[removed] THIS IEP INCLUDES: FORMCHECKBOX Transitions FORMCHECKBOX Interim Service Plan NEW YORK CITY BOARD OF EDUCATION INDIVIDUALIZED EDUCATION PROGRAM CONFERENCE INFORMATION CSE Case#   -      Home District: Service District: Date: / / Type: STUDENT INFORMATION *Age as of the date of the conference Name: NYC ID#    -   -    Date of Birth   /  /     Gender FORMDROPDOWN Address: Age: Phone: (   )    -     English LAB Year Spanish LAB Year Grade FORMDROPDOWN Language(s) Spoken/Mode of Communication FORMDROPDOWN Primary Agency with whom student is involved Name of Contact       FORMTEXT       Phone: (   )    -     Agency Case# PARENT/GUARDIAN INFORMATION Relationship to Student Name: FORMDROPDOWN Address: Phone (Home): (   )    -     Phone (Work): (   )    -     Interpreter Required FORMCHECKBOX Yes FORMCHECKBOX No Preferred Language/ Mode of Communication FORMDROPDOWN SPECIAL MEDICAL/PHYSICAL ALERTS (Refer to Health & Physical Development Page for additional details.) The student has FORMCHECKBOX medical conditions and/or FORMCHECKBOX physical limitations which affect his/her FORMCHECKBOX learning FORMCHECKBOX behavior and/or FORMCHECKBOX participation in school activities. The student requires FORMCHECKBOX medication and/or FORMCHECKBOX health care treatment(s) or procedure(s) during the school day. Other alerts: SUMMARY OF RECOMMENDATIONS Eligibility FORMCHECKBOX Yes FORMCHECKBOX No Recommended Services Classification of Disability FORMDROPDOWN FORMDROPDOWN       Staffing Ratio FORMDROPDOWN Twelve Month School Year FORMCHECKBOX Yes FORMCHECKBOX No Recommended Services for the Twelve Month School Year FORMDROPDOWN       Staffing Ratio FORMDROPDOWN Other Recommendations (Check all that apply) .

1. [removed]
THIS IEP INCLUDES:
FORMCHECKBOX
Transitions
FORMCHECKBOX
Interim Service Plan
NEW YORK CITY
BOARD OF EDUCATION
INDIVIDUALIZED EDUCATION PROGRAM
CONFERENCE INFORMATION
CSE Case#
-
Home District:
Service District:
Date:
/
/
Type:

2. STUDENT INFORMATION
*Age as of the date of the conference
Name:
NYC ID#
- -
Date of Birth
/ /
Gender
FORMDROPDOWN
Address:
Age:
Phone:
( ) -
English LAB
Year
Spanish LAB

3. Year
Grade
FORMDROPDOWN
Language(s) Spoken/Mode of Communication
FORMDROPDOWN
Primary Agency with whom student is involved
Name of Contact
FORMTEXT
Phone:
( ) -
Agency Case#
PARENT/GUARDIAN INFORMATION

4. Relationship to Student
Name:
FORMDROPDOWN
Address:
Phone (Home):
( ) -
Phone (Work):
( ) -
Interpreter Required
FORMCHECKBOX
Yes
FORMCHECKBOX
No
Preferred Language/ Mode of Communication
FORMDROPDOWN
SPECIAL MEDICAL/PHYSICAL ALERTS
(Refer to Health & Physical Development Page for
additional details.)
The student has
FORMCHECKBOX
medical conditions and/or FORMCHECKBOX
physical limitations which affect his/her
FORMCHECKBOX

5. learning FORMCHECKBOX
behavior and/or FORMCHECKBOX
participation in school activities.
The student requires FORMCHECKBOX
medication and/or FORMCHECKBOX
health care treatment(s) or procedure(s) during the school day.
Other alerts:
SUMMARY OF RECOMMENDATIONS
Eligibility
FORMCHECKBOX
Yes FORMCHECKBOX
No
Recommended Services
Classification of Disability
FORMDROPDOWN
FORMDROPDOWN
Staffing Ratio

6. FORMDROPDOWN
Twelve Month School Year
FORMCHECKBOX
Yes FORMCHECKBOX
No
Recommended Services for the Twelve Month School Year
FORMDROPDOWN
Staffing Ratio
FORMDROPDOWN
Other Recommendations (Check all that apply)
*Details are provided in relevant sections of IEP
FORMCHECKBOX
Program Accessibility

7. FORMCHECKBOX
Adaptive Phys. Ed.*
FORMCHECKBOX
Bilingual Instruction
FORMCHECKBOX
Related Services
FORMCHECKBOX
Assistive Technology
FORMCHECKBOX
Monolingual Services with ESL
FORMCHECKBOX
Monolingual Services without ESL
FORMCHECKBOX
Special Education Transportation – Comment
Students who are blind or visually impaired:
Students who are deaf or hard of hearing
Braille instruction needed
FORMCHECKBOX
Yes FORMCHECKBOX
No
Language of Instruction
Mode of Communication

8. Copy for
FORMCHECKBOX
CSE
FORMCHECKBOX
Parent
FORMCHECKBOX
School
FORMCHECKBOX
Student
FORMCHECKBOX
Other
Page 1
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
CONFERENCE INFORMATION
Referral Type:
FORMCHECKBOX
Initial
FORMCHECKBOX

9. Annual Review
Conference Type:
FORMCHECKBOX
EPC
FORMCHECKBOX
Annual Review
FORMCHECKBOX
Triennial
FORMCHECKBOX
Requested Review
FORMCHECKBOX
CSE Review
FORMCHECKBOX
CPSE Review
Attendance at Conference
Please note that your signature reflects your participation at the
conference and does not necessarily indicate agreement with the
Individualized Education Program.
Signature/Title
Role
(Indicate if Bilingual)
Signature/Title
Role
(Indicate if Bilingual)
FORMTEXT
Parent/Legal Guardian

10. Parent/Legal Guardian
District Representative
Special Education Teacher
Or Related Service Provider
General Education Teacher
Parent Member (CPSE/CSE)
Student
Other
Education Evaluator

11. School Psychologist
Other
School Social Worker
Other
Other
Use an asterisk(*) to signify the participant who interprets the
instructional implications of evaluation results.
Use the letter (T) to signify participation by teleconference.
Conference Result
FORMCHECKBOX
Initiate Service
FORMCHECKBOX

12. Modify Service
FORMCHECKBOX
Change Recommended Service
FORMCHECKBOX
No Change
Indicate Modifications
Initiation, Duration and Review of IEP
Projected Date of Initiation of IEP
/ /
Projected Date of Review of IEP
/ /
Duration of Services
Contacts with Parent/Legal Guardian
Date Notice of Meeting Sent
/ /
Date IEP and Notice of Recommendation
Date of Follow-up (if any)
/ /

13. FORMCHECKBOX
Given to Parent
/ /
Type of Follow-up
FORMCHECKBOX
Letter
FORMCHECKBOX
Telephone
FORMCHECKBOX
Sent to Parent
/ /
Page 2
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
ACADEMIC PERFORMANCE AND LEARNING
CHARACTERISTICS
Describe the student’s present levels of academic achievement,
language development, cognitive development and learning

14. style in English and the other than English language for LEP
students. Discuss how the student’s disability affects his/her
involvement and progress in the general curriculum or, for
preschool students, as appropriate, how the student’s disability
affects participation in appropriate activities.
PRESENT PERFORMANCE:
READING and WRITING
MATH
Area
Date
Test/Evaluation
Score
Instructional Level
Area
Date
Test/Evaluation
Score
Instructional Level
Decoding
/ /

15. Computation
/ /
Reading Comprehension
/ /
Problem Solving
/ /
Listening Comprehension
/ /
/ /
Writing
/ /

16. / /
/ /
/ /
/ /
/ /
ACADEMIC MANAGEMENT NEEDS
(Environmental modifications and human/material resources)
Page 3
Student:

17. NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
ACADEMIC PERFORMANCE AND LEARNING
CHARACTERISTICS
Describe the student’s present levels of academic achievement,
language development, cognitive development and learning
style in English and the other than English language for LEP
students. Discuss how the student’s disability affects his/her
involvement and progress in the general curriculum or, for
preschool students, as appropriate, how the student’s disability
affects participation in appropriate activities.
PRESENT PERFORMANCE:
ACADEMIC MANAGEMENT NEEDS
(Environmental modifications and human/material resources)
Page 3-1
Student:
NYC ID#
- -
CSE Case#
-

18. Date of Conference:
/
/
ACADEMIC PERFORMANCE AND LEARNING
CHARACTERISTICS
Describe the student’s present levels of academic achievement,
language development, cognitive development and learning
style in English and the other than English language for LEP
students. Discuss how the student’s disability affects his/her
involvement and progress in the general curriculum or, for
preschool students, as appropriate, how the student’s disability
affects participation in appropriate activities.
PRESENT PERFORMANCE:
ACADEMIC MANAGEMENT NEEDS
(Environmental modifications and human/material resources)
Page 3-2
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
SOCIAL/EMOTIONAL PERFORMANCE

19. Describe the student’s strengths and weaknesses in the area of
social and emotional development in English and the other than
English language for LEP students.
Consider the degree and quality of the student’s relationships
with peers and adults, feelings about self and social adjustment
to school and community environments. Discuss how the
student’s disability affects his/her involvement and progress in
a general curriculum or, for preschool students, as appropriate,
how the student’s disability affects participation in appropriate
activities.
PRESENT PERFORMANCE:
BEHAVIOR AND THE INSTRUCTIONAL PROCESS
FORMCHECKBOX
Behavior is age appropriate
Describe present levels of support including personnel
responsible for providing behavioral support
FORMCHECKBOX
Behavior does not seriously interfere with instruction and can
be addressed by the FORMCHECKBOX
general education and/or FORMCHECKBOX
special education classroom teacher.
FORMCHECKBOX
Behavior seriously interferes with instruction and requires
additional adult support.
FORMCHECKBOX
Behavior requires highly intensive supervision.

20. SOCIAL/EMOTIONAL MANAGEMENT NEEDS
(Environmental modifications and human/materials resources)
A behavior intervention plan has been developed
FORMCHECKBOX
Yes FORMCHECKBOX
No
Page 4
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
SOCIAL/EMOTIONAL PERFORMANCE
Describe the student’s strengths and weaknesses in the area of
social and emotional development in English and the other than
English language for LEP students.
Consider the degree and quality of the student’s relationships
with peers and adults, feelings about self and social adjustment
to school and community environments. Discuss how the
student’s disability affects his/her involvement and progress in
a general curriculum or, for preschool students, as appropriate,

21. how the student’s disability affects participation in appropriate
activities.
PRESENT PERFORMANCE:
BEHAVIOR AND THE INSTRUCTIONAL PROCESS
FORMCHECKBOX
Behavior is age appropriate
Describe present levels of support including personnel
responsible for providing behavioral support
FORMCHECKBOX
Behavior does not seriously interfere with instruction and can
be addressed by the FORMCHECKBOX
general education and/or FORMCHECKBOX
special education classroom teacher.
FORMCHECKBOX
Behavior seriously interferes with instruction and requires
additional adult support.
FORMCHECKBOX
Behavior requires highly intensive supervision.
SOCIAL/EMOTIONAL MANAGEMENT NEEDS
(Environmental modifications and human/materials resources)
A behavior intervention plan has been developed

22. FORMCHECKBOX
Yes FORMCHECKBOX
No
Page 4-1
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
HEALTH AND PHYSICAL DEVELOPMENT
Describe the student’s health and physical development
including the degree or quality of the student’s motor and
sensory development, health, vitality and physical skills or
limitations which pertain to the learning process, behavior and
participation in physical education or other school activities.
Discuss how the student’s disability affects his/her involvement
and progress in the general curriculum or, for preschool
students, as appropriate, how the student’s disability affects
participation in appropriate activities.
PRESENT PERFORMANCE:
MEDICAL/HEALTH CARE NEEDS
PHYSICAL NEEDS
During the school day, the student requires:
The student FORMCHECKBOX
does FORMCHECKBOX

23. does not have mobility limitations.
Medication
FORMCHECKBOX
Yes FORMCHECKBOX
No
(if yes, functionality describe the limitations(s).)
(if yes, functionality describe the limitations(s).)
The student requires:
Treatment(s) or other health procedure(s)
FORMCHECKBOX
Yes FORMCHECKBOX
No
(If yes, functionally describe the condition for which
treatment(s) or procedure(s) are required)
Accessible program
FORMCHECKBOX
Yes FORMCHECKBOX
No

24. Adaptive Physical Education
FORMCHECKBOX
Yes FORMCHECKBOX
No
Health as a related service
FORMCHECKBOX
Yes FORMCHECKBOX
No
(If yes indicate staffing ratio:
FORMDROPDOWN
(If yes, functionally describe the condition for which
treatment(s) or procedure(s) are required)
Assistive Technology Device(s)
FORMCHECKBOX
Yes FORMCHECKBOX
No

25. Assistive Technology Service(s)
FORMCHECKBOX
Yes FORMCHECKBOX
No
(If assistive technology device(s) or service(s) are required,
specify in management needs.)
HEALTH/PHYSICAL MANAGEMENT NEEDS
(Environmental modifications, human/material resources or
specialized equipment)
Page 5
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
HEALTH AND PHYSICAL DEVELOPMENT
Describe the student’s health and physical development
including the degree or quality of the student’s motor and

26. sensory development, health, vitality and physical skills or
limitations which pertain to the learning process, behavior and
participation in physical education or other school activities.
Discuss how the student’s disability affects his/her involvement
and progress in the general curriculum or, for preschool
students, as appropriate, how the student’s disability affects
participation in appropriate activities.
PRESENT PERFORMANCE:
MEDICAL/HEALTH CARE NEEDS
PHYSICAL NEEDS
During the school day, the student requires:
The student FORMCHECKBOX
does FORMCHECKBOX
does not have mobility limitations.
Medication
FORMCHECKBOX
Yes FORMCHECKBOX
No
(if yes, functionality describe the limitations(s).)
(if yes, functionality describe the limitations(s).)
The student requires:
Treatment(s) or other health procedure(s)
FORMCHECKBOX
Yes FORMCHECKBOX

27. No
(If yes, functionally describe the condition for which
treatment(s) or procedure(s) are required)
Accessible program
FORMCHECKBOX
Yes FORMCHECKBOX
No
Adaptive Physical Education
FORMCHECKBOX
Yes FORMCHECKBOX
No
Health as a related service
FORMCHECKBOX
Yes FORMCHECKBOX
No
(If yes indicate staffing ratio:
FORMDROPDOWN

28. (If yes, functionally describe the condition for which
treatment(s) or procedure(s) are required)
Assistive Technology Device(s)
FORMCHECKBOX
Yes FORMCHECKBOX
No
Assistive Technology Service(s)
FORMCHECKBOX
Yes FORMCHECKBOX
No
(If assistive technology device(s) or service(s) are required,
specify in management needs.)
HEALTH/PHYSICAL MANAGEMENT NEEDS
(Environmental modifications, human/material resources or
specialized equipment)

29. Page 5-1
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
HEALTH AND PHYSICAL DEVELOPMENT
Describe the student’s health and physical development
including the degree or quality of the student’s motor and
sensory development, health, vitality and physical skills or
limitations which pertain to the learning process, behavior and
participation in physical education or other school activities.
Discuss how the student’s disability affects his/her involvement
and progress in the general curriculum or, for preschool
students, as appropriate, how the student’s disability affects
participation in appropriate activities.
PRESENT PERFORMANCE:
MEDICAL/HEALTH CARE NEEDS
PHYSICAL NEEDS
During the school day, the student requires:
The student FORMCHECKBOX
does FORMCHECKBOX
does not have mobility limitations.
Medication

30. FORMCHECKBOX
Yes FORMCHECKBOX
No
(if yes, functionality describe the limitations(s).)
(if yes, functionality describe the limitations(s).)
The student requires:
Treatment(s) or other health procedure(s)
FORMCHECKBOX
Yes FORMCHECKBOX
No
(If yes, functionally describe the condition for which
treatment(s) or procedure(s) are required)
Accessible program
FORMCHECKBOX
Yes FORMCHECKBOX
No
Adaptive Physical Education

31. FORMCHECKBOX
Yes FORMCHECKBOX
No
Health as a related service
FORMCHECKBOX
Yes FORMCHECKBOX
No
(If yes indicate staffing ratio:
FORMDROPDOWN
(If yes, functionally describe the condition for which
treatment(s) or procedure(s) are required)
Assistive Technology Device(s)
FORMCHECKBOX
Yes FORMCHECKBOX
No
Assistive Technology Service(s)

32. FORMCHECKBOX
Yes FORMCHECKBOX
No
(If assistive technology device(s) or service(s) are required,
specify in management needs.)
HEALTH/PHYSICAL MANAGEMENT NEEDS
(Environmental modifications, human/material resources or
specialized equipment)
Page 5-2
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
HEALTH AND PHYSICAL DEVELOPMENT
Describe the student’s health and physical development
including the degree or quality of the student’s motor and
sensory development, health, vitality and physical skills or
limitations which pertain to the learning process, behavior and

33. participation in physical education or other school activities.
Discuss how the student’s disability affects his/her involvement
and progress in the general curriculum or, for preschool
students, as appropriate, how the student’s disability affects
participation in appropriate activities.
PRESENT PERFORMANCE:
MEDICAL/HEALTH CARE NEEDS
PHYSICAL NEEDS
During the school day, the student requires:
The student FORMCHECKBOX
does FORMCHECKBOX
does not have mobility limitations.
Medication
FORMCHECKBOX
Yes FORMCHECKBOX
No
(if yes, functionality describe the limitations(s).)
(if yes, functionality describe the limitations(s).)
The student requires:
Treatment(s) or other health procedure(s)
FORMCHECKBOX
Yes FORMCHECKBOX
No

34. (If yes, functionally describe the condition for which
treatment(s) or procedure(s) are required)
Accessible program
FORMCHECKBOX
Yes FORMCHECKBOX
No
Adaptive Physical Education
FORMCHECKBOX
Yes FORMCHECKBOX
No
Health as a related service
FORMCHECKBOX
Yes FORMCHECKBOX
No
(If yes indicate staffing ratio:
FORMDROPDOWN
(If yes, functionally describe the condition for which

35. treatment(s) or procedure(s) are required)
Assistive Technology Device(s)
FORMCHECKBOX
Yes FORMCHECKBOX
No
Assistive Technology Service(s)
FORMCHECKBOX
Yes FORMCHECKBOX
No
(If assistive technology device(s) or service(s) are required,
specify in management needs.)
HEALTH/PHYSICAL MANAGEMENT NEEDS
(Environmental modifications, human/material resources or
specialized equipment)
Page 5-3

36. Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
ANNUAL GOALS AND SHORT-TERM OBJECTIVES
There will be
reports of progress per year using the
coding system shown below.
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th

37. Methods of Measurement
Report of Progress
Progress Toward Annual Goal
Reasons for not Meeting Annual Goal

38. COMMENTS:
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement

39. Report of Progress
Progress Toward Annual Goal
Reasons for not Meeting Annual Goal

40. COMMENTS:
EXPLANATION OF CODING SYSTEM
METHODS OF MEASURMENT
REPORT OF PROGRESS
PROGRESS TOWARD GOAL
REASONS FOR NOT MEETING GOAL
1. Teacher made Materials
2. Standardized Tests
3. Class Activities
4. Portfolio(s)
5. Teacher/Provider Observations
6. Performance Assessment Task
7. Check Lists
8. Verbal Explanations
9. Other (specify)
1. Not applicable during this grading period
2. No progress made
3. Little progress made

41. 4. Progress made; goal not yet met
5. Goal met
A. Anticipate meeting goal
B. Do not anticipate meeting goal
(Note reason)
C. Goal met
1. More time needed
2. Excessive absence or lateness
3. Assignments not completed
4. Other (specify)
*While a review of your child’s educational program occurs
every year please be advised that you have a right to request a
review of your child’s program at any time.
1st
2nd
3rd
4th
5th
6th
7th
8th
The student’s performance is approaching his/her promotion
criteria as set forth on Page 9 of the IEP:

42. For students who are not anticipated to meet their annual goals
and/or promotion criteria: We recommend that the IEP Team be
reconvened:

43. Use a Y (Yes) or N (No) in the appropriate column
Page 6
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
ANNUAL GOALS AND SHORT-TERM OBJECTIVES
There will be
reports of progress per year using the
coding system shown below.
/
/
/
/
/
/
/
/

44. ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress
Progress Toward Annual Goal

45. Reasons for not Meeting Annual Goal
COMMENTS:
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th

46. 6th
7th
8th
Methods of Measurement
Report of Progress
Progress Toward Annual Goal

47. Reasons for not Meeting Annual Goal
COMMENTS:
EXPLANATION OF CODING SYSTEM
METHODS OF MEASURMENT
REPORT OF PROGRESS
PROGRESS TOWARD GOAL
REASONS FOR NOT MEETING GOAL
1. Teacher made Materials
2. Standardized Tests
3. Class Activities
4. Portfolio(s)
5. Teacher/Provider Observations
6. Performance Assessment Task
7. Check Lists

48. 8. Verbal Explanations
9. Other (specify)
1. Not applicable during this grading period
2. No progress made
3. Little progress made
4. Progress made; goal not yet met
5. Goal met
A. Anticipate meeting goal
B. Do not anticipate meeting goal
(Note reason)
C. Goal met
1. More time needed
2. Excessive absence or lateness
3. Assignments not completed
4. Other (specify)
*While a review of your child’s educational program occurs
every year please be advised that you have a right to request a
review of your child’s program at any time.
1st

49. 2nd
3rd
4th
5th
6th
7th
8th
The student’s performance is approaching his/her promotion
criteria as set forth on Page 9 of the IEP:
For students who are not anticipated to meet their annual goals
and/or promotion criteria: We recommend that the IEP Team be
reconvened:

50. Use a Y (Yes) or N (No) in the appropriate column
Page 6-1
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
ANNUAL GOALS AND SHORT-TERM OBJECTIVES
There will be
reports of progress per year using the
coding system shown below.

51. /
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress

52. Progress Toward Annual Goal
Reasons for not Meeting Annual Goal
COMMENTS:
/
/
/
/
/
/

53. /
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress

54. Progress Toward Annual Goal
Reasons for not Meeting Annual Goal
COMMENTS:
EXPLANATION OF CODING SYSTEM
METHODS OF MEASURMENT
REPORT OF PROGRESS
PROGRESS TOWARD GOAL
REASONS FOR NOT MEETING GOAL
1. Teacher made Materials
2. Standardized Tests

55. 3. Class Activities
4. Portfolio(s)
5. Teacher/Provider Observations
6. Performance Assessment Task
7. Check Lists
8. Verbal Explanations
9. Other (specify)
1. Not applicable during this grading period
2. No progress made
3. Little progress made
4. Progress made; goal not yet met
5. Goal met
A. Anticipate meeting goal
B. Do not anticipate meeting goal
(Note reason)
C. Goal met
1. More time needed
2. Excessive absence or lateness

56. 3. Assignments not completed
4. Other (specify)
*While a review of your child’s educational program occurs
every year please be advised that you have a right to request a
review of your child’s program at any time.
1st
2nd
3rd
4th
5th
6th
7th
8th
The student’s performance is approaching his/her promotion
criteria as set forth on Page 9 of the IEP:

57. For students who are not anticipated to meet their annual goals
and/or promotion criteria: We recommend that the IEP Team be
reconvened:
Use a Y (Yes) or N (No) in the appropriate column
Page 6-2
Student:
NYC ID#
- -
CSE Case#

58. -
Date of Conference:
/
/
ANNUAL GOALS AND SHORT-TERM OBJECTIVES
There will be
reports of progress per year using the
coding system shown below.
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement

59. Report of Progress
Progress Toward Annual Goal
Reasons for not Meeting Annual Goal

60. COMMENTS:
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress

61. Progress Toward Annual Goal
Reasons for not Meeting Annual Goal
COMMENTS:
EXPLANATION OF CODING SYSTEM
METHODS OF MEASURMENT
REPORT OF PROGRESS

62. PROGRESS TOWARD GOAL
REASONS FOR NOT MEETING GOAL
1. Teacher made Materials
2. Standardized Tests
3. Class Activities
4. Portfolio(s)
5. Teacher/Provider Observations
6. Performance Assessment Task
7. Check Lists
8. Verbal Explanations
9. Other (specify)
1. Not applicable during this grading period
2. No progress made
3. Little progress made
4. Progress made; goal not yet met
5. Goal met
A. Anticipate meeting goal

63. B. Do not anticipate meeting goal
(Note reason)
C. Goal met
1. More time needed
2. Excessive absence or lateness
3. Assignments not completed
4. Other (specify)
*While a review of your child’s educational program occurs
every year please be advised that you have a right to request a
review of your child’s program at any time.
1st
2nd
3rd
4th
5th
6th
7th
8th
The student’s performance is approaching his/her promotion
criteria as set forth on Page 9 of the IEP:

64. For students who are not anticipated to meet their annual goals
and/or promotion criteria: We recommend that the IEP Team be
reconvened:

65. Use a Y (Yes) or N (No) in the appropriate column
Page 6-3
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
ANNUAL GOALS AND SHORT-TERM OBJECTIVES
There will be
reports of progress per year using the
coding system shown below.
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th

66. 5th
6th
7th
8th
Methods of Measurement
Report of Progress
Progress Toward Annual Goal

67. Reasons for not Meeting Annual Goal
COMMENTS:
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement

68. Report of Progress
Progress Toward Annual Goal
Reasons for not Meeting Annual Goal

69. COMMENTS:
EXPLANATION OF CODING SYSTEM
METHODS OF MEASURMENT
REPORT OF PROGRESS
PROGRESS TOWARD GOAL
REASONS FOR NOT MEETING GOAL
1. Teacher made Materials
2. Standardized Tests
3. Class Activities
4. Portfolio(s)
5. Teacher/Provider Observations
6. Performance Assessment Task
7. Check Lists
8. Verbal Explanations
9. Other (specify)
1. Not applicable during this grading period

70. 2. No progress made
3. Little progress made
4. Progress made; goal not yet met
5. Goal met
A. Anticipate meeting goal
B. Do not anticipate meeting goal
(Note reason)
C. Goal met
1. More time needed
2. Excessive absence or lateness
3. Assignments not completed
4. Other (specify)
*While a review of your child’s educational program occurs
every year please be advised that you have a right to request a
review of your child’s program at any time.
1st
2nd
3rd
4th
5th
6th
7th

71. 8th
The student’s performance is approaching his/her promotion
criteria as set forth on Page 9 of the IEP:
For students who are not anticipated to meet their annual goals
and/or promotion criteria: We recommend that the IEP Team be
reconvened:

72. Use a Y (Yes) or N (No) in the appropriate column
Page 6-4
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
ANNUAL GOALS AND SHORT-TERM OBJECTIVES
There will be
reports of progress per year using the
coding system shown below.
/
/
/
/

73. /
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress

74. Progress Toward Annual Goal
Reasons for not Meeting Annual Goal
COMMENTS:
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st

75. 2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress
Progress Toward Annual Goal

76. Reasons for not Meeting Annual Goal
COMMENTS:
EXPLANATION OF CODING SYSTEM
METHODS OF MEASURMENT
REPORT OF PROGRESS
PROGRESS TOWARD GOAL
REASONS FOR NOT MEETING GOAL
1. Teacher made Materials
2. Standardized Tests
3. Class Activities
4. Portfolio(s)
5. Teacher/Provider Observations

77. 6. Performance Assessment Task
7. Check Lists
8. Verbal Explanations
9. Other (specify)
1. Not applicable during this grading period
2. No progress made
3. Little progress made
4. Progress made; goal not yet met
5. Goal met
A. Anticipate meeting goal
B. Do not anticipate meeting goal
(Note reason)
C. Goal met
1. More time needed
2. Excessive absence or lateness
3. Assignments not completed
4. Other (specify)
*While a review of your child’s educational program occurs
every year please be advised that you have a right to request a

78. review of your child’s program at any time.
1st
2nd
3rd
4th
5th
6th
7th
8th
The student’s performance is approaching his/her promotion
criteria as set forth on Page 9 of the IEP:
For students who are not anticipated to meet their annual goals
and/or promotion criteria: We recommend that the IEP Team be
reconvened:

79. Use a Y (Yes) or N (No) in the appropriate column
Page 6-5
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
ANNUAL GOALS AND SHORT-TERM OBJECTIVES

80. There will be
reports of progress per year using the
coding system shown below.
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement

81. Report of Progress
Progress Toward Annual Goal
Reasons for not Meeting Annual Goal
COMMENTS:
/
/

82. /
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress

83. Progress Toward Annual Goal
Reasons for not Meeting Annual Goal
COMMENTS:
EXPLANATION OF CODING SYSTEM
METHODS OF MEASURMENT
REPORT OF PROGRESS
PROGRESS TOWARD GOAL
REASONS FOR NOT MEETING GOAL

84. 1. Teacher made Materials
2. Standardized Tests
3. Class Activities
4. Portfolio(s)
5. Teacher/Provider Observations
6. Performance Assessment Task
7. Check Lists
8. Verbal Explanations
9. Other (specify)
1. Not applicable during this grading period
2. No progress made
3. Little progress made
4. Progress made; goal not yet met
5. Goal met
A. Anticipate meeting goal
B. Do not anticipate meeting goal
(Note reason)
C. Goal met

85. 1. More time needed
2. Excessive absence or lateness
3. Assignments not completed
4. Other (specify)
*While a review of your child’s educational program occurs
every year please be advised that you have a right to request a
review of your child’s program at any time.
1st
2nd
3rd
4th
5th
6th
7th
8th
The student’s performance is approaching his/her promotion
criteria as set forth on Page 9 of the IEP:

86. For students who are not anticipated to meet their annual goals
and/or promotion criteria: We recommend that the IEP Team be
reconvened:
Use a Y (Yes) or N (No) in the appropriate column
Page 6-6
Student:

87. NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
ANNUAL GOALS AND SHORT-TERM OBJECTIVES
There will be
reports of progress per year using the
coding system shown below.
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement

88. Report of Progress
Progress Toward Annual Goal
Reasons for not Meeting Annual Goal

89. COMMENTS:
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement

90. Report of Progress
Progress Toward Annual Goal
Reasons for not Meeting Annual Goal
COMMENTS:

91. EXPLANATION OF CODING SYSTEM
METHODS OF MEASURMENT
REPORT OF PROGRESS
PROGRESS TOWARD GOAL
REASONS FOR NOT MEETING GOAL
1. Teacher made Materials
2. Standardized Tests
3. Class Activities
4. Portfolio(s)
5. Teacher/Provider Observations
6. Performance Assessment Task
7. Check Lists
8. Verbal Explanations
9. Other (specify)
1. Not applicable during this grading period
2. No progress made
3. Little progress made
4. Progress made; goal not yet met

92. 5. Goal met
A. Anticipate meeting goal
B. Do not anticipate meeting goal
(Note reason)
C. Goal met
1. More time needed
2. Excessive absence or lateness
3. Assignments not completed
4. Other (specify)
*While a review of your child’s educational program occurs
every year please be advised that you have a right to request a
review of your child’s program at any time.
1st
2nd
3rd
4th
5th
6th
7th
8th
The student’s performance is approaching his/her promotion
criteria as set forth on Page 9 of the IEP:

93. For students who are not anticipated to meet their annual goals
and/or promotion criteria: We recommend that the IEP Team be
reconvened:

94. Use a Y (Yes) or N (No) in the appropriate column
Page 6-7
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
ANNUAL GOALS AND SHORT-TERM OBJECTIVES
There will be
reports of progress per year using the
coding system shown below.
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress

95. 1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress
Progress Toward Annual Goal

96. Reasons for not Meeting Annual Goal
COMMENTS:
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th

97. 8th
Methods of Measurement
Report of Progress
Progress Toward Annual Goal
Reasons for not Meeting Annual Goal

98. COMMENTS:
EXPLANATION OF CODING SYSTEM
METHODS OF MEASURMENT
REPORT OF PROGRESS
PROGRESS TOWARD GOAL
REASONS FOR NOT MEETING GOAL
1. Teacher made Materials
2. Standardized Tests
3. Class Activities
4. Portfolio(s)
5. Teacher/Provider Observations
6. Performance Assessment Task
7. Check Lists
8. Verbal Explanations

99. 9. Other (specify)
1. Not applicable during this grading period
2. No progress made
3. Little progress made
4. Progress made; goal not yet met
5. Goal met
A. Anticipate meeting goal
B. Do not anticipate meeting goal
(Note reason)
C. Goal met
1. More time needed
2. Excessive absence or lateness
3. Assignments not completed
4. Other (specify)
*While a review of your child’s educational program occurs
every year please be advised that you have a right to request a
review of your child’s program at any time.
1st
2nd
3rd

100. 4th
5th
6th
7th
8th
The student’s performance is approaching his/her promotion
criteria as set forth on Page 9 of the IEP:
For students who are not anticipated to meet their annual goals
and/or promotion criteria: We recommend that the IEP Team be
reconvened:

101. Use a Y (Yes) or N (No) in the appropriate column
Page 6-8
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
ANNUAL GOALS AND SHORT-TERM OBJECTIVES
There will be
reports of progress per year using the
coding system shown below.

102. /
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress

103. Progress Toward Annual Goal
Reasons for not Meeting Annual Goal
COMMENTS:
/
/
/
/
/
/
/
/

104. ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress
Progress Toward Annual Goal

105. Reasons for not Meeting Annual Goal
COMMENTS:
EXPLANATION OF CODING SYSTEM
METHODS OF MEASURMENT
REPORT OF PROGRESS
PROGRESS TOWARD GOAL
REASONS FOR NOT MEETING GOAL
1. Teacher made Materials
2. Standardized Tests
3. Class Activities

106. 4. Portfolio(s)
5. Teacher/Provider Observations
6. Performance Assessment Task
7. Check Lists
8. Verbal Explanations
9. Other (specify)
1. Not applicable during this grading period
2. No progress made
3. Little progress made
4. Progress made; goal not yet met
5. Goal met
A. Anticipate meeting goal
B. Do not anticipate meeting goal
(Note reason)
C. Goal met
1. More time needed
2. Excessive absence or lateness
3. Assignments not completed

107. 4. Other (specify)
*While a review of your child’s educational program occurs
every year please be advised that you have a right to request a
review of your child’s program at any time.
1st
2nd
3rd
4th
5th
6th
7th
8th
The student’s performance is approaching his/her promotion
criteria as set forth on Page 9 of the IEP:
For students who are not anticipated to meet their annual goals

108. and/or promotion criteria: We recommend that the IEP Team be
reconvened:
Use a Y (Yes) or N (No) in the appropriate column
Page 6-9
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:

109. /
/
ANNUAL GOALS AND SHORT-TERM OBJECTIVES
There will be
reports of progress per year using the
coding system shown below.
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement

110. Report of Progress
Progress Toward Annual Goal
Reasons for not Meeting Annual Goal

111. COMMENTS:
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress

112. Progress Toward Annual Goal
Reasons for not Meeting Annual Goal
COMMENTS:
EXPLANATION OF CODING SYSTEM
METHODS OF MEASURMENT
REPORT OF PROGRESS
PROGRESS TOWARD GOAL
REASONS FOR NOT MEETING GOAL

113. 1. Teacher made Materials
2. Standardized Tests
3. Class Activities
4. Portfolio(s)
5. Teacher/Provider Observations
6. Performance Assessment Task
7. Check Lists
8. Verbal Explanations
9. Other (specify)
1. Not applicable during this grading period
2. No progress made
3. Little progress made
4. Progress made; goal not yet met
5. Goal met
A. Anticipate meeting goal
B. Do not anticipate meeting goal

114. (Note reason)
C. Goal met
1. More time needed
2. Excessive absence or lateness
3. Assignments not completed
4. Other (specify)
*While a review of your child’s educational program occurs
every year please be advised that you have a right to request a
review of your child’s program at any time.
1st
2nd
3rd
4th
5th
6th
7th
8th
The student’s performance is approaching his/her promotion
criteria as set forth on Page 9 of the IEP:

115. For students who are not anticipated to meet their annual goals
and/or promotion criteria: We recommend that the IEP Team be
reconvened:
Use a Y (Yes) or N (No) in the appropriate column

116. Page 6-10
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
SCHOOL ENVIRONMENT AND SERVICE
RECOMMENDATIONS
GENERAL EDUCATION ENVIRONMENT
Area of Instruction
Language of Instruction Communication Mode
Periods per week
Supplementary Aids and Services
Program Modifications and Supports for School Personnel
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN

117. FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN

118. SPECIAL CLASS ENVIRONMENT
Area of Instruction
Language of Instruction Communication Mode
Periods per week
Special Class Staffing Ratio
Supports
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN

119. Reason for Non–Participation in General Education
Environment
Page 7
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
OTHER PROGRAMS/SERVICES CONSIDERED AND
REASONS FOR REJECTION
Provide an explanation of the programs/services considered and
the reason for rejection. Specify why the student can not
achieve the goals
of his/her IEP within a general education program with the
assistance of supplementary aids and services.
Second Language Instruction:
If the student is exempt from second language instruction,
explain why:
Page 8

120. Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
PARTICIPATION IN SCHOOL ACTIVITIES, RELATED
SERVICE RECOMMENDATIONS
AND PARTICPATION IN ASSESSMENTS
PARTICIPATION IN SCHOOL ACTIVITIES
If the student cannot participate in lunch, assemblies, trips
and/or other school activities with non-disabled students,
indicate the activity and
reason(s) for non-participation.
RELATED SERVICE RECOMMENDATIONS
Status
Related Service
Language of Service
Location**
Sessions/Week
Duration
Group Size
FORMDROPDOWN
FORMDROPDOWN

121. FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN

122. FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN

123. FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
*Indicate status of recommendation: Indicate; Continue;

124. Modify; or Terminate.
**Indicate whether service is provided outside the general
education classroom.
PARTICIPATION IN ASSESSMENTS
FORMCHECKBOX
The student will participate in state and local assessments.
FORMCHECKBOX
Without Accommodations
FORMCHECKBOX
With Accommodations
FORMCHECKBOX
The student WILL NOT PARTICIPATE in state and local
assessments. Reason for non-participation: (see page 9-1)
Describe accommodations, if any, that will be used consistently
throughout the student’s educational program:
Page 9
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
PARTICIPATION IN SCHOOL ACTIVITIES, RELATED
SERVICE RECOMMENDATIONS

125. AND PARTICPATION IN ASSESSMENTS (Cont.)
FORMCHECKBOX
The student will participate in Alternative Assessment.
Reason for participation in Alternative Assessment
In addition to Alternative Assessment, describe how the student
will be assessed:
PROMOTION
Promotion:
FORMCHECKBOX
Standard Criteria
FORMCHECKBOX
Modified Criteria*
*Describe the modified promotion criteria:
Page 9-1
Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
TRANSITION

126. LONG TERM ADULT OUTCOMES
(Beginning at age 14 or younger if appropriate, state long term
outcomes based on the student’s preferences, needs and
interests.)
Community Integration: FORMDROPDOWN
FORMDROPDOWN
Post-Secondary Placement: FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
Independent Living: FORMDROPDOWN
FORMDROPDOWN
Employment: FORMDROPDOWN
FORMDROPDOWN
DIPLOMA OBJECTIVES
FORMCHECKBOX
Regents Diploma FORMCHECKBOX
Advanced Regents Diploma FORMCHECKBOX
Local Diploma FORMCHECKBOX
IEP Diploma
Expected High School Completion Date
/

127. Credits Earned
As of Date
/ /
TRANSITION SERVICES
(Required for students 15 years of age and older)
Instructional Activities
Responsible Party:
FORMCHECKBOX
Parent
FORMCHECKBOX
School
FORMCHECKBOX
Student
FORMCHECKBOX
Agency
FORMCHECKBOX
Fall
FORMCHECKBOX
Spring
FORMCHECKBOX
Summer
Community Integration
Responsible Party:
FORMCHECKBOX

128. Parent
FORMCHECKBOX
School
FORMCHECKBOX
Student
FORMCHECKBOX
Agency
FORMCHECKBOX
Fall
FORMCHECKBOX
Spring
FORMCHECKBOX
Summer
Post High School
Responsible Party:
FORMCHECKBOX
Parent
FORMCHECKBOX
School
FORMCHECKBOX
Student
FORMCHECKBOX
Agency
FORMCHECKBOX
Fall
FORMCHECKBOX
Spring
FORMCHECKBOX
Summer
Page 10

129. Student:
NYC ID#
- -
CSE Case#
-
Date of Conference:
/
/
TRANSITION SERVICES
(Required for students 15 years of age and older)
Independent Living
Responsible Party:
FORMCHECKBOX
Parent
FORMCHECKBOX
School
FORMCHECKBOX
Student
FORMCHECKBOX
Agency
FORMCHECKBOX
Fall
FORMCHECKBOX
Spring
FORMCHECKBOX
Summer
Community Integration
Responsible Party:
FORMCHECKBOX

130. Parent
FORMCHECKBOX
School
FORMCHECKBOX
Student
FORMCHECKBOX
Agency
FORMCHECKBOX
Fall
FORMCHECKBOX
Spring
FORMCHECKBOX
Summer
FORMCHECKBOX
Acquisition of Daily Skills
FORMCHECKBOX
Functional Vocational Assessment
Responsible Party:
FORMCHECKBOX
Parent
FORMCHECKBOX
School
FORMCHECKBOX
Student
FORMCHECKBOX
Agency
FORMCHECKBOX
Fall
FORMCHECKBOX

131. Spring
FORMCHECKBOX
Summer
Page 10-1
NEW YORK CITY BOARD OF EDUCATION
STUDENT ACCOMMODATION PLAN
(SUMMER SCHOOL)
Name:
NYC ID#
- -
Date of Birth
/ /
Gender:
Date of Conference
/
/
Home School
Grade:
CSE Case#
-
Date of Plan
/ /
Name of Guardian –Relationship
-

132. Address
Phone (Home)
( ) -
Phone (Work)
( ) -
Interpreter Required
FORMCHECKBOX
Yes FORMCHECKBOX
No
Preferred Language/Mode of Communication:
1. Describe INSTRUCTIONAL/BEHAVIORAL adaptations,
modifications or accommodations to be provided including any
testing modifications:
AREA
Adaptations. Modifications, Accommodations
(INSTRUCTIONAL / BEHAVIORAL

133. 2. List/describe any PHYSICAL/MEDICAL accommodations to
be provided:
(Does not include INSTRUCTIONAL/BEHAVIORAL
interventions.)
a.
b.
c.
3. Participants (Name/Title):