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Individual Education Plan (IEP)

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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 Applicable
Interpreter/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
Page 1 of
Additional Exceptionalities
E-mail Address
PBSD 0659 (Rev. 2/10/2015) ORIGINAL - Student ESE Folder COPY - Parent/Guardian
Exceptional Student Education Individual Education Plan (IEP)
Individual Education Plan (IEP) Team/Signatures
The 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 on
Parent/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
Page 2 of
Date
Yes No
Standard High School Diploma Certificate of Completion
I have been provided information and chose:
Initials
DateSignature of Parent/Guardian
N/A
(For students turning 14 and older only)
PBSD 0659 (Rev. 2/10/2015) ORIGINAL - Student ESE Folder COPY - Parent/Guardian
Exceptional Student Education Individual Education Plan (IEP)
I. Special Considerations the IEP Team Must Consider Before Developing the IEP
Any 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)
Page 3 of
Important MEDICAL information
PBSD 0659 (Rev. 2/10/2015) ORIGINAL - Student ESE Folder COPY - Parent/Guardian
Exceptional Student Education Individual Education Plan (IEP)
II. Present Levels of Academic Achievement and Functional Performance
Include 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
Page of
PBSD 0659 (Rev. 2/10/2015) ORIGINAL - Student ESE Folder COPY - Parent/Guardian
Exceptional Student Education Individual Education Plan (IEP)
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
Limit 500 characters per text box. Do not exceed field boundaries - Attach additional information, if necessary.
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PBSD 0659 (Rev. 2/10/2015) ORIGINAL - Student ESE Folder COPY - Parent/Guardian
Exceptional Student Education Individual Education Plan (IEP)
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 Diploma
Special 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 Applicable
Measurable 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 Services
Information provided to parent List agency if current client
District designee
for agency follow-up:
Limit 300 characters per text box. Do not exceed field boundaries - Attach additional information, if necessary.
Not Applicable
Transfer 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 Diploma
9th grade students in 2015 cohort only choose (entering 9th 2014-2015
or later):
Choose one
Career Goal (long term)
PBSD 0659 (Rev. 2/10/2015) ORIGINAL - Student ESE Folder COPY - Parent/Guardian
Exceptional Student Education Individual Education Plan (IEP)
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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PBSD 0659 (Rev. 2/10/2015) ORIGINAL - Student ESE Folder COPY - Parent/Guardian
Exceptional Student Education Individual Education Plan (IEP)
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 Equipment
B = Medical Condition
C = Aide/Monitor Required
D = 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 Year
The 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 the
student'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?
PBSD 0659 (Rev. 2/10/2015) ORIGINAL - Student ESE Folder COPY - Parent/Guardian
Exceptional Student Education Individual Education Plan (IEP)
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 Accommodations
Assessment 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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PBSD 0659 (Rev. 2/10/2015) ORIGINAL - Student ESE Folder COPY - Parent/Guardian
Exceptional Student Education Individual Education Plan (IEP)
VII. Educational Placement
A. 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.
Limit 500 characters per text box. Do not exceed field boundaries - Attach additional information, if necessary.
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 Implementation
The 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 Notice
Does 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 Notes
Limit 500 characters per text box. Do not exceed field boundaries - Attach additional information, if necessary.
PBSD 1051
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Individual Education Plan (IEP)

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Completed 1 February 2022

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