STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: _______________________________________
INDIVIDUALIZED EDUCATION PROGRAM (CONFERENCE SUMMARY REPORT)
DATE OF MOST RECENT EVALUATION:______________________________________ DATE OF NEXT REEVALUATION: __________________________________________
PURPOSE OF CONFERENCE (Check all that apply)
Review of Existing Data Reevaluation IEP Review/Revision FBA/BIP Graduation
Initial Evaluation/Eligibility Initial IEP Secondary Transition Manifestation Determination Other _________________
STUDENT IDENTIFICATION INFORMATION
STUDENT’S ADDRESS (Street, City, State, Zip Code) STUDENT’S DATE OF BIRTH SIS ID NUMBER
MALE
FEMALE
ETHNICITY
LANGUAGE/MODE OF COMMUNICATION USED BY STUDENT
CURRENT GRADE LEVEL ANTICIPATED DATE OF HIGH
SCHOOL GRADUATION
PLACEMENT(To be completed after placement determination)
Yes No Placement is in Resident School
DISABILITY(S) MEDICAID NUMBER
RESIDENT DISTRICT RESIDENT SCHOOL
PLACEMENT
SERVING DISTRICT SERVING SCHOOL
PARENT INFORMATION
(1) PARENT’S NAME EDUCATIONAL SURROGATE PARENT (2) PARENT’S NAME EDUCATIONAL SURROGATE PARENT
(1) PARENTS ADDRESS (Street, City, State, Zip Code) (2) PARENTS ADDRESS (Street, City, State, Zip Code)
(1) PARENT’S TELEPHONE NUMBER (Include Area Code) (2) PARENT’S TELEPHONE NUMBER (Include Area Code)
(1) LANGUAGE/MODE OF COMMUNICATION USED BY PARENT’S)
Yes No Interpreter
(2) LANGUAGE/MODE OF COMMUNICATION USED BY PARENT’S)
Yes No Interpreter
PROCEDURAL SAFEGUARDS
Explanation of Procedural Safeguards were provided to/reviewed with the parent(s) on _______________________________________________________.
Transfer of Rights - Seventeen-year old student informed of his/her rights that will transfer to the student upon reaching age 18. Yes No
Parent(s) were given a copy of the: Evaluation report and eligibility determination IEP
District’s behavioral intervention policies District’s behavioral intervention procedures (initial IEP only)
PARTICIPANTS INFORMATION
Signature indicates attendance. Check appropriate boxes to indicate which meetings were attended. Anyone serving in a dual role should indicate so on
the following lines. If a required participant participates through written input or is excused from all or part of the IEP meeting, the required excusal and written
report, as necessary, is attached.
ELIGIBILITY
REVIEW
IEP
ELIGIBILITY
REVIEW
IEP
________________________________________________
Parent
________________________________________________
School Social Worker
________________________________________________
Parent
________________________________________________
Speech-Language Pathologist
________________________________________________
Student
________________________________________________
Bilingual Specialist
________________________________________________
LEA Representative
________________________________________________
Interpreter
________________________________________________
General Education Teacher
________________________________________________
School Nurse
________________________________________________
Special Education Teacher
________________________________________________
Other (specify)
________________________________________________
School Psychologist
________________________________________________
Other (specify)
If the parent(s) did not attend the IEP meeting, document the attempts to contact the parent(s) prior to the IEP meeting.
ISBE 34-54 (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
DOCUMENTATION OF EVALUATION RESULTS
Complete for initial evaluations, reevaluations, or a review of an independent or outside evaluation.
Considering all available evaluation data, record the team’s analyses of the student’s functioning levels. Only those areas which were identied as relevant to the current evaluation
must be completed. All other areas should be noted as “Not Applicable”. Evaluation data may include: parental input, teacher recommendations, physical condition, social or
cultural background, adaptive behavior, record reviews, interviews, observations, testing etc. Describe the observed strengths and/or decits in the student’s functioning in the
following domains.
Academic Achievement (Current or past academic achievement data pertinent to current educational performance.)
Functional Performance (Current or past functional performance data pertinent to current functional performance.)
Cognitive Functioning (Data and other Information regarding intellectual ability; how the student takes in information, understands information, and expresses information.)
Communicative Status (Information regarding communicative abilities (language, articulation, voice, uency) affecting educational performance.)
For EL students explain EL STATUS: Has Linguistic status changed? Yes No
Health (Current or past medical difculties affecting educational perf
ormance.)
Hearing/Vision (Auditory/visual problems that would interfere with testing or educational performance. Include dates and results of last hearing/vision test.)
Motor Abilities (Fine and gross motor coordination difculties, functional mobility, or strength and endurance issues affecting educational performance.)
Social/Emotional Status/Social Functioning (Information regarding how the environment affects educational performance--life history, adaptive behavior, independent functioning,
personal and social responsibility, cultural background.)
ISBE 34-54A (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
ELIGIBILITY DETERMINATION
ALL DISABILITIES (OTHER THAN SPECIFIC LEARNING DISABILITY)
DETERMINANT FACTORS
The determinant factor for the student’s suspected disability is:
Yes No Lack of appropriate instruction in reading, including the essential components of reading instruction (Evidence Provided): _________________
_________________________________________________________________________________________________________________
Yes
Yes
No Lack of appropriate instruction in math (Evidence Provided): _________________________________________________________________
_________________________________________________________________________________________________________________
No English learner status (Evidence Provided): __________________________________________________________________________
_________________________________________________________________________________________________________________
If any of the above answers is “yes,” the student is not eligible for services under IDEA and the team must complete Step 1 and 4 below. If all of the answers are “no,”
complete Steps 1-4.
COMPLETE FOR STUDENTS SUSPECTED OF HAVING A DISABILITY UNDER IDEA
STEP 1 – DISABILITY
No Disability Identied (Complete Step 4 and write “Not Eligible for Special Education Services” in the Disability section of the Conference Summary Report
page.)
Disability Identied Based on the team’s analysis, identify the disability(s):
Primary Secondary Primary Secondary
Autism (O) Multiple Disabilities (M)
Deaf/Blindness (H) Orthopedic Impairment (C)
Deafness (G) Other Health Impairment (L)
Developmental Delay (3-9) (N) Speech or Language Impairment (I)
Emotional Disability (K) Traumatic Brain Injury (P)
Hearing Impairment (F) Visual Impairment including Blindness (E)
Intellectual Disability (A)
Step 2 – ADVERSE EFFECTS
No Adverse Effect Identied. (Complete Step 4 and write “Not Eligible for Special Education Services” in the Disability section of the Conference
Summary Report page.)
Adverse Effect Identied. For each disability identied, describe how the disability adversely affects the student’s educational performance.
STEP 3 – EDUCATIONAL NEEDS
State to what extent the student requires special education and related services to address educational needs.
STEP 4 – ELIGIBILITY
Based on the steps above, the student is entitled to special education and related services.
No (Not Eligible)
Yes (Eligible)
ISBE 34-54B (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: _______________________________________
DOCUMENTATION OF INTERVENTION/EVALUATION RESULTS
(SPECIFIC LEARNING DISABILITY)
Complete for initial evaluations, reevaluations, or a review of an independent or outside evaluation when a specic learning disability
is suspected.
As part of the evaluation process, relevant behavior noted during observation in the child’s age-appropriate learning environment, including
the general education classroom setting for school-age children, and the relationship of that behavior to the child’s academic functioning and
educationally relevant medical ndings, if any, must be documented.
PROBLEM IDENTIFICATION / STATEMENT OF PROBLEM:
Using baseline data, please provide an initial performance discrepancy statement for all identified areas of concern in the relevant domains
[academic performance; functional performance; cognitive functioning, c
ommunicative status (for EL students include an explanation of EL status and
any change in linguistic status); social/emotional status/functioning, motor abilities, health, hearing and vision] including information about the student’s
performance discrepancy prior to intervention. Attach evidence.
PROBLEM ANALYSIS / STRENGTHS AND WEAKNESSES:
Describe student’s skill strengths and weaknesses in the identied area(s) of concern within the relevant domains. Attach evidence, including evidence
of skills decit versus performance decit.
PLAN DEVELOPMENT / INTERVENTION(S):
Describe the previous and current intervention plan (core/Tier 1, supplemental/Tier 2, and intensive/Tier 3) including evidence that the intervention is
scientically based and was implemented with integrity. Attach plan/evidence.
PLAN EVALUATION / EDUCATIONAL PROGRESS:
Provide documentation of student progress over time as a result of the intervention. Attach evidence/graphs.
PLAN EVALUATION / DISCREPANCY:
State the current performance discrepancy after intervention, i.e., the difference between a student’s level of performance compared to the performance
of peers or scientically-based standards of expected performance. Attach evidence.
PLAN EVALUATION / INSTRUCTIONAL NEEDS:
Summarize the student’s needs in the areas of curriculum, instruction, and environment. Include a statement of whether the student’s needs in terms
of materials, planning, and personnel required for intervention implementation are signicantly different from those of general education peers. Attach
evidence.
ADDITIONAL INFORMATION NECESSARY FOR DECISION-MAKING (INCLUDE AS APPROPRIATE):
Report any educationally relevant information necessary for decision-making, including information regarding eligibility exclusionary and inclusionary
criteria. Attach evidence.
ISBE 34-54C (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
ELIGIBILITY DETERMINATION
(SPECIFIC LEARNING DISABILITY)
Complete for initial evaluations, reevaluations, or a review of an independent or outside evaluation when a specic learning
disability is suspected.
DETERMINANT FACTORS
The determinant factor for the student’s suspected disability is:
Yes No
Yes No
Yes No
Lack of appropriate instruction in reading, including the essential components of reading instruction
(Evidence Provided) ___________________________________________
Lack of appropriate instruction in math (Evidence Provided) ________________________________________
English learner status (Evidence Provided) _____________________________________________________
If any of the above answers is “yes,” the student is not eligible for services under IDEA and the team must complete the Eligibility Determination
section accordingly. If all of the answers are “no,” complete the following sections.
EXCLUSIONARY CRITERIA
The team determined that the following factors are the primary basis for the student’s learning difculties. Document the source of evidence
in each area:
Yes No A visual, hearing or motor disability: ________________________________________________________________
Yes No Intellectual Disability: ____________________________________________________________________________
Yes No Emotional disability: _____________________________________________________________________________
Yes No Cultural factors: ________________________________________________________________________________
Yes No Environmental or economic disadvantage: ___________________________________________________________
If any of the boxes immediately above is checked “yes,” the student cannot have a specic learning disability and the team must
complete the Eligibility Determination section accordingly.
INCLUSIONARY CRITERIA
Educational Progress (Over Time)
Evidence in the Documentation of Evaluation Results should support the team’s answer to this question.
Is the student progressing at a signicantly slower rate than is expected in any areas of concern?
(Select One)
No
Yes The student is progressing at a signicantly slower rate than expected
Yes The student is currently making an acceptable rate of progress but only because of the intensity of the intervention that is
being provided.
If yes, in which area(s)?
Discrepancy (At One Point in Time)
Evidence in the Documentation of Evaluation Results should support the team’s answer to this question.
Is the student’s performance signicantly below performance of peers or expected standards in any areas of concern?
(Select One)
No
Yes The student’s performance is signicantly discrepant.
Yes The student’s performance is not currently discrepant but only because of the intensity of the intervention that is being
provided.
If yes, in which area(s)?
ISBE 34-54D (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
ELIGIBILITY DETERMINATION
(SPECIFIC LEARNING DISABILITY)
Instructional Need
Evidence in the Documentation of Evaluation Results should support the team’s answer to this question.
Are this student’s needs in any areas of concern signicantly different from the needs of typical peers and of an intensity or type that exceeds
general education resources?
(Select One)
No
Yes The student’s instructional needs are signicantly different and exceed general education resources.
If yes, in which area(s)?
If any of the boxes in this section (Inclusionary Criteria) are marked “No”, the student does not have a Specic Learning Disability
and the team must complete the Eligibility Determination section accordingly.
Optional Criteria
After determining that the criteria in the preceding section are met, the district may choose to use an IQ-achivement discrepancy model. If
using this model, complete this section.
IQ-Achievement Discrepancy:
Yes No NA
Does a severe discrepancy exist between achievement and ability that is not correctable without special education
and related services? (Please refer to evidence in Documentation of Evaluation Results)
If yes, in which area(s)?
ELIGIBILITY DETERMINATION
Step 1: Disability Adversely Affecting Educational Performance
Yes No
Based on the answers to the questions in the “Determinant Factors, Exclusionary Criteria,” and “Inclusionary Criteria,”
sections, does the student have a specic learning disability?
If the answer is “no” the student is not eligible for special education services under the category of Specic Learning Disability and the team
must complete Step 2 below.
If the answer is “yes,” indicate the area below and complete Step 2.
Basic reading skills Mathematical calculation Oral expression
Reading uency skills Mathematical problem solving Listening comprehension
Reading comprehension Written expression
Step 2: Special Education and Related Services
Specialized instruction is required in order for the student to make progress and reduce discrepancy (Eligible)
Specialized instruction is not required in order for the student to make progress and reduce discrepancy (Not Eligible)
Each team member must sign below to certify that the report reects his/her conclusions for specic learning disability. Any participant who
disagrees with the team’s decision must submit a separate statement presenting her/his conclusions.
Yes No
_________________________________________
Yes No
______________________________________
Yes No
_________________________________________
Yes No
______________________________________
Yes No
_________________________________________
Yes No
______________________________________
Yes No
_________________________________________
Yes No
______________________________________
ISBE 34-54E (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
DATA CHART
(OPTIONAL)
REPORT OF PERFORMANCE (READING, WRITING, MATH)
Insert a data chart that displays the student’s performance in reading, writing, and/or math relative to his/her peer group. Data charts may
be provided for other areas, as well.
REPORT OF PERFORMANCE
(INSERT DATA CHART)
REPORT OF PERFORMANCE
(INSERT DATA CHART)
ISBE 34-54F (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Complete for initial IEPs and annual reviews.
When completing this page, include all areas from the following list that are impacted by the student’s disability: academic performance,
social/emotional status, independent functioning, vocational, motor skills, and speech and language/communication. This may include
strengths/weaknesses identied in the most recent evaluation.
Student’s Strengths
Parental Educational Concerns/Input
Student’s Present Level of Academic Achievement (Include strengths and areas needing improvement)
Student’s Present Levels of Functional Performance (Include strengths and areas needing improvement)
Describe the effect of this individual’s disability on involvement and progress in the general education curriculum and the functional implications
of the student’s skills.
For a preschool child, describe the effect of this individual’s disability on involvement in appropriate activities.
By age 14½, describe the effect of this individual’s disability on the pursuit of post-secondary expectations (living, learning, and
working).
ISBE 34-54G (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
SECONDARY TRANSITION
Complete for students age 14½ and older, and when appropriate for students younger than age 14½. Post-school outcomes should
guide the development of the IEP for students age 14½ and older.
AGE-APPROPRIATE TRANSITION ASSESSMENTS
TRANSITION ASSESSMENTS
(Including student and family survey/interview)
Assessment
Type
Responsible Agency/Person
Date
Conducted
EMPLOYMENT
EDUCATION
TRAINING
INDEPENDENT LIVING SKILLS
POST-SECONDARY OUTCOMES (Address By Age 14 1/2)
Indicate and project the desired appropriate measurable post-secondary outcomes/goals as identied by the student, parent and IEP team.
Goals are based upon age appropriate transition assessments related to employment, education and/or training, and independent living
skills.
Employment Outcomes/Goals (e.g., competitive, supported shelter, non-paid employment as a volunteer or training capacity, military): AND
Post-Secondary Education Outcomes/Goals (e.g., community college, 4-year university, technical/vocational/trade school): AND/OR
Post-Secondary Training Outcomes/Goals (e.g., vocational or career eld, vocational training program, independent living skills training,
apprenticeship, OJT, job corps): AND
Independent Living Outcomes/Goals (e.g., independent living, health/safety, self-advocacy/future planning, transportation/mobility, social
relationships, recreation/leisure, nancial/income needs):
COURSE OF STUDY (address by age 14 1/2)
Identify a course of study that is a long-range educational plan or multi-year description of the educational program that directly relates to
the student’s anticipated post-school goals, preferences and interests as described above.
Year 1 Year 2 Year 3 Year 4 Extended
ISBE 34-54H (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: _______________________________________
TRANSITION SERVICES (address by age 141/2)
Please include, if appropriate, needed linkages for outside agencies, (e.g., DMH, DRS, DSCC, PAS, SASS, SSI, WIC, DHFS, etc.)
INSTRUCTION (e.g., tutoring, skills training, prep for college entrance exam,
accommodations, adult basic education.)
Provider Agency and Position
Goal #(s) if appropriate
Date/Year to be Addressed
Date/Year Completed
RELATED SERVICES (e.g., transportation, social services, medical services, technology,
support services)
Provider Agency and Position
Goal #(s) if appropriate
Date/Year to be Addressed
Date/Year Completed
COMMUNITY EXPERIENCES (e.g., job shadow, work experiences, banking, shopping,
transportation, tours of post-secondary settings)
Provider Agency and Position
Goal #(s) if appropriate
Date/Year to be Addressed
Date/Year Completed
DEVELOPMENT OF EMPLOYMENT AND OTHER POST-SCHOOL ADULT LIVING
OBJECTIVES (e.g., career planning, guidance counseling, job try-outs, register to vote,
adult benets planning)
Provider Agency and Position
Goal #(s) if appropriate
Date/Year to be Addressed
Date/Year Completed
APPROPRIATE ACQUISITION OF DAILY LIVING SKILLS AND/OR FUNCTIONAL
VOCATIONAL EVALUATION (e.g., self-care, home repair, home health, money,
independent living, / job and career interests, aptitudes and skills)
Provider Agency and Position
Goal #(s) if appropriate
Date/Year to be Addressed
Date/Year Completed
LINKAGES TO AFTER GRADUATION SUPPORTS/SERVICES (e.g. DRS, DMH,
DSCC, PAS, SASS, SSI, WIC, DHFS, CILs)
Provider Agency and Position
Goal #(s) if appropriate
Date/Year to be Addressed
Date/Year Completed
HOME-BASED SUPPORT SERVICES PROGRAM
Yes No The student has a developmental disability and may become eligible for the program after reaching age 18 and when
no longer receiving special education services.
If yes, complete the following statements:
Plans for determining the student’s eligibility for home-based services:
Plans for enrolling the student in the program of home-based services:
Plans for developing a plan for the student’s most effective use of home-based services after reaching age 18 and when no longer receiving
special education services:
ISBE 34-54I (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
FUNCTIONAL BEHAVIORAL ASSESSMENT (AS APPROPRIATE)
Complete when gathering information about a student’s behavior to determine the need for a Behavioral Intervention Plan. When
used in developing a Behavioral Intervention Plan, the Functional Behavioral Assessment must be reviewed at an IEP meeting
and should be attached to the IEP.
The Functional Behavioral Assessment must include data collected through direct observation of the target behavior. Attach documentation
of data collection.
Student’s Strengths – Include a description of behavioral strengths (e.g., ignores inappropriate behavior of peers, positive interactions
with staff, accepts responsibility, etc.)
Operational Denition of Target Behavior – Include a description of the frequency, duration and intensity of the behavior.
Setting – Include a description of the setting in which the behavior occurs (e.g., physical setting, time of day, persons involved.)
Antecedents – Include a description of the relevant events that preceded the target behavior.
Consequences – Include a description of the result of the target behavior (e.g. removed from classroom and did not complete assignment.
What is the payoff for the student?)
Environmental Variables – Include a description of any environmental variables that may affect the behavior (e.g., medication, weather,
diet, sleep, social factors.)
Hypothesis of Behavioral Function - Include a hypothesis of the relationship between the behavior and the environment in which it occurs.
ISBE 34-54J (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
BEHAVIORAL INTERVENTION PLAN (AS APPROPRIATE)
Complete when the team has determined a Behavioral Intervention Plan is needed.
Target Behavior
Is this behavior a Skill Decit or a Performance Decit?
Skill Decit: The student does not know how to perform the desired behavior.
Performance Decit: The student knows how to perform the desired behavior, but does not consistently do so.
Student’s Strengths – Describe student’s behavioral strengths.
Hypothesis of Behavioral Function – Include hypothesis developed through the Functional Behavioral Assessment (attach completed
form). What desired thing(s) is the student trying to get? OR What undesired thing(s) is the student trying to avoid?
Summary of Previous Interventions Attempted – Describe any environmental changes made, evaluations conducted, instructional strategy
or curriculum changes made or replacement behaviors taught.
Replacement Behaviors – Describe which new behaviors or skills will be taught to meet the identied function of the target behavior (e.g.
student will slap his desk to replace striking out at others). Include description of how these behaviors/skills will be taught.
ISBE 34-54K (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
Page 1 of 2
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
BEHAVIORAL INTERVENTION PLAN (AS APPROPRIATE)
Behavioral Intervention Strategies and Supports
Environment – How can the environment or circumstances that trigger the target behavior be adjusted?
Instruction and/or Curriculum – What changes in instructional strategies or curriculum would be helpful?
Positive Supports Describe all additional services or supports needed to address the student’s identied needs that contribute to the
target behavior.
Motivators and/or Rewards – Describe how the student will be reinforced to ensure that replacement behaviors are more motivating than
the target behavior.
Restrictive Disciplinary Measures – Describe any restrictive disciplinary measures that may be used with the student and any conditions
under which such measures may be used (include necessary documentation and timeline for evaluation.)
Crisis Plan – Describe how an emergency situation or behavior crisis will be handled.
Data Collection Procedures and Methods – Describe expected outcomes of the interventions, how data will be collected and measured,
timelines for and criteria to determine success or lack of success of the interventions.
Provisions For Coordination with Caregivers – Describe how the school will work with the caregivers to share information, provide
training to caregivers if needed, and how often this communication will take place.
ISBE 34-54L (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
Page 2 of 2
SENT
HER A
NOTE
ABOUT
THIS.
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: _______________________________________
GOALS AND OBJECTIVES/BENCHMARKS
Complete for initial IEPs and annual reviews. (Anyone responsible for implementing the IEP (e.g., goals and objectives/benchmarks,
accommodations, modications and supports) must be notied of her/his specic responsibilities.)
REPORTING ON GOALS
The progress on annual goals will be measured by the short-term objectives/benchmarks. Check the methods that will be used to notify parents
of the student’s progress on annual goals and if the progress is sufcient to achieve the goals by the end of the IEP year:
Report card Progress reports Parent conference Other (specify) _________________________________
CURRENT ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Results of the initial or most recent evaluation and results on district-wide assessments relevant to this goal; performance in comparison to
general education peers and standards.
GOALS AND OBJECTIVES/BENCHMARKS
The goals and short-term objectives or benchmarks shall meet the student’s educational needs that result from the student’s disability,
including involvement in and progress in the general curriculum, or for preschool students, participation in appropriate activities.
Goal Statement # ____ of ____ Indicate Goal Area: Academic Functional Transition Illinois Learning Standard: # ____
Title(s) of Goal Implementer(s)
Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal
Evaluation
Criteria
Evaluation
Procedures
Schedule for
Determining Progress
Dates Reviewed/
Extent of Progress
______ % Accuracy
___/___ # of attempts
Other (specify)
________________
Observation Log
Data Charts
Tests
Other (specify)
____________________
Daily
Weekly
Quarterly
Semester
Other (specify)
____________________
Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal
Evaluation
Criteria
Evaluation
Procedures
Schedule for
Determining Progress
Dates Reviewed/
Extent of Progress
______ % Accuracy
___/___ # of attempts
Other (specify)
________________
Observation Log
Data Charts
Tests
Other (specify)
____________________
Daily
Weekly
Quarterly
Semester
Other (specify)
____________________
Short-Term Objective/Benchmark for Measuring Progress on the Annual Goal
Evaluation
Criteria
Evaluation
Procedures
Schedule for
Determining Progress
Dates Reviewed/
Extent of Progress
______ % Accuracy
___/___ # of attempts
Other (specify)
________________
Observation Log
Data Charts
Tests
Other (specify)
____________________
Daily
Weekly
Quarterly
Semester
Other (specify)
____________________
ISBE 34-54M (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
EDUCATIONAL ACCOMMODATIONS AND SUPPORTS
Complete for initial IEPs and annual reviews. (Anyone responsible for implementing the educational accommodations must be
notied of her/his specic responsibilities).
CONSIDERATION OF SPECIAL FACTORS
Check the boxes to indicate if the student requires any supplementary aids and/or services due to the following factors. For any box checked
“yes,” specify the special factors in the “Supplementary Aids, Accommodations and Modications” section and/or the Linguistic
and Cultural Accommodations section listed below.
Yes No
Yes No
Yes No
Yes No
Yes No
assistive technology devices and/or services. If yes, please specify needed AT. If no, specify why AT is not needed to access FAPE.
communication needs including students who are deaf/hard of hearing. If yes, complete linguistic and cultural accommodations
section below.
English learner status– language needs
blind/visually impaired – provision of Braille instruction
behavior impedes student’s learning or that of others. If yes, the team must consider strategies, including positive behavioral
interventions and supports to address behavior. This may include a Functional Behavioral Assessment and/or a
Behavioral Intervention Plan. If so, attach any completed forms.
LINGUISTIC AND CULTURAL ACCOMMODATIONS
Yes No
The student requires accommodations for the IEP to meet her/his linguistic and cultural needs. This includes students who are
deaf/hard of hearing. If yes, specify any needed accommodations:
Yes No
Special education and related services will be provided in a language or mode of communication other than or in addition to English.
This includes services provided to students who are deaf/hard of hearing. If yes, specify any needed accommodations:
For students who are deaf/hard of hearing and others, as applicable:
Identify the language and communication need(s): ASL Auditory/Oral Cued Speech Speech Generated Device Tactile
Signed English Other (please describe) ________________________
List the opportunities for direct communication/interaction with peers and professional personnel in the child’s language and communication mode:
List the identied mode of communication accessible in academic instruction, school services, and extracurricular activities that the student will receive:
SUPPLEMENTARY AIDS, ACCOMMODATIONS, AND MODIFICATIONS
Specify what aids, accommodations, and modications are needed for the child to make progress toward annual goals, to progress in the general education
curriculum, participate in extracurricular and other non-academic activities, and to be educated and participate with other children with disabilities and/
or nondisabled children (e.g., accommodations for daily work, environmental accommodations, moving from class to class, etc.). Supplementary aids,
accommodations, and modications must be based upon peer-review research to the extent practicable.
SUPPORTS FOR SCHOOL PERSONNEL
Yes No
Program trainings and/or supports for school personnel are needed for the student to advance appropriately
toward attaining the annual goals, participate in the general curriculum, and be educated and participate with
other students in educational activities. If yes, specify what trainings and/or supports are needed, including
when appropriate, the information that clarifies when the trainings and/or supports will be provided, by
whom, in what location, etc.
ISBE 34-54N (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
Student will participate in classroom assessments with no accommodation(s).
Student will participate in classroom assessments with accommodation(s). (Complete Assessment Accommodations).
District does not administer district-wide assessments.
District does not administer district-wide assessments at this grade level. ___________
Student will:
Not participate in the entire district-wide assessment.
Participate in the entire district-wide assessment with no accommodation(s).
Participate in entire assessment with accommodation(s). (Complete Assessment Accommodations section)
Participate in part(s) of the district-wide assessment (specify which part(s) and what, if any, accommodations
are required). (Complete Assessment Accommodations section on the IEP).
Participate in the district-wide alternate assessment without accommodation(s).
Participate in the district-wide alternate assessment with accommodation(s). (Complete Assessment Accommodations)
Indicate which state academic assessment(s) student will take and, if applicable, if accessibility feature(s) and/or accommodation(s)
are needed.
State academic assessments are not administered at this grade level:
1. Illinois Assessments of Readiness (IAR) (grades 3-8)
The IAR assessment is not appropriate. (Go to #2)
Student will:
Participate in IAR with no accessibility features turned on in advance and no accommodation(s).
Participate in IAR assessment with accessibility features turned on in advance and/or accommodation(s). (Complete
IAR Accessibility Features and Accommodations form and attach).
2. Dynamic Learning Maps (DLM) (ELA/L, Math, Science) (Alternate assessment Grades 3-11)
The DLM Participation Guidelines were met. (Complete the DLM Participation Guidelines and attach).
If met, the student will:
Participate in DLM with no accessibility features/accommodation(s).
Participate in DLM with accessibility features/accommodation(s). (Complete the DLM Accessibility Features and
Accommodations form and attach)
3. College Board Assessments (Grades 9-11)
Participate in PSAT 9, PSAT 10, and SAT assessments with no accommodations.
Participate in PSAT 9, PSAT 10, and SAT assessments with accommodation(s). (Complete College Board Assessments
Accommodations Section)
4. Illinois Science Assessment (ISA) (Grades 5, 8, High School) (Biology)
Not administered at student’s current grade level or course.
Participate in science assessment with no accommodation(s).
Participate in science assessment with accommodation(s). (Complete Science Assessment Accommodations section)
5. Physical Fitness Assessment (e.g.Brockport ,FitnessGram )
Willnotparticipateinthephysicalfitnessassessment(Explain):
Participate in FitnessGram
©
with no accommodation(s). Participate in Fitness Gram© with accommodation(s).
Participate in the Brockport
©
with no accommodation(s).
Participate in the Brockport
©
with accommodation(s). (As delineated in the test manual)
6. Kingergarten Individual Development Survey (KIDS)
The KIDS Assessment is not appropriate.
Participate in KIDS with no accommodation(s). Indicate which subsets: 1 2 3
Participate in KIDS with accommodation(s). Indicate which subsets: 1 2 3
(Complete Assessment Accommodation Section)
ISBE34-54O(2/19)
IllinoisStateBoardofEducation,SpecialEducationServices,100NorthFirstStreet,Springeld,Illinois62777-0001
DISTRICT-WIDE ASSESSMENTS
STATE ASSESSMENTS
CLASSROOM-BASED ASSESSMENTS
ASSESSMENT
STUDENT NAME: _____________________________________ DATE OF MEETING: __________________________
©
©
STATE ASSESSMENT OF ENGLISH LANGUAGE PROFICIENCY
ASSESSMENT ACCOMODATIONS
ThestateassessmentsoflanguageproficiencyforEnglishlearners(EL)ingradesK-12include:AccessingComprehensionand
CommunicationinEnglishStatetoState(ACCESS)andtheAlternateACCESS.
Yes No Englishlearner(EL).If“NO”,skiptonextsection
If yes, the student will:
ParticipateintheACCESSwithnoaccommodation(s).
ParticipateintheACCESSwithaccommodation(s).(Complete Assessment Accommodations section).
ParticipateinthealternateACCESSwithnoaccommodation(s).
ParticipateinthealternateACCESSwithaccommodation(s).(Complete Assessment Accommodations section of the IEP).
If the student will participate in assessments withaccommodations, other than IAR, DLM, and/or ISA, document any needed
accommodations for the content area(s) in the section below.
Classroom-basedAssessments
District-based Assessments
CollegeBoardAssessments
Science Assessment
Physical Fitness Assessment (e.g. Brockport
©
)
KIDS Assessment
Indicate which accommodations are needed:
CommunicationDevices Braille EnlargedPrint/pictures FMSystem
Adapted Writing Utensils Adapted Scissors
ACCESS/AlternateACCESS
ISBE34-54O(2/19)
IllinoisStateBoardofEducation,SpecialEducationServices,100NorthFirstStreet,Springeld,Illinois62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
EDUCATIONAL SERVICES AND PLACEMENT
Initiation Date: ______ / ______ / ______ Duration Date: ______ / ______ / ______
PARTICIPATION IN GENERAL EDUCATION CLASSES
The IEP must address all content areas, classes, and specify if the student will participate in general physical education.
General Education with No Supplementary Aids
(Specify content areas, classes, whether or not the child will participate in general physical education, and extracurricular
and other nonacademic activities.)
Minutes Per Week
In Setting
(Optional)
General Education with Supplementary Aids (as specied in the Supplementary Aids section)
Specify content areas, classes, whether or not the child will participate in general physical education, and extracurricular
and other nonacademic activities with supports, if applicable.)
Minutes Per Week
In Setting
(Optional)
Special Education and Related Services within the General Education Classroom
(Specify content areas and classes in which the child will participate with the provision of special education and related
services. List each special education and related service that will be provided during each class.)
Minutes Per Week
In Setting
PARTICIPATION IN SPECIAL EDUCATION CLASSES/SERVICES
The IEP must address all special education and related services.
Special Education Services – Outside General Education
Minutes Per Week
In Setting
A.
Related Services – Outside General Education
Minutes Per Week
In Setting
B.
Educational Environment (EE) Calculation (Ages 3-5) Educational Environment (EE) Calculation (Ages 6-21)
_________ 1. Minutes spent in regular early childhood program
_________ 2. Minutes spent receiving special education and related
services outside regular early childhood (A+B)
_________ 1. Total Bell to Bell Minutes
_________ 2. Total Number of Minutes Outside of the General
Education Setting (A+B)
_________ 3. Total Number of Minutes inside the General
Education Setting (line #1 minus line #2)
_________ 4. Percentage of time inside the General Education
Environment (line #3 divided by line #1)
ISBE 34-54P (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
EDUCATIONAL SERVICES AND PLACEMENT
EDUCATIONAL ENVIRONMENT CONSIDERATIONS
To the maximum extent appropriate, all students shall be educated and participate with students who are non-disabled. Provide an
explanation of the extent, if any, to which the student will not participate in general education classes and activities.
Yes No Special education classes, separate schooling, or removal from the regular education environment is required because
the nature or severity of the student’s disability is such that education in general classes with the use of supplementary
aids and services cannot be achieved satisfactorily.
Explain:______________________________________________________________________________________
Yes No Will participate in nonacademic activities with nondisabled peers and have the same opportunity to participate in
extracurricular activities as nondisabled peers?.
If no, explain: _________________________________________________________________________________
Yes No Will attend the school he or she would attend if nondisabled?
If no, explain: _________________________________________________________________________________
PLACEMENT CONSIDERATIONS
When determining the placement, consider any potentially harmful effect either on the student or the quality of services that he/she needs.
After determining the student’s placement, complete the “Placement” section on this cover sheet.
Yes N/A For a child who is deaf, hard or hearing, blind or visually impaired, parents have been informed of existence of the Illinois
School for the Deaf or the Illinois School for the Visually Impaired, and other local schools that provide similar services.
PLACEMENT OPTIONS CONSIDERED
POTENTIALLY HARMFUL EFFECT/
REASONS REJECTED
TEAM ACCEPTS PLACEMENT
Yes No
Yes No
Yes No
TRANSPORTATION
Check all that apply
Yes No
Special transportation is required to and from schools and/or between schools.
Yes No
Special transportation is required in and around school buildings.
Yes No
Specialized equipment (such as special or adapted buses, lifts, and ramps) is required.
Please explain and/or detail transportation plan:
EXTENDED SCHOOL YEAR SERVICES
Yes No Extended school year services are needed. The IEP team must document the consideration of the need for extended
school year services and the basis for the determination.
If yes, the IEP must indicate the type, amount and duration of services to be provided.
SPECIAL EDUCATION
SERVICE(S)
LOCATION
AMOUNT/FREQUENCY
OF SERVICES
INITIATION OF
SERVICES
DURATION OF
SERVICES
GOAL(S)
ADDRESSED
ISBE 34-54Q (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
MANIFESTATION DETERMINATION (AS APPROPRIATE)
Complete when determining whether a student’s behavior was a manifestation of her/his disability.
Disability:
Incident(s) that Resulted in Disciplinary Action
The Student’s IEP and Placement (include a review of all relevant information in the child’s le, including the child’s IEP)
Observations of the Student (include a review of staff observations regarding the student’s behavior)
Information provided by the Parents (include a review of any relevant information provided by the parent(s)
Based upon the above information, the team has determined that:
Yes No The conduct was caused by or had a direct and substantial relationship to the student’s disability.
Yes No The conduct was the direct result of the school district’s failure to implement the IEP.
If “Yes” to either of the above, the behavior must be considered a manifestation of the student’s disability.
Check the appropriate box:
The student’s behavior WAS NOT a manifestation of her/his disability. The relevant disciplinary procedures applicable to students without disabilities
may be applied to the student in the same manner in which they are applied to students without disabilities. If the district initiates disciplinary
procedures applicable to all students, the district shall ensure that the special education and disciplinary records of the student with a disability are
transmitted for consideration by the person or persons making the nal determination regarding the disciplinary action.
The student’s behavior WAS a manifestation of her/his disability. The team must review and revise the student’s IEP as appropriate and the district
must take appropriate action. A functional behavior analysis will or has been completed. The behavior intervention plan shall be completed or
modied/reviewed as required to address behavior.
ISBE 34-54R (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
ADDITIONAL NOTES/INFORMATION
ISBE 34-54S (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
REPORT OF PROGRESS ON ANNUAL GOALS (Option 1)
Specify the extent to which the student’s progress is sufcient to enable the student to achieve the goals by the end of the IEP
year. Districts may use this page to report on student progress OR may use the option two page that would include data charts
to indicate a student’s progress.
Student’s Name Type of Report
Date
Report Card 1 2 3 4 Quarter
Staff Name
Progress Report 1 2 3 4 Quarter
Title
Parent Conference
GOAL
NUMBER
MEASURABLE ANNUAL GOAL
REPORT OF PROGRESS
ADDITIONAL COMMENTS
Completed
Making
Expected
Progress
Not Making
Expected
Progress
ISBE 34-54T (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
REPORT OF PROGRESS ON ANNUAL GOALS (Option 1)
Specify the extent to which the student’s progress is sufcient to enable the student to achieve the goals by the end of the IEP
year. Districts may use this page to report on student progress OR may use the option two page that would include data charts
to indicate a student’s progress.
Student’s Name Type of Report
Date
Report Card 1 2 3 4 Quarter
Staff Name
Progress Report 1 2 3 4 Quarter
Title
Parent Conference
GOAL
NUMBER
MEASURABLE ANNUAL GOAL
REPORT OF PROGRESS
(Insert Data Charts)
ISBE 34-54U (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
STUDENT NAME: _______________________________________________________________________ DATE OF MEETING: ____________________________________
AUTISM CONSIDERATIONS
In accordance with Section 14-8.02 of the School code, “In the development of the individualized education program for a student
who has a disability on the autism spectrum (which includes autistic disorder, Asperger disorder, pervasive developmental disorder not
otherwise specied, childhood disintegrative disorder, and Rett Syndrome, as dened in the [(DSM-IV,2000)], the IEP team shall consider
all the following factors.”
1. Verbal and nonverbal communication needs
Student Needs:
Supports Identied:
2. Social interaction skills and prociencies
Student Needs:
Supports Identied:
3. Needs resulting from unusual responses to sensory experience
Student Needs:
Supports Identied:
4. Needs resulting from resistance to environmental change or change in daily routines
Student Needs:
Supports Identied:
5. Needs resulting from engagement in repetitive activities and stereotyped movements
Student Needs:
Supports Identied:
6. Needs for any positive behavioral interventions, strategies and supports
Student Needs:
Supports Identied:
7. Other needs which impact progress in general curriculum, including social and emotional development
Student Needs:
Supports Identied:
ISBE 34-54V (2/19) Illinois State Board of Education, Special Education Services, 100 North First Street, Springfield, Illinois 62777-0001
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