Parent FORMCHECKBOX School FORMCHECKBOX Student FORMCHECKBOX Other Page 1

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

CONFERENCE INFORMATION

Referral Type:

FORMCHECKBOX Initial

FORMCHECKBOX Annual Review

Conference Type:

FORMCHECKBOX EPC

FORMCHECKBOX Annual Review

FORMCHECKBOX Triennial

FORMCHECKBOX Requested Review

FORMCHECKBOX CSE Review

FORMCHECKBOX CPSE Review

Attendance at Conference

Please note that your signature reflects your participation at the conference and does not necessarily indicate agreement with the

Individualized Education Program.

Signature/Title

Role

(Indicate if Bilingual)

Signature/Title

Role

(Indicate if Bilingual)

      FORMTEXT      

Parent/Legal Guardian

Parent/Legal Guardian

District Representative

Special Education Teacher

Or Related Service Provider

General Education Teacher

Parent Member (CPSE/CSE)

Student

Other

Education Evaluator

School Psychologist

Other

School Social Worker

Other

Other

Use an asterisk(*) to signify the participant who interprets the instructional implications of evaluation results.

Use the letter (T) to signify participation by teleconference.

Conference Result

FORMCHECKBOX Initiate Service

FORMCHECKBOX Modify Service

FORMCHECKBOX Change Recommended Service

FORMCHECKBOX No Change

Indicate Modifications

Initiation, Duration and Review of IEP

Projected Date of Initiation of IEP   /  /    

Projected Date of Review of IEP   /  /    

Duration of Services      

Contacts with Parent/Legal Guardian

Date Notice of Meeting Sent   /  /    

Date IEP and Notice of Recommendation

Date of Follow-up (if any)   /  /    

FORMCHECKBOX Given to Parent   /  /    

Type of Follow-up FORMCHECKBOX Letter FORMCHECKBOX Telephone

FORMCHECKBOX Sent to Parent   /  /    

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

ACADEMIC PERFORMANCE AND LEARNING CHARACTERISTICS

Describe the student’s present levels of academic achievement, language development, cognitive development and learning style in English and the other than English language for LEP students. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.

PRESENT PERFORMANCE:

READING and WRITING

MATH

Area

Date

Test/Evaluation

Score

Instructional Level

Area

Date

Test/Evaluation

Score

Instructional Level

Decoding

  /  /    

Computation

  /  /    

Reading Comprehension

  /  /    

Problem Solving

  /  /    

Listening Comprehension

  /  /    

  /  /    

Writing

  /  /    

  /  /    

  /  /    

  /  /    

  /  /    

  /  /    

ACADEMIC MANAGEMENT NEEDS

(Environmental modifications and human/material resources)

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

ACADEMIC PERFORMANCE AND LEARNING CHARACTERISTICS

Describe the student’s present levels of academic achievement, language development, cognitive development and learning style in English and the other than English language for LEP students. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.

PRESENT PERFORMANCE:

ACADEMIC MANAGEMENT NEEDS

(Environmental modifications and human/material resources)

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

ACADEMIC PERFORMANCE AND LEARNING CHARACTERISTICS

Describe the student’s present levels of academic achievement, language development, cognitive development and learning style in English and the other than English language for LEP students. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.

PRESENT PERFORMANCE:

ACADEMIC MANAGEMENT NEEDS

(Environmental modifications and human/material resources)

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

SOCIAL/EMOTIONAL PERFORMANCE

Describe the student’s strengths and weaknesses in the area of social and emotional development in English and the other than English language for LEP students.

Consider the degree and quality of the student’s relationships with peers and adults, feelings about self and social adjustment to school and community environments. Discuss how the student’s disability affects his/her involvement and progress in a general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.

PRESENT PERFORMANCE:

BEHAVIOR AND THE INSTRUCTIONAL PROCESS

FORMCHECKBOX Behavior is age appropriate

Describe present levels of support including personnel responsible for providing behavioral support

FORMCHECKBOX Behavior does not seriously interfere with instruction and can be addressed by the FORMCHECKBOX general education and/or FORMCHECKBOX special education classroom teacher.

FORMCHECKBOX Behavior seriously interferes with instruction and requires additional adult support.

FORMCHECKBOX Behavior requires highly intensive supervision.

SOCIAL/EMOTIONAL MANAGEMENT NEEDS

(Environmental modifications and human/materials resources)

A behavior intervention plan has been developed FORMCHECKBOX Yes FORMCHECKBOX No

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

SOCIAL/EMOTIONAL PERFORMANCE

Describe the student’s strengths and weaknesses in the area of social and emotional development in English and the other than English language for LEP students.

Consider the degree and quality of the student’s relationships with peers and adults, feelings about self and social adjustment to school and community environments. Discuss how the student’s disability affects his/her involvement and progress in a general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.

PRESENT PERFORMANCE:

BEHAVIOR AND THE INSTRUCTIONAL PROCESS

FORMCHECKBOX Behavior is age appropriate

Describe present levels of support including personnel responsible for providing behavioral support

FORMCHECKBOX Behavior does not seriously interfere with instruction and can be addressed by the FORMCHECKBOX general education and/or FORMCHECKBOX special education classroom teacher.

FORMCHECKBOX Behavior seriously interferes with instruction and requires additional adult support.

FORMCHECKBOX Behavior requires highly intensive supervision.

SOCIAL/EMOTIONAL MANAGEMENT NEEDS

(Environmental modifications and human/materials resources)

A behavior intervention plan has been developed FORMCHECKBOX Yes FORMCHECKBOX No

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

HEALTH AND PHYSICAL DEVELOPMENT

Describe the student’s health and physical development including the degree or quality of the student’s motor and sensory development, health, vitality and physical skills or limitations which pertain to the learning process, behavior and participation in physical education or other school activities. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.

PRESENT PERFORMANCE:

MEDICAL/HEALTH CARE NEEDS

PHYSICAL NEEDS

During the school day, the student requires:

The student FORMCHECKBOX does FORMCHECKBOX does not have mobility limitations.

Medication FORMCHECKBOX Yes FORMCHECKBOX No

(if yes, functionality describe the limitations(s).)

(if yes, functionality describe the limitations(s).)

The student requires:

Treatment(s) or other health procedure(s) FORMCHECKBOX Yes FORMCHECKBOX No

(If yes, functionally describe the condition for which treatment(s) or procedure(s) are required)

Accessible program FORMCHECKBOX Yes FORMCHECKBOX No

Adaptive Physical Education FORMCHECKBOX Yes FORMCHECKBOX No

Health as a related service FORMCHECKBOX Yes FORMCHECKBOX No

(If yes indicate staffing ratio: FORMDROPDOWN

(If yes, functionally describe the condition for which treatment(s) or procedure(s) are required)

Assistive Technology Device(s) FORMCHECKBOX Yes FORMCHECKBOX No

Assistive Technology Service(s) FORMCHECKBOX Yes FORMCHECKBOX No

(If assistive technology device(s) or service(s) are required, specify in management needs.)

HEALTH/PHYSICAL MANAGEMENT NEEDS

(Environmental modifications, human/material resources or specialized equipment)

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

HEALTH AND PHYSICAL DEVELOPMENT

Describe the student’s health and physical development including the degree or quality of the student’s motor and sensory development, health, vitality and physical skills or limitations which pertain to the learning process, behavior and participation in physical education or other school activities. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.

PRESENT PERFORMANCE:

MEDICAL/HEALTH CARE NEEDS

PHYSICAL NEEDS

During the school day, the student requires:

The student FORMCHECKBOX does FORMCHECKBOX does not have mobility limitations.

Medication FORMCHECKBOX Yes FORMCHECKBOX No

(if yes, functionality describe the limitations(s).)

(if yes, functionality describe the limitations(s).)

The student requires:

Treatment(s) or other health procedure(s) FORMCHECKBOX Yes FORMCHECKBOX No

(If yes, functionally describe the condition for which treatment(s) or procedure(s) are required)

Accessible program FORMCHECKBOX Yes FORMCHECKBOX No

Adaptive Physical Education FORMCHECKBOX Yes FORMCHECKBOX No

Health as a related service FORMCHECKBOX Yes FORMCHECKBOX No

(If yes indicate staffing ratio: FORMDROPDOWN

(If yes, functionally describe the condition for which treatment(s) or procedure(s) are required)

Assistive Technology Device(s) FORMCHECKBOX Yes FORMCHECKBOX No

Assistive Technology Service(s) FORMCHECKBOX Yes FORMCHECKBOX No

(If assistive technology device(s) or service(s) are required, specify in management needs.)

HEALTH/PHYSICAL MANAGEMENT NEEDS

(Environmental modifications, human/material resources or specialized equipment)

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

HEALTH AND PHYSICAL DEVELOPMENT

Describe the student’s health and physical development including the degree or quality of the student’s motor and sensory development, health, vitality and physical skills or limitations which pertain to the learning process, behavior and participation in physical education or other school activities. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.

PRESENT PERFORMANCE:

MEDICAL/HEALTH CARE NEEDS

PHYSICAL NEEDS

During the school day, the student requires:

The student FORMCHECKBOX does FORMCHECKBOX does not have mobility limitations.

Medication FORMCHECKBOX Yes FORMCHECKBOX No

(if yes, functionality describe the limitations(s).)

(if yes, functionality describe the limitations(s).)

The student requires:

Treatment(s) or other health procedure(s) FORMCHECKBOX Yes FORMCHECKBOX No

(If yes, functionally describe the condition for which treatment(s) or procedure(s) are required)

Accessible program FORMCHECKBOX Yes FORMCHECKBOX No

Adaptive Physical Education FORMCHECKBOX Yes FORMCHECKBOX No

Health as a related service FORMCHECKBOX Yes FORMCHECKBOX No

(If yes indicate staffing ratio: FORMDROPDOWN

(If yes, functionally describe the condition for which treatment(s) or procedure(s) are required)

Assistive Technology Device(s) FORMCHECKBOX Yes FORMCHECKBOX No

Assistive Technology Service(s) FORMCHECKBOX Yes FORMCHECKBOX No

(If assistive technology device(s) or service(s) are required, specify in management needs.)

HEALTH/PHYSICAL MANAGEMENT NEEDS

(Environmental modifications, human/material resources or specialized equipment)

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

HEALTH AND PHYSICAL DEVELOPMENT

Describe the student’s health and physical development including the degree or quality of the student’s motor and sensory development, health, vitality and physical skills or limitations which pertain to the learning process, behavior and participation in physical education or other school activities. Discuss how the student’s disability affects his/her involvement and progress in the general curriculum or, for preschool students, as appropriate, how the student’s disability affects participation in appropriate activities.

PRESENT PERFORMANCE:

MEDICAL/HEALTH CARE NEEDS

PHYSICAL NEEDS

During the school day, the student requires:

The student FORMCHECKBOX does FORMCHECKBOX does not have mobility limitations.

Medication FORMCHECKBOX Yes FORMCHECKBOX No

(if yes, functionality describe the limitations(s).)

(if yes, functionality describe the limitations(s).)

The student requires:

Treatment(s) or other health procedure(s) FORMCHECKBOX Yes FORMCHECKBOX No

(If yes, functionally describe the condition for which treatment(s) or procedure(s) are required)

Accessible program FORMCHECKBOX Yes FORMCHECKBOX No

Adaptive Physical Education FORMCHECKBOX Yes FORMCHECKBOX No

Health as a related service FORMCHECKBOX Yes FORMCHECKBOX No

(If yes indicate staffing ratio: FORMDROPDOWN

(If yes, functionally describe the condition for which treatment(s) or procedure(s) are required)

Assistive Technology Device(s) FORMCHECKBOX Yes FORMCHECKBOX No

Assistive Technology Service(s) FORMCHECKBOX Yes FORMCHECKBOX No

(If assistive technology device(s) or service(s) are required, specify in management needs.)

HEALTH/PHYSICAL MANAGEMENT NEEDS

(Environmental modifications, human/material resources or specialized equipment)

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

ANNUAL GOALS AND SHORT-TERM OBJECTIVES

There will be    reports of progress per year using the coding system shown below.

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

EXPLANATION OF CODING SYSTEM

METHODS OF MEASURMENT

REPORT OF PROGRESS

PROGRESS TOWARD GOAL

REASONS FOR NOT MEETING GOAL

1. Teacher made Materials

2. Standardized Tests

3. Class Activities

4. Portfolio(s)

5. Teacher/Provider Observations

6. Performance Assessment Task

7. Check Lists

8. Verbal Explanations

9. Other (specify)      

1. Not applicable during this grading period

2. No progress made

3. Little progress made

4. Progress made; goal not yet met

5. Goal met

A. Anticipate meeting goal

B. Do not anticipate meeting goal

(Note reason)

C. Goal met

1. More time needed

2. Excessive absence or lateness

3. Assignments not completed

4. Other (specify)      

*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time.

1st

2nd

3rd

4th

5th

6th

7th

8th

The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP:

For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened:

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

ANNUAL GOALS AND SHORT-TERM OBJECTIVES

There will be    reports of progress per year using the coding system shown below.

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

EXPLANATION OF CODING SYSTEM

METHODS OF MEASURMENT

REPORT OF PROGRESS

PROGRESS TOWARD GOAL

REASONS FOR NOT MEETING GOAL

1. Teacher made Materials

2. Standardized Tests

3. Class Activities

4. Portfolio(s)

5. Teacher/Provider Observations

6. Performance Assessment Task

7. Check Lists

8. Verbal Explanations

9. Other (specify)      

1. Not applicable during this grading period

2. No progress made

3. Little progress made

4. Progress made; goal not yet met

5. Goal met

A. Anticipate meeting goal

B. Do not anticipate meeting goal

(Note reason)

C. Goal met

1. More time needed

2. Excessive absence or lateness

3. Assignments not completed

4. Other (specify)      

*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time.

1st

2nd

3rd

4th

5th

6th

7th

8th

The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP:

For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened:

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

ANNUAL GOALS AND SHORT-TERM OBJECTIVES

There will be    reports of progress per year using the coding system shown below.

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

EXPLANATION OF CODING SYSTEM

METHODS OF MEASURMENT

REPORT OF PROGRESS

PROGRESS TOWARD GOAL

REASONS FOR NOT MEETING GOAL

1. Teacher made Materials

2. Standardized Tests

3. Class Activities

4. Portfolio(s)

5. Teacher/Provider Observations

6. Performance Assessment Task

7. Check Lists

8. Verbal Explanations

9. Other (specify)      

1. Not applicable during this grading period

2. No progress made

3. Little progress made

4. Progress made; goal not yet met

5. Goal met

A. Anticipate meeting goal

B. Do not anticipate meeting goal

(Note reason)

C. Goal met

1. More time needed

2. Excessive absence or lateness

3. Assignments not completed

4. Other (specify)      

*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time.

1st

2nd

3rd

4th

5th

6th

7th

8th

The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP:

For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened:

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

ANNUAL GOALS AND SHORT-TERM OBJECTIVES

There will be    reports of progress per year using the coding system shown below.

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

EXPLANATION OF CODING SYSTEM

METHODS OF MEASURMENT

REPORT OF PROGRESS

PROGRESS TOWARD GOAL

REASONS FOR NOT MEETING GOAL

1. Teacher made Materials

2. Standardized Tests

3. Class Activities

4. Portfolio(s)

5. Teacher/Provider Observations

6. Performance Assessment Task

7. Check Lists

8. Verbal Explanations

9. Other (specify)      

1. Not applicable during this grading period

2. No progress made

3. Little progress made

4. Progress made; goal not yet met

5. Goal met

A. Anticipate meeting goal

B. Do not anticipate meeting goal

(Note reason)

C. Goal met

1. More time needed

2. Excessive absence or lateness

3. Assignments not completed

4. Other (specify)      

*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time.

1st

2nd

3rd

4th

5th

6th

7th

8th

The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP:

For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened:

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

ANNUAL GOALS AND SHORT-TERM OBJECTIVES

There will be    reports of progress per year using the coding system shown below.

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

EXPLANATION OF CODING SYSTEM

METHODS OF MEASURMENT

REPORT OF PROGRESS

PROGRESS TOWARD GOAL

REASONS FOR NOT MEETING GOAL

1. Teacher made Materials

2. Standardized Tests

3. Class Activities

4. Portfolio(s)

5. Teacher/Provider Observations

6. Performance Assessment Task

7. Check Lists

8. Verbal Explanations

9. Other (specify)      

1. Not applicable during this grading period

2. No progress made

3. Little progress made

4. Progress made; goal not yet met

5. Goal met

A. Anticipate meeting goal

B. Do not anticipate meeting goal

(Note reason)

C. Goal met

1. More time needed

2. Excessive absence or lateness

3. Assignments not completed

4. Other (specify)      

*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time.

1st

2nd

3rd

4th

5th

6th

7th

8th

The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP:

For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened:

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

ANNUAL GOALS AND SHORT-TERM OBJECTIVES

There will be    reports of progress per year using the coding system shown below.

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

EXPLANATION OF CODING SYSTEM

METHODS OF MEASURMENT

REPORT OF PROGRESS

PROGRESS TOWARD GOAL

REASONS FOR NOT MEETING GOAL

1. Teacher made Materials

2. Standardized Tests

3. Class Activities

4. Portfolio(s)

5. Teacher/Provider Observations

6. Performance Assessment Task

7. Check Lists

8. Verbal Explanations

9. Other (specify)      

1. Not applicable during this grading period

2. No progress made

3. Little progress made

4. Progress made; goal not yet met

5. Goal met

A. Anticipate meeting goal

B. Do not anticipate meeting goal

(Note reason)

C. Goal met

1. More time needed

2. Excessive absence or lateness

3. Assignments not completed

4. Other (specify)      

*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time.

1st

2nd

3rd

4th

5th

6th

7th

8th

The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP:

For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened:

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

ANNUAL GOALS AND SHORT-TERM OBJECTIVES

There will be    reports of progress per year using the coding system shown below.

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

EXPLANATION OF CODING SYSTEM

METHODS OF MEASURMENT

REPORT OF PROGRESS

PROGRESS TOWARD GOAL

REASONS FOR NOT MEETING GOAL

1. Teacher made Materials

2. Standardized Tests

3. Class Activities

4. Portfolio(s)

5. Teacher/Provider Observations

6. Performance Assessment Task

7. Check Lists

8. Verbal Explanations

9. Other (specify)      

1. Not applicable during this grading period

2. No progress made

3. Little progress made

4. Progress made; goal not yet met

5. Goal met

A. Anticipate meeting goal

B. Do not anticipate meeting goal

(Note reason)

C. Goal met

1. More time needed

2. Excessive absence or lateness

3. Assignments not completed

4. Other (specify)      

*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time.

1st

2nd

3rd

4th

5th

6th

7th

8th

The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP:

For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened:

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

ANNUAL GOALS AND SHORT-TERM OBJECTIVES

There will be    reports of progress per year using the coding system shown below.

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

EXPLANATION OF CODING SYSTEM

METHODS OF MEASURMENT

REPORT OF PROGRESS

PROGRESS TOWARD GOAL

REASONS FOR NOT MEETING GOAL

1. Teacher made Materials

2. Standardized Tests

3. Class Activities

4. Portfolio(s)

5. Teacher/Provider Observations

6. Performance Assessment Task

7. Check Lists

8. Verbal Explanations

9. Other (specify)      

1. Not applicable during this grading period

2. No progress made

3. Little progress made

4. Progress made; goal not yet met

5. Goal met

A. Anticipate meeting goal

B. Do not anticipate meeting goal

(Note reason)

C. Goal met

1. More time needed

2. Excessive absence or lateness

3. Assignments not completed

4. Other (specify)      

*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time.

1st

2nd

3rd

4th

5th

6th

7th

8th

The student’s performance is approaching his/her promotion criteria as set forth on Page 9 of the IEP:

For students who are not anticipated to meet their annual goals and/or promotion criteria: We recommend that the IEP Team be reconvened:

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

ANNUAL GOALS AND SHORT-TERM OBJECTIVES

There will be    reports of progress per year using the coding system shown below.

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

  /  

  /  

  /  

  /  

  /  

  /  

  /  

  /  

ANNUAL GOAL:      

Progress

1st

2nd

3rd

4th

5th

6th

7th

8th

Methods of Measurement

Report of Progress

Progress Toward Annual Goal

Reasons for not Meeting Annual Goal

COMMENTS:      

EXPLANATION OF CODING SYSTEM

METHODS OF MEASURMENT

REPORT OF PROGRESS

PROGRESS TOWARD GOAL

REASONS FOR NOT MEETING GOAL

1. Teacher made Materials

2. Standardized Tests

3. Class Activities

4. Portfolio(s)

5. Teacher/Provider Observations

6. Performance Assessment Task

7. Check Lists

8. Verbal Explanations

9. Other (specify)      

1. Not applicable during this grading period

2. No progress made

3. Little progress made

4. Progress made; goal not yet met

5. Goal met

A. Anticipate meeting goal

B. Do not anticipate meeting goal

(Note reason)

C. Goal met

1. More time needed

2. Excessive absence or lateness

3. Assignments not completed

4. Other (specify)      

*While a review of your child’s educational program occurs every year please be advised that you have a right to request a review of your child’s program at any time.

1st

2nd

3rd

4th

5th

6th

7th