NYSED-IEP-PS 12-05

Confidential Student Information

PreSchool
Individualized Education Program (IEP)

School District
Street Address
City, State, and Zip Code
Telephone Number

Student Name:

Date of Birth:  /   /

 Age:

 

Disability Classification:
[  ] Preschool Student with a Disability
[  ] Declassified

 

Street:

City:

Zip:

Student ID#:

Medical Alerts:

Surrogate Parent Needed: Yes [  ] No [  ]

Telephone:

County of Residence:

Male [  ] Female [  ]

Racial/Ethnic Group of Student: Choose one

Native Language of Student:

 

Other Information:

 

[  ]  Child received Early Intervention Services

Date of initial referral to CPSE:    /    /     

Date initial consent for evaluation received:    /    /   

Date of IEP meeting to determine initial eligibility:     /    /     

 

Date of Committee on Preschool Special Education (CPSE) Meeting:   /   /

Type of Meeting:
[  ] Initial   [  ] Requested Review   [  ] Annual Review    [  ] Reevaluation
[  ] ___________________________________________

Date IEP is to be Implemented:  /  /

Projected Date of Next Review: /  /

Projected Date of Reevaluation Meeting: /  /

 

 

Present Levels of Academic Achievement,  Functional Performance and Individual Needs

Current functioning and individual needs in consideration of:

  • the results of the initial or most recent evaluation, the student’s strengths and the concerns of the parents;
  • the student’s needs related to communication, behavior, use of Braille, assistive technology, limited English proficiency; and
  • how the student’s disability affects participation in appropriate activities.

 

Academic Achievement, Functional Performance and Learning Characteristics:

Current 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.

 

 

 

 

 

Social Development:

The degree and quality of the student’s relationships with peers and adults, feelings about self and social adjustment to school and community environments.

 

 

 

Physical Development:

The degree or quality of the student’s motor and sensory development, health, vitality and physical skills or limitations that pertain to the learning process.

 

 

 

 

 

Management Needs:

The nature of and degree to which environmental modifications and human or material resources are required to enable the student to benefit from instruction. Management needs are determined in accordance with the factors identified in the areas of academic achievement, functional performance and learning characteristics, social development and physical development.

 

 

 

 

 

Measurable Annual Goals and Short-Term Instructional
Objectives/Benchmarks

 

Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal: 
Evaluation Schedule:
Instructional Objectives or Benchmarks:

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Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal: 
Evaluation Schedule:
Instructional Objectives or Benchmarks:

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Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal: 
Evaluation Schedule:
Instructional Objectives or Benchmarks:

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Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal: 
Evaluation Schedule:
Instructional Objectives or Benchmarks:

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Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal: 
Evaluation Schedule:
Instructional Objectives or Benchmarks:

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Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal: 
Evaluation Schedule:
Instructional Objectives or Benchmarks:

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 Recommended Special Education Programs And Services

 

Special Education Program/Services

 

Frequency

Duration

Location

Initiation Date

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Related Services

 

Frequency

Duration

Location

Initiation Date

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Program Modifications/Accommodations/Supplementary Aids and Services

 

Frequency

Duration

Location

Initiation Date

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Assistive Technology Devices/Services

 

Frequency

Duration

Location

Initiation Date

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/   /
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Supports for School Personnel On Behalf of Student

 

Frequency

Duration

Location

Initiation Date

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Special Transportation Needs:

 None

[ ] Student has special transportation needs as recommended below:

[ ] Special seating - Specify:   

[ ] Vehicle and/or equipment needs - Specify:      

[ ] Adult Supervision - Specify:      

[ ] Type of transportation Specify:     

[ ] Other Accommodations – Specify:      

Other Preschool Transportation Needs: _____________________

 

Testing Accommodations

The following individual appropriate accommodations are necessary to measure the academic achievement and functional performance of the student on State and districtwide assessments.  Recommended testing accommodations will be used consistently in the student’s education program:

  • in the administration of districtwide assessments of student achievement, consistent with school district policy; and

  • in the administration of State assessments of student achievement, consistent with State Education Department policy.

Testing Accommodation

Conditions

Specifications

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Participation In State and Districtwide Assessments

[  ] The student will participate in the same State or districtwide assessments that are administered to general education students.

[  ] The student will participate in the following alternate assessments for State and districtwide assessments: ___________________________

Explain why the State and districtwide alternate assessments selected are appropriate for the student: _________________________

 

Participation With Age Appropriate Peers

Provision of special education services in a setting with no regular contact with age appropriate peers without disabilities should only be considered when the nature or severity of the child's disability is such that education in a less restrictive environment with the use of supplementary aids and services, cannot be satisfactorily achieved.

[  ] Explanation of the extent, if any, to which the student will not participate in appropriate activities with age-appropriate non-disabled peers: ______________________________________________
__________________________________________________________________________

Will the preschool student receive services in a setting with no regular contact with age-appropriate peers without disabilities? Yes [  ]  No [  ]

 

Reporting Progress to Parents

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

 

 

Placement Recommendation

10 Month Placement: _________________________________________________

Approved Preschool Program Provider: ___________________________________

 

Extended School Year Eligible: Yes [  ] No [  ]

If yes: Reason:___________________________________________________

Projected dates of services:  /   /   to   /  / 

Provider:__________________________

Site: ____________________________

 

Parent Information

Student’s Name:

Mother’s/Guardian’s Name:

Street:

City:

Zip:

Telephone:

County of Residence:

Native Language of Parent/Guardian:

Interpreter Needed for Meeting: Yes [  ]  No [  ]

Father’s/Guardian’s Name:

Street:

City:

Zip:

Telephone:

County of Residence:

Native Language of Parent/Guardian:

Interpreter Needed for Meeting: Yes [  ]  No [  ] 

[  ]  Surrogate Parent Needed

Surrogate Parent’s Name :

Street:

City:

Zip:

 

Date Appointed:   /   /

Telephone:

Native Language of Surrogate Parent:

Interpreter Needed for Meeting: Yes [  ]  No [  ] 

 

 

CPSE Participants

. Name

.Professional Title

.CPSE Member Role1

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1If the parent or other CPSE member participated (with parent and school district agreement) through alternative means, indicate the manner in which he or she participated (e.g., video or telephone conference telephone call).

SUPPLEMENTAL PAGE FOR ADDITIONAL ANNUAL GOALS AND SHORT-TERM INSTRUCTIONAL OBJECTIVES AND BENCHMARKS

 

Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal: 
Evaluation Schedule:
Instructional Objectives or Benchmarks:

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Annual Goal:
Evaluative Criteria:
Procedures to Evaluate Goal: 
Evaluation Schedule:
Instructional Objectives or Benchmarks:

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