INVITATION TO A MEETING OF THE

INDIVIDUALIZED EDUCATION PROGRAM (IEP) TEAM

Form I-1 (Rev. 10/06)

_____________________________________ SCHOOL DISTRICT

[If you need this invitation in a different language or communicated in a different way, or have
questions about this invitation, please contact________________________ at ____________________.]

Dear _____Mr. & Mrs. Kanzia______________________ Date ___05/01/2017_____________

You are a participant on the IEP Team which will meet to address the educational needs of your child, ____Kimika_____.
IEP team meetings must be held at a mutually agreeable time and place. An IEP team meeting has tentatively been
scheduled for the following date __05/09/2017___, time _12:20 pm______ and location ___Blue Elementary
School__________. If these meeting arrangements are not agreeable to you, please call _____________________ at
__________________. You may bring other people who you believe have knowledge or special expertise about your
child to the meeting with you. If your child is transferring from a Birth to 3 Early Intervention Program we will, at your
request, send to the Birth to 3 coordinator or other representative an invitation to the IEP meeting.

The purpose of this IEP team meeting is (check all that apply):

EVALUATION AND REEVALUATION

Determine initial eligibility for special education
Determine continuing eligibility for special education
INDIVIDUALIZED EDUCATION PROGRAM (IEP) (if student is eligible)
Develop an initial IEP
x Develop an annual IEP
x Review/revise IEP
Transition the consideration of postsecondary goals and transition services
(required for students beginning at age 14)

PLACEMENT (if student is eligible)

Determine initial placement
x Determine continuing placement
OTHER
Review existing information to determine need for additional assessments or other evaluation materials
(meeting optional)
Conduct a manifestation determination (check appropriate boxes under IEP and placement if changes in
either are contemplated)
Determine setting for services during disciplinary change in placement (must also check appropriate
boxes under IEP & placement)
Specify: _______________________________________________________________
______________________________________________________________________________________
If transition is checked as one of the purposes of this meeting, your child will be invited to attend. Because you provided
your consent we are also inviting representatives from the following agencies who may assist in the transition planning for
your child: x None
________________________________________________________________________
1Academic content standards for the grade in which the child is enrolled and general education assessments refer to the
Wisconsin Academic Standards. Alternate achievement standards and assessments reflect the Wisconsin Essential Elements.
Students who are English Learners are required to participate in an annual English language proficiency assessment.
 Agency Name (if known), and Title/Position

________________________________________________________________________
Agency Name (if known), and Title/Position

If at any point during this meeting you or other IEP team participants believe that additional time is needed to permit your
meaningful involvement, additional time will be provided. Decisions related to the purpose(s) checked above may be
made in one meeting or may require more than one meeting, depending on individual circumstances. In addition and
upon request you may receive a copy of the IEP teams most recent evaluation report.

The following individuals have been appointed as IEP team participants and will attend the meeting.

______________Ms, White_____________ _____________Ms. Kleven__________________

Name/Reg. Ed. Teacher Name/Sp. Ed. Teacher

______________Mr. Anderson_________ _____Ms. Kate, SLP________________________

Name/LEA Representative Name &Title

_________Mr. Javier, OT______________ ________________School Nurse________________________

Name & Title Name & Title

____________PT_________________________ ________________________________________
Name & Title Name & Title

_____________________________________ ________________________________________
Name & Title Name & Title

You and your child have protection under the procedural safeguards (rights) of special education law. The school district
must provide you with a copy of your procedural safeguards once a year.

X You received a copy of your procedural safeguard rights in a brochure about parent and child rights earlier this year.
If you would like another copy of this brochure, please contact the district at the telephone number above.

A copy of the parent and child rights brochure is enclosed with this invitation.

In addition to district staff, you may also contact _________________________________ at ___________________if

you have questions about your rights.

Sincerely,

Name and Title of District Contact Person

 ________________________________ SCHOOL DISTRICT

Name of Student DOB Grade WISEid LEAs Student ID

Parent or Legal Guardian Telephone (area code/number)

Address

District of Residence Current District of Placement

For students transferring between public agencies: For students transferring between public agencies:
Evaluation Report reviewed and adopted (if applicable) by IEP reviewed and adopted (if applicable) by
______________________ on ________________ _______________ on ___________________

Date of Meeting: ____________________________ (month/day/year)

PURPOSE OF MEETING (check all that apply):

EVALUATION AND REEVALUATION

Evaluation including determination of initial eligibility for special education
Reevaluation including determination of continuing eligibility for special education

INDIVIDUALIZED EDUCATION PROGRAM (IEP) (if student is eligible)

Develop an initial IEP
x Annual IEP review
x Review/revise IEP
Transition the consideration of post-secondary goals and transition services
(Required for students beginning at age 14.)

PLACEMENT (must be determined when the IEP is developed or reviewed/revised)

Determine initial placement
x Determine continuing placement

OTHER
Review existing information to determine need for additional assessments or other evaluation materials (IEP team
meeting optional)

Conduct a manifestation determination (check appropriate boxes under IEP and PLACEMENT if changes in either
are contemplated)

Determine setting for services during disciplinary change in placement (must check appropriate boxes under IEP
& PLACEMENT)

Other. Specify: ________________________________________________________

If a purpose of this meeting is IEP development, review, and/or revision related to the academic, developmental and functional needs
of the child, the IEP team considered the results of:
 Initial or most recent evaluation x Yes Not applicable
Statewide assessments x Yes Not applicable
District-wide assessments Yes x Not applicable

IEP Team Participants Attending or Participating by Alternate Means in the Meeting:

Parent/Guardian Regular education teacher/title: Regular education teacher/title:

Mrs. Brown
Mrs. Kanzia

Student (if appropriate): Special education teacher/title: Ms. Special education teacher/title:
Kleven

LEA Representative/title: Other: SLP Other: OT

Mr. Anderson

Other: Other: School Nurse Other:

PT

If the parent did not attend or participate in the meeting by other means and did not agree to the time and place of the IEP team
meeting, document three efforts to involve the parent:

Date Method Result

INFORMATION ABOUT THE STUDENT
Information about the student, including strengths, effects of the disability / special factors, present level of academic
achievement and functional performance, and any concerns must be considered when identifying the students disability-
related needs and developing goals and services to address those needs. Include strategies that have been effective in
improving the students academic achievement and functional performance and access to general education.
Parents are important members of the IEP team and are encouraged to share information throughout the process.
The student should be included, whenever appropriate, and encouraged to provide input throughout the process.

A. Strengths
Describe the students strengths (including academic skills, communication skills, social skills, and interests).
Kimika works hard to complete preferred tasks. Kimika understands a token economy and will work
hard to collect small rewards.

B. Current Academic Achievement and Functional Performance

Academic achievement generally refers to a students performance in academic content areas (e.g., reading, math, written
language, etc.). For preschool children, academic achievement generally refers to knowledge and skills such as early
language development/communication, early literacy, cognition and general knowledge. Academic achievement
statements must include information about student achievement and/or progress compared to grade-level expectations.
Sources of information may include state, district-wide, or classroom assessments, rubrics, screeners, recent evaluations,
etc.

1. Describe the students present level of academic achievement (including reading achievement). For preschool children,
describe the childs acquisition and use of knowledge and skills (including early language/communication and early
literacy).
Reading: Kimika scored in the .03 percentile in the wide range achievement test for reading. Her skills are below average for her age
at this time. Kimika is able to recognize 5 out of 40 pre-primer sight words and 7 out of 26 letter sounds. She also recognizes 11
functional words (Exit, danger, go, police, poison, walk, keep out, in, ladies, women, out) and 4 directional words (name, address,
telephone, and date) Kimika have below average performance in spelling and oral language skills. She struggles with listening
comprehension and following direction at this time.

Math: Kimika displays some basic math skills but still displays skill below average for her age. Her overall score on the wide range
achievement test for math was in the .04 percentile. She is able to rote count to 12, recognize number to 15, and write numerals 1-8.
She also can identify the value of 3 (penny, nickel, dime) out of 4 coins, can identify time to the hour, and is able to complete addition
facts problems to 5.

Writing: Writing is a struggle for Kimika due to her limited motor skills. She is able to write 10 out of 26 uppercase letters (M, K, S,
P, F, B, A, C, D, and I). Kimika is unable to draw a person at this time.

Functional performance includes activities and nonacademic skills needed for independence, access to instruction and
performance at school, in the home, in the community, for leisure time, and for post-secondary and lifelong learning
(including reading). Some examples include: activities of everyday living, school/work/play habits, and social-emotional
behavior.

2. Describe the students present level of functional performance. For preschool children, describe the child's positive social-
emotional skills (including social relationships) and use of appropriate behaviors to meet their needs and the impact on
early literacy.

Behavior: Kimika displays challenging behaviors at time that are disruptive to her learning and the learning of others in
her class. Kimika uses a behavior management plan of earing pennies for having appropriate behavior and completing work,
but this has not been enough to limit her verbal and physical outbursts at this time. When Kimika is having an outburst, she
will yell, swear, kicked walls, and spit toward other students. She has also thrown her work in an effort express frustration
and avoid work. In the past, outbursts have been handled by taking away earned pennies or extend time outs. These attempts
at intervention have not been successful in changing behavior and sometimes increase and extend the behaviors. Kimika has
also dumped food she has not liked on the floor in the cafeteria.
 Adaptive: Kimika scored a 50 on the Daily Living Skills domain on the Vineland Adaptive Behavior Scale. Due to
motor difficulties and a seizure condition, Kimika needs to be monitored while completing all daily living skills as she
could lose her balance, fall, and hurt herself.

Communication: Kimika is hard to understand when she is communicating with unfamiliar listeners. Kimika speaks in
short incomplete sentences at this time. Her receptive language skills are also delayed which make following directions
or completing tasks challenging. Kimika scored a 40 on the Communication Domain on the Vineland Adaptive Behaviors
Scale.

Social: Kimikas behavior affects her peer interaction. She has in the past spent extended periods of time in a day in time
out. She also has acted out toward peers by spitting and verbal aggression. Her score on the Socialization Domain of the
Vineland Adaptive Behavior Scale was a 68.

Motor: Kimika is ambulatory but does walk with a limp. The makes he balance unsteady and can make mobility a
challenge. Kimika struggles with fine motor tasks and is resistive to complete these tasks. Score on the Vineland
Adaptive Behavior Scale-Motor Skills was a 52

Health: Kimika has been diagnosed with multiple disabilities. Her health is affected by grand mal seizures. She is
currently medicated and a health and safety plan has been created.

C. Special Factors
Special Factors must be considered when developing the individualized education program. Consider the special factors
when identifying the effects of disability, summarizing disability related needs, developing goals, and determining services
in the Program Summary. For example, if a students behavior impedes learning, the positive behavioral interventions,
strategies, and supports could include specially designed instruction, related services, supplementary aids and services and/or
program modifications and supports for staff. The behavioral needs of the student may be determined through a functional
behavioral assessment (FBA).

1. Does the students behavior impede his/her learning or that of others?

x Yes No
If yes, describe how this factor affects learning: (Document positive behavioral interventions, strategies, and supports, and
other services in the Program Summary)
Kimikas behavior often escalated quickly after attempting to avoid work tasks. It takes her an extended period of time to
calm down so she misses instruction. Kimika has not responded positively consistently to any behavior interventions.

2. Is the student an English Learner (EL)?

Yes x No
If yes, describe how this factor affects the students needs related to this IEP:

3. In the case of a child who is blind or visually impaired, does the student need instruction in Braille or the use of Braille?
(Attach Determining Braille Needs (ER-3) from the latest evaluation/reevaluation or any updated information.)
x Not Applicable Yes No Cannot be determined at this time
If yes, describe needs, including Braille needs:

4. Does the student have communication needs that could impede his/her learning?
x Yes No
a. If yes, describe the communication needs (including speech and language needs):
Kimika has a severe language delay that effect bother her receptive and expressive speech.

b. If the student is deaf or hard of hearing, describe (a) the students language and communication needs; (b) opportunities
for direct communication with peers and professional personnel in the students language and communication mode; and,
(c) academic level and full range of needs including opportunities for direct instruction in the students language and
communicative mode:
 5. Does the student need assistive technology services or devices, including any services or devices needed to assist with
reading?
Yes x No
If yes, describe the needed services in the Program Summary:

D. Concerns of the Parent(s)/Family

1. Describe the concerns of the parent(s)/family for enhancing the education of the student. This may include concerns about
reading achievement, early language/communication or early literacy skills, other academic areas, social-emotional needs,
sensory needs, behavior, the childs future and postsecondary transition, etc.:
Kimikas mother is concerned about her daughters behavior at school as well as her lack of academic progress at this
time.

2. Describe the concerns (if any) of the student for enhancing his or her education:

None at this time

E. Effects of Disability
Effects of the disability identifies how the students disability affects academic achievement and functional performance. The
effects are what the IEP Team observes when the student has difficult accessing, engaging and making progress in the general
education curriculum, instruction, and environments.

1. Does the students disability adversely affect his or her progress toward meeting grade-level reading standards? For
preschoolers, does the disability adversely affect progress toward the early learning standards for language development,
communication and/or early literacy?

x Yes No

2. Describe how the students disability affects his or her access, involvement and progress in the general education
curriculum, including how the disability affects reading. For preschool children, describe how the disability affects
participation in age-appropriate activities, including language development, communication and/or early literacy.

Kimikas multiple disabilities affect her acquisition of academic skills, her receptive and expressive
communication, motor skills and behavior. Kimika requires significantly remediated instruction in all academic
areas as well as direct instruction in behavior and communication skills to make gains in skills. These needs
cannot be met within the general education curriculum.

Summary of Disability-Related Needs

If the IEP team determines the student has a disability-related need(s) that affects reading (academic and/or functional), the IEP
must include a minimum of one goal to address this need(s). Each identified disability-related need must have at least one
corresponding goal and/or service to address the need. A goal or service may address more than one need. Services include
special education, related services, supplementary aids and services, or program modifications or supports for school personnel.

List and number the disability-related needs. Include reading needs, or early literacy needs, and needs due to special factors, if
identified. Reference numbered needs in the measurable annual goal statements (add rows, as needed).
1 Challenging Behaviors

2 Communication Delays

3 Delays in Academic, Motor, and Adaptive Skills

4 Task Completion
FAMILY ENGAGEMENT
How will school staff engage parent(s)/families in the education of the student (e.g. sharing resources, communicating with
parent(s)/families, building upon family strengths, connecting parent(s)/families to learning activities, etc.)?

School and parents will continue to share and collaborate on success and challenges. School will also inform the
family of opportunities to learn outside of the typical school day as well as school events like concerts and
conferences.
 II. PARTICIPATION IN GENERAL EDUCATION CURRICULUM Choose one of the following:
The IEP team determines whether the student is in the general education curriculum (the same curriculum as for students without
disabilities) or the curriculum aligned with alternate achievement standards. Unless a student is expected to take alternate
assessments aligned with alternate achievement standards, the student is full time in the general education curriculum. If the
student participates in curriculum aligned with alternate achievement standards, include benchmarks or short-term objectives with
the measurable annual goals. (Select one below.)

The student participates full-time in general education curriculum aligned with the general education standards that apply to all
students, or for preschoolers, in age-appropriate activities aligned with early learning standards.
x The student is a student with the most significant cognitive disability participating in curriculum aligned with alternate achievement
standards. See the definition of a student with the most significant cognitive disability on the Participation Guidelines for Alternate
Assessment (DPI Model Form I-7-A).
III. MEASURABLE ANNUAL GOALS
Each goal must address at least one disability-related need.
Develop / revise one or more measurable annual academic or functional goal to:
address any lack of expected progress toward the annual goals, if appropriate;
address the unique needs of the student that result from the students disability (see section I.F. above);
enable the student to progress toward grade-level reading standards, or for preschoolers, early learning standards for
language development, communication and early literacy;
enable the student to be involved in the general education curriculum i.e., the same curriculum as for nondisabled students;
enable the student to progress toward meeting grade-level academic standards; and
enable the student to be educated and participate with nondisabled students.
If the IEP team determines the student has a disability-related need that affects reading (academic or functional), the IEP must
include a minimum of one goal to address this need.

A. Before developing annual goals, review the previous IEP goals and progress (document review and students progress on the
I-5, Annual Review of IEP Goals)
Previous IEP goals reviewed: x Yes No Not Applicable
.
B. Goal #_1_ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
Kimika will improve her basic literacy skills.

a. Baseline (Students current level of performance from which progress toward this goal will be measured):
K=imika knows five pre-primer level works, 11 functional words, and 7 beginning word sounds
b. Level of Attainment (Must relate to the baseline measurement and reflect progress):
Kimika will demonstrate literacy skills at 80% across skills over a two week period
2. Benchmarks or Short-Term Objectives (Required if student participates in curriculum and assessment aligned with
alternate academic achievement standards and each must include baseline and level of attainment.): Not Applicable
-Kimika will match pre-primer level words from a word card to words in a story.
-Kimika will increaser her knowledge of functional/ content words to 21.
-Kimika will match letters to pictures with the same beginning sound.

3. Annual goal addresses disability-related need(s) #___3____ of the student. (Needs identified in Section I.F).

4. Procedures for measuring the students progress toward meeting the annual goal from baseline to level of attainment:
Records of Observations, Checklists

5. When will reports about the students progress toward meeting the annual goal be provided to parent(s)? (Document
reviews and students progress on the I-6, Interim Review of IEP Goals.)
With regularly scheduled report cards

IV. MEASURABLE ANNUAL GOALS

Each goal must address at least one disability-related need.
Develop / revise one or more measurable annual academic or functional goal to:
address any lack of expected progress toward the annual goals, if appropriate;
address the unique needs of the student that result from the students disability (see section I.F. above);
enable the student to progress toward grade-level reading standards, or for preschoolers, early learning standards for
language development, communication and early literacy;
enable the student to be involved in the general education curriculum i.e., the same curriculum as for nondisabled students;
enable the student to progress toward meeting grade-level academic standards; and
enable the student to be educated and participate with nondisabled students.
If the IEP team determines the student has a disability-related need that affects reading (academic or functional), the IEP must
include a minimum of one goal to address this need.

C. Before developing annual goals, review the previous IEP goals and progress (document review and students progress on the
I-5, Annual Review of IEP Goals)
Previous IEP goals reviewed: x Yes No Not Applicable
.
D. Goal #__2_ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
Kimika will increase her functional math skills.

c. Baseline (Students current level of performance from which progress toward this goal will be measured):
Kimika is able to identify 3 coins value and tell time to the hour.
d. Level of Attainment (Must relate to the baseline measurement and reflect progress):
Kmika will demonstrate functional math skills with 80% accuracy over a two week period
2. Benchmarks or Short-Term Objectives (Required if student participates in curriculum and assessment aligned with
alternate academic achievement standards and each must include baseline and level of attainment.): Not Applicable
- Kimika will identify 4 coins and 4 bills by name and amount.
- Kimika will tell time to the half hour
- Kimika will be given an amount of money under $1.00 and an item price and tell whether she has enough
money to purchase that item
3. Annual goal addresses disability-related need(s) #__3___ of the student. (Needs identified in Section I.F).

4. Procedures for measuring the students progress toward meeting the annual goal from baseline to level of attainment:
Records of Observations

5. When will reports about the students progress toward meeting the annual goal be provided to parent(s)? (Document
reviews and students progress on the I-6, Interim Review of IEP Goals.)
With regularly scheduled report cards

V. MEASURABLE ANNUAL GOALS

Each goal must address at least one disability-related need.
Develop / revise one or more measurable annual academic or functional goal to:
address any lack of expected progress toward the annual goals, if appropriate;
address the unique needs of the student that result from the students disability (see section I.F. above);
enable the student to progress toward grade-level reading standards, or for preschoolers, early learning standards for
language development, communication and early literacy;
enable the student to be involved in the general education curriculum i.e., the same curriculum as for nondisabled students;
enable the student to progress toward meeting grade-level academic standards; and
enable the student to be educated and participate with nondisabled students.
If the IEP team determines the student has a disability-related need that affects reading (academic or functional), the IEP must
include a minimum of one goal to address this need.

E. Before developing annual goals, review the previous IEP goals and progress (document review and students progress on the
I-5, Annual Review of IEP Goals)
Previous IEP goals reviewed: xYes No Not Applicable
.
F. Goal #__3_ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
 Kimika will increase her ability to produce written word.
e. Baseline (Students current level of performance from which progress toward this goal will be measured):
Kimika is able to write 10 letters and unable to draw a person
f. Level of Attainment (Must relate to the baseline measurement and reflect progress):
Kimika will complete a writing task with no more than two errors in 4 out of 5 attempts
2. Benchmarks or Short-Term Objectives (Required if student participates in curriculum and assessment aligned with
alternate academic achievement standards and each must include baseline and level of attainment.): Not Applicable
-Kimika will write her first and last name from memory
-Kimika will draw a picture of a person with head, torso, legs, arms, eyes, nose, mouth, ear, and hair
-Using a key board, Kimika will type pre-primer sight words and functional/ content words with no errors
3. Annual goal addresses disability-related need(s) #_3___ of the student. (Needs identified in Section I.F).

4. Procedures for measuring the students progress toward meeting the annual goal from baseline to level of attainment:
Work samples, Records of Observations

5. When will reports about the students progress toward meeting the annual goal be provided to parent(s)? (Document
reviews and students progress on the I-6, Interim Review of IEP Goals.)
With regularly scheduled report cards

VI. MEASURABLE ANNUAL GOALS

Each goal must address at least one disability-related need.
Develop / revise one or more measurable annual academic or functional goal to:
address any lack of expected progress toward the annual goals, if appropriate;
address the unique needs of the student that result from the students disability (see section I.F. above);
enable the student to progress toward grade-level reading standards, or for preschoolers, early learning standards for
language development, communication and early literacy;
enable the student to be involved in the general education curriculum i.e., the same curriculum as for nondisabled students;
enable the student to progress toward meeting grade-level academic standards; and
enable the student to be educated and participate with nondisabled students.
If the IEP team determines the student has a disability-related need that affects reading (academic or functional), the IEP must
include a minimum of one goal to address this need.

G. Before developing annual goals, review the previous IEP goals and progress (document review and students progress on the
I-5, Annual Review of IEP Goals)
Previous IEP goals reviewed: x Yes No Not Applicable
.
H. Goal #_4__ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
Kimika will improve her listening comprehension

g. Baseline (Students current level of performance from which progress toward this goal will be measured):
Kimika struggles with listening comprehension at this time.
h. Level of Attainment (Must relate to the baseline measurement and reflect progress):
Kimika will demonstrate listening comprehension skills with 80% accuracy across skills for two consecutive
weeks
2. Benchmarks or Short-Term Objectives (Required if student participates in curriculum and assessment aligned with
alternate academic achievement standards and each must include baseline and level of attainment.): Not Applicable
-Using visuals, Kimika will answer basic WH- question about a story that has been read to her
- Using visuals and verbal pairing, Kimika will complete a one-step task with no more than two prompts

3. Annual goal addresses disability-related need(s) #__2,3___ of the student. (Needs identified in Section I.F).
 4. Procedures for measuring the students progress toward meeting the annual goal from baseline to level of attainment:
Records of Observations

5. When will reports about the students progress toward meeting the annual goal be provided to parent(s)? (Document
reviews and students progress on the I-6, Interim Review of IEP Goals.)
With regularly scheduled report cards

VII. MEASURABLE ANNUAL GOALS

Each goal must address at least one disability-related need.
Develop / revise one or more measurable annual academic or functional goal to:
address any lack of expected progress toward the annual goals, if appropriate;
address the unique needs of the student that result from the students disability (see section I.F. above);
enable the student to progress toward grade-level reading standards, or for preschoolers, early learning standards for
language development, communication and early literacy;
enable the student to be involved in the general education curriculum i.e., the same curriculum as for nondisabled students;
enable the student to progress toward meeting grade-level academic standards; and
enable the student to be educated and participate with nondisabled students.
If the IEP team determines the student has a disability-related need that affects reading (academic or functional), the IEP must
include a minimum of one goal to address this need.

I. Before developing annual goals, review the previous IEP goals and progress (document review and students progress on the
I-5, Annual Review of IEP Goals)
Previous IEP goals reviewed: x Yes No Not Applicable
.
J. Goal #_5__ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
Kimika will complete vocation tasks.

i. Baseline (Students current level of performance from which progress toward this goal will be measured):
Kimika is resistant to vocational tasks at this time.
j. Level of Attainment (Must relate to the baseline measurement and reflect progress):
Kimika will meet all objectives with no verbal or physical outbursts in 4 out of 5 opportunities across one
month
2. Benchmarks or Short-Term Objectives (Required if student participates in curriculum and assessment aligned with
alternate academic achievement standards and each must include baseline and level of attainment.): Not Applicable
-Kimika will select 5 vocational tasks from a choice of 8 and create a visual schedule for herself
-Kimika will complete each vocational task needing no more than 2 reminders or prompts
-Kimika will put away her vocational tasks and engage in the next activity with no more than 2 prompts

3. Annual goal addresses disability-related need(s) #___1,4____ of the student. (Needs identified in Section I.F).

4. Procedures for measuring the students progress toward meeting the annual goal from baseline to level of attainment:
Records of Observations

5. When will reports about the students progress toward meeting the annual goal be provided to parent(s)? (Document
reviews and students progress on the I-6, Interim Review of IEP Goals.)
With regularly scheduled report cards
VIII. MEASURABLE ANNUAL GOALS
Each goal must address at least one disability-related need.
Develop / revise one or more measurable annual academic or functional goal to:
address any lack of expected progress toward the annual goals, if appropriate;
address the unique needs of the student that result from the students disability (see section I.F. above);
enable the student to progress toward grade-level reading standards, or for preschoolers, early learning standards for
language development, communication and early literacy;
enable the student to be involved in the general education curriculum i.e., the same curriculum as for nondisabled students;
enable the student to progress toward meeting grade-level academic standards; and
enable the student to be educated and participate with nondisabled students.
If the IEP team determines the student has a disability-related need that affects reading (academic or functional), the IEP must
include a minimum of one goal to address this need.

K. Before developing annual goals, review the previous IEP goals and progress (document review and students progress on the
I-5, Annual Review of IEP Goals)
Previous IEP goals reviewed: xYes No Not Applicable
.
L. Goal #_6__ (The Goal # changes as goals are added. Complete 1 through 5 below for each goal.)
1. Goal Statement:
Kimika will engage in appropriate school behavior.

k. Baseline (Students current level of performance from which progress toward this goal will be measured):
Kimika is both verbally and physical outbursts while at school. She will through materials, yell, and swear
l. Level of Attainment (Must relate to the baseline measurement and reflect progress):
Kimika will decrease her verbal and physical outburst to 1 or less in a two week period.
2. Benchmarks or Short-Term Objectives (Required if student participates in curriculum and assessment aligned with
alternate academic achievement standards and each must include baseline and level of attainment.): Not Applicable
-Kimika will use a visual board to state when she is getting upset before she yells or throws and item
-Kimika will transition from one activity to the next using a visual schedule with no nore than 2 prompts
3. Annual goal addresses disability-related need(s) #_1,4___ of the student. (Needs identified in Section I.F).

4. Procedures for measuring the students progress toward meeting the annual goal from baseline to level of attainment:
Records of Observations

5. When will reports about the students progress toward meeting the annual goal be provided to parent(s)? (Document
reviews and students progress on the I-6, Interim Review of IEP Goals.)
With regularly scheduled report cards
 IX. PROGRAM SUMMARY
Include a statement for each of A, B, C and D below to allow the student to (1) access, be involved in and make progress in the
general education curriculum, (2) be educated and participate with other students with and without disabilities to the extent
appropriate, (3) participate in extracurricular and other nonacademic activities, and (4) advance appropriately toward attaining the
annual IEP goals. Include frequency, amount, location, & duration (if different from projected IEP beginning and ending dates). The
services must be stated in the IEP so the level of the LEAs commitment of resources is clear to the parent(s) and other IEP team
members. At least one special education service must be specified; include other services, if needed.

Projected beginning and ending date(s) of IEP services & modifications from __05/15/2017____ to _05/08/2018___.
(month/day/year) (month/day/year)

A. Supplementary Aids and Services

Aids, services, and other supports (accommodations) that are provided in regular education, other educational settings, and in
extracurricular and nonacademic settings, to enable students with disabilities to be educated with nondisabled children to the
maximum extent appropriate. The amount of time specified for each service must be appropriate to the service and stated in a
manner that can be understood by all involved in developing and implementing the IEP. For each supplementary aid and
service, identify the corresponding annual goal(s). In some situations, there may not be a corresponding goal. In those
situations it is acceptable to identify the disability-related need(s).
None needed
Frequency & Amount Addresses Addresses
(describe the circumstances, Goal(s) Need(s)
Describe if appropriate) Location Duration #_______ #_______
05/09/17 1, 2, 3, 4, 1, 2, 3, 4
Positive Reinforcement Consistently and frequently Special - 5, 6
educatio 05/08/18
Use of visual schedule and other visual to support n
communication and expectations Classroo
m
Visual Expectations for different areas or tasks

B. Special Education / Specially Designed Instruction

Adapting, as appropriate to the needs of an eligible student, the content, methodology, or delivery of instruction to address the
unique needs of the student that result from the students disability; and ensure access of the student to the general curriculum,
so the student can meet the educational standards of the public agency that apply to all students. For each special education
service, identify the corresponding annual goal(s).
Addresses Goal(s)
Describe Frequency Amount Location Duration #________
Specially designed environment for all academic 1x/ week 2,100 min Special 05/09/17- 1, 2, 3, 4, 5, 6
and social instruction concurrent with behavior education 05/08/18
support classroom

C. Related Services Needed to Benefit from Special Education

Transportation and such developmental, corrective, and other supportive services as are required to assist a student with a disability
to benefit from special education. For each related service, identify the corresponding annual goal(s). In some situations, there may
not be a corresponding goal. In those situations it is acceptable to identify the disability-related need(s).
 None needed
Addresses Addresses
Goal(s) Need(s)
Describe Frequency Amount Location Duration #_______ # ______
Assistive Technology

Audiology

Counseling

Educational Interpreting

Medical Services for Diagnosis and Evaluation

x Occupational Therapy 3

Orientation and Mobility

(For students with Visual Impairments)
x Physical Therapy 3

Psychological Services

Recreation

Rehabilitation Counseling Services

x School Health Services

School Nurse Services

School Social Work Services

x Speech / Language 2

x Transportation 2x/ day 10 min Special 05/09/17 6 3

educatio -
n 05/08/18
classroo
m
Other: specify

D. Program Modifications or Supports for School Personnel

Services or activities for school personnel to meet the needs of the student. Identify the goal(s) or need(s) addressed.

None needed
Addresses Addresses
Goal(s) Need(s)
Describe Frequency Amount Location Duration #_______ #_______
Yearly Staff Training about health and 1x/ yr 20 Special 05/09/1 6 1
safety plan minutes Educati 7-
on 05/08/1
Classro 8
om
 X. STUDENT PARTICIPATION
A. Participation in Regular Education Environment (location, including regular education classrooms, extracurricular and
nonacademic activities, and workplace settings) Ensure any supplementary aids and services needed for the student to
participate in the regular education environment, including regular education classrooms, extracurricular and nonacademic
activities, and workplace settings, are included in the Program Summary.

The student will participate full-time with non-disabled peers in regular education environment, or for preschoolers, with
non-disabled peers in age-appropriate settings.

If you have indicated in the Program Summary a location other than regular education environment, or age-appropriate
settings for preschoolers, you must check the box below and answer Questions 1 and 2.

x The student will not participate full-time with non-disabled peers in regular education environment, or for preschoolers,
with non-disabled peers in age-appropriate settings.

1. Describe the extent to which the student will not participate with non-disabled students in the regular education
classroom, or age-appropriate settings in the case of a preschooler, including extracurricular and nonacademic activities:
Kimikas multiple disabilities cause her to need a high level of support in all areas of her day. Because of this she
requires a specially designed environment and her needs cannot be met in the regular education classroom.

2.Explain why full-time participation with non-disabled peers is not appropriate, or in the case of a preschooler,
participation in age-appropriate settings including extracurricular and nonacademic activities:
Kimika displays significant delays in cognitive skills, motor skills, and communication skills as well as consistently challenging
behaviors. She requires a high level of support and modification to her daily work that cannot be met through the general
education curriculum. She requires specially designed instruction at her cognitive level in a specially designed environment to
be able to gain and maintain skills.

Ensure any supplementary aids and services needed for the student to participate in the regular education environment, including
regular education classrooms, extracurricular and nonacademic activities, and workplace settings, are included in the Program
Summary.

B. Participation in Physical Education Not Applicable (If the student is in a grade-level where physical education is not
offered and the student does not require specially designed physical education as part of a free appropriate public education.)

xRegular Physical Education

Specially Designed Physical Education

If the IEP team determines the student requires specially designed physical education, there must be a corresponding disability-
related need and goal, and this service must be included in the Program Summary with the appropriate frequency and amount.
INDIVIDUALIZED EDUCATION PROGRAM: To be completed for students participating in
PARTICIPATION IN DISTRICT-WIDE ASSESSMENTS district-wide assessments
Form I-7 District-wide Assessment (Rev. 05/2017)

Name of Student______Kimika Kanzia_____________________

District-wide assessments are tests given at the district level and can apply to students in all grade levels (4K-12). District wide
assessments include the high school civics test requirement and the assessment for reading readiness.

Students with disabilities must be included in district-wide assessments unless the IEP team determines that an alternate to the
district-wide assessment is appropriate. Alternate assessments are intended only for students with the most significant cognitive
disabilities. If the student will be taking an alternate assessment, the I-7-A Participation Guidelines for Alternate Assessment
(http://dpi.wi.gov/sites/default/files/imce/sped/doc/form-i7a.doc) must be included with the IEP.

District-wide Assessment-If the IEP team determines the student will take district-wide assessments, the IEP must
contain a statement of any individual appropriate accommodations needed to measure the academic achievement and
functional performance of the student on district-wide assessments.

Students with IEPs must take the civics exam unless the IEP team determines it is not appropriate, but graduation cannot
be conditioned upon passing a certain number of questions correctly. If the student will take the civics exam, list it as a
district-wide assessment and include a statement of any needed accommodations.

Not applicable, the student is not in a grade in which they will take the high school civics exam.
It is appropriate to administer the high school civics test to the student.
x It is not appropriate to administer the high school civics test to the student.

District-wide assessment(s) the Are accommodations needed? If yes, describe the accommodations
student will take (yes/no) needed

Alternate District-wide Assessment If the IEP team determines the student will take an alternate assessment, the IEP must
describe why the student cannot participate in the regular assessment, why the particular alternate district-wide assessment is
appropriate and contain a statement of any needed accommodations.

Alternate district- Describe why the Describe why Are accommodations If yes, describe the
wide assessment(s) student cannot the particular needed? (yes/no) accommodations
the student will take participate in the alternate district- needed
district-wide wide assessment
assessment is appropriate.
Classroom based Delays in Assessments can no
assessments cognitive and be done at
communication students pace, at
skills her level, and
show true
progress
INDIVIDUALIZED EDUCATION PROGRAM: To be completed for students participating
PARTICIPATION IN STATEWIDE ASSESSMENTS in Dynamic Learning Maps
Form I-7-DLM (Rev 10/2016)

Name of Student___Kimika Kanzia________________________

The student will be in (circle one) 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th or 11th grade when the Dynamic Learning Maps (DLM)
assessment is administered in English language arts, mathematics, and science. IEP teams do not need to document
accommodations for social studies in grades 4, 8, and 10 as it is rated based on classroom observation using a teacher rating
form. The student will be taking the alternate assessment1 for all content areas required at this grade level (the I-7-A
Participation Guidelines for Alternate Assessment must be included with the IEP).

The DLM was designed using the principles of universal design for learning, as such the term accommodation is replaced with
the phrases accessibility features and supports. IEP determinations regarding the use of accommodations on the DLM
assessment apply to all of the content areas the student is participating in based on their grade level. Please check the Office of
Student Assessment website for the current accommodation policies: http://dpi.wi.gov/assessment/dlm/accommodations.

Category 1: Accessibility features/supports provided within the DLM system must be activated via the Personal Needs Profile
(PNP) prior to administering the assessment. Please list required supports:

None at this time

Category 2: Accessibility features/supports requiring additional tools/materials. Please list required supports:

None at this time

Category 3: Accessibility features/supports provided outside of the DLM system. Please list required supports:

None at this time

PARTICIPATION GUIDELINES FOR ALTERNATE ASSESSMENT
Form I-7-A (Rev. 05/2017)

Name of Student __________________________________________________

IEP teams are responsible for deciding whether students with disabilities will participate in general education
assessments with or without testing accommodations, or in the alternate assessment with or without
accommodations.1 In a given year, a student must participate in either all general education assessments or all
alternate assessments, not parts of both.

Agree (Yes) or
Participation Criterion Participation Criterion Descriptors Disagree (No)?
In order to define a student as having a most significant
cognitive disability, the IEP team must review student
records and agree:
The student typically characterized as functioning
at least two and a half to three standard
deviations below the mean in both adaptive
1. The student has a most behavior and cognitive functioning; and
significant cognitive The student performs substantially below grade Yes / No
disability. level expectations on the academic content
standards for the grade in which they are
enrolled, even with the use of adaptations and
accommodations; and
The student requires extensive, direct
individualized instruction and substantial
supports to achieve measurable gains, across all
content
Goals listed inareas andfor
the IEP settings.
this student are linked to
2. The student is instructed
the enrolled grade level alternate achievement
using the alternate Yes / No
standards and address knowledge and skills that are
achievement standards.
appropriate and challenging for this student.
The parent(s) and LEA have discussed:
The differences between the alternate
achievement standards and academic content
standards for the grade in which the child is
enrolled, and
3. Parent notification That the students achievement will be measured Yes / No
based on alternate achievement standards, and
How the students participation in alternate
standards and assessment(s) may delay or
otherwise affect the student from completing the
requirements for a regular high school diploma.
The IEP team agrees that all three of the criteria describe the student, and determined
Yes / No
the student must participate in alternate assessment(s).

Decisions for determining participation in the alternate assessment must not be based solely on any of the following:
1. A disability category or label 7. Percent of time receiving special education
2. Poor attendance or extended absences 8. English Learner (EL) status
3. Native language/social/cultural or economic 9. Low reading level/achievement level
difference 10. Anticipated students disruptive behavior
4. Expected poor performance on the general 11. Impact of student scores on accountability
education assessment system
5. Academic and other services student receives 12. Administrator decision
6. Educational environment or instructional 13. Anticipated emotional distress
setting
14. Need for accommodations (e.g., assistive
technology/Augmentative and Alternative
Communication) to participate in assessment
process

district-wide assessments
DETERMINATION AND NOTICE OF PLACEMENT
Form P-2 (Rev. 7/06)

__________________________________ SCHOOL DISTRICT

[If you need this notice in a different language or communicated in a different way, or have
questions about this notice, please contact _________________________ at ____________________.]

Date of the placement determination: ___05/09/2017_________

Date parent provided with notice of placement ___05/10/207_________

Name of student: ____Kimika Kanzia_________________________

Dear _____Mrs. Kanzia___________________________

The IEP developed on ___05/09/207______________ will be implemented at ____Green

Elementary_______________________ in the ________Brown_____________ School District/City,
with a projected date of implementation on __05/15/2017________.

Will the child attend the school he/she would attend if nondisabled?
x Yes No (If no, explain)

List other options considered, if any, related to the placement site (school building or school district),
frequency, location, and duration of the special education and related services, supplementary aids and
services, program modifications and supports, and the place of those services. List the reason(s) rejected,
and description of any other factors relevant to the proposed action:
x None

x You previously received a copy of your childs evaluation report and a copy of his/her IEP is
enclosed.

A copy of your childs evaluation report and IEP are enclosed.

You and your child have protection under the procedural safeguards (rights) of special education law.
The school district must provide you with a copy of your procedural safeguards once a year. Enclosed is
a copy or earlier this year you received a copy of your procedural safeguard rights in a brochure about
parent and child rights. If you would like another copy of this brochure, please contact the district at the
telephone number above. In addition to district staff, you may also contact _CESA #3_______ at __(608)
822-3726_____ if you have questions about your rights.

Sincerely,

________Kelsey Kleven, Special Education Teacher____

 As someone who has spent most of their career working in behavior support and intervention, Kimikas
case study immediately interested me. While the behavior was an interesting puzzle to try solve, I was not
prepared to write an IEP with such a lack of information. Kimika had obviously had a long history of
support at school, but the information presented in the write up did not necessarily show that. It focused
more on adult frustrations with Kimikas behavior than with actual data and intervention.
If I was a teacher receiving this case with only this information, it would be my priority to try to get more
data and detailed information about Kimika. I would start with doing basic skills assessments in topics like
letters, sounds, and basic math skills both expressively and receptively. This is due to Kimikas severe
language delay. There is a chance that he lack of skills could be from struggles with expressive language
instead of lack of knowledge or skills. I would also try to collect some comparative data between behaviors
seen during vocational tasks compared to the rest of the day. It is hard to sum up behavior with details on
three incidents. Also, the details about the behavior incidents lead me to many other conclusions than just
facts about Kimika.
The detailed reports of Kimikas behavior incidents led me to realize that there are also adult problems at
work. Kimika is obviously using her behavior to communicate something she find displeasing, but the adult
response to the behavior does not help any of the situations. The fact that Kimika was losing earned pennies
goes against just about all positive behavior support models. One bad moment doesnt negate good choices.
Also, the use of extend time out times like 30 minutes and 1 hour seemed excessive. Adults are obviously
frustrated by Kimikas behavior and not handling it well. This is evident in two teachers basically saying
they cant handle her anymore and dont want her in their classrooms. The interaction between the teacher
and Kimika when she fell asleep was also hard to read. My initial reaction was with a seizure disorder and
note of barbiturate being taken regularly that she may have tiredness and irritability at times. Medications to
combat seizures are heavy duty and can have many side effects. That would have been of my first thoughts
would be to try to find a connect between medications and times of behaviors and/or side effect reactions.
Once I was done with assessments and trying to find the function of Kimikas behavior, I would focus on
planning out her day. To me a high level of structure and consistent expectations are a requirement in my
classroom for everyone, but for Kimika I would also want to build in choices for her to make to try to avoid
the power struggles that she seemed to be getting in. I would allow her to make choices about her tasks and
work out of a group that I want her to complete. I would also start encouraging her to use visual supports
more to aid in communication, understanding expectations and rules, and completing tasks. The goals I
wrote for Kimika were focused on academic skills, communication, task completion, a behavior but all had a
larger focus on how meeting these goals could help her further her education and in life after school. Being
able to complete tasks and follow directions are a must for everyone as they get older, so I would work with
Kimika through positive behavior supports to make good choices for herself and be more independent in
working. In my classroom, everyone works on being more independent at all times so she would not be
singled out or working at a different location or in different skills than everyone else.
One area that was not discussed in the write up but would be essential at the IEP meeting would be a
discussion about alternative standards and participating in district-wide and state assessments. Kimika is 9
years old and most likely in second or third grade. This is good time to start discussing alternative standards
especially with a student like Kimika who has multiple disabilities and shows such delayed cognitive skills.
As her placement becomes more restrictive, this would be a natural change to her programming. It would
also open up questions about assessment. Since most districts are using MAP or STAAR as their district-
wide assessment, it would make sense to have Kimika not participate in these as they are hard to modify and
her skills at this time do not warrant her participation. To me, good classroom based assessment and data
keeping is the best way to track progress and skill progression. I would also consider using something like
The Assessment of Basic Language and Learning Skills (ABLLS) to track progress and consider which skills
to start targeting next. For state testing, if Kimika was using the alternative standards then she would
participate in DLM. This would make sense and be a better assessment of her skills.
Overall while Kimika has many challenges she is facing, there are many issues within her day that are
exacerbated by the adults interacting with her. Students with multiple disabilities can be very hard to support
especially when they are displaying challenging behaviors, but giving up on a student and just passing them
along should never be an option. This is a child who needs a team not just isolated teachers to help her
succeed. It would be really interesting with some changes to her day and changes in the attitudes that
surround her what types of gains she could make.