Jane Doe Sample IEP

STUDENT NAME: Jane NAME: Jane Doe DATE OF BIRTH: 7/7/2000 BIRTH: 7/7/2000

DISABILITY CLASSIFICATION: Learning CLASSIFICATION: Learning Disability LOCAL ID #: 5555555 #: 5555555

PROJECTED DATE IEP IS TO BE IMPLEMENTED:02/13/2015 IMPLEMENTED: 02/13/2015

PROJECTED DATE OF ANNUAL REVIEW:05/19/2016 REVIEW:05/19/2016

STUDENT NAME: Jane NAME: Jane Doe

NYC ID:5555555 ID:5555555 PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL NEEDS

DOCUMEN!"ON O# $UDEN%$ CU&&EN 'E&#O&M!NCE !ND !C!DEM"C( DE)ELO'MEN!L !ND #UNC"ON!L NEED$

EVALUATION RESULTS (INCLUDING FOR SCHOOL-AGE STUDENTS, PERFORMANCE ON STATE AND DISTRICTWIDE ASSESSMENTS) ELA Stat E!a" $%& 'resent Le*el 2 'ro+i,ien,y &ating- 2.90 rot &ate- 77 $,ale $,ore 300 MATHEMATICS Stat E!a" $%& 'resent Le*el- 2 'ro+i,ien,y &ating- 2.57 rot &ate- 2 $,ale $,ore- 32 ACADEMIC ACHIEVEMENT, FUNCTIONAL PERFORMANCE AND LEARNING CHARACTERISTICS LE)EL$ O# 4NOLEDE !ND DE)ELO'MEN "N $UJEC !ND $4"LL !&E!$ "NCLUD"N !C")""E$ O# D!"L L")"N( LE)EL O# "NELLECU!L #UNC"ON"N( !D!'")E E8!)"O&( E'ECED &!E O# '&O&E$$ "N !C:U"&"N $4"LL$ $4"LL$ !ND !ND "N#O&M!"ON( "N#O&M!"ON( !ND LE!&N"N LE!&N"N $LE; "n EL!( base< on te "nent #ra>eor? #ra>eor? Jane Doe is reaonstrates tat Jane Doe as >astere< ,o>>on ,ore reai, lang@age an< or< @sage. en as?e< to @se teBt@al e*ionstrates ,allenges to a,ie*e tis tas? on er on an< reA@ires s@==orts in te +or> o+ s,a++olonstrates ,allenges it >a?ing in+eren,es an< ( o+ten Jane Doe onstrates a la,? o+ +o,@s. $e is *ery easily onitoring to ,o>=lete ,lassroo> tas?s.

PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL NEEDS DOCUMEN!"ON O# $UDEN%$ CU&&EN 'E&#O&M!NCE !ND !C!DEM"C( DE)ELO'MEN!L !ND #UNC"ON!L NEED$

Jane Doe is able to or? in s>all gro@=s( b@t o+ten reA@ires re- a,,@rate ,on,l@sions a+ter rea. "n riting Jane Doe str@ggles it str@,t@ring essays an< sort res=onses. C@rrently Jane Doe as son =rogress @sing te &.!.C.E +or>@la to res=on< to sort assess>ent A@estions. Essay riting is still a ,allenge. Jane Doe bene+its +ro> @sing gra=i, organiers tat o@tline ere to =la,e transition or=leting an< t@rning in 8.. assign>ents an< bene+its +ro> te rein+or,e>ent an< >onitoring o+ er s,ool =lanner to stay organie< an< to b@il< res=onsibility a==ro=riate +or >i<ati,s. Jane Doe as a< . Jane Doe as basi, a<bers it regro@=ing( Jane Doe is >ore li?el y to >a?e errors. Jane Doe still reA@ires =ra,ti,e it er >@lti=li,ation an< @lti=li,ation an< aster to=i,s s@, as +inal o=erations as ell. Jane Doe as able to >@lti=ly si>=le +ra,tions( oe*er( en se as instr@,te< to ,on*ert >iBe< n@>bers an< i>=ro=er +ra,tions be+ore >@lti=lying( tere ere >any errors. Jane Doe as able to +ollo te ste=s +or =le +ra,tions( se as able to e s@,,ess. Jane Doe is o+ten =letion. Jane Doe is A@ite tal?ati*e in ,lass an< ,o@l< so >ore =rogress i+ se o@l< =rioritie an< stay +o,@se<. $C"ENCE Jane Doe sos illingness to learn ne ,on,e=ts. $e ,o>es to s,ien,e ,lass =re=are< an< rea or?ing one on one it a tea,er or in s>all gro@=s it a tea,er. "t is el=+@l +or Jane Doe en instr@,tions are bro?en =le ste=s. ra=i, organiers tat ,@n? or se,tion =ie,es o+ in+or>ation el= Jane Doe to @n=leB >aterial. E>be<aterial el= Jane Doe to stay +o,@se< en reaostly ell >annere< an< res=e,t+@l se re>ains on tas? it +reA@ent tea,er ,e,?-ins to ens@re +o,@s an< @n a<e to ,o>=lete er assign>ents. Jane Doe is able to ,o>=reen< s,ienti+i, teBts ile @sing *o,ab@lary re+eren,e so@r,es li?e a teBtboo?. $e also bene+its +ro> s an< i>ages tat =ortray s,ienti+i, i eBa>=les. $UDEN $&EN8$( '&E#E&ENCE$( "NE&E$$;


Jane Doe enoys s,ool( se eB=resses a at( EL! an< 'E ,lass. $e +eels li?e se enoys te so,ial as=e,t o+ s,ool( se as >any +riene it er +a>ily an< is loo?ing +orar>er *a,ation as er +a>ily as =lanne< tri=s. Jane Doe =lays in te s,ool or,estra an< enoys learning te *iola. !C!DEM"C( DE)ELO'MEN DE)ELO'MEN!L !L !ND #UNC"ON!L #UNC"ON!L NEED$ NEED$ O# 8E $UDEN( $UDEN( "NCLUD"N "NCLUD"N CON$"DE&! CON$"DE&!"ON "ON O# $UDEN NEED$ 8! !&E O# CONCE&N O 8E '!&EN; Mo> is trying to >a?e an a ==oint>ent it a =sy,ologist b@t is a*ing eone. Mo> nee>eneo> +eels li?e Jane Doe o@l< bene+it +ro> being on >eotion in a t@tor o@tsie one-to-one instr@,tion. Mo> +eels tat Jane Doe is str@ggling at in te "C ,lasses it $E$$ ser*i,es. !t !t o>e( Jane Doe be,o>es =ting to eor? >ore so ten =re*io@s years. Mo> o@l< li?e Jane Doe to ,ontin@e it "C ,lass an< $E$$ ser*i,es an< a<< >ee< a ,eerleaa?e +rien is ,on,erne< tat Jane Doe =lay +igts it oter st@o> s=ea?s to er abo@t ti s +reA@ently. PHYSICAL DEVELOPMENT 8E DE&EE GEENH !ND :U!L" O# 8E $UDENI$ MOO& !ND $EN$O& DE)ELO'MEN( 8E!L8(


)"!L" !ND '8$"C!L $4"LL$ O& L"M"!"ON$ 8"C8 'E&!"N O 8E LE!&N"N '&OCE$$; Jane Doe as been ee. MANAGEMENT NEEDS 8E N!U&E G'EH !ND DE&EE GEENH O 8"C8 EN)"&ONMEN!L !ND 8UM!N O& M!E&"!L &E$OU&CE$ !&E NEEDED O !DD&E$$ NEED$ "DEN"#"ED !O)E; D@ring ,lassroo> lessons( Jane Doe reA@ires; -s>all gro@= instr@,tions -re=eate< =ts -re=eate< e to ,o>=lete A@estions EFFECT OF STUDENT NEEDS ON INVOLVEMENT AND PROGRESS IN THE GENERAL EDUCATION CURRICULUM OR, FOR A PRESCHOOL STUDENT, EFFECT OF STUDENT NEEDS ON PARTICIPATION IN APPROPRIATE ACTIVITES Jane Doe ,ontin@e to in a general e<@,ation setting it te str@,t@re an< s@==ort =ro*iore s>all gro@= intera,tion an< i n
NYC ID:555555 ID:555555

STUDENT NEEDS RELATING TO SPECIAL FACTORS !$ED ON 8E "DEN"#"C!"ON "DEN"#"C!"ON O# 8E $UDEN%$ NEED$( 8E COMM"EE MU$ CON$"DE& 8E8E& 8E $UDEN NEED$ ! '!&"CU '!&"CUL!& L!& DE)"CE O& $E&)"CE O !DD&E$$ 8E 8E $'EC"!L #!CO&$ #!CO&$ !$ "ND"C!ED "ND"C!ED ELO( ELO( !ND !ND "# $O( 8E 8E !''&O'&"!E !''&O'&"!E $EC"ON O# 8E "E' MU$ "DEN"# 8E '!&"CUL!& DE)"CE O& $E&)"CEG$H NEEDED;

Does te st@=e
No

es es

#or a st@ite< Englis =ro+i,ien,y( =aire<(
es es

Not !==li,able

Does te st@>@ni,ation nee
es es

No

"n te ,ase o+ a st@>@ni,ation nee>@ni,ations it =eers an< =ro+essional =ersonnel in te st@>@ni,ation >oi, le*el( an< +@ll range o+ nee>@ni,ation >o
es es

No

"+ yes( >ittee re,o>>en< tat te eF


es es

No

NYC ID:555555 ID:555555

E"NN"N NO L!E& 8!N 8E #"&$ DEE&M"NED !''&O'&"!EH

"E' O E "N E##EC 8EN 8E $UDEN "$ !E 15 G!ND ! ! OUNE& !E "# MEASURABLE POSTSECONDARY GOALS

LON-E&M O!L$ #O& L")"N( O&4"N !ND LE!&N"N !$ !N !DUL

EDUCATION'TRAINING: EMPLOYMENT: INDEPENDENT LIVING SILLS (WHEN APPROPRIATE): TRANSITION NEEDS "n ,onsian,e( transition ser*i,e nee s,ool to =ost-s,ool a,ti*ities; STUDENT NAME: Jane NAME: Jane Doe

NYC ID:555555 ID:555555 MEASURABLE ANNUAL GOALS

8E #OLLO"N O!L$ !&E &ECOMMENDED O EN!LE 8E $UDEN O E "N)OL)ED "N !ND '&O&E$$ "N 8E ENE&!L EDUC!"ON CU&&"CULUM( !DD&E$$ O8E& EDUC!"ON!L NEED$ 8! &E$UL #&OM 8E $UDEN%$ D"$!"L"( !ND '&E'!&E 8E $UDEN O MEE 8"$/8E& 'O$$ECOND!& O!L$.

ANNUAL GOALS 8! 8E $UDEN "LL E E'ECED O !C8"E)E  8E END O# 8E E!& "N 8"C8 8E "E' "$ "N E##EC

$C"ENCE Deter>ine te ,entral i>ary o+ te teBt =rior ?nole
CRITERIA ME!$U&E O DEE&M"NE "# O!L 8!$ EEN !C8"E)ED

60 !,,@ra,y

METHOD 8O '&O&E$$ "LL E ME!$U&ED

SCHEDULE 8EN '&O&E$$ "LL E ME!$U&ED

ea,er Ma
1 ti>e =er A@arter

CRITERIA

METHOD

SCHEDULE

8! 8E $UDEN "LL E E'ECED O !C8"E)E  8E 8E END O# 8E 8E E!& "N 8"C8 8"C8 8E "E' "$ "N E##EC

ME!$U&E O DEE&M"NE "# O!L 8!$ EEN !C8"E)ED

$C"ENCE Deter>ine te >eaning o+ sy>bols( ?ey ter>s( an< oter ain-s=e,i+i, or
ANNUAL GOALS 8! 8E $UDEN "LL E E'ECED O !C8"E)E  8E 8E END O# 8E E!& "N 8"C8 8E "E' "$ "N E##EC


Co>>on Core EL!

"n one year Jane Doe ill be able to ine te >eaning o+ oreanings. $e ill onstrate tis s?ill by reailiar or<( se ill ten @se ,onteBt ,l@es or si>ilar strategies to ine te >eaning.

ANNUAL GOALS 8! 8E $UDEN "LL E E'ECED O !C8"E)E  8E 8E END O# 8E E!& "N 8"C8 8"C8 8E "E' "$ "N E##EC

Co>>on Core EL!


8O '&O&E$$ "LL E ME!$U&ED

ea,er Ma

ea,er Maan,e !ssess>ent as? as?


7 o@t o+ 10 trials +or ea,er ea,er Ma
8EN '&O&E$$ "LL E ME!$U&ED

1 ti>e =er A@arter


1 ti>e =er A@arter


1 ti>e =er A@arter

"n one year it s@==ort as neeonstrate @nonstrate tis s?ill b y re+erring eB=li,itly to te teBt as te basis +or te ansers.



EL! Co>>on Core- riting "n one year it it g@ionstrate tis s?ill by ,onstr@,ting an essay on a gra=leting all 5 stages o+ te riting =ro,ess.



M!8EM!"C$ 60 !,,@ra,y itin one a,ai, s,ool year( Jane Doe ill be able to bers. Jane Doe ill be able to re=resent +ra,tions on a n@>ber line( i=are +ra,tions. Jane Doe ill also be able to onstrate te

Materials Class !,ti*ities ea,er/'ro*ian,e !ssess>ent as? as?




ea,er Ma Maan,e !ssess>ent as? as?


1 ti>e =er A@arter


1 ti>e =er A@arter

r@les +or >@lti=lying an<


M!8EM!"C$ itin one a,ai, s,ool year( Jane Doe ill be able to in,rease er ability to sele,t an< 60 !,,@ra,y a==ly >ate>ati,al o=erations in a *ariety o+ ,onteBts to ,o>=@te ole n@>bers( +ra,tions( als an< integers.


M!8EM!"C$ itin one a,ai, s,ool year( Jane Doe ill in,rease er >@lti=li,ation an< @lti=li,ation an< gra

60 !,,@ra,y

CRITERIA ME!$U&E O DEE&M"NE "# O!L 8!$ EEN







1 ti>e =er A@arter


1 ti>e =er A@arter


!C8"E)ED

Co@nseling; itin one year( Jane Doe ill i>=ro*e er ,o>>@ni,ation s?ills as onstrate< 3 o@t o+  by eB=ressing er to@gts an< +eelings trials ito@t te @se o+ +o@l an
Ce,? Lists )erbal )erbal EB=lanation 'er+or>an,e !ssess>ent !ssess>ent as? as? ea,er/'ro*i

Co@nseling; itin one year( Jane Doe ill i>=ro*e er ,on+li,t resol@tion s?ills as onstrate< by 1H ,al>ly an< rationally ily an< rationally 3 o@t o+ 5 trials e iss@e 3H =atiently an< a,ti*ely listening to te oter =erson%s =oint o+ *ie H a,ti*ely engaging in a =ro,ess o+ establising a >@t@ally agreeable sol@tion to te i.


Ce,? Lists )erbal EB=lanation Jo@rnal or ritten state>ant 'er+or>an,e !ssess>ent as? as? ea,er/'ro*i

1 ti>e =er A@arter


1 ti>e =er A@arter

NYC ID: 555555 ID: 555555 REPORTING PROGRESS TO PARENTS

"eeting te ann@al goals ill be =ro*ie ti>e s,ool re=ort ,ar
NYC ID:555555 ID:555555

RECOMMENDED SPECIAL EDUCATION PROGRAMS AND SERVICES

SPECIAL EDUCATION PROGRAM'SERVICES

SERVICE DELIVERY FRE*UENCY RECOMMENDATION HOW OFTEN S PROVIDED

DURATION LENGTH OF SESSION

LOCATION WHERE SERVICE WILL BE PROVIDED

PROJECTED BEGINNING ' SERVICE DATE(S)

SPECIAL EDUCATION PROGRAM:

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RELATED SERVICES:

Co@nseling $er*i,es

SUPPLEMENTARY AIDS AND SERVICES'PROGRAM MODIFICATIONS'ACCOMMODATION S:

RECOMMENDED SPECIAL EDUCATION PROGRAMS AND SERVICES ASSISTIVE TECHNOLOGY DEVICES AND'OR SERVICES: SUPPORTS FOR SCHOOL PERSONNEL ON BEHALF OF THE STUDENT:

 "aBi>@> st@>en
NYC ID:555555 ID:555555

%-MONTH SERVICE AND'OR PROGRAM - $t@ <@ring J@ly/!@g@st; No es es "+ yes;  $t@e s=e,ial e<@,ation =rogra>/ser*i,es as re,o>>en>en/ser*i,es;

SPECIAL EDUCATION PROGRAM'SERVICES

SERVICE DELIVERY RECOMMENDATIONS FRE*UENCY

DURATION

Na>e o+ s,ool/agen,y =ro*i
LOCATION

PROJECTED BEGINNING ' SERVICE DATE(S)


NYC ID:555555 ID:555555

TESTING ACCOMMODATIONS GO E COM'LEED #O& '&E$C8OOL C8"LD&EN ONL "# 8E&E "$ !N !$$E$$MEN '&O&!M #O& NOND"$!LED '&E$C8OOL C8"LD&ENH; "ND")"DU!L E$"N !CCOMMOD!"ON$( $'EC"#"C O 8E $UDENI$ D"$!"L" !ND NEED$( O O E U$ED CON$"$ENL CON$"$ENL  8E $UDEN $UDEN "N 8E 8E &ECOMMENDED &ECOMMENDED EDUC!"ON!L EDUC!"ON!L '&O&!M !ND "N 8E !DM"N"$&!"ON !DM"N"$&!"ON O# D"$&"CD"$&"C-"DE "DE !$$E$$MEN$ !$$E$$MEN$ O# $UDEN $UDEN !C8"E)EMEN !C8"E)EMEN !ND( !ND( "N !CCO&D!NC !CCO&D!NCE E "8 DE'!&MEN DE'!&MEN 'OL"C( $!E !$$E$$MEN$ O# $UDEN !C8"E)EMEN. TESTING ACCOMMODATIONS

CONDITIONS

IMPLEMENTATION RECOMMENDATIONS

NONE

EBtene

"n all EBa>s in,l@s

i>e eBten
rea?s

"n all EBa>s in,l@
rea?s gi*en as nee
&e*ise< est #or>at

"n all EBa>s in,l@ st@
&e*ise< est Dire,tions

"n all EBa>s in,l@
:@estions rea< alo@< to st@
$e=arate Lo Lo,ation/&oo>

"n al all EB EBa>s in in,l@
Jane Do Doe ne nee>o
On- n-as? #o, #o,@s @sin ing g 'r 'ro>=t o>=ts s

"n all all EB EBa>s a>s in, in,l@ l@
On- n-as?s +o, +o,@s @sin ing g =r =ro>=t o>=ts s as as nee nee
Con>o=le>entation &e,o>>en>eno@nt o+ eBtene( ty=e o+ setting( et,.( s=e,i+i, to te testing a,,o>>o
NYC ID:555555 ID:555555

E"NN"N NO L!E& 8!N 8E #"&$ "E' O E "N E##EC 8EN 8E $UDEN "$ !E 15 G!ND ! ! OUNE& !E( "# DEE&M"NED !''&O'&"!EH. COORDINATED SET OF TRANSITION ACTIVITIES NEEDED ACTIVITIES TO FACILITATE THE STUDENT+S MOVEMENT FROM SCHOOL TO POST-SCHOOL ACTIVITIES

SERVICE'ACTIVITY

SCHOOL DISTRICT'AGENCY RESPONSIBLE

It./0t12 R3at4 S.510 C2""/1t6 E!7.10 D5327"t 28 E"7326"t a4 Ot9. P2t-09223 A4/3t L151 O;<0t15 A0=/11t12 28 Da136 L151 S>133 (18 a77310a;3) F/0t12a3 V20at12a3 A"t (18 a77310a;3) STUDENT NAME: Jane NAME: Jane Doe

NYC ID:555555 ID:555555

PARTICIPATE IN STATE AND DISTRICT-WIDE ASSESSMENTS GO E COM'LEED #O& '&E$C8OOL $UDEN$ ONL "# 8E&E "$ !N !$$E$$MEN '&O&!M #O& NOND"$!LED '&E$C8OOL $UDEN$H

e st@e $tate an< ents o+ st@ent tat are a<>inistere< to general e<@,ation st@ent on a =arti,@lar =arti,@lar $tate or ent o+ st@ent. STUDENT NAME: Jane NAME: Jane Doe

NYC ID:555555 ID:555555

PARTICIPATION WITH STUDENTS WITHOUT DISABILITIES

&EMO)!L #&OM 8E ENE&!L EDUC!"ON EN)"&ONMEN OCCU&$ ONL 8EN 8E N!U&E O& $E)E&" O# 8E D"$!"L" "$ $UC8 8!( E)EN "8 8E U$E O# $U''LEMEN!& !"D$ !ND $E&)"CE$( EDUC!"ON C!NNO E $!"$#!CO&"L !C8"E)ED. FOR THE PRESCHOOL STUDENT: EB=lain te eBtent( i+ any( to i, te st@i, a,ti*ities Ge.g.( =er,ent o+ te s,ool ( i>ittee Co>>ittee as ine< tat te te st@>en=t +ro> te lang@age oter tan Englis reA@ire>ent.


NYC ID:555555 ID:555555

SPECIAL TRANSPORTATION &!N$'O&!"ON &ECOMMEND!"ON O !DD&E$$ NEED$ O# 8E $UDEN &EL!"N O 8"$/8E& D"$!"L"

None. $t@>o>o s=e,ial ,lasses or =rogra>s at anoter site; PLACEMENT RECOMMENDATION

SPECIAL TRANSPORTATION &!N$'O&!"ON &ECOMMEND!"ON O !DD&E$$ NEED$ O# 8E $UDEN &EL!"N O 8"$/8E& D"$!"L"

NC DOE Co>>@nity $,ool

SUMMARY STUDENT INFORMATION

St/4t Na": Jane Na": Jane Doe NYC ID: 555555 ID: 555555 DOB: 7/7/2000 DOB: 7/7/2000 G4.: #e>ale Pa.t La/a() S72>'M24 C2""/10at12: Englis C2""/10at12: Englis IEP INFORMATION

Dat 28 IEP Mt1: 05/21/2015 Mt1: 05/21/2015 IEP A"4"t: A"4"t: es No R025 28 IEP Mt1: Mt1:

es

No

INSTRUCTIONAL'FUNCTIONAL LEVELS

Ra41:t Ra41:t ra
C3a1810at12 28 D1a;131t6: Oter 8ealt ">=air>ent R02""44 S.510: $=e,ial E<@,ation 'rogra>s

$=e,ial E<@,ation ea,er $@==ort $er*i,es K$E$$ "ntegrate< Co-ea,ing $er*i,es "ntegrate< Co-ea,ing $er*i,es "ntegrate< Co-ea,ing $er*i,es $=e,ial E<@,ation ea,er $@==ort $er*i,es K$E$$ &elate< $er*i,es

Englis Englis Englis Englis Englis

Co@nseling $er*i,es

Englis

%-M2t9 S.510:

e st@e $tate an< ents o+ st@ent tat are a<>inistere< to general e<@,ation st@
$t@
S09223 T67: NC T67: NC DOE Co>>@nity $,ool M410a3 A3.t: e st@ee
=ysi,al =ysi,al li>itations li>itations i, i, a++e,t a++e,t er

learning( learning(

=arti,i=ation in s,ool a,ti*ities.

e st@
>e
ealt ,are treat>entGsH or =ro,e<@reGsH <@ring te s,ool
$tan
Mo
M/3t173 C.1t.1a a4 M241810at12 28 A0915"t 28 P.82."a0 Sta4a.4

E319 La/a A.t (ELA) e st@
Mat9 e Mat9 e st@@st >eet 50  o+

Doe >@st >eet 50  o+ te 6 gra@st be te 6 gra@st be >astere< as e*iastere< as e*ients/graents/graents/gra
$tan
Mo
M/3t173 C.1t.1a a4 M241810at12 28 A0915"t 28 P.82."a0 Sta4a.4

PROMOTION CRITERIA

E319 La/a A.t (ELA) e st@
Mat9 e Mat9 e st@@st >eet 50  o+

Doe >@st >eet 50  o+ te 7 gra@st be te 7 gra@st be >astere< as e*iastere< as e*ients/graents/graents/gra
$=e,ial E<@,ation ea,er ea,er $@==ort $er*i,es "ntegrate< Co-tea,ing Co@nseling $er*i,es Ra2() 82. R<0t12: Jane R<0t12: Jane Doe M,Call%s neeet it s=e,ial e<@,ation tea,er s@==ort ser*i,es in te general e<@,ation ,lassroo>.

ATTENDANCE PAGE

'LE!$E NOE 8! OU& $"N!U&E &E#LEC$ OU& '!&"C"'!"ON ! 8E CON#E&ENCE !ND DOE$ NO NECE$$!&"L "ND"C!E !&EEMEN "8 8E "ND")"DU!L"ED EDUC!"ON '&O&!M. ROLE (INDICATE IF BILINGUAL)

NAME

SIGN ATURE

Jane Doe Sample IEP

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