MT 4 – Level 4 – Completing a Mock Individualized Education Plan (IEP) 

For this project, you and your group are in the roles of the Learner, School Administrator, and Parent. As a group, you will 

complete each page of the IEP. The goal is to develop an understanding of what information is reviewed and discussed in 

the IEP. 

Tips of Completing the Packet: 

Page 1:  

Background information – you and your group can be creative and determine all background information (you can make up 

names of participants and school/school district). Make sure that the Date of Birth (DOB) matches the grade level that you 

are stating the learner is in. 

Indicate Disability: 

DISABILITY CODES, CATEGORIES AND ABBREVIATIONS Code Disability Category Code Disability Category 210 Mental Retardation (MR)     280 Other Health Impaired (OHI)    220 Hard of Hearing (HH)  281 Established Medical Disability (EMD)  230 Deafness (Deaf) 290 Specific Learning Disability (SLD) 240 Speech or Language Impairment (SLI)             300 Deaf Blindness (DB) 250 Visual Impairment (VI)               310 Multiple Disabilities (MD) 260 Emotional Disturbance (ED)               320 Autism (AUT) 270 Orthopedic Impairment (OI)     330 Traumatic Brain Injury (TBI) 

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Strengths/Performance on tests: you and your group can be creative and determine all testing information 

Ca Standards Test: CST 

CMA: California Modified Assessment (modified version of the STAR test for those who have an IEP) 

CAPA: California Alternate Performance Assessment (modified version of STAR, for those who aren’t able to take the CST 

or CMA) 

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Special Factors you and your group can be creative and determine all special factor information 

Page 4:  

Offer of FAPE (Free Appropriate Public Education): you and your team will determine what type of setting would the 

learner benefit from the most: 

Modified PE or General PE 

Will the learner spend 100% of their time in a regular classroom or a modified amount? 

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Specific Learning Disability: ONLY COMPLETE THIS PAGE IF THE DISABILITY THAT YOU CHOSE IS 290 – SLD 

Check off boxes that apply to your learner’s disability 

Page 6: 

Signature Page – Have those who participate in the IEP sign the form and check off appropriate boxes 

Copyright by Goodheart-Willcox Co., Inc. Permission granted to reproduce for educational use only

Chapter 9 Teaching Diverse LearnersTeaching

Transparency Master 9-3

Individualized Education Program (IEP)

By law, the IEP must include certain information about the child and the educational program designed to meet his or her unique needs. This information includes the following:

Current_performance. The IEP must state how the child is currently doing in school and how the child’s disability affects his or her involvement and progress in the general curriculum.Annual_goals. These are goals that the child can reasonably accomplish in a year.Special_education_and_related_services. The IEP must list the special education and related services to be provided to the child or on behalf of the child.Participation_with_nondisabled_children. The IEP must explain the extent (if any) to which the child will not participate with nondisabled children in the regular class and other school activities.Participation_in_state_and_district-wide_tests. Most states and districts give achievement tests to children in certain grades or age groups. The IEP must state what modifications in the administration of these tests the child will need.Dates_and_places. The IEP must state when services will begin, how often they will be provided, where they will be provided, and how long they will last.Transition_service_needs. Beginning when the child is age 14 (or younger, if appropriate), the IEP must address the courses he or she needs to take to reach his or her post-school goals. A statement of transition services needs must also be included in each of the child’s subsequent IEPs.Needed_transition_services. Beginning when the child is age 16 (or younger, if appropriate), the IEP must state what transition services are needed to help the child prepare for leaving school.Age_of_majority. Beginning at least one year before the child reaches the age of majority, the IEP must include a statement that the student has been told of any rights that will transfer to him or her.Measuring_progress. The IEP must state how the child’s progress will be measured and how parents will be informed of that progress.

Source: United States Department of Education

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STATE SELPA IEP TEMPLATE INDIVIDUALIZED EDUCATION PROGRAM (IEP) - INFORMATION / ELIGIBILITY

Revised 07/2013 Form 1

Student Name _____________________ Date of Birth ___/___/________ IEP Date ___/___/________

Last IEP ____ / ____ / ______ Next IEP ____ / ____ / ______ Original SpEd Entry Date ___/___/________

Last Eval ____ / ____ / ______ Next Eval ____ / ____ / ______

Purpose of Meeting Initial Annual Triennial Transition Pre-Expulsion Interim Other_____________

Date of Birth ____/____/______ Age _________________ Gender __________________

Grade ______________________ Migrant Yes No Native Language __________________

EL Yes No Redesignated Interpreter Yes No

Student ID ________________________ SSN _________________ SSID __________________

Residency Parent/Guardian Foster LCI

Adult Student Other

Parent / Guardian _________________________________ Home Phone _________________________________

Home Address _________________________________ Work Phone _________________________________

City _________________________________ Cell Phone _________________________________

State, Zip _________________________________ Email _________________________________

Parent / Guardian _________________________________ Home Phone _________________________________

Home Address _________________________________ Work Phone _________________________________

City _________________________________ Cell Phone _________________________________

State, Zip _________________________________ Email _________________________________

Ethnicity (Select One) Hispanic or Latino Not Hispanic or Latino

Race (Enter Code, must select one or more, regardless of Ethnicity): Race 1 ________ Race 2 ________ Race 3 ________

INDICATE DISABILITY/IES (P = Primary, S = Secondary) Note: For Initial and triennial IEPs, assessment must be done and discussed by IEP Team before determining eligibility.

_______ 210 ID _______ 220 HH * _______ 230 Deaf * _______ 240 SLI _______ 250 VI *

_______ 260 ED _______ 270 OI* _______ 280 OHI _______ 290 SLD _______ 300 DB *

_______ 310 MD _______ 320 AUT _______ 330 TBI _______ 281 Est. Med. Dis. (0-5)

* Low Incidence Disability

_______Not Eligible for Special Education _______Exiting from Sp. ED. (returned to reg. ed/no longer eligible)

Describe how student’s disability affects involvement and progress in the general curriculum (or for preschoolers, participation in appropriate activities) ________________________________________________________________________________________ ____________________________________________________________________________________________________________

FOR INITIAL PLACEMENTS ONLY

Has the student received IDEA Coordinated Early Intervening Services (CEIS) in the past two years? Yes No

Date of Initial Referral for Special Education Services _____/_____/_____

Person Initiating the Referral for Special Education Services _________________

Date District Received Parent Consent _____/_____/_____

Date of Initial Meeting to Determine Eligibility _____/_____/_____

STATE SELPA IEP TEMPLATE PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Revised 07/2013 Form 2

Student Name _____________________ Date of Birth ___/___/________ IEP Date ___/___/________

Strengths/Preferences/Interests _________________________________________________________________________________

Concerns of parent relevant to educational progress ________________________________________________________________

CA Standards Test

English/Language Arts Adv. Proficient Basic Below Basic Far Below Basic

Math Adv. Proficient Basic Below Basic Far Below Basic

Hist./Soc.Sciences Adv. Proficient Basic Below Basic Far Below Basic

Science Adv. Proficient Basic Below Basic Far Below Basic

CMA

English Language Arts _____ Mathematics _____ Science _____ Other ________________

CAPA

English/Language Arts Adv. Proficient Basic Below Basic Far Below Basic

Math Adv. Proficient Basic Below Basic Far Below Basic

Science Adv. Proficient Basic Below Basic Far Below Basic

CELDT

Listening ____________ Speaking ___________ Reading ________________ Writing ______________

Physical Education Testing (grades 5, 7 & 9): ________________________________________________________________________

Other Assessment Data (e.g., curriculum assessment, other district assessment, etc.) _______________________________________

Hearing Date ___ / ___ / ________ Pass Fail Other ____________________________

Vision Date ___ / ___ / ________ Pass Fail Other ____________________________

Preacademic/Academic/Functional Skills __________________________________________________________________________

Communication Development ___________________________________________________________________________________

Gross/Fine Motor Development __________________________________________________________________________________

Social Emotional/Behavioral _____________________________________________________________________________________

Vocational___________________________________________________________________________________________________

Adaptive/Daily Living Skills ______________________________________________________________________________________

Health ______________________________________________________________________________________________________

STATE SELPA IEP TEMPLATE SPECIAL FACTORS

Revised 07/2013 Form 3A

Student Name _____________________ Date of Birth ___/___/________ IEP Date ___/___/________

Does the student require assistive technology devices and/or services? Yes No (if yes, specify) ________________________________________________________________________________________________ _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Does the student require low incidence services, equipment and/or materials to meet educational goals? Yes No (if yes, specify) ________________________________________________________________________________________________ _____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Considerations if the student is blind or visually impaired: ____________________________________________________________ ___________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Considerations if the student is deaf or hard of hearing: ______________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

If the student is an English Learner, complete the following section:

Does the student need primary language support? Yes No If yes, who will provide? ___________________________

What will be the language of instruction for the student? ____________________________________________________________

Who will provide ELD program to student? General Education Special Education

What type of ELD program will be provided? English Language Mainstream Structured English Immersion

Alternative Program (native language instruction)

Comments: __________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Does student's behavior impede learning of self or others? Yes No ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ If yes, specify positive behavior interventions, strategies, and supports _______________________________________ _____________________________________________________________________________________________________

Behavior Support Plan Attached Behavior Intervention Plan (BIP) attached Behavior Goal is part of this IEP For student to receive educational benefit, goals will be written to address the following areas of need: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

STATE SELPA IEP TEMPLATE OFFER OF FAPE - EDUCATIONAL SETTING

Revised 07/2013 Form 5B

Student Name _____________________ Date of Birth ___/___/________ IEP Date ___/___/________

Physical Education General Specially Designed Other ________________

District of Service _____________________ School of Attendance _____________________ School Type _____________

Federal Setting _____________________ Federal Preschool Setting _____________________

All special education services provided at student’s school of residence? Yes No (rationale) _________________________

_______% of time student is outside the regular class & extracurricular & non academic activities

_______% of time student is in the regular class & extracurricular & non academic activities

Student will not participate in the regular class and/or extracurricular and/or non academic activities ________________________ because ____________________________________________________________________________________________________ ____________________________________________________________________________________________________________

Other Agency Services

California Children’s Services (CCS) Regional Center

Probation Department of Rehabilitation

Department of Social Services (DSS) County Mental Health (CMH)

Other

Promotion Criteria District Progress on Goals Other _________________________________

Parents will be informed of progress Quarterly Trimester Semester Other __________________

How? Progress Summary Report Other _________________________________

ACTIVITIES TO SUPPORT TRANSITION (e.g., preschool to kindergarten, special education and/or NPS to general education class, 7th – 9th grade)

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

GRADUATION PLAN (Grade 7 and Higher)

Projected graduation date and/or secondary completion date ___/___/________

To participate in high school curriculum leading to a Diploma

To participate in high school curriculum leading to a Certificate of Completion

STATE SELPA IEP TEMPLATE SPECIFIC LEARNING DISABILITY TEAM DETERMINATION OF ELIGIBILITY PAGE 1

Revised 07/2013 Form 9A

Student Name _____________________ Date of Birth ___/___/________ IEP Date ___/___/________

School __________________________________ Initial Evaluation

Date ___/___/________ 3-Year Re-evaluation

I. Presence of Severe Discrepancy. (Select either A or B and then complete items II through IV.)

A. The IEP Team finds a severe discrepancy between measures of intellectual ability and one or more of the following areas of achievement: Oral Expression Written Expression Listening Comprehension Mathematics Calculation Basic Reading Skills Mathematics Reasoning Reading Comprehension Reading Fluency

B. Standard measures do not reveal a severe discrepancy, but the IEP Team finds that a severe discrepancy does exist based upon the additional documentation provided in the attached report. (Complete and attach Specific Learning Disability Discrepancy documentation form)

II. The discrepancy identified in Item I. (above) is directly related to a processing disorder. Yes No

Check appropriate area(s): Sensory Motor Skills Visual Processing Auditory Processing Attention Cognitive Abilities, (including association, conceptualization and expression)

III. If any of the items below (A-G) are checked “Yes”, the student may not be identified as having a specific learning disability.

A. The discrepancy is due primarily to limited school experience or poor school attendance. Yes No B. The discrepancy is a result of environmental, cultural difference or economic disadvantage. Yes No C. The discrepancy is due primarily to Intellectual Disability or Emotional Disturbance. Yes No D. The discrepancy is due primarily to a visual, hearing, or motor disability. Yes No

IV. This discrepancy can be corrected through other regular or categorical services offered within the Yes No regular Instructional program.

F. The discrepancy is due to limited English proficiency. Yes No G. The discrepancy is due to lack of appropriate instruction in reading and math. Yes No

V. The Student has a specific learning disability. Yes No

VI. Basis for determination of eligibility

Psychoeducational Evaluation utilizing multiple measures. See attached psychoeducational report. Other (specify)

VII. Relevant behavior related to academic functioning, noted during observation ________________________________________ ____________________________________________________________________________________________________________ See attached Psychoeducational report.

VIII. Educationally relevant medical findings, if any (describe) _________________________________________________________ ____________________________________________________________________________________________________________

STATE SELPA IEP TEMPLATE SIGNATURE AND PARENT CONSENT

Revised 7/2013 Form 6A

Student Name _____________________ Date of Birth ___/___/________ IEP Date ___/___/________

IEP MEETING PARTICIPANTS

_________________________________ ___/___/______ _________________________________ ___/___/______ Parent / Guardian / Surrogate Date Parent / Guardian Date

_________________________________ ___/___/______ _________________________________ ___/___/______ Student / Adult Student Date General Education Teacher Date

_________________________________ ___/___/______ _________________________________ ___/___/______ LEA Representative/Admin. Designee Date Special Education Specialist Date

_________________________________ ___/___/______ _________________________________ ___/___/______ Additional Participant/Title Date Additional Participant/Title Date

_________________________________ ___/___/______ _________________________________ ___/___/______ Additional Participant/Title Date Additional Participant/Title Date

_________________________________ ___/___/______ _________________________________ ___/___/______ Additional Participant/Title Date Additional Participant/Title Date

CONSENT _______ I agree to all parts of the IEP.

_______ I agree with the IEP, with the exception of ________________________________________________________________

_______ I decline the offer of initiation of special education services.

_______ I understand that my child is not eligible for special education.

_______ I understand that my child is no longer eligible for special education

As a means of improving services and results for your child did the school facilitate parent involvement? Yes No No Response

Signature below is to authorize and approve the IEP. Signature____________________________________________________ ___/___/______ Parent Guardian Surrogate Adult Student Date Signature____________________________________________________ ___/___/______ Parent Guardian Surrogate Adult Student Date

If my child is or may become eligible for public benefits (Medi-Cal): I authorize district to access Medi-Cal: health insurance benefits for applicable services. Yes No

Parent / Guardian Signature _____________________________________________________________

Parent has received a copy of the Procedural Safeguards Parent has received a copy of assessment report (if applicable) Parent has received a copy of Individualized Education Plan (IEP) Parent has received written notification of protections available to parents when LEA requests to access Medi-cal benefits Student enrolled in private school by their parents. Refer to Individual Service Plan, if appropriate.