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) *Details are provided in relevant sections of IEP FORMCHECKBOX Program Accessibility 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       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 Annual Review Conference Type: FORMCHECKBOX EPC FORMCH ...

1. 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

2. *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#

3. 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

4. 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

5. 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

6. 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
Copy for

7. 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
Annual Review
Conference Type:
FORMCHECKBOX
EPC
FORMCHECKBOX
Annual Review
FORMCHECKBOX
Triennial

8. 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
Parent/Legal Guardian
District Representative
Special Education Teacher

9. Or Related Service Provider
General Education Teacher
Parent Member (CPSE/CSE)
Student
Other
Education Evaluator
School Psychologist
Other

10. 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
Modify Service
FORMCHECKBOX
Change Recommended Service
FORMCHECKBOX
No Change
Indicate Modifications

11. 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)
/ /
FORMCHECKBOX
Given to Parent
/ /
Type of Follow-up
FORMCHECKBOX
Letter
FORMCHECKBOX
Telephone
FORMCHECKBOX
Sent to Parent
/ /
Page 2

12. 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
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
/ /

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

14. / /
/ /
/ /
/ /
/ /
ACADEMIC MANAGEMENT NEEDS
(Environmental modifications and human/material resources)
Page 3
Student:
NYC ID# - -
CSE Case# -

15. 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# -
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.

16. 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
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

17. 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
FORMCHECKBOX
Yes FORMCHECKBOX
No
Page 4
Student:
NYC ID# - -
CSE Case# -
Date of Conference: //
SOCIAL/EMOTIONAL PERFORMANCE

18. 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.

19. SOCIAL/EMOTIONAL MANAGEMENT NEEDS
(Environmental modifications and human/materials resources)
A behavior intervention plan has been developed
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:

20. 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
(If yes, functionally describe the condition for which
treatment(s) or procedure(s) are required)
Accessible program
FORMCHECKBOX
Yes FORMCHECKBOX
No

21. 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

22. 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
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.

23. 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
(If yes, functionally describe the condition for which
treatment(s) or procedure(s) are required)
Accessible program

24. 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
treatment(s) or procedure(s) are required)
Assistive Technology Device(s)

25. 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 5-1
Student:
NYC ID# - -
CSE Case# -
Date of Conference: //
HEALTH AND PHYSICAL DEVELOPMENT
Describe the student’s health and physical development

26. 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
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

27. 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
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

28. 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 5-2

29. 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
FORMCHECKBOX
Yes FORMCHECKBOX
No

30. (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
FORMCHECKBOX
Yes FORMCHECKBOX
No
Health as a related service

31. 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)
FORMCHECKBOX
Yes FORMCHECKBOX
No
(If assistive technology device(s) or service(s) are required,
specify in management needs.)

32. HEALTH/PHYSICAL MANAGEMENT NEEDS
(Environmental modifications, human/material resources or
specialized equipment)
Page 5-3
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
5th
6th
7th
8th

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

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

35. 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

36. 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
1. More time needed

37. 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:

38. 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
Student:
NYC ID# - -
CSE Case# -
Date of Conference: //

39. 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
Report of Progress

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

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

42. 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

43. 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
review of your child’s program at any time.
1st
2nd

44. 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:

45. 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.
/
/
/
/
/
/
/
/

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

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

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

49. 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
4. Progress made; goal not yet met

50. 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:

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

52. Use a Y (Yes) or N (No) in the appropriate column
Page 6-2
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
Methods of Measurement

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

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

55. 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

56. 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
1. More time needed
2. Excessive absence or lateness

57. 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:
For students who are not anticipated to meet their annual goals

58. and/or promotion criteria: We recomme nd that the IEP Team be
reconvened:
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

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

60. Progress Toward Annual Goal
Reasons for not Meeting Annual Goal
COMMENTS:
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress

61. 1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress
Progress Toward Annual Goal

62. 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

63. 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
2nd
3rd
4th
5th

64. 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:

65. 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.
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st

66. 2nd
3rd
4th
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
COMMENTS:

69. 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
5. Goal met
A. Anticipate meeting goal

70. 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:

71. 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

72. Page 6-5
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
Methods of Measurement

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

74. /
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress

75. 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

76. 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
3. Assignments not completed
4. Other (specify)

77. *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
and/or promotion criteria: We recommend that the IEP Team be
reconvened:

78. Use a Y (Yes) or N (No) in the appropriate column
Page 6-6
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.
/

79. /
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress

80. Progress Toward Annual Goal
Reasons for not Meeting Annual Goal
COMMENTS:
/
/
/
/
/
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd

81. 4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress
Progress Toward Annual Goal

82. 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
8. Verbal Explanations
9. Other (specify)

83. 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
4th
5th
6th
7th
8th

84. 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:

85. 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
1st
2nd
3rd
4th

86. 5th
6th
7th
8th
Methods of Measurement
Report of Progress
Progress Toward Annual Goal
Reasons for not Meeting Annual Goal

87. COMMENTS:
/
/
/
/
/
/
/
/
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
COMMENTS:
EXPLANATION OF CODING SYSTEM
METHODS OF MEASURMENT

89. 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
5. Goal met
A. Anticipate meeting goal
B. Do not anticipate meeting goal

90. (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:

91. 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 6-8

92. 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
Methods of Measurement

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

94. /
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress

95. 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
3. Class Activities

96. 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
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.

97. 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:

98. Use a Y (Yes) or N (No) in the appropriate column
Page 6-9
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.
/
/
/
/

99. /
/
/
/
ANNUAL GOAL:
Progress
1st
2nd
3rd
4th
5th
6th
7th
8th
Methods of Measurement
Report of Progress
Progress Toward Annual Goal

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

101. 7th
8th
Methods of Measurement
Report of Progress
Progress Toward Annual Goal
Reasons for not Meeting Annual Goal

102. 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

103. 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
8th
The student’s performance is approaching his/her promotion
criteria as set forth on Page 9 of the IEP:

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

105. Use a Y (Yes) or N (No) in the appropriate column
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

106. FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN

107. SPECIAL CLASS ENVIRONMENT
Area of Instruction
Language of Instruction Communication Mode
Periods per week
Special Class Staffing Ratio
Supports
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
Reason for Non–Participation in General Education

108. 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
Student:
NYC ID# - -
CSE Case# -
Date of Conference: //
PARTICIPATION IN SCHOOL ACTIVITIES, RELATED
SERVICE RECOMMENDATIONS
AND PARTICPATION IN ASSESSMENTS

109. 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
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN

110. FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN

111. FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN

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

113. 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
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:

114. Page 9-1
Student:
NYC ID# - -
CSE Case# -
Date of Conference: //
TRANSITION
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

115. Expected High School Completion Date /
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:

116. FORMCHECKBOX
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

117. 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
Parent
FORMCHECKBOX
School
FORMCHECKBOX
Student

118. 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
Spring
FORMCHECKBOX
Summer
Page 10-1
NEW YORK CITY BOARD OF EDUCATION

119. 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 -
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

120. 2. List/describe any PHYSICAL/MEDICAL accommodations to
be provided:
(Does not include INSTRUCTIONAL/BEHAVIORAL
interventions.)
a.
b.
c.
3. Participants (Name/Title):
School District Identifying Information
INDIVIDUALIZED EDUCATION PROGRAM (IEP)
Student Name:
Date of Birth:Local ID #:
Disability Classification: FORMDROPDOWN

121. Projected date IEP is to be implemented:
Projected date of annual review:
PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL
NEEDS
Documentation of student's current performance and academic,
developmental and functional needs
Evaluation Results (including for school-age students,
performance on State and district-wide assessments)
Academic Achievement, Functional Performance and Learning
Characteristics
Levels of knowledge and development in subject and skill areas
including activities of daily living, level of intellectual
functioning, adaptive behavior, expected rate of progress in
acquiring skills and information, and learning style:
Student strengths, preferences, interests:
Academic, developmental and functional needs of the student,
including consideration of student needs that are of concern to
the parent:
Social Development
The degree (extent) and quality of the student's relationships
with peers and adults; feelings about self; and social adjustment
to school and community environments:

122. Student strengths:
Social development needs of the student, including
consideration of student needs that are of concern to the parent:
Physical Development
The degree (extent) and quality of the student’s motor and
sensory development, health, vitality and physical skills or
limitations which pertain to the learning process:
Student strengths:
Physical development needs of the student, including
consideration of student needs that are of concern to the parent:
Management Needs
The nature (type) and degree (extent) to which environmental
and human or material resources are needed to address needs
identified above:
Effect of Student Needs on Involvement and Progress in the
General Education Curriculum or, for a Preschool Student,
Effect of Student Needs on Participation in Appropriate
Activities
Student Needs Relating to Special Factors

123. Based on the identification of the student's needs, the
Committee must consider whether the student needs a particular
device or service to address the special factors as indicated
below, and if so, the appropriate section of the IEP must
identify the particular device or service(s) needed.
Does the student need strategies, including positive behavioral
interventions, supports and other strategies to address behaviors
that impede the student's learning or that of others?
FORMCHECKBOX
Yes FORMCHECKBOX
No
Does the student need a behavioral intervention plan?
FORMCHECKBOX
No FORMCHECKBOX
Yes:
For a student with limited English proficiency, does he/she need
a special education service to address his/her language needs as
they relate to the IEP?
FORMCHECKBOX
Yes FORMCHECKBOX
No FORMCHECKBOX
Not Applicable
For a student who is blind or visually impaired, does he/she
need instruction in Braille and the use of Braille?
FORMCHECKBOX
Yes FORMCHECKBOX
No FORMCHECKBOX
Not Applicable
Does the student need a particular device or service to address
his/her communication needs? FORMCHECKBOX
Yes FORMCHECKBOX
No

124. In the case of a student who is deaf or hard of hearing, does the
student need a particular device or service in consideration of
the student's language and communication needs, opportunities
for direct communications with peers and professional
personnel in the student's language and communication mode,
academic level, and full range of needs, including opportunities
for direct instruction in the student's language and
communication mode?
FORMCHECKBOX
Yes FORMCHECKBOX
No FORMCHECKBOX
Not Applicable
Does the student need an assistive technology device and/or
service? FORMCHECKBOX
Yes FORMCHECKBOX
No
If yes, does the Committee recommend that the device(s) be
used in the student's home? FORMCHECKBOX
Yes FORMCHECKBOX
No
Beginning not later than the first IEP to be in effect when the
student is age 15 (and at a younger age if determined
appropriate)
MEASURABLE POSTSECONDARY GOALS
long-term goals for living, working and learning as an adult
Education/Training:
Employment:
Independent Living Skills (when appropriate):
TRANSITION NEEDS
In consideration of present levels of performance, transition
service needs of the student that focus on the student's courses

125. of study, taking into account the student’s strengths,
preferences and interests as they relate to transition from school
to post-school activities:
MEASURABLE ANNUAL GOALS
The following goals are recommended to enable the student to
be involved in and progress in the general education curriculum,
address other educational needs that result from the student's
disability, and prepare the student to meet his/her postsecondary
goals.
Annual Goals
What the student will be expected to achieve by the end of the
year in which the IEP is in effect
Criteria
Measure to determine if goal has been achieved
Method
How progress will be measured
Schedule
When progress will
be measured

126. REPORTING PROGRESS TO PARENTS
Identify when periodic reports on the student's progress toward
meeting the annual goals will be provided to the student's
parents:
Alternate Section for Students Whose IEPs will Include Short-
term Instructional Objectives and/or Benchmarks
(required for preschool students and for school-age students

127. who meet eligibility criteria to take the New York State
alternate assessment)
MEASURABLE ANNUAL GOALS
The following goals are recommended to enable the student to
be involved in and progress in the general education curriculum
or, for a preschool child, in appropriate activities, address o ther
educational needs that result from the student's disability, and,
for a school-age student, prepare the student to meet his/her
postsecondary goals.
Annual Goal
What the student will be expected to achieve by the end of the
year in which the IEP is in effect
Criteria
Measure to determine if goal has been achieved
Method
How progress will be measured
Schedule
When progress will
be measured
Short-term Instructional Objectives and/or Benchmarks
(intermediate steps between the student’s present level of
performance and the measurable annual goal):

128. Annual Goal
Criteria
Method
Schedule
Short-term Instructional Objectives and/or Benchmarks
(intermediate steps between the student’s present level of
performance and the measurable annual goal):
Annual Goal
Criteria
Method
Schedule
Short-term Instructional Objectives and/or Benchmarks
(intermediate steps between the student’s present level of
performance and the measurable annual goal):
(Duplicate table/rows as needed)
REPORTING PROGRESS TO PARENTS
Identify when periodic reports on the student's progress toward

129. meeting the annual goals will be provided to the student's
parents:
RECOMMENDED SPECIAL EDUCATION PROGRAMS AND
SERVICES
Special Education Program/Services
Service Delivery Recommendations*
Frequency
How often provided
Duration
Length of session
Location
Where service will be provided
Projected Beginning/ Service Date(s)
Special Education Program:
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN

130. FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
Related Services:
FORMDROPDOWN

131. FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN

132. Supplementary Aids and Services/Program
Modifications/Accommodations:
Assistive Technology Devices and/or Services:

133. Supports for School Personnel on Behalf of the Student:
*
Identify, if applicable, class size (maximum student-to-staff
ratio), language if other than English, group or individual
services, direct and/or indirect consultant teacher services or
other service delivery recommendations.
12-Month Service and/or Program – Student is eligible to
receive special education services and/or program during
July/August: FORMCHECKBOX
No FORMCHECKBOX
Yes

134. If yes:
FORMCHECKBOX
Student will receive the same special education
program/services as recommended above.
OR
FORMCHECKBOX
Student will receive the following special education
program/services:
Special Education Program/Services
Service Delivery Recommendations
Frequency
Duration
Location
Projected Beginning/ Service Date(s)

135. Name of school/agency provider of services during July and
August:
For a preschool student, reason(s) the child requires services
during July and August:
Testing Accommodations (to be completed for preschool
children only if there is an assessment program for nondisabled
preschool children):
Individual testing accommodations, specific to the student’s
disability and needs, to be used consistently by the student in
the recommended educational program and in the administration
of district-wide assessments of student achievement and, in
accordance with Department policy, State assessments of
student achievement
Testing Accommodation
Conditions*
Implementation Recommendations**
FORMCHECKBOX
None
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN

136. FORMDROPDOWN
*Conditions – Test Characteristics: Describe the type, length,
purpose of the test upon which the use of testing
accommodations is conditioned, if applicable.
**Implementation Recommendations: Identify the amount of
extended time, type of setting, etc., specific to the testi ng
accommodations, if applicable.
Beginning not later than the first IEP to be in effect when the
student is age 15 (and at a younger age, if determined
appropriate).
COORDINATED SET OF TRANSITION ACTIVITIES
Needed activities to facilitate the student’s movement from
school to
post-school activities
Service/Activity
School District/
Agency Responsible
Instruction
Related Services

137. Community Experiences
Development of Employment and Other Post-school Adult
Living Objectives
Acquisition of Daily Living Skills (if applicable)
Functional Vocational Assessment (if applicable)
PARTICIPATION IN STATE AND DISTRICT-WIDE
ASSESSMENTS
(To be completed for preschool students only if there is an
assessment program for nondisabled preschool students)
FORMCHECKBOX
The student will participate in the same State and district-wide
assessments of student achievement that are administered to
general education students.
FORMCHECKBOX
The student will participate in an alternate assessment on a
particular State or district-wide assessment of student
achievement.
Identify the alternate assessment:

138. Statement of why the student cannot participate in the regular
assessment and why the particular alternate assessment selected
is appropriate for the student:
PARTICIPATION WITH STUDENTS WITHOUT
DISABILITIES
Removal from the general education environment occurs only
when the nature or severity of the disability is such that, even
with the use of supplementary aids and services, education
cannot be satisfactorily achieved.
For the preschool student:
Explain the extent, if any, to which the student will not
participate in appropriate activities with age-appropriate
nondisabled peers (e.g., percent of the school day and/or specify
particular activities):
For the school-age student:
Explain the extent, if any, to which the student will not
participate in regular class, extracurricular and other
nonacademic activities (e.g., percent of the school day and/or
specify particular activities):
If the student is not participating in a regular physical education
program, identify the extent to which the student will
participate in specially-designed instruction in physical
education, including adapted physical education:
Exemption from language other than English diploma
requirement: FORMCHECKBOX
No FORMCHECKBOX
Yes - The Committee has determined that the student's
disability adversely affects his/her ability to learn a language
and recommends the student be exempt from the language other
than English requirement.
SPECIAL TRANSPORTATION
Transportation recommendation to address needs of the student

139. relating to his/her disability
FORMCHECKBOX
None.
FORMCHECKBOX
Student needs special transportation accommodations/services
as follows:
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMDROPDOWN
FORMCHECKBOX
Student needs transportation to and from special classes or
programs at another site:
PLACEMENT RECOMMENDATION
New York State Education Department IEP Form