INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Students Name:

School Age

James Mackey

IEP Team Meeting Date (mm/dd/yy):

10/19/16

IEP Implementation Date (Projected Date when Services and Programs Will Begin):
Anticipated Duration of Services and Programs:
Date of Birth:

10/18/16

10/19/17

02/26/2007

Age:

Grade:

4th

Anticipated Year of Graduation:

2025

Local Education Agency (LEA):

County of Residence:

Mastery Charter School Fredrick Douglass

Philadelphia County

Name and Address of Parent/Guardian/Surrogate:

Phone (Home):

Tyreek Mackey

Phone (Work):

(215) 433 - 9655

(215) 232 - 7767

2334 Master Street

Philadelphia, PA, 19122

Other Information:

Most Recent Evaluation: 10/9/16

Primary Disability: Other Health Impairment
Secondary Disability:
Related Services: Counseling 30 min/wk small group
Types of Support: Emotional Support / Learning Support
Level of Support: Itinerant Behavioral Support
Other:

The LEA and parent have agreed to make the following changes to the IEP without convening an IEP meeting, as documented by:

Date of Revision(s)
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Participants/Roles

IEP Section(s) Amended

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IEP TEAM/SIGNATURES
The Individualized Education Program team makes the decisions about the students program and placement. The students parent(s), the students special
education teacher, and a representative from the Local Education Agency are required members of this team. Signature on this IEP documents attendance, not
agreement.
Role

Printed Name

Signature

Parent/Guardian/Surrogate

Tyreek Mackey

Tyreek Mackey

Student*

James Mackey

James Mackey

Regular Education Teacher**

Blake Gans

Blake Gans

Special Education Teacher

Samuel Sutton

Samuel Sutton

Local Ed Agency Rep

Julia Edwards

Julia Edwards

Parent/Guardian/Surrogate

Career/Tech Ed Rep***
Community Agency Rep
Teacher of the Gifted****

*
The IEP team must invite the student if transition services are being planned or if the parents choose to have the student participate.
**
If the student is, or may be, participating in the regular education environment
***
As determined by the LEA as needed for transition services and other community services
****
A teacher of the gifted is required when writing an IEP for a student with a disability who also is gifted.
One individual listed above must be able to interpret the instructional implications of any evaluation results.
Written input received from the following members:

Transfer of Rights at Age of Majority

For purposes of education, the age of majority is reached in Pennsylvania when the individual reaches 21 years of age. Likewise, for purposes of the Individuals
with Disabilities Education Act, the age of majority is reached for students with disabilities when they reach 21 years of age.

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Students Name:
PROCEDURAL SAFEGUARDS NOTICE
I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides information about my rights,
including the process for disagreeing with the IEP. The school has informed me whom I may contact if I need more information.
Signature of Parent/Guardian/Surrogate:

James Mackey

MEDICAL ASSISTANCE PROGRAM BILLING NOTICE

(Applicable only to parents who have consented to the release of billing information to Medical Assistance programs)
I understand that the school may charge the School-Based Access Program (SBAP)or any program that replaces or supplements the SBAPthe cost of certain
special education and related services described in my childs IEP. To make these charges to the SBAP, the school will release to the administrator of that
program the name, age, and address of my child, verification of Medicaid eligibility for my child, a copy of my childs IEP, a description of the services
provided and the times and dates during which such services were provided to my child, and the identity of the provider of such services. I understand that
such information will not be disclosed, and such charges will not be made, unless I consent to the disclosure. I acknowledge that I have provided written
consent to disclose such information.
I understand that my consent is ongoing from year-to-year unless and until I withdraw it. I can withdraw my consent in writing, or orally if I am unable to
write, at any time. My refusal to consent or my withdrawal of consent will not relieve the school of the obligation to provide, at no cost to me or my family,
any service or program to which my child is entitled under the Individuals with Disabilities Education Act (IDEA) or that is necessary to enable my child to
receive a free appropriate public education as described in my childs IEP.
I understand that the school cannot
Require me or my family to sign up for or enroll in any public benefits or insurance program, such as Medicaid, as a conditio n of receiving a free appropriate
public education for my child;
Require me or my family to incur any expense for the provision of a free appropriate public education to my child, including co-payments and deductibles,
unless it agrees to pay such expenses on my or my familys behalf;
Cause a decrease in available lifetime coverage or any other insured benefit;
Cause me or my family to pay for services that would otherwise be covered by a public benefits or insurance program and that are required for my child
outside the time that he or she is in school;
Risk the loss of eligibility for home and community-based waivers, based on aggregate health-related expenditures.

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Students Name:
I. SPECIAL CONSIDERATIONS THE IEP TEAM MUST CONSIDER BEFORE DEVELOPING THE IEP. ANY FACTORS CHECKED AS YES MUST BE ADDRESSED IN THE IEP.
Is the student blind or visually impaired?
Yes
The IEP must include a description of the instruction in Braille and the use of Braille unless the IEP team determines, after an
evaluation of the students reading and writing skills, needs, and appropriate reading and writing media (including an
evaluation of the students future needs for instruction in Braille or the use of Braille), that instruction in Braille or the use of
Braille is not appropriate for the student.
x No
Is the student deaf or hard of hearing?
Yes
The IEP must include a communication plan to address the following: language and communication needs; opportunities for
direct communications with peers and professional personnel in the students language and communication mode; academic
level; full range of needs, including opportunities for direct instruction in the students language and communication mode;
and assistive technology devices and services. Indicate in which section of the IEP these considerations are addressed. The
Communication Plan must be completed and is available at www.pattan.net
x

No

Does the student have communication needs?

Yes
Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)
x

No

Does the student need assistive technology devices and/or services?

Yes
Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)
x

No

Does the student have limited English proficiency?

Yes
The IEP team must address the students language needs and how those needs relate to the IEP.
x

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No

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Students Name:

Does the student exhibit behaviors that impede his/her learning or that of others?
The IEP team must develop a Positive Behavior Support Plan that is based on a functional assessment of behavior and that
x Yes
utilizes positive behavior techniques. Results of the functional assessment of behavior may be listed in the Present Levels
section of the IEP with a clear measurable plan to address the behavior in the Goals and Specially Designed Instruction
sections of the IEP or in the Positive Behavior Support Plan if this is a separate document that is attached to the IEP. A
Positive Behavior Support Plan and a Functional Behavioral Assessment form are available at www.pattan.net
No

Other (specify):

II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Include the following information related to the student:
Present levels of academic achievement (e.g., most recent evaluation of the student, results of formative assessments, curriculum-based
assessments, transition assessments, progress toward current goals)
Present levels of functional performance (e.g., results from a functional behavioral assessment, results of ecological assessments, progress
toward current goals)
Present levels related to current postsecondary transition goals if the students age is 14 or younger if determined appropriate by the IEP team
(e.g., results of formative assessments, curriculum-based assessments, progress toward current goals)
Parental concerns for enhancing the education of the student
How the students disability affects involvement and progress in the general education curriculum
Strengths
Academic, developmental, and functional needs related to students disability
Present Levels of Academic Achievement:
James Mackey is a nine-year old student at who currently attends Fredrick Douglass Mastery Charter
Elementary School. He is part of a fourth grade classroom in which he shares with approximately 27
other students. James was diagnosed with Fetal Alcohol Syndrome at four months which now impacts
his ability to fully and successfully participate in school. So far, James has done a good job learning and
completing grade level work for most subject areas. He struggles most with subjects that require good
attention or memory skill. In light of Jamess diagnosis and his behaviors becoming a barrier to his
academic achievement, he qualifies to receive special education under the IDEIA educational category
of Other Health Impairment.
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James demonstrated variable cognitive skills on the DAS-II. He showed relative strength, in the average
range, in the areas of nonverbal abilities, including understanding patterns, manipulating designs and
processing speed. He struggled with verbal abilities and tasks of working memory, which is the ability to
hold recently learned information in ones mind and manipulate that information immediately. Also,
James difficulty with attention affected his performance.

Evaluation/Test
Reading
Pseudo Reading
Word Reading
Oral Reading
Fluency
Reading
Comprehension
Written Expression
Spelling
Sentence
Composition
Essay Composition

Standard Score
101
117
99
108

Percentile
53
87
47
70

Grade Equivalent
10.7
3.9
5.4

Classifications
Average
Above Average
Average
Average

85

16

2.0

Low Average

81
98
93

10
45
32

4.2
3.4

Below Average
Average
Average

63

<3.0

Mathematics
Numerical
Operations
Math Problem
Solving

90
97

25
42

4.0

Significantly Below
Average
Average
Average

86

18

3.0

Low Average

Reading:
James performed in the average range for academic skills on standardized assessments (WIAT-III, PSSA
& Benchmarks), with exception of listening comprehension and on essay composition task. However
both of these skills were likely affected by his poor working memory and attention. James struggles
with comprehending information he recently read which leads to undesired behaviors in the classroom.
When the teacher is able to modify or chunk Jamess independent work he performs at a higher level
but still needs to be constantly redirected back to his work.
Comprehension:
When asked questions about short stories and to identify vocabulary from verbal descriptions, he
occasionally answered impulsively and did not attend to the information given. This is most likely
connected to his difficulties with comprehension and working memory which limits his ability to recite
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recently learned information.
Writing:
Jamess writing skills vary by task. He becomes easily overwhelmed and frustrated with assignments he
view as difficult. James is a good speller due to his skills in phonics. James struggled with writing last
year, producing kindergarten level work. James doesnt stay on topic when writing and provides details
that have nothing to do with the main idea of the prompt. James has a hard time completing writing
assignments once he reaches his frustration level. Struggles in this area is most likely due to his
difficulties with working memory. James will benefit from having his writing assignment broken down
into smaller task (story web, chart etc) before he is asked to write an essay.

2015 16 Report Card

COURSE
Text Study
Writing
Reading Comp/Word Study
Math
Science
Spanish
Music
Interactive Read Aloud

RP2
75
64
80

RP3
76
69
-

RP4
61
70
81

64
90
-

80
76
-

81
90

YEAR END
72
68
81
88
75
90
76
90

Present Level of Functional Performance:

The behavioral Assessment System for Children Second Edition (BASC-2) was used to assess Jamess scioemotional development. The BASC-2 Parent Rating Scale (PRS) and the BASC 2 Teacher Rating Scale (TRS)
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Students Name:
were completed by Mr. James Mackey (Jamess father) and Jamess 4th grade teacher Ms. Baldwin. On the
BASC 2 both his teacher and father noted at-risk concerns about depression and withdrawal. While James is
described as a happy child who gets along with most people, he often prefers to be alone and sometimes
avoids others. James demonstrates difficulty with attention, hyperactivity, impulsivity, working memory,
emotional regulation and social skills. These deficits make it hard for James to pay attention to directions
and instructions, initiate and complete work, stay on task and appropriately interact with others. All of
these skills are critical to success at school. The areas he struggles in most are subjects that require good
attention and working memory skill.
Peers:
James is having trouble making friends and seems to be a target for bullying. Even though James is if a
friendly energetic student, his peers seems to be annoyed by his presence. When James becomes upset he
tends to cry, this leads to his classmates making fun of him later down the line. Despite being a victim of
bullying, James attempts to make new friends on a daily basis. James will benefit from attending 30 minute
counseling sessions that focus on social skills and emotional regulation twice a week.
Teachers:
James seems to have a good relationship with all of his teachers for the most part. When he is being
bothered by another student James feel comfortable with talking to any of his teachers about the problem.
Jamess disruptive behaviors are the same in all classroom settings and isnt triggered by a specific teacher.
Ms. Baldwin states that James struggles with remaining focus, distractibility and slow rate of work. He
frequently does not finish his classwork and often fails to follow directions. In order to complete his work he
needs frequent redirections and one on one support. Its best to get Jamess full attention before giving
directions and also checking to make sure he understands the directions.
Attendance:
James has perfect attendance with no tardiness.
Cultural Data:
James has not been involved in any incidents.

Teacher Input 2016 2017:

Ms. Baldwin described James as a student with the potential to perform at a high level in her class but is
held back by his behavioral barriers. When James becomes frustrated he tends to become disruptive in class
distracting the rest of his peers. She learned that James performs better when he fully understands the
directions and receives positive praise for doing so. During writing James completely checks out because he
has a hard time focusing during independent work. She did mention that small breaks helps reset him but his
writing skills needs lot of improvement. During reading, James reads well but has trouble telling what
happened in the story and answering questions about the story.
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Students Name:

Present Levels Related to Current Postsecondary Transition Goals:

James do not qualify for postsecondary transition goals.

Parental Concerns for Enhancing the Education of the Student:

Mr. Mackeys main concern is Jamess difficulty with following directions and paying attention. Specifically,
James has a hard time staying focused at home. For example, it takes him a long time to complete his
homework because he frequently get distracted. He also expressed concerns about Jamess emotional
regulation and sleep habits. In particular, Jamess temper is a problem. He will become upset easily if he
cannot have his way. He may also avoid activities that require mental effort such as chores or homework.
Overall, James is displaying some concerning behaviors that may be affecting his behavior and participation
at school.
How the students disability affects involvement and progress in the general education curriculum:
Other health impairment means having limited strength, vitality or alertness, including a heightened
alertness to environmental stimuli, that results in limited alertness with respect to the educational
environment, that Is due to chronic or acute health problems such as asthma, attention decit disorder or
attention decit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning,
leukemia, nephritis, rheumatic fever, and sickle cell anemia; and Adversely affects a childs educational
performance. At this time, James meets the criteria to receive accommodation under this definition due to
his difficulty with controlling his behaviors and emotions due to his diagnosis of Partial FAS.
Strengths
Casimior shows strengths in the following areas:
- Nonverbal Skills
- Processing Speed
- Decoding and blending unfamiliar words
- Math Skills
- Flexible with changes
Academic, developmental, and functional needs related to students disability:

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- Improve working memory (SDI)
- Improve Reading Comprehension (Reading Goal 1)
- Improve Writing Skills (Writing Goal 1)
- Increase Attention Span (Behavioral Goal 2)
- Improve emotional regulation / social skills (Counseling)
III. TRANSITION SERVICES This is required for students age 14 or younger if determined appropriate by the IEP team. If the student does not attend the
IEP meeting, the school must take other steps to ensure that the students preferences and interests are considered. Transition services are a coordinated
set of activities for a student with a disability that is designed to be within a results oriented process, that is focused on improving the academic and
functional achievement of the student with a disability to facilitate the students movement from school to post school activities, including postsecondary
education, vocational education, integrated employment (including supported employment), continuing and adult education, adult services, independent
living, or community participation that is based on the individual students needs taking into account the students strengths, preferences, and interests.
POST SCHOOL GOALS Based on age appropriate assessment, define and project the appropriate measurable postsecondary goals that address education
and training, employment, and as needed, independent living. Under each area, list the services/activities and courses of study that support that goal.
Include for each service/activity the location, frequency, projected beginning date, anticipated duration, and person/agency responsible.
For students in Career and Technology Centers, CIP Code:

Postsecondary Education and Training Goal:

Measurable Annual Goal

Yes/No
(Document in Section V)

Courses of Study:

Service/Activity

Employment Goal:

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Location

Frequency

Projected
Beginning Date

Anticipated
Duration

Person(s)/Agency
Responsible

Measurable Annual Goal

Yes/No
(Document in Section V)
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Students Name:
Courses of Study:

Service/Activity

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Location

Frequency

Projected
Beginning Date

Anticipated
Duration

Person(s)/Agency
Responsible

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Independent Living Goal, if appropriate:

Measurable Annual Goal

Yes/No
(Document in Section V)

Courses of Study:

Service/Activity

Location

Frequency

Projected
Beginning Date

Anticipated
Duration

Person(s)/Agency
Responsible

IV. PARTICIPATION IN STATE AND LOCAL ASSESSMENTS

Instructions for IEP Teams:
Please select the appropriate assessment option. Information on available testing accommodations may be found in the Accommodations Guidelines
available on www.education.state.pa.us.
State Assessments
Not Assessed
No statewide assessment is administered at this students grade level.
x

No English proficiency assessment administered because the student is not an English Language Learner.

PSSA (Math administered in grades 3-8; Science administered in grades 4 and 8; Reading administered in grades 3-8; Writing administered in grades 5
and 8; and ELA*)
Without
With
Tested Subject Accommodations Accommodations
Accommodations to be Provided
Math
x
- Extended Time
- Small Group Setting
- Use of Noise Cancelling Headphones.
- Access to study carrel
- Use of multiple shortened test periods..
Science
x
- Extended Time
- Small Group Setting
- Use of Noise Cancelling Headphones.
- Access to study carrel
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- Use of multiple shortened test periods..
- Extended Time
- Small Group Setting
- Use of Noise Cancelling Headphones.
- Access to study carrel
- Use of multiple shortened test periods..
Writing
x
- Extended Time
- Small Group Setting
- Use of Noise Cancelling Headphones.
- Access to study carrel
- Use of multiple shortened test periods..
ELA*
x
- Extended Time
- Small Group Setting
- Use of Noise Cancelling Headphones.
- Access to study carrel
- Use of multiple shortened test periods..
*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.
Reading

Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11th grade)
Without
With
Tested Subject
Accommodations
Accommodations
Accommodations to be Provided
Algebra 1
Literature
Biology
Keystone Project Based Assessment (Available when student is unable to demonstrate proficiency on a Keystone Exam or Keystone Exam module.)
Without
With
Tested Subject
Accommodations
Accommodations
Accommodations to be Provided
Algebra 1
Literature
Biology
Validated Local Assessment (Available when selected as option by LEA)
Without
With
Tested Subject
Accommodations
Accommodations
Algebra 1
Literature
Biology
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Accommodations to be Provided

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PASA (Administered in grades 3-8, 11 for Reading and Math; Grades 4, 8, 11 for Science)
Student will participate in the PASA.
Explain why the student cannot participate in the PSSA or the Keystone Exam for Reading/Literature, Math/Algebra 1,
Science/Biology, and Composition (The Composition exam will be available for the 2016-17 school year):

Explain why the PASA is appropriate:

Choose how the students performance on the PASA will be documented.

Videotape (preferred method)
Written narrative notes (requires prior approval in accordance with PDE
guidance)

ACCESS for ELLs (Administered in grades K-12)

Domains
Without
With
Accommodations Accommodations
Listening
Reading
Writing
Speaking

Unable to
Participate

Accommodations to be Provided or Rationale for Inability to

Participate in Selected Domains

Alternate ACCESS for ELLs (Administered in grades 1-12)

Student will participate in the Alternate ACCESS for ELLs.
Explain why the student cannot participate in the ACCESS for ELLs:

Explain why the Alternate ACCESS for ELLs is appropriate:

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Domains

Without
Accommodations

With
Accommodations

Unable to
Participate

Accommodations to be Provided or Rationale for Inability to

Participate in Selected Domains

Listening
Reading
Writing
Speaking

Local Assessments
Local assessment is not administered at this students grade level; OR
Student will participate in local assessments without accommodations; OR
x Student will participate in local assessments with the following accommodations; OR
- Extended Time
- Small Group Setting
- Use of Noise Cancelling Headphones.
- Access to study carrel
- Use of multiple shortened test periods..

The student will take a local alternate assessment.

Explain why the student cannot participate in the local regular assessment:

Explain why the local alternate assessment is appropriate:

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V. GOALS AND OBJECTIVES Include, as appropriate, academic and functional goals. Use as many copies of this page as needed to plan appropriately.
Specially designed instruction may be listed with each goal/objective or listed in Section VI.
Short term learning outcomes are required for students who are gifted. The short term learning outcomes related to the students gifted program may be
listed under Goals or Short Term Objectives.
MEASURABLE ANNUAL GOAL
Include: Condition, Name, Behavior, and Criteria
(Refer to Annotated IEP for description of these
components)

Describe HOW the

students progress toward
meeting this goal will be
measured

Reading Goal 1: James will read at on a Level Q

(4.3 grade level equivalency) with 98% accuracy,
7/10 comprehension and 150 words per minute.
(1.0 years growth).
Baseline: Level N (3.3 grade level
equivalency) 99% accuracy - 7/10
comprehension 120 wpm
Writing Goal 1: Given a narrative writing prompt,
James will have the opportunity to go from
writing one complete on-topic sentence (with
appropriate capital letters and punctuation) to a
goal of 5 complete on topic sentences. Measured
every other week.
Baseline: 1 out of 5 on topic sentences.
Behavioral Goal 1: Improve completion of
tasks/assignments given. Given an assignment
tracker, James will have the opportunity to
complete 80% of his class work on a daily basis.
(Baseline 40%)
Behavioral Goal 2: Maintain attention during
instruction. When given the opportunity, direct
instruction and clear expectations, James will
maintain attention to instruction for 70% of the
time when observed for 20 minutes. (Baseline:
46%)

Progress will be
monitored via Fontus and
Pinnelll Reading
Assessment.

Quarterly IEP Progress

report.

Data Collection from the

teacher.

Quarterly IEP Progress

report.

Student Tracker, Data

collection for the teacher.

Quarterly IEP Progress

report.

Teacher observation.

Quarterly IEP Progress

report.

Describe WHEN periodic

reports on progress will be
provided to parents

Report of Progress

SHORT TERM OBJECTIVES Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).
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Students Name:
Short term objectives / Benchmarks

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VI. SPECIAL EDUCATION / RELATED SERVICES / SUPPLEMENTARY AIDS AND SERVICES / PROGRAM MODIFICATIONS Include, as appropriate, for nonacademic
and extracurricular services and activities.
A. PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED INSTRUCTION (SDI)
SDI may be listed with each goal or as part of the table below.
Include supplementary aids and services as appropriate.
For a student who has a disability and is gifted, SDI also should include adaptations, accommodations, or modifications to the general
education curriculum, as appropriate for a student with a disability.
Modifications and SDI
Due to Jamess struggles
with remaining focus when
giving directions, make sure
you have his attention first
by either calling his name
or gaining eye contact.
Repeat direction frequently
to endure understanding
and compliance.
Due to Jamess working
memory ability, teachers
should break multi-task
directions into steps and
have James repeat to check
for comprehension.
Due to distractions
hindering Jamess ability to
learn, provide him with a
study carrel during
independent seatwork to
avoid distractions.
Due to Jamess frustrations
with writing break down
larger assignments into
chunks.
Due to Jamess issues with
working memory, allow him
to preview assignments and
work on outlines or graphic
organizers before
completing the assignment.
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Location

Frequency

Projected Beginning Date

Anticipated Duration

All Classrooms

Daily

10/19/16

10/19/17

All Classrooms

Daily

10/19/16

10/19/17

All Classrooms

Daily

10/19/16

10/19/17

Writing

Daily

10/19/16

10/19/17

Daily

10/19/16

10/19/17

Writing

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Students Name:
When James seems
frustrated with a task,
allow him to take a 5
minute break before
continuing to complete his
work to avoid incompletion
of assignments.

Writing & Reading

Daily

10/19/16

10/19/17

B. RELATED SERVICES List the services that the student needs in order to benefit from his/her special education program.
Service
Counseling small group

Location
Mastery Charter School
Fredrick Douglass

Frequency

Projected Beginning Date

Anticipated Duration

960 minutes per IEP term

10/19/16

10/19/17

C. SUPPORTS FOR SCHOOL PERSONNEL List the staff to receive the supports and the supports needed to implement the students IEP.
School Personnel to
Receive Support

Support

Location

Frequency

Projected Beginning
Date

Anticipated Duration

Regular Education
Teacher

On-going
communication and
support between
general education
teachers and special
education
department.

Across all settings

Monthly 30 minutes

10/19/16

10/19/17

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Students Name:
D. GIFTED SUPPORT SERVICES FOR A STUDENT IDENTIFIED AS GIFTED WHO ALSO IS IDENTIFIED AS A STUDENT WITH A DISABILITY Support services are
required to assist a gifted student to benefit from gifted education (e.g., psychological services, parent counseling and education, counseling services,
transportation to and from gifted programs to classrooms in buildings operated by the school district).

Support Service
Support Service
Support Service
E. EXTENDED SCHOOL YEAR (ESY) The IEP team has considered and discussed ESY services, and determined that:

Student IS eligible for ESY based on the following information or data reviewed by the IEP team:

OR
As of the date of
x this IEP, student is NOT eligible for ESY based on the following information or data reviewed by the IEP team:
x

The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the students ESY Program are:

If the IEP team has determined ESY is appropriate, complete the following:
ESY Service to be Provided

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Location

Frequency

Projected Beginning Date

Anticipated Duration

April 2014

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
VII. EDUCATIONAL PLACEMENT
A. QUESTIONS FOR IEP TEAM The following questions must be reviewed and discussed by the IEP team prior to providing the explanations regarding
participation with students without disabilities.
It is the responsibility of each public agency to ensure that, to the maximum extent appropriate, students with disabilities, including those in public
or private institutions or other care facilities, are educated with students who are not disabled. Special classes, separate schooling or other removal
of students with disabilities from the general educational environment occurs only when the nature or severity of the disability is such that education
in general education classes, EVEN WITH the use of supplementary aids and services, cannot be achieved satisfactorily.

What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the supplementary
aids and services will or will not enable the student to make progress on the goals and objectives (if applicable) in this IEP in the general
education class.

What benefits are provided in the general education class with supplementary aids and services versus the benefits provided in the special
education class?

What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the other students in the
class, even with supplementary aids and services?

To what extent, if any, will the student participate with nondisabled peers in extracurricular activities or other nonacademic activities?

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the regular education class:

Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
B. Type of Support
1. Amount of special education supports
x

Itinerant: Special education supports and services provided by special education personnel for 20% or less of the school day
Supplemental: Special education supports and services provided by special education personnel for more than 20% of the day but less than
80% of the school day
Full-Time: Special education supports and services provided by special education personnel for 80% or more of the school day

2. Type of special education supports

Autistic Support
Blind-Visually Impaired Support
Deaf and Hard of Hearing Support
x

Emotional Support
Learning Support
Life Skills Support
Multiple Disabilities Support
Physical Support
Speech and Language Support

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
C. Location of students program
Mastery Charter School Fredrick Douglass

Name of School District where the IEP will be implemented:

Mastery Charter School Fredrick Douglass

Name of School Building where the IEP will be implemented:

Is this school the students neighborhood school (i.e., the school the student would attend if he/she did not have an IEP)?
x Yes
No. If the answer is no, select the reason why not.
Special education supports and services required in the students IEP cannot be provided in the neighborhood school
Other. Please explain:

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INDIVIDUALIZED EDUCATION PROGRAM (IEP)

Students Name:
VIII. PENNDATA REPORTING: Educational Environment (Complete either Section A or B; Select only one Educational Environment)
To calculate the percentage of time inside the regular classroom, divide the number of hours the student spends inside the regular classroom by the total number of hours in the school day (including
lunch, recess, study periods). The result is then multiplied by 100.

SECTION A: For Students Educated in Regular School Buildings with Non Disabled Peers Indicate the Percentage of time INSIDE the regular classroom for this student:
Time spent outside the regular classroom receiving services unrelated to the students disability (e.g., time receiving ESL services) should be considered time inside the regular classroom.
Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as college campuses or vocational sites, should be counted as time
spent inside the regular classroom.
Calculation for this Student:

Column 1

Column 2

Calculation

Indicate Percentage

Percentage Category

Total hours the student

spends in the regular
classroom per day

Total hours in a typical

school day

(Hours inside regular

classroom hours in
school day) x 100 = %

Section A: The percentage of

time student spends inside the
regular classroom:

Using the calculation result select the appropriate percentage category

(including lunch, recess

& study periods)

7.10

(Column 1 Column 2) x
100 = %
(7.10 8) x 100

___89__% of the day

x INSIDE the Regular Classroom 80% or More of the Day

INSIDE the Regular Classroom 79-40% of the Day
INSIDE the Regular Classroom Less Than 40% of the Day

SECTION B: This section required only for Students Educated OUTSIDE Regular School Buildings for more than 50% of the day select and indicate the Name of School or
Facility on the line corresponding with the appropriate selection: (If a student spends less than 50% of the day in one of these locations, the IEP team must do the calculation
in Section A)
Approved Private School (Non Residential)
Approved Private School (Residential)
Other Private Facility (Non Residential)
Other Private Facility (Residential)
Other Public Facility (Residential)

_________________________
_________________________
_________________________
________________________
________________________

Other Public Facility (Non Residential) _________________________

Hospital/Homebound
_________________________
Correctional Facility
_________________________
Out of State Facility
_________________________
Instruction Conducted in the Home
_________________________

EXAMPLES for Section A: How to Calculate PennDataEducational Environment Percentages

Column 1

Column 2

Calculation

Indicate Percentage

Total hours the student spends in the

regular classroom per day

Total hours in a typical school day

(including lunch, recess & study
periods)

(Hours inside regular classroom hours in school day)

x 100 = %

Section A: The percentage of time student

spends inside the regular classroom:

(Column 1 Column 2) x 100 = %

Example 1

5.5

6.5

(5.5 6.5) x 100 = 85%

85% of the day

(Inside 80% or More of Day)

Example 2

(3 5) x 100 = 60%

60% of the day

(Inside 79-40% of Day)

Example 3

(1 5) x 100 = 20%

20% of the day

(Inside less than 40% of Day)

For help in understanding this form, an annotated IEP is available on the PaTTAN website at www.pattan.net Type Annotated Forms in the Search feature on the website. If you do not have access
to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.
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April 2014