Individualized Education Program (Aug 2014 revision) Page 1 .docx

Individualized Education Program (Aug 2014 revision) Page 1
School District
Special Education Dept
City, State Zip
Student Name: Zach Brehm Grade: 5 Gender: DOB:
4/22/05 Age: 10
Meeting Date IEP Implementation date
Projected Date when services will begin Anticipated Duration of
this IEP
School Year
02/03/16 02/12/16 02/02/17 2015-2016
Student Address:
City/State/Zip:
Parent/Guardian Name (include address in section I if different
that above):

Contact numbers Home Work(1) Work(2) Cell/Other
Phone
E-Mail
County of Residence: Anticipated Year of Graduation: 2023
If consortium class or Placement: Sending District: School
Building:
Current Vo-Tech Student
Future Vo-Tech Student CIP Code:
Primary Disability: Secondary Disability (If applies)
Other Information: Autism, Other Health Impairment,
Speech/Language Impairment
*Medical Assistance #:
IEP TEAM/SIGNATURES* Signature on this IEP documents
attendance, and not agreement.
The Individualized Education Program (IEP) Team makes the
decisions about the student’s program and placement. The
student’s parent(s), the
student’s special education teacher, and a representative from
the local education agency are required members of this team.
Signature on this
IEP documents attendance, not agreement.
NAME (typed or printed) POSITION (typed or printed)
SIGNATURE*
Parent/Guardian/Surrogate
Parent/Guardian/Surrogate

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

PROCEDURAL SAFEGUARDS NOTICE
I have received a copy of the Procedural Safeguards Notice
during this school year. The Local Education Agency has
informed me whom I may
contact if I need more information. (Note a copy of the notice
may be available on the District Web Page)
Signature of Parent/Guardian/Surrogate:
IEP for
TRANSFER OF RIGHTS AT AGE OF MAJORITY
For purposes of education, the age of majority is reached in
Pennsylvania when the individual reaches 21 years of age.
Likewise, for purposes of the Individuals
with Disabilities Education Act, the age of majority is reached
for students with disabilities when they reach 21 years of age.
REVISIONS
The LEA and parent have agreed to make the following changes
to the IEP without convening an IEP meeting, as documented
by:
see attached IEP Revision forms
Date of Revision(s) Participants / Roles IEP Section(s)
Amended

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

No
Does the student have communication needs?
Yes Student needs must be addressed in the IEP (i.e.,
present levels, specially designed instruction (SDI), annual
goals,
etc.)
No
Does the student need assistive technology devices and/or
services?
goals,
etc.)
No
Does the student have limited English proficiency?
goals,
etc.)
No
Does the student exhibit behaviors that impede his/her learning
or that of others?
Yes The IEP team must develop a Positive Behavior
Support Plan that is based on a functional assessment of
behavior
and that utilizes positive behavior techniques. Results of the
functional assessment of behavior may be listed in
the Present Levels section of the IEP with a clear measurable
plan to address the behavior in the Goals and
Specially Designed Instruction sections of the IEP or in the
Positive Behavior Support Plan if this is a separate

document that is attached to the IEP. A Positive Behavior
Support Plan and a Functional Behavioral
Assessment form are available at www.pattan.net
No
Other (Specify)
IEP for
IEP for
II. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT &
FUNCTIONAL PERFORMANCE
Include the following information related to the student:
1. Student’s present levels of academic achievement (e.g.,
most recent evaluation of the student, results of
formative assessments, curriculum based-assessments, transition
assessments, progress toward current
annual goals)
Summative Data (i.e. PSSA)
Zach did not receive scores for the 4th grade PSSA due to

refusing to participate and attempting to destroy the
testing materials.
PSSA results for 3rd grade were: Proficient in math and Below
Basic in reading.
Benchmark (i.e. 4Sight, MAPS, DIBELS)
The following EasyCBM data has been collected from the
beginning of 5th grade:
Measure Grade Season Date Raw Score Percentile
Passage Reading Fluency 5_Fall 5 Fall 9/2/2015 122 wpm 29th
CCSS Math 5_Fall 5 Fall 8/26/2015 27 63th
Reading Comprehension 5_Fall 5 Fall 9/12/2015 12 27th
Vocabulary 5_Fall 5 Fall 9/19/2015 7 2nd
CCSS Reading 5_Fall
5 Fall 8/28/2015 17/25 68% 31st
The following EasyCBM data has been collected from the
middle of the year, 5th grade:
Measure Grade Season Date Raw Score Percentile
Passage Reading Fluency 5_Winter 5 Winter 1/7/2016 117 wpm
20th -9

CCSS Math 5_Winter 5 Winter 1/7/2016 25/45 60% 40th -23
Reading Comprehension 5_Winter 5 Winter 1/14/2016 8/20 40%
6th -21
Vocabulary 5_Winter 5 Winter 1/7/2016 12/20 60% 10th +8
CCSS Reading 5_Winter 5 Winter 1/8/2016 18/25 72% 26th -5
Students in 5th grade are given an EasyCBM assessment at
three points in the school
year; fall, winter, and spring. Students take 5 tests; Passage
Reading Fluency, CCSS Math, Reading
Comprehension, Vocabulary, and CCSS Reading. Given these 5
different assessments, Zach’s scores
all except for Vocabulary dropped percentile categories. In
Reading Fluency he went down 9
percentage points. In CCSS Math he went down 23 percentage
points. In Reading Comprehension he
went down 21 percentage points. In Vocabulary he went up 8
percentage points. In CCSS Reading he
went down 5 percentage points. Combined, that makes for an
overall loss of 58 percentage points.
Diagnostic (i.e. DRA, Running Record, baseline scores)
Zach was given a 5th grade math computation probe with 4
minutes to complete 25 problems. He able to
complete 4 problems (16% correct) of the 8 he attempted. When
given 4th grade math computation

IEP for
probe with 4 minutes to complete 25 problems he did much
better, answering 12 correct (36%) out of 12
he attempted. He did however stop working after 3 minutes and
refused to do any more problems. He
took a total of 3 computation probes on the 4th grade level. He
averaged 12 correct on all three probes
(answering 12 correct on all 3).
Zach was given a 5th grade reading fluency probe with 1 minute
to read quickly, fluently, and
accurately. He was able to read an average of 126 words per
minute with 100% accuracy.
Formative (i.e. curriculum based assessments, rubrics, LFS
summarizers, progress monitoring
data)
SUBJECT 1st MP
Letter
Grade
1st MP
Average
2nd MP
Letter
Grade

2nd MP
Average
Change in
average
+/_
Art S S =
English U 48 U 65 +17
Health A 95 A 100 +5
Library S+ 84 S+ 85 +1
Math C 74 U 63 -11
Physical Education O 98 S+ 85 -13
Reading U 61 D 67 +6
Science/Health C 78 C 75 -3
Spelling U 54 D 71 +17
Social Studies C 79 C 81 +2
Vocal Music O 99 S+ 86 -13
Chorus U 25
Zach’s teachers and aides have done the following to ensure his
success in the regular education

classroom and in the special education classroom: Introduction
and lessons using “The Zones of Regulation”,
Explanation of emotions with use of visual tools from “The
Zones of Regulation” and, Use of a reward system
using highly preferred items and a daily tracking chart for
rewards earned, Positive behavior reinforcement,
Use of verbal and non-verbal reminders to stay on task, Emails
home to communicate behaviors of concern,
Preferential seating within the classroom, Visual timer used for
classroom tasks
1-1 “pep-talks” to motivate the student in the morning, Limiting
distractions within the classroom
environment, Avoiding known, possible behavioral triggers
when possible, Frequent communication with other
professionals that work with P.D. to ensure SDI’s and his
behavior plan are being implemented
Extended time for taking tests and in small group setting, Use
of planned ignoring of small, behavior-seeking
types of behavior to avoid a larger behavioral issue, Classroom
visuals to help manage behavior (T.H.I.N.K.,
S.L.A.N.T, Small/Medium/Big Problem Poster, The Zones of
Regulation Posters), Frequent review of the schools
“Goals”, Reinforcement of the “Goals” with our school wide
system for PBIS with “Goals”, Providing high-
interest items for rewards or use during breaks
Agenda sent home daily for communication between school and
home, Larger spaced paper available upon
request, Velcro on his desk, Extended time for writing
assignments or the availability of alternative,
assignments that wouldn’t include such large amounts of
writing, Use of vocabulary from “The Zones of
Regulation” and our school wide PBIS system of “Expected and
Unexpected” with frequent reminders, Modeling
of expected social skills and strategies, Repetition of directions
to assure understanding, Chunking of
assignments into smaller, more manageable pieces, Non-verbal

reminders to not pick at himself during class,
Consultation with the Autistic Support professional, Speech and
Language Therapist, and the Occupational
IEP for
Therapist, Implementation and closely following the behavior-
reduction strategies for de-escalation, Wait time
to respond to directives, questions, and directions to return to
task, Assisting in de-escalation by removing
others from the room to ensure student safety, Constant
reevaluation of strategies and which to use, Use of a
calm speaking voice and overall manner in dealing with
unexpected behaviors, Giving access to my classroom
for independent work space when needed to eliminate
distractions to student in class. Despite the many
accommodations that we have made for Zach, many of his
grades have gone down since the first marking
period. There are, however, areas where he has made
improvements in his grades. See the chart above for
specifics.
Student’s present levels of functional performance (e.g. results
from a functional behavioral assessment,
results of ecological assessments, progress towards current
goals).
In a structured teaching situation with an adult, Zach will

complete assigned activities/tasks before gaining access to his
preferred item/activity in 80% of opportunities charted for 5
consecutive days.
-Zach did not make Progress towards this goal. Over the 2nd
Marking period he averaged 37% work completion even though
he has demonstrated that he can complete all of it with the
accommodations that his teachers make for him.
During structured teaching sessions, Zach will independently
use a strategy to gain the teacher’s attention (i.e.
raising hand, saying, “Excuse me”) in 80% of opportunities for
5 consecutive charted days.
Zach is not making progress towards this goal. He is using his
strategies to appropriately gain the teacher’s
attention 13% of the time.
Classroom skills (study skills, on task, homework. Etc.)
Teacher: Mr. Math Guy
Subject: Math/Science
Please comment on Strengths, Weaknesses and Needs in the
classroom in the following areas:
IEP for
Work Completion: It is very difficult to understand exactly
what Zach can and can’t complete on his own in
class. Mrs. Aide is with him 100% of the time. She assists him

in all his work. The decline in his math grade
from marking period 1 to 2 is due to less support being given on
her part. At the beginning of the year, she
pretty much told him answers to get through the assignments.
Now, he is actually completing them on his own
more, but at a less successful rate.
In the 21 days of logging that I kept track of instructional time,
there were 2,520 minutes of instruction given
in the classroom. He lost 1,710 minutes, 68% of the time, of
instruction from either being removed from my
classroom or being in my classroom not completing work or
participating in the instruction. On the flip side, he
was in class with or without participation 940 minutes, 37% of
the time. You will notice the percentages add
up to 105%. This is due to changing the tracking mechanism
part way through my logging.
Obviously, I am concerned. He misses large group instruction
most days and participated in small group
instruction around 2 out of the 21 days. If I am not able to meet
his needs in either setting, how is he learning
the 5th grade curriculum?
Preparedness for class: Zach is always prepared for class. He
has his materials. Homework completion has
been 100%.
On task/off task behavior: Mrs. Aide helps keep Zach on track.
She usually gets him started with his
assignments unless he is motivated to begin on his own. He
gets a lot of positive encouragement from both of
us during the lessons he is in the class for. Usually things
deteriorate when I begin teaching the large group
lesson. He will state that it is too hard, although most times he
does not give any effort to see where he is

getting stuck. This results in crawling around the floor and
eventually being removed from the classroom.
Homework Completion: Zach finishes his homework.
General Classroom Skills: Zach has a few boys that work with
him because they have known him for a few
years. For the most part, he works with Mrs. Aide. She gives
him work breaks when he asks.
Behaviors of concern: Given the structure of the classroom,
which includes large and small group instruction,
and the supports Zach is receiving, I don’t think regular
education math is the proper placement for him.
Clearly, his grades the first marking period show that with a lot
of one on one assistance, there can be some
success, although I question how much of the work was being
completed by just him. Now that he has worked
back into doing things independently, the success is not there
because some of the foundational blocks of math
are not being used or shown. I honestly have very little idea
what Zach can independently complete. I do
know, however, that when you miss 68% of instructional time,
generally, there are not real positive results.
In order to help support behavior within the classroom setting, I
give him an endless amount of verbal
praise. I also reduce the amount of problems he has to complete
on assignments. He has earned gold
(Schoolwide Positive Behavior Acknowledgement System) for
participating by giving answers or finishing
tasks. Sometimes he earns extra technology time for completing
his work. Otherwise, I support the
mechanisms Mrs. Aide has in place for him.
Teacher: Mrs. Social Studies

Subject: Social Studies
Work Completion- Zach gets his work done but usually it is not
in the classroom as he rarely makes it to social
studies. He completes his missing assignments for homework or
the next day. His aide usually writes the
answers for him in order for him to complete it.
Behaviors of concern- He makes noises and crawls on the floor
when he doesn’t want to work. In order to help
support behavior within the classroom setting, I will tell him
what he needs to do and not do. If he continues
the inappropriate behavior, the aide will take him out of the
room as he is being a distraction. Please note
again there are many times he is not in my room at S.S. is at
2:10 and he is already gotten in trouble or is going
to be a distraction. Please note sometimes the aide will take
him out without being directed him because she
knows he is going to be disruptive. Additional strategies used
to help support behavior in the classroom include
use of nonverbal cues or changes to tone of voice to prompt for
expected behaviors, feedback regarding overall
performance for the day; Sometimes he will give me a hug if he
knows it was a good 25 minutes in my room.
Homework completion- He gets it done at some point during the
week but not necessarily when it is due.
IEP for
Classroom skills- He does not participate to the same extent as

the other students. He does not like writing
short answer responses or essays.
Other- Zach had only been in class for 29 out of the first 62
days of school. When he is in class, he does not
follow along in the book or pay attention to the class
discussions. He will choose to look at other pages of the
social studies book that interest him instead of participating.
Teacher: Mrs. SPED Two
Subject: English, Reading, Spelling
Work Completion: On average, Zach probably completes 10-
15% of his work. Usually this small percentage is
with a lot of adult praise and heavy incentives. Most of the time
he zones out when asked to do something, and
instead of working he will pick at his skin and completely hyper
focuses on that and that alone!
Preparedness for class: I honestly can’t say he is ever prepared
for class. Mrs. Aide, his 1-1 aide, gets
everything he needs and makes sure he is prepared for class.
Zach never does this on his own.
On task/off task behavior: Zach has the ability to pay attention
to a highly preferred activity. During class, I
say he pays attention less than 20% of the time.
Homework Completion: 50/50 He does have his homework
completed most of the time, but usually his
homework is classwork that wasn’t completed during the school
day.
General Classroom Skills: Zach does not interact well with
other students, and he doesn’t seem to associate
with a group of people like “friends”. He’s off task, disruptive,
and a danger to himself and others. When he is

engaged in a lesson, he very rarely will offer answers and
participate in classroom instruction. If something
seems too hard for him, he shuts down completely and there is
nothing we can do. He often growls at other
students and other students find this to be scary and threatening.
Behaviors of concern: Multiple concerns. Physical outbursts,
refusal to attend class and learn the content,
failure to complete assignments at school, does not follow
directions-even if broken down into smaller tasks or
given in a different way. There have been many days that I was
unable to teach my language arts lesson
because Zach’s behaviors has become so bad, we were pulling
the students into another room. Some of his
most frequent behaviors are biting, kicking and spitting. He
displays a lot of unsafe behaviors when he is
struggling with his class work.
In order to help support behavior across the school setting, the
following strategies have been implemented:
• Introduction and lessons using “The Zones of Regulation”
• Explanation of emotions with use of visual tools from “The
Zones of Regulation” and
• Use of a reward system using highly preferred items and a
daily tracking chart for rewards earned.
• Positive behavior reinforcement
• Use of verbal and non-verbal reminders to stay on task
• Emails home to communicate behaviors of concern
• Preferential seating within the classroom
• Visual timer used for classroom tasks
• 1-1 “pep-talks” to motivate the student in the morning
• Limiting distractions within the classroom environment
• Avoiding known, possible behavioral triggers when possible
• Frequent communication with other professionals that work
with P.D. to ensure SDI’s and his behavior

plan are being implemented
• Extended time for taking tests and in small group setting
• Use of planned ignoring of small, behavior-seeking types of
behavior to avoid a larger behavioral issue
• Classroom visuals to help manage behavior (T.H.I.N.K.,
S.L.A.N.T, Small/Medium/Big Problem Poster,
The Zones of Regulation Posters)
• Frequent review of the schools “ Goals”
• Reinforcement of the “ Goals” with our school wide system
for PBIS with “ Goals”
• Providing high-interest items for rewards or use during breaks
• Agenda sent home daily for communication between school
and home
• Larger spaced paper available upon request
• Velcro on his desk
IEP for
• Extended time for writing assignments or the availability of
alternative assignments that wouldn’t
include such large amounts of writing
• Use of vocabulary from “The Zones of Regulation” and our
school wide PBIS system of “Expected and
Unexpected” with frequent reminders
• Modeling of expected social skills and strategies
• Repetition of directions to assure understanding
• Chunking of assignments into smaller, more manageable

pieces
• Non-verbal reminders to not pick at himself during class
• Consultation with the Autistic Support professional, Speech
and Language Therapist, and the
Occupational Therapist
• Implementation and closely following the behavior-reduction
strategies for de-escalation
• Wait time to respond to directives, questions, and directions to
return to task
• Assisting in de-escalation by removing others from the room
to ensure student safety
• Constant reevaluation of strategies and which to use
• Use of a calm speaking voice and overall manner in dealing
with unexpected behaviors
• Giving access to my classroom for independent work space
when needed to eliminate distractions to
student in class
Other functional skills (i.e. related service reports and
Employment Skills)
Speech and Language Support- SPEECH Person, MS; CCC/SLP
Zach has been attending the Busytown Intermediate School
since August of 2014. He is currently in 5th
grade. According to record review (RR dated 5-6-15), Zach’s
primary disability category is Emotional
Disturbance and secondary disability categories of Autism,
Other Health Impairment &
Speech/Language Impairment. Zach attended an out-of-district
full-time emotional support classroom
for Kindergarten, First and Second grade. He transferred back
to The Other Elementary school in third
grade. He has continued to receive Speech/Language Support

services while in the Busytown School
District.
Zach’s speech/language goal is to improve his pragmatic
language by using targeted skills. Below is his
most recent progress monitoring information that was sent home
for the first marking period of fifth
grade.
Goal Area: Pragmatic Language
Measurable Annual Goal
Include: Condition, Name, Behavior, and Criteria
(Refer to Annotated IEP for description of these
components)
Report of Progress
Using an expected vs. unexpected behavior(s)
framework, Zach will identify and use targeted social
skills, with reduced cueing/prompting required, in
structured to less structured settings/opportunities 75%
of the time.
When presented with a social behavior/interaction
scenario Zach will:
-- Define/ Describe
-- Contrast (expected vs unexpected)
-- Predict
■ consequences/outcomes
■ feelings (his and others as related to The
Zones)
■ reactions (his and others)

-- Interpret (perspective/body language)
-- Modify (suggest/implement changes)
(PA Standard Reference 1.6)
Marking Period S L N
1st marking
period
October 2015
80% overall
accuracy
2nd marking
period
January 2015
74%
overall
accuracy
3rd marking
period
April 2015

73%
accuracy
IEP for
4th marking
period
June 2015
90%
accuracy
Progress Report Key (extent to which progress is sufficient to
meet the annual goal)
S = making sufficient progress (75% or better) L = making
limited progress (65% - 74%) N = not making
sufficient progress at this time (0-64%)
Following is a discussion of Zach’s current speech and language
skills:
Social Skills Instruction:
In a structured therapy setting, Zach’s performance for therapy

tasks is within an average range for
identifying and using the social skills targeted for each
session’s lesson as long as he is prompted to
respond. Notable this year has been Zach’s inability to attend
group. He is not able to profit from the
points of instruction that could help him be successful at school
when his behavior precludes him from
attending. When in attendance, he does not volunteer often but
will answer if called on by the
instructor. He needs to be prompted to answer “how” or “why”
questions as they pertain to social
situations and the topics discussed. Zach often displays
unexpected behavior in our group. He begins
to make screeching/high-pitched sounds and refuses to respond
when he does not want to participate
or do what is expected of him and his same-age peers. His
peers recognize his unexpected behavior
and display non-verbal signs that they are upset. His peers have
also verbalized their annoyance with
his unexpected behavior, in a respectful manner directly to
Zach, in an effort to help him change.
When this happens, Zach does not demonstrate acknowledgment
of his peers’ comments, nor does it
alter/change his behavior from unexpected to expected.
Overall, his pragmatic language skills are
below average in comparison to same-age peers.
Social skills lessons so far this school year have involved
discussion and practice with the following topics:
• Expected/Unexpected behaviors
• Problem solving
• Emotions/feelings

• Perspective taking- realizing that others have thoughts about
you based on: what you say;
what you do; and how you look
• Flexibility of thought
It is the opinion of this examiner that Zach experiences
difficulty knowing what is expected of him in
specific social situations. In structured tasks, he knows and can
state the expected behavior with
prompting. However, when he is asked to describe and use the
social behavior map to discuss
behavior, he struggles to demonstrate comprehension of the fact
that there are consequences to
behavior, both expected and unexpected. He presents with age
and grade appropriate receptive
and expressive vocabulary abilities. It is recommended that
Zach continue to receive Speech and
Language Support. He needs to increase and improve his social
pragmatic language abilities so he
can be successful independently in all social interactions.
The following information was reported by Mrs. PBA Person,
IU 49 Consultant on 12/15/15:
Consultant Visitation Summary--Autism Support to Personnel
Dates Support Provided: October, 2015 – November, 2015
Student: Zach Brehm
Consultant: PBA Person
Purpose/Focus of Visits: Support/suggestions for Zach’s
educational programming needs

IEP for
Summary of Support provided to team:
Observation of Zach in his current educational setting,
supporting staff with suggestions for revision of positive
behavior support plan, culmination/analysis of data collected,
assessment of potential reinforcers for Zach,
modeling/guided practice regarding implementation of
strategies to trial, attending team meetings
Reinforcers
• Potential reinforcers are continually being assessed for Zach.
Those that have been currently identified
though observations of the student, include:
• Edibles: Parent requested that edibles not be utilized. Zach
will request a red/white mint at times
throughout his school day.
• Items/Activities: Earning praying mantis visuals, various
books about insects, catching a grasshopper or
cricket and keeping it in a container to look at when earned as a
reward
• Activities on computer: Games and websites with information
about insects
• A visual reinforcer menu was created for Zach containing the
names of the identified reinforcing items
available at school. Newly identified items/activities should
continue to be added as they are identified by

staff.
• Team should continue to identify additional reinforcers for
Zach to expand the number and variety available
throughout his day. Team should consider the features of
Zach’s current reinforcers to determine potential
new reinforcers. Staff should continue to work on varying
reinforcers (when possible) so Zach does not
satiate (get tired of) items/activities.
• Staff should continue to spend time “pairing” with Zach by
engaging in reinforcing activities with him and
delivering reinforcers to Zach.
Instruction/Participation (please see charts for analysis of
participation data below):
• The team has made offering breakfast part of Zach’s morning
to avoid concerns about him beginning his day
hungry.
• Data gathered have indicated that Zach will remain in his
inclusion and/or special education settings at times
but does not participate in the classroom activities and/or
follow directions.
• Observations and analysis of the data collected for Zach’s
participation skills indicate that he engages in
behaviors of concern in order to escape, postpone, avoid
tasks/activities that he does not want to complete.
Zach will then continue and/or increase the intensity of his
behaviors in order to maintain and/or gain
attention.
• Staff has had the opportunity to attempt to provide instruction

to Zach in a 1:1 setting in a separate room
when he is not participating in his inclusion setting and/or
special education classroom setting. Staff has had
success in gaining participation to complete non-academic and
academic tasks/activities in this 1:1 setting.
• The team has been challenged to find reinforcers that are more
powerful for Zach to earn for participation in
tasks/activities than escaping the tasks and receiving attention
for the behaviors of concern. However,
assessment of reinforcers should continue on an ongoing basis.
• Staff should continue to chunk assignments into smaller
segments to increase Zach’s ability to complete
tasks.
• Staff should continue to offer alternatives to Zach writing his
answers when he does not want to complete
paper/pencil tasks (Ex: Zach tells staff the answer and staff
write for the answer for him).
The following is the OCCUPATIONAL THERAPY
EVALUATION REPORT provided by Mrs. OT Person, IU 49
Occupational Therapist, on 12/22/15:
NAME: Zach Brehm DOE: 12/8/2015
DOB: 4/27/2005 GRADE: 5th
CA: 10 years, 7 months SCHOOL: Busytown Middle
THERAPIST: Amy L. Cook, MS, OTR/L TEACHER: Math
Guy/Social Studies

REASON FOR REFERRAL: Zach was referred for a full scale
Occupational Therapy evaluation as part of a Multi-
Disciplinary Re-evaluation.
IEP for
BACKGROUND INFORMATION: Zach participated in an
Occupational Therapy evaluation on 11/7/2014 and
again on 4/21/15 as a present level update. Focus of this
evaluation surrounded concerns regarding fine motor
needs (written work excessively slow, often breaks pencil lead,
difficulty coordinating eyes), gross motor
(difficulty with new motor tasks), behavior (easily frustrate and
distractible), and tactile needs(has difficulty
interacting in a group game).
Presently, Zach receives Occupational Therapy Support to
School Personnel, 60 minutes per month, for self-
regulation needs.
OBSERVATIONS: Zach’s participation with transitions and
typical educational expectations was observed on
December 8, 2015. He entered the school prior to the entrance
of the student body, given verbal cues to
proceed to breakfast in the cafeteria. He independently went
through the food line to get his tray and bag of
breakfast food. He brought his tray to a half table, located in
the back of the cafeteria near one of the
entrances. This half table is positioned in the middle of the
wall, facing away from the other tables. Zach

typically sits at this location for school meals.
Zach sat his tray and bag of food down, taking out a collection
of permissible fine motor activities. He
proceeded to work on a puzzle for the first 10 minutes of
breakfast. At this time, verbal cues were used to
encourage him to eat in addition to working on the puzzle.
After approximately 8 more minutes, Zach’s aide
arrived and joined him at the breakfast table, providing the
additional verbal cues for him to eat breakfast. At
this point, he ate two waffle bites, with observable mouth
stuffing in 2 -3 bites, followed by drinking his
beverage. When cued following the school bell, he gathered his
items and threw them away. Zach did inquire
about wanting to eat a few more items of his meal, but was
reminded that he chose to play with the puzzle
instead of eating. He was additionally cued that it was time for
school/homeroom activities and that there
was no longer time for eating.
When transitioning from the cafeteria to his homeroom, Zach
needed verbal cues to stay focused on keeping a
faster pace. He stopped to inquire about dead bugs on the floor
in the stairwell, needing cues to continue
transitioning. His aide offered additional cues and contingencies
regarding what he was allowed to have from
his locker and what things were to remain in his locker.
In homeroom, he sat in the back left corner of the room with his
aide at an adjacent desk. While the teacher
was going over a math paper with the remainder of the class,
which was already in session by the time Zach
arrived, Zach worked on his own math paper. He worked,
answering the math questions quickly with
responses. During this he continually made verbalizations to
himself and to his aide, some being questions

appropriate to the worksheet and some not on topic. When it
was time to transition with the class to the first
period special, Zach lined up beside his classmates line, at the
front. At this time, he grabbed onto Mr. Math
Guy’s mid-section, hugging him around the waist. Mr. Math
Guy responded by acknowledging Zach verbally,
patting him on the back and then releasing him from the hug.
While the remainder of the class went to their
special, Zach joined this therapist in a separate room for his
Occupational Therapy evaluation. Also in
attendance in the room were Zach’s aide and his community
TSS.
With regard to the actual evaluation, Zach benefitted from use
of verbal cues and models for expectations
(only as permitted by each standardized evaluation). When this
therapist entered the cafeteria in the morning
for initial observation, prior to specific assessments being
administered, Zach responded by “squawking” at the
therapist instead of responding with words for
answers/conversation. Within 10 minutes, the squawking
decreased, only surfacing again during the evaluation when
requested to complete handwriting samples for
analysis. During the structured, one to one evaluation, Zach
benefitted from verbal cues for giving his best
work, redirection if off-topic, contingencies for least desirable
activities prior to desired ones or being
finished, and clear choices for ways to accomplish expected
outcomes.
EVALUATION METHOD:
• Teacher Interview
• Records Review
• Clinical Observation

• Handwriting Assessment
• The Bruininks-Oseretsky Test of Motor Proficiency
• Sensory Profile School Companion: Teacher Questionnaire
• Test of Visual-Motor Skills - Revised
IEP for
EVALUATION RESULTS:
Postural Control/Muscle strength/tone – Postural strength is the
ability of the student to control and stabilize
his trunk and neck muscles to maintain an upright posture.
Zach continues to demonstrate the ability to
maintain an upright sitting and standing posture and to change
between postures.
Ocular motor function – Ocular motor function is the ability of
the child to separate the movements of his eyes
from his head, maintain fixation with the eyes on an object,
follow the object around the visual field (track),
move the eyes back and forth between objects (saccadic eye
movements), bring the eyes together
(convergence) and apart (divergence). Zach continues to
demonstrate the ability to perform tracking,
convergence, and divergence activities. During saccadic
movement, he did have difficulty, at first,
maintaining a fixed eye position until directed to change. He
demonstrated increased ability with this after
the first two directives of where to look, fixing on the object
until directed to change.

Sensory processing/Self-regulation/Attention –
Sensory Profile Caregiver Questionnaire information is from the
initial evaluation report in November of 2014.
It is considered valid assessment input for this evaluation.
Sensory Profile Caregiver Questionnaire (reported November
2014): The Sensory Profile is a measure of
sensory processing in daily life as assessed through the
completion of 125 questions using a 5 point Likert Scale
of “Never to Always”. The purpose of the Questionnaire is to
evaluate the possible contributions of sensory
processing to the child’s daily performance patterns, and to
provide information about both the child’s
tendencies to respond to stimuli and which sensory systems are
likely to be contributing to or creating barriers
to functional performance. The questionnaire is completed by
the child’s caregiver. Summary of scores are
obtained in six areas of sensory processing, five areas of
modulation, and areas of behavioral and emotional
responses. The areas are rated as “Typical Performance”,
“Probable Difference” or “Definite Difference”
when compared to a normative group. Raw scores are the
results of the student’s parent’s response to the
questionnaire. Areas rated as “Definite Difference” are
considered to indicate sensory processing problems in
those areas.
The results of the Sensory Profile Questionnaire, based on the
information provided by Mom, indicate a
Definite Difference in the Sensory Processing Areas of
Vestibular, Touch and Multisensory Processing and the
modulation areas related to Endurance/Tone, Body Position, and
Emotional Responses and the Behavioral and
Emotional areas of Emotional/Social and Behavioral Outcomes
related to his sensory processing. Based on the
responses provided, Zach demonstrates a high threshold for

Vestibular, indicating that he benefits from
increased amounts of movement opportunities to meet his
threshold levels and low threshold levels for touch
processing, indicating that he reaches his threshold levels for
touch processing at lower levels. The responses
indicate that Zach seeks out the movement opportunities and
requires increased movement to activate his
body thresholds. The results indicate that Zach responds to
sensory input with emotional/behavioral
responses.
Based on these results, recommendations for the school
environment include providing increased movement
opportunities (through alternative seating options including but
not limited to a sit-n-move cushion or ball chair
and the ability to change positions while working or in between
work tasks such as walking to bathroom or to
get a drink, etc.), use of a hand-fidget as a tool, continued
participation in recess and physical education class.
Based on the results he would also benefit from participation in
movement activities outside of the school
environment (participation in a variety of movement, sporting,
and recreational activities).
The Sensory Profile School Companion (November 2015)
Additionally, the Sensory Profile School Companion: Teacher
Questionnaire was completed as a current
evaluation of Zach’s sensory responses in the educational
environment. The Sensory Profile School Companion
is a standardized assessment tool for measuring a student’s
sensory processing abilities and their effect on the
student’s functional performance in the classroom and school
environment. It is a questionnaire consisting of
62 items organized in sensory groups: auditory, visual,
movement, touch and behavior. The teacher scores
each item by reporting the frequency with which the student

responds to various sensory experiences (Almost
Always, Frequently, Occasionally, Seldom, or Almost Never).
Explanation of Scores on the Sensory Profile School Companion
Teacher Questionnaire
Zach’s sensory responses in the school environment fall within
the Typical Performance range for the
following School Factor areas:
School Factor 2 (Seeking and Sensitivity)
IEP for
the Definite Difference range for the following
School Factor areas:
School Factor 1 (Seeking and Registration)
School Factor 3 (Avoiding and Sensitivity)
School Factor 4 (Avoiding and Registration)
School Factor Scores
School Factor Scores reflect the teacher’s perspective about the
student within the context of the classroom,
learning activities and the school day. Scores reflect the ways
that student’s might learn or have barriers to
learning. Each School Factor Score contains two sensory
processing patterns.
School Factor 1: represents the student’s need for external
supports. It encompasses Seeking and Registration
patterns. If scores fall in the probable/definite difference range

these student’s typically need a lot of extra
sensory input to activate their high thresholds in order to be
prepared for learning. They will likely need
supports within the learning environment to participate
successfully.
School Factor 2: represents the student’s awareness and
attention within the learning environment. It includes
Seeking and Sensitivity patterns. If scores fall in the
probably/definite difference range, these student’s may
be getting pulled away from learning activities because of
attention to other stimuli in the environment. They
will likely need adjustments within the learning environment so
they can participate successfully (i.e. less
stimulation).
School Factor 3: represents the student’s range of tolerance for
sensory input. It includes Avoiding and
Sensitivity patterns. If scores fall in the probable/definite
difference range, student’s may get overloaded
quickly in the typical learning environments, interfering with
their ability to get instructions, complete
independent work or cooperate with other students in groups.
The student may be seen as less tolerant, overly
reactive and picky. They will need reductions in stimuli within
the learning environment so they can
participate successfully.
School Factor 4: represents the student’s availability for
learning. It includes Avoiding and Registration
patterns. If scores fall in the probably/definite difference
range, students are likely missing opportunities to
participate and appear disinterested to the teacher. They may
require less input so they can concentrate or
more input so they notice what is going on. It is critical to find
just the right amount of sensory input. They will

need adjustments within the learning environment so they can
participate successfully and strategies that the
teacher can use to keep them engaged in learning throughout the
day.
the Probable Difference range for the following
Quadrant areas:
Quadrant 2 (Seeking)
Quadrant 3 (Sensitivity)
the Definite Difference range for the following
Quadrant areas:
Quadrant 1 (Registration)
Quadrant 4 (Avoiding)
Quadrant Scores
Registration: scores in the probable/definite difference range
represent students who likely miss sensory input
that provide cues about what is going on in the context. The
brain may not be getting what it needs to
generate responses. It is hypothesized that student’s in this
range have inadequate neural activation to support
sustained performance and consequently may miss salient cues
in the context to support ongoing responsivity.
They may appear uninterested and can have a dull or flat affect.
They may seem to have low energy levels and
act as if they are overly tired all of the time.
Seeking: scores in the probable/definite difference range
represent students who tend to be active and
continuously engaged in their environments. They add sensory
input to every experience in daily life. They may
make noises while working, fidget, rub or explore objects with
their skin, chew on things and wrap body parts

around furniture or people as ways to increase input during
tasks. They may appear excitable or lack
consideration for safety when playing.
IEP for
Sensitivity: scores in the probable/definite difference range
represent students who tend to be distractible
and may display hyperactivity. It is hypothesized that students
in this range have over-reactive neural systems
that make them aware of every stimulus that becomes available,
and they do not have the commensurate
ability to habituate to these stimuli.
Avoiding: scores in the probable/definite difference range
represent students who may engage in very
disruptive behaviors hypothetically because meeting thresholds
occurs too often, which is uncomfortable for
the student. In order to keep the stimulation at bay, they avoid it
by either withdrawing or engaging in
emotional outbursts that enable them to get out of the situation.
From a behavioral standpoint, the child might
seem stubborn or controlling. They function best with rituals
and tend to create them for their daily lives. The
student is creating a situation to limit sensory input to those
events that are familiar and therefore easy for the
nervous system to interpret.
Observations of Sensory Responses –
During this current evaluation, Zach was observed to engage in

the following sensory responses: munching and
stuffing waffle bites in mouth during breakfast, visual
distraction for dead bugs on floor in expected area of
stairwell, constant verbalizations during opening math exercises
in homeroom, seeking hug from
homeroom/math teacher, Mr. Math Guy, seeking hug from his
aide during the evaluation, multiple
‘squawkings’ and verbalizations during various portions of the
evaluation, use of staccato-like robotic voice
(fast-paced) when talking to therapist requiring cues for slowing
down, and smelling hands when finished
washing or using hand sanitizer (negative and positive
reactions, respectively). Additionally, he engaged in
oral activities throughout the testing, including sucking his
pinky finger and picking at his nose/mouth area due
to a running nose.
In the structured evaluation setting, Zach did respond to cues
and redirection for participating in all activities
presented. Use of contingency statements and the provision of
clear choices for therapist’s expected outcome
also assisted him with participating. During the evaluation, his
overall sensory regulation for attention and
participation was in or near an optimal state for attending to,
attempting, and/or completing activities, given
the previous described supports. Additionally, opportunities
were provided for movement on the testing side
of the room. Varying seated activities with standing or large
body movement also seemed beneficial to him for
attention and participation.
Upper Extremity Function/Hand Skills – (In-Hand Manipulation
Skills)
Shift: moving or “walking” fingers along the shaft of a pencil.
Intact for both hands.
Rotation: turning a pencil in one hand, unassisted. Intact for

both hands.
Translation with stabilization: moving three pennies from
fingertip-to-palm and out again, individually, while
maintaining others in palm. Intact for both hands.
Fine motor/Perceptual motor -
Handwriting –
Zach uses a right quadrupod grasp with dynamic wrist motion
when drawing and writing. When
writing, Zach produces samples with a consistent backward
slant and decreased legibility due
to size, spacing, and baseline anchoring of letters. His
legibility for written work was
evaluated by clinical observation using the following: near
point copy, far point copy, and keyboarding
skills.
Average Handwriting Speeds for Letters per Minute (Boys) are
as follows:
Grade 1 = 17 Letters per minute
Near-point copy: 23 Letters per minute
Letter formation – average
Letter size – ½”
Far-point copy: 39 Letters per minute
Letter formation: 97% accuracy
Baseline anchoring: 69% accuracy
Letter size: 66% accuracy

IEP for
Word spacing: 44% accuracy
Keyboarding skills: Timed typing test; 33 characters in one
minute
6 WPM (Words per minute)
1 Error
5 WPM (adjusted speed)
Zach uses the hunt/peck method for typing on a computer
keyboard. He uses bilateral index fingers to strikes
keys and produce typed letters.
Scissor skills – Zach was able to independently use Fiskar
scissors to cut around a 2” diameter circle.
Visual Perception/Visual Motor Integration –
Test of Visual-Motor Skills: Revised Edition [TVMS-R] Ages
3-13 years 11 months-This well-accepted, well-
normed, and standardized test has been revised with the
following changes: addition of new geometric forms,
deletion of some original geometric forms, revised norms for
subjects ages 3 years to 13 years 11 months,
revised standardization, and revised method of scoring. New
scoring requires each geometric form to be
evaluated by visual-motor characteristics, unlike the right or
wrong method. A scoring-criterion form for each
test booklet is needed. Still easy to administer, the revised form
of the TVMS can be administered to groups as
well as to individuals.

Total Raw Score: 112
Motor Age: 7 year, 0 months
Standard Score: 66
Scaled Score: 3
Percentile Rank: 1
Error (Zero) Characteristics:
Classification Total Error Raw Scores Standard Scores
Scaled Scores Percentile Ranks
1 - Closure 9 55 1 1
2 - Angles 7 99 10 47
3 – Intersecting and/or 3 73 5 3
Overlapping Individual Lines
4 – Size of Form or Part of Form 3 61 2 1
5 – Rotation or Reversal 0 > 112 > 12 > 80
6 – Line Length 3 63 3 1
7 – Under/Over Penetration 3 55 1 1
8 – Modification of Form 3 84 7 14
Based upon evaluation results, Zach presents with visual motor
strength in the areas of angle precision and
rotation/reversal (not rotating or reversing the design or part of
the design). His areas of need include
precision with closures, intersecting and/or overlapping
individual lines (unequal extensions), size of form or
part of form, line length, and over-penetrating or under-
penetrating the design or parts of design.
Praxis/motor planning – Praxis involves the ability to develop
an idea about an activity or movement, make
the necessary plans to perform the activity based on both
environmental factors and the knowledge of one’s
body and then carry out the plan. Timing is an important
aspect of praxis.

R/L discrimination – Zach was able identify right and left
body parts upon request; some hesitation
evidenced as he paused before two of the requests. He self-
corrected one of the ten without assistance,
resulting in 10/10 correctly identified.
Bilateral coordination – Zach was able to string beads and cut
with scissors in an expected manner.
Novel motor movements – Zach was able to demonstrate
alternate hand flips with eyes closed and
demonstrate thumb-to-finger opposition in varying patterns
following an initial model.
The Bruininks-Oseretsky Test of Motor Proficiency – The test is
an individually administered test that assesses
the motor function of children from 4 ½ to 14 ½ years of age.
Raw Score Scale Score Age Equivalent
Fine Motor Precision – 27 7 – Below Average 5 years,
7 months
IEP for
Fine Motor Integration – 32 9 – Below Average
6 years, 8 months
Manual Dexterity - 19 6 – Below Average 5 years, 9
months
Bilateral Coordination – 21 12 – Average 7 years, 11
months
Gross motor/Mobility in the school – Zach is able to access and
utilize his educational environment. He is able
to replicate six different arm positions (using both arms). He is

able to complete two jumping jacks, given a
model and cues, before demonstrating decreased rhythm and
coordination.
Self – Help – Zach is able to independently function in the
educational environment for breakfast, lunch, and
using the bathroom. He benefits from adult supervision and cues
for remaining on task with regard to meals.
Zach is beginning to learn how to blow his nose.
Strengths:
Good postural control for educational environment and
expectations
Increased participation in structured, one-to-one evaluation
setting, given adult assistance with cues,
contingencies, redirection, and clear choices for expected
outcomes
In-hand manipulation skills
Bilateral coordination for cutting
Visual motor integration: angles and non-reversals or incorrect
rotation
Bilateral coordination emerging
R/L discrimination and novel motor movements
Beginning typing skills
Needs:
Sensory regulation/processing, particularly for
Seeking/Registration, Avoiding/Sensitivity, and
Avoiding/Registration
Decreased legibility for written expression
Visual Motor Integration: overall precision and size
characteristics
Fine motor: precision, integration, and dexterity
SUMMARY:
Zach is a 10 year, 7 month old boy who receives Occupational

Therapy Support to School Personnel for sensory
regulation needs in the educational environment. During this
time of observation and evaluation, Zach
presented with increased needs in the areas of fine motor
precision, visual motor integration, and manual
dexterity (greater than 25% delay). These areas of fine motor
need directly impact legibility for written
expression. He is beginning the use of keyboarding, using a
hunt-and-peck method of typing.
Zach benefits from clear models, use of visual and verbal cues,
contingency statements (first ___ , then ____),
and clear choices for expected outcomes. Given these supports,
he participated well in the structured, one-to-
one Occupational Therapy evaluation. Zach also presents with
caregiver and teacher identified sensory needs,
particularly in the areas of seeking input and needing movement
to meet and activate threshold levels.
RECOMMENDATIONS:
Zach would benefit from Occupational Therapy Support to focus
on fine motor and sensory regulation strategies
in the educational environment. He would also benefit from
Occupational Therapy Support to School Personnel
to continue supporting strategies for optimal regulation with
regard to participation and attention in the
educational environment.
Behaviors that Impede Learning (Describe the behavior, the
triggers of the behavior and the
function of the behavior)
Daily living/skills: (hygiene, dressing, basic consumer skills)

NA
2. Present levels related to current postsecondary transition
goals if the student’s age is 14 or younger if
determined appropriate by the IEP team (e.g., results of
formative assessments, curriculum-based
assessments, progress toward current goals)
IEP for
NA
3. Parental concerns for enhancing the education of the student
Parent did not share any concerns not already addressed in 1-3
4. Other Relevant Information
In previous IEP’s, Zach has had an SDI to address the excessive
skin picking that he does during the day.
This SDI was to have pieces of Velcro on the bottom of his
desk, and he was encouraged to use the
Velcro instead of picking at himself. This SDI was not useful
for Zach, and he was caught several times

eating pieces of the Velcro. This SDI has been removed from
his IEP due to the unsafe nature of having
an additional non-edible within his reach.
Zach has received Out of School Suspension 3 times and In
School Suspension 2 times during the current
2015/2016 School year because of his dangerous or destructive
behaviors.
5. How the student’s disability affects involvement and progress
in the general education curriculum
With Specially Designed Instruction and Program Modifications
to meet his needs as a student requiring Emotional,
Speech/Language and Autism Support, Zach will receive the
general education curriculum when he is attending
Math, ELA, Science and Social Studies in the Special Education
Classroom.
6. Student’s Strengths (include interests and preferences for
students who will be 16 or over during the
duration of this IEP)
• Strengths:
• Curriculum Based Measurement from beginning of 5th grade
school year indicates average
performance in reading fluency, reading comprehension, and
mathematics
• Completes homework
• With assistance from aide, comes prepared to class
• In a structured speech therapy setting, performance for therapy
tasks is in an average range when

he is prompted to respond
• Age and grade appropriate receptive and expressive
vocabulary abilities
• History of overall Average to Low Average cognitive abilities
on standardized tests administered
within school setting
• History of overall High Average to Low Average academic
skills on standardized tests administered
within school setting
• Good postural control for educational environment and
expectations
• Increased participation in structured, one-to-one evaluation
setting, given adult assistance with
cues, contingencies, redirection, and clear choices for expected
outcomes
• In-hand manipulation skills
• Bilateral coordination for cutting
• Visual motor integration: angles and non-reversals or incorrect
rotation
• Bilateral coordination emerging
• R/L discrimination and novel motor movements
• Beginning typing skills
• Parent reports indicate adaptive strengths within the home
setting in the areas of leisure skills
(ABAS-3), self-care skills (ABAS-3), health and safety skills
(ABAS-3), social skills (BASC-3), and
adaptability (BASC-3)
• Teacher reports indicate relative adaptive strengths within the
school setting in the areas of
functional academics (as rated by Mrs. Sheller and Mr Math

Guy on the ABAS-3), community use (as
rated by Mr. Math Guy on the ABAS-3), and self-care skills (as
rated by Mr. Math Guy on the ABAS-3)
IEP for
7. Academic, Developmental, Functional Needs Related to the
Student’s Disability (include transition
related needs for students who will be 16 or over during the
duration of this IEP)
IEP for
• Curriculum Based Measurement from beginning of year
indicated below average performance in
reading vocabulary
• Teacher reports indicate that Zach is missing some basic
foundational pieces in mathematics and
grade has declined since he is being asked to complete more
work independently in this area
• Limited progress toward IEP goals

• Significant loss in instructional time due to behaviors of
concern (e.g. work refusal, lack of
participation, or behaviors requiring removal from classroom
such as crawling on floor and
noisemaking)
• Requires constant prompting and encouragement to stay on
task, but even with this dos not always
pay attention and/or participate
• Limited completion of in class tasks/assignments
• Picks at skin
• Poor social interaction skills (growls at others, biting, kicking,
spitting, etc.)
• Difficulty following one-step directions
• Below average pragmatic language skills
• Sensory regulation/processing, particularly for
• Seeking/Registration, Avoiding/Sensitivity, and
Avoiding/Registration
• Decreased legibility for written expression
• Visual Motor Integration: overall precision and size
characteristics
• Fine motor: precision, integration, and dexterity
• Adaptively, parent reports indicate below average
communication skills (ABAS-3) and social skills
(ABAS-3) and low self-direction skills (ABAS-3)
• Adaptively, teacher reports indicate significant limitations in
overall adaptive functioning as
assessed on the ABAS-3 across the conceptual, social, and
practical domains
• Parent ratings of Zach’s social-emotional-behavioral
functioning indicated elevated levels of

concern in the areas of hyperactivity/impulsivity,
aggression/defiance, inattention, conduct
problems, atypicality, withdrawal, leadership skills, activities of
daily living, functional
communication skills, learning problems, executive functioning
difficulties, and peer relations.
• Teacher ratings of Zach’s social-emotional-behavioral
functioning indicated elevate levels of
concern in the areas of hyperactivity/impulsivity,
aggression/defiance, conduct problems, anxiety,
depression, atypicality, withdrawal, attention problems, learning
problems, executive functioning
difficulties, adaptability, social skills/peer relations, leadership,
study skills, and functional
communication.
III. TRANSITION SERVICES – This is required for students
age 14 or younger if determined appropriate by
the IEP team. If the student does not attend the IEP meeting, the
school must take other steps to ensure that the student’s
preferences and
interests are considered. Transition services are a coordinated
set of activities for a student with a disability that is designed
to be within a

results oriented process, that is focused on improving the
academic and functional achievement of the student with a
disability to facilitate the
student’s movement from school to post school activities,
including postsecondary education, vocational education,
integrated employment
(including supported employment), continuing and adult
education, adult services, independent living, or community
participation that is
based on the individual student’s needs taking into account the
student’s strengths, preferences, and interests.
Transition does not apply to this student (skip this section)
Postsecondary Education and Training Goal: Measurable Annual
Goal
Yes/No
(Document in Section V)
Courses of Study:
Service/Activity Location Frequency Projected
Beginning Date
Anticipated
Duration
Person(s)/Agency
Responsible
Employment Goal:
Yes/No

Courses of Study:
Beginning Date
Anticipated
Duration
Person(s)/Agency
Responsible
Independent Living Goal, if appropriate:
Yes/No
Courses of Study:
Beginning Date
Anticipated
Duration
Person(s)/Agency
Responsible
IV. PARTICIPATION IN STATE AND LOCAL
ASSESSMENTS
Please check the appropriate assessment option. Information on
available testing accommodations may be found in the
Accommodations Guidelines available on
http://www.education.pa.gov/K-12/Assessment and

Accountability/PSSA/
State Assessments
Not Assessed
No statewide assessment is administered at this student’s
grade level.
No English proficiency assessment administered because the
student is not an English Language Learner.
PSSA (Math administered in grades 3-8; Science administered
in grades 4 and 8; Reading administered in grades 3-8; Writing
administered in
grades 5 and 8; and ELA*)
Tested
Subject
W
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A
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Accommodations to be provided
Please consult
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Math Questions read aloud(when appropriate), 1-1 testing,
extended time, extra breaks
Science NA
Reading NA
Writing NA
ELA* 1-1 testing, extended time, extra breaks
*ELA will replace the Reading and Writing PSSAs in 2014-
2015 for grades 3-8.
Keystone Exam (Replaces the 11th grade PSSA in high school;
Student must participate by 11th grade)
Tested
Subject
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Accommodations to be provided**
Please consult
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*
Algebra 1 NA
Literature NA
Biology NA
*Available when student is unable to demonstrate proficiency
on a Keystone Exam or Keystone Exam Module)
** Available when selected as an option by LEA
PASA (Grades 3-8, 11 for Reading and Math, Grades 4, 8 , 11
for Science)
Student will participate in the PASA

Explain why the child cannot participate in the PSSA:
Explain why the PASA is appropriate:
Choose how the student’s performance on the PASA will be
documented
Videotape (which will be kept confidential as all other school
records)
Written narrative (which will be kept confidential as all other
school records)
ACCESS for ELLs (Administered in grades K-12)
Domains Without
Accommodations
With
Accommodations
Unable to
Participate

Accommodations to be Provided or Rationale for
Inability to
Participate in Selected Domains
Listening NA
Reading NA
Writing NA
Speaking NA
Alternate ACCESS for ELLs (Administered in grades 1-12)
Alternate ACCESS for ELLs (Administered in grades 1-12)
☐Student will participate in the Alternate ACCESS for ELLs.
Explain why the student cannot participate in the ACCESS for
ELLs:
Explain why the Alternate ACCESS for ELLs is appropriate:
Domains Without
Accommodations
With
Accommodations
Unable to
Participate

Accommodations to be Provided or Rationale for
Inability to
Participate in Selected Domains
Listening NA
Reading NA
Writing NA
Speaking NA
STUDENT PARTICIPATION – LOCAL ASSESSMENTS
Student will not participate in Local assessments because there
are none given during the duration of this IEP.
Student will participate in Local assessments without
accommodations; or
Student will participate in Local assessments with the
following accommodations: Please see PSSA Section Above; or
The student will take an alternate local assessment
Explain why the child cannot participate in the regular
assessment:
Explain why the alternate assessment is appropriate:

Complete this heading chart only when issuing these goal pages
as an IEP report Card
Reporting
Period: School year
Date Issued To
Parent
V. GOALS AND OBJECTIVES – Include, as appropriate,
academic and functional goals. Use as many copies of this page
as
needed to plan appropriately. Specially designed instruction
may be listed with each goal/objective or listed in Section VI.
Short term learning outcomes are required for students who are
gifted. The short term learning outcomes related to the student’s
gifted program may be listed under Goals or Short Term
Objectives.
MEASURABLE ANNUAL GOAL
MEASURABLE ANNUAL GOAL
components)

Describe HOW the student’s
progress toward meeting
this goal will be measured
Describe WHEN periodic
reports on progress will be
provided to parents
Report of Progress
When given a timed 4th grade math computation probe,
Zach correct answer problems with at least 80% accuracy
on 3 out of 5 trials.
Math computation probes
administered at least 4 times
per marking period.
Quarterly with Report cards
When given a timed 4th grade level reading fluency
probe, Zach read 150 Words Correct Per Minute with at
least 95% accuracy on 3 out of 5 trials.
Leveled Reading Passages
administered at least 4 times
per marking period.
When given his assigned classroom schedule, Zach will
transition to the assigned location within the allotted 5
minute time frame for 5 consecutive days.
Daily behavior logs will be

used to track his progress on a
weekly basis
When in assigned classroom, Zach will remain in the
classroom environment with no more than 1 five minute
break for every 30 minutes of instructional time for 5
consecutive days.
weekly basis
When in assigned classroom during a structured teaching
situation, Zach will complete assignments before gaining
access to his preferred item/activity in 80% of
opportunities charted for 5 consecutive days.
weekly basis
SHORT TERM OBJECTIVES – Required for students with
disabilities who take alternate assessments aligned to alternate
achievement standards (PASA).
Short term objectives / Benchmarks

V. GOALS AND OBJECTIVES - Include, as appropriate,
academic and functional goals. Use as many
copies of this page as needed to plan appropriately. Specially
designed instruction may be listed with
each goal/objective or listed in Section VI.
Short term learning outcomes are required for students who are
gifted. The short term learning outcomes
related to the student’s gifted program may be listed under
Goals or Short Term Objectives.
Student
Name: Zach Brehm
Area of planned instruction: (Refer to PA Academic Standards
or District Curriculum) Speech and Language Support 2016 -
2017
components)
Describe HOW the student’s progress

toward meeting this goal will be
measured and WHEN periodic reports
on progress will be provided to
parents.
Report of Progress
Using an expected vs. unexpected behavior(s)
framework, Zach will identify and use targeted social
skills, with reduced cueing/prompting
Required, in structured to less structured
settings/opportunities 80% of the time.
When presented with a social behavior/interaction
scenario Zach will:
-- Define/ Describe
-- Contrast (expected vs unexpected)
-- Predict
■ consequences/outcomes
■ feelings (his and others as related to The
Zones)
■ reactions (his and others)
-- Interpret (perspective/body language)
-- Modify (suggest/implement changes)
(PA Standard Reference 1.6)

Analysis of data collected during classroom
activities, standardized tests, and therapy
notes used to measure progress.
Progress will be reported once every 9 weeks
when report cards are sent home
Marking Period S L N
1st marking period
October 2016
2nd marking period
January 2016
3rd marking period
March 2016
4th marking period
May 2016

Progress Report Key (extent to which progress is sufficient to
meet the annual goal)
S = making sufficient progress (80% or better) L = making
limited progress (70% - 79%) N = not making
sufficient progress at this time (0-69%)
VI. SPECIAL EDUCATION/ RELATED SERVICES /
SUPPLEMENTARY AID AND SERVICES /
PROGRAM MODIFICATIONS - – Include, as appropriate, for
nonacademic and extracurricular services and
activities.
PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED
INSTRUCTION:
• SDI may be listed with each goal or as part of the table below.
• Include supplementary aids and services as appropriate.
• For a student who has a disability and is gifted, SDI also
should include adaptations, accommodations, or
modifications to the general education curriculum, as
appropriate for a student with a disability.

Due to the need for… Modification Or SDI Location*
Frequency Beginning Date Anticipated Duration
Increased age
appropriate
communication
abilities
Daily use of agenda for home and school
communication
School/Home Sent home Daily
to relay
information
between home
and school
02/12/16 02/02/17
Increased
frequency of on
task behavior
Verbal and non-verbal reminders to stay on task During
Instructional
Periods
When
demonstrating
off-task behavior

02/12/16 02/02/17
An increase in
completion of in
class
tasks/assignments
Visual timer Regular Ed
and Special
Ed Classrooms
When requested
by
student/teacher
02/12/16 02/02/17
Increasing
functional
communication
ability
Encourage Zach to use his “boy” voice and good
sounds to communicate with adults and peers.
Regular Ed
and Special
Ed Classrooms
daily 02/12/16 02/02/17

An increase in the
amount of work
completed
Extended time for taking tests/small group daily When off task
behaviors
impede his ability
to complete tests
in the given
timeframe
02/12/16 02/02/17
An increase in the
amount of time
student spends on
task in the
classroom
Low distraction area within the classroom All classroom
settings
During times of
instruction,
independent
work, or when
otherwise
necessary

02/12/16 02/02/17
an increase in time
spent on task
during instruction,
and to decrease
unexpected
behaviors
*Classroom Positive Behavior Plan
Change to PBSP?
All school
settings
Every day 02/12/16 02/02/17
Increased age-
appropriate social-
emotional-
behavioral
functioning

Emotional cards to express feelings Speech
Classroom
1x per 6 day
cycle during
social skills group
02/12/16 02/02/17
An increase in the
amount of time on
task, and to
provide
reinforcement
Participate in the reg. classroom behavior
management plan
General
Education
Classrooms
During times of
inclusion
02/12/16 02/02/17
legibility for written
expression
Visual Motor
Integration

3/4” lined primary journal to use for writing logs
and math logs
Math and ELA
classrooms
When a writing
assignment or
task is given
02/12/16 02/02/17
Addressed with a
different SDI
Velcro strip attached to the bottom of desk for
sensory purpose/prompts to use
See above*** 02/12/16 02/02/17
Fine motor:
precision,
integration, and
dexterity
Extra time for long writing assignments In class
assignments
When a written
assignment is
given
02/12/16 02/02/17

An increase in
appropriate social
interaction skills
Preferential seating/desk away from others All areas of
instruction
Always 02/12/16 02/02/17
An increase in
ability to follow
single-step
directions
Clear and concise explanation of directions and
expectations
All areas of
instruction
Whenever
directions are
given
02/12/16 02/02/17

An increase of
age-appropriate
social-emotional-
behavioral
functioning
Model/encourage Zach to use social skills and
strategies
Social Skills
group, small
group setting,
classroom
During social skills
group, when the
need arises in the
classroom setting
02/12/16 02/02/17
A decrease in the
amount of
picking/biting/che
wing on his
skin/hair
Signal folded hands when picking skin Classroom/
hallway

When picking at
self
02/12/16 02/02/17
An increase in the
amount of time on
task, and to
provide
reinforcement
Immediate feedback for retention of information Classroom
When retention
of information is
observed, as
often as possible
02/12/16 02/02/17
Increase the
amount of
expected
behaviors
Praise frequently for on-task behavior Classroom Starting out
more
often, with a
decrease as
more on-task
behavior is
observed

02/12/16 02/02/17
Making progress
toward current IEP
goals
Chunk work to be less overwhelming Classroom Prior to
presenting to
student, as often
as necessary to
limit behavioral
issues
02/12/16 02/02/17
An increase in on
task behavior
A 5 minute break per 30 minutes of instructional
time
*Include CPAVTS in location if student is enrolled in Vo-Tech
Positive Behavior Support Plan (If not needed check box )
Positive Behavior Support Plan
Updated Behavior Information Summary:

Data was collected regarding the behaviors of concern which
include: a) mouthing inedible objects b)
biting/sucking/picking skin/hair c) verbal/nonverbal refusal
behaviors. The team reported concerns the recent
change in behavior from the beginning of the school year to the
present time may be related to changes in
medications/or changes in effectiveness of medications.
Antecedents to the
behavior of concern
Behavior of concern
Consequences maintaining the
behavior of concern
Perceived function
of the behavior of
concern
• Instruction/direction to
individual student

• Teacher redirection
• Instruction/direction to
whole group
• Biting/sucking/picking skin
• Verbal/non-verbal task
refusal
• Mouthing inedible objects
• Verbal prompt from
teacher
• Aide/TSS
prompting/redirection
To Escape
• Direction
To Gain
• Attention
When (antecedents to the behavior of concern) given
instruction/direction to individual student, teacher redirection,
instruction/direction
to whole group
Zach (behavior of concern) will engage in
biting/sucking/picking skin, verbal/non-verbal task refusal, and
mouthing inedible objects
in order to (perceived function of the behavior of concern)
escape/avoid/postpone direction followed by trying to gain
attention

PROGRAM MODIFICATIONS AND SPECIALLY DESIGNED
INSTRUCTION FOR THE POSITIVE BEHAVIOR
SUPPORT PLAN:
A Antecedent (prevention) Strategies
What To Avoid:
• Avoid Zach being able to escape from task/activity
• Avoid providing attention for behaviors of concern (unless his
safety/safety of others is at risk)
• Avoid access to preferred items/activities when displaying
behaviors of concern
• Adults should not discuss Zach’s behavior when he is able to
hear their conversations
Sensory Strategies/Tools:
• Continue to explore use of structured opportunities for sensory
input built into the classroom routine
• Increase Zach’s vocabulary of emotions and recognition of
facial expressions
• Use of matched stimulation to find more socially appropriate
behaviors to teach Zach to replace his socially unexpected
sensory seeking behaviors (i.e.:
mouthing inedible objects, biting/picking/sucking skin)
• Encourage Zach to verbally to express his wants and/or needs
when he is attempting to engage in unexpected sensory seeking
behaviors(verbally or pointing to a

picture)
Environmental Structures and Transition:
• Assessment of Zach’s reinforcers (edible items, non-edible
items/activities)
• Visual reinforcer menu of options for Zach to choose from to
earn for participation in following directions
• Visual/verbal reminders of what is next on the schedule
• Use social stories and/or rules to explain behavioral
expectations for specific situations
• Provide a transition warning (e.g. timer, check schedule, one
more minute)
• Provide Zach with expectations of what is coming/transitions
and warnings of changes in schedule
• Give clear and concise directions
• Allow Zach to make choices when possible
• Pre-correction procedures (a proactive strategy designed to
prevent or interrupt predictable problem behavior from
occurring and
increase the likelihood of expected behavior taking place), used
in conjunction with correction procedures, provide educators
with
a very effective and efficient method for preventing and
managing a wide range of problem behavior that occurs in
classroom and
school settings. The combined uses of these two procedures
involve seven basic steps:
Identifying the Context (trigger) and the Predictable
Problem Behavior
Specifying Expected Behaviors
Modifying the Context
Conducting Behavior Rehearsals

Providing Strong Reinforcement for Expected
Behaviors
Prompting Expected Behaviors
Monitoring the Plan
Instructional Strategies:
• Errorless learning and shaping procedures when teaching new
content
• Gain Zach’s attention before a demand is placed upon him
• Staff should model and explain to Zach what is expected when
introducing instructional lessons/activities
• Reduce amount of work presented at one time to increase the
likelihood of assignment completion
• Use clear and concise directions
• When possible allow Zach to make choices appropriate to
instructional activity/lesson (Ex: which one do you want to do
first?)
• When possible fade prompts within the instructional session to
promote independent skills
• Use of first/then statements when presenting activities/tasks
perceived to be non-preferred/difficult to promote task
completion
• Use of continuous reinforcement to establish new skills
• Use of a timer when appropriate
• Teach Zach the expected ways to gain attention through
modeling, role-playing, and the use of visual supports
• Develop daily tracking form of tasks completed and preferred
activities/items utilized

Communication Strategies:
• Use of behavior report between staff and parents to report
positive behavioral experiences and number of tokens earned
• Provide Zach with choices when given tasks/directives when
possible. Talk to Zach about which task he wants to complete
first and second. The goal is to
keep Zach motivated and working toward a teacher expected
outcome. Allow Zach to take ownership of the task and
completion of the task.
Motivational Strategies:
• Conduct preference assessments with Zach – Staff will assess
his interest in potential reinforcers on a daily basis
• Deliver and/or change schedule of reinforcement based on
Zach’s performance at the “moment”
• Use promise reinforcers when transitioning from a preferred to
less preferred activity
• Use of continuous reinforcement when trying to establish a
new skill (provide reinforcement every time Zach uses
replacement behavior in his PBSP) Make
it immediate, descriptive and enthusiastic
• Use of an intermittent schedule (strengthens behavior) of
reinforcement for known activities/tasks
• Use of a visual reinforcement system
• Use a variety of reinforcement- verbal praise, high fives,
tangibles, and/or non-verbal (e.g. thumbs up, pat on back)
• Differential reinforcement of alternative behavior (DRA)-
reinforce the alternative behaviors we want (not the interfering
behavior)

Behavioral Strategies:
• At first sign that Zach’s behaviors of concern may begin (pre-
cursor behaviors identified = moving around in his seat, talking
faster and at a higher pitch),
present Zach with a visual choice of options to try
• Staff will assist in helping Zach self-reflect to increase
awareness of the effectiveness of strategies for him
• Use of a clear, calm, neutral low voice
• Be aware of Zach’s warning signs which can be due to a
stressful events, communication, and/or overwhelming
situations in which he may need to try his
identified strategies
• Use close proximity when Zach is off task
• Use of behavioral momentum techniques to increase
participation
• Use of 1:1 correspondence in earning tokens for each response
Zach provides to increase his motivation to participate
• Provide the student with direct instruction in replacement
strategies for unexpected behaviors. Allow plenty of
opportunities for
Zach to practice/role play the replacement strategy in a safe
setting. When the unexpected behavior is observed in a natural
setting,
be sure to prompt the student to use the replacement strategy
rather than simply requesting that the student terminate the
unexpected behavior. The prompt used to cue the replacement
behavior can be verbal or nonverbal, but should be discussed
with to
the student prior to use. Immediately reward the student with a
high-interest incentive when the replacement behavior is used.

B Replacement Behavior (achieving the same function):
• When given his assigned classroom schedule, Zach will
transition to the assigned location within the allotted 5 minute
time frame for 5 consecutive days.
• When in assigned classroom, Zach will remain in the
classroom environment with no more than 1 five minute break
for every 30 minutes of instructional time
for 5 consecutive days.
• When in assigned classroom during a structured teaching
situation, Zach will complete assignments before gaining access
to his preferred item/activity in 80% of
opportunities charted for 5 consecutive days.
ÓC
Consequences (reinforcement) for when the student performs
the replacement behavior:
• When delivering reinforcement it needs to be immediate,
descriptive, and enthusiastic. When Zach chooses to do what is
expected, give him immediate
verbal praise and appropriate reinforcement (catch him being
good).
• Deliver and/or change schedule of reinforcement based on
Zach’s body language at the “moment”
• Proactive use of sensory activities in collaboration with Zach
and the staff working with him

• Use a variety of reinforcement- verbal praise, high fives,
tangibles, and/or non-verbal (e.g. thumbs up, knuckle bump)
• Differential reinforcement of alternative behaviors (DRA)-
reinforce the alternative behaviors we want (not the interfering
behaviors)
• Increasing the ratio of replacement behavior to reinforcement
until the desired skill is more consistently established
• Reevaluate reinforcers every other week and continue to add
them as they are identified by staff
• Teach alternative behaviors by reinforcing the replacement
behaviors
ÔC Consequences (including procedures to follow) when the
student performs the behavior of concern:
• Do not allow Zach to escape demands (may need to interrupt
the behavior with a different task/activity and then bring back
the original task/activity)
• Staff should withhold attention (no eye contact, do not talk to
the student) when Zach engages in behaviors of concern to get
adult attention. Staff should
provide a neutral, visual prompt for the replacement behavior
(e.g. raise hand, say, “Excuse me.”)
• Staff will remind Zach that he has strategies to use/reinforcers
he is working to earn
• Staff will reinforce when Zach uses his strategies or continues
with activity with appropriate behavior

Behavior-Reduction Strategies (De-escalation):
*Strategies are NOT meant to be followed in a hierarchical
order, but use of each strategy is dependent upon level of
escalation and student response to the
strategy itself
*To avoid multiple people giving verbal prompts at one time –
select one person to give directives
At the onset of the behaviors, use one of the following
strategies:
Strategy 1 using Communication: (use during mild signs of
agitation such as moving around in his seat or talking in higher
pitch)
• Staff will verbally/visually remind Zach he has strategies to
use/reinforcers he is working to earn
• Staff will reinforce immediately when Zach uses his strategies
or continues with activity with appropriate behavior
• Approach Zach maintaining a safe distance (3-5 feet)
• Use Prompts to guide Zach in communicating his wants and/or
needs
o Ask Zach to state what he wants. Say “What do you want? or
“What do you need?”àverbally/visually cue Zach to use his
words
o If you think you know what Zach wants, try to help him
verbalize it- Say “I want…”
• Allow 5 seconds for Zach to process the request
• Repeat the prompt if necessary
• If Zach makes an appropriate request, then praise him for
communicating. Honor the request if possible and appropriate
• When calm or back on task a staff member should debrief
Zach utilizing visual supports
• If signs of agitation increase, then stop and consider switching
to a different strategy

Strategy 2: Prompt Strategy (incompatible behavior) (use when
Strategy 1 has not been effective or not appropriate, when it is
likely he will comply with
request)
• Approach student maintaining a 3-5 foot distance
• Prompt an incompatible behavior in a calm, neutral tone (e.g.
if student is kicking, ask him to jump up and down) OR prompt
a high probability behavior-
something Zach already knows how to do, a simple brief action
person can do. The activity can NOT be highly reinforcing
• Allow 5-10 seconds for Zach to process your request
o Praise any participation. Begin again with another
incompatible or high-probability behavior (reverse the
behavioral momentum)
o If he responds reinforce and continue task/activity on
schedule
• If non-participation occurs, identify a different incompatible
or high-probability behavior and start over
• If Zach engages in an incompatible behavior without being
prompted- reinforce immediately
• When calm a staff member will debrief with Zach utilizing
visual supports
• If signs of agitation increase, then stop and consider switching
to a different strategy
Strategy 3: De-escalation Strategies (used for automatic
reinforcement/escape)

• Staff will reinforce immediately when Zach uses his strategies
or continues with an activity with expected behavior
• Approach Zach maintaining a safe distance (3-5 feet)
• Repeat prompt if necessary
• Staff will ask Zach if he wants a 2 minute or 3 minute break
• Staff will check back with him
• Staff will offer Zach suggestions on strategies that can be used
• Praise any participation
• When calm a staff member will debrief with Zach utilizing
visual supports
• If signs of agitation increase, stop and consider switching to a
different strategy
Strategy 4: Wait Strategies: (use for attention or when other
strategies appear to increase the escalation of the behavior(s)
and to avoid external reinforcement of
behaviors of concern)
• Staff will reinforce when Zach uses his strategies or continues
with the activity with appropriate behavior
• When Zach is engaging in behaviors that are dangerous to
himself or others, staff will utilize behavioral safety guidelines
to give Zach the opportunity to de-
escalate in a quiet setting
• If it is not safe to remove Zach from the area, staff should
remove other students from the area

• Maintain a safe distance of 3-5 feet and position yourself to be
able to monitor Zach’s behaviors while keeping movements
slow and voices low-due to Zach’s
body being out of control (ex: flailing arms & legs, etc.)
• Staff will use a calm, neutral tone of voice to state strategies
he could use one time and then remove attention until Zach
complies (offer suggestions 1 time)
• Avoid reinforcing Zach’s behavior (don’t talk, give eye
contact, etc.)
• When Zach is showing self-regulation/emotional control
(attempting to respond to teacher direction),
return him to some/all part(s) of the activity/task he was doing
and then put him back on schedule (this is to avoid Zach
escaping activity/task)
• When calm a staff will debrief with Zach utilizing visual
supports
CRISIS PLAN
Note:
• The use of emergency physical intervention is considered a
measure of last resort, only to be used after other less restrictive
measures: including de-escalation techniques have been
implemented.
• If Zach’s behavior warrants the use of emergency physical
intervention due to imminent risk of serious harm to himself or
others, staff
will assess if there is a safe place in the room keeping Zach,
other students and staff safe.
• Other students will be removed from the classroom or Zach

will be removed from the classroom utilizing an appropriate
behavioral
safety technique
• Staff will utilize an appropriate one person behavioral safety
technique to stabilize Zach
• If sufficient staff present, an appropriate two person
behavioral safety technique will be utilized to stabilize Zach if
a one person
technique is not sufficient
• Staff will then:
a. Return other students to classroom if necessary
b. Notify Principal, Supervisor
c. Notify parents that Zach needs to be picked up from school
d. Complete incident report
e. Schedule a follow-up IEP team meeting to discuss and
determine action to be taken (i.e., FBA, new or revised positive
behavior
support plan, etc.)
If Zach’s behaviors continue to escalate and he remains in a
state of crisis for more than 30 minutes, a call will be made to
the following persons regarding
a call to Crisis Intervention.
1. School Principal
2. Supervisor of Special Education/ Central Office/
Administration Staff
3. Parents. Mother should be called first. Her contact number
is: cell 717-867-5309. If mother is not available, father should
be called. His contact
number is: 717-777-8888.

4. Call to Crisis Intervention (717-888-5555) will be followed
by a 911 call requesting Emergency medical response.
B. RELATED SERVICES:
1. List the services that the student needs in order to benefit
from or access his/her special education program:
Service Location Frequency* Projected
Beginning Date
Anticipated
Duration
Speech Room 30 minutes per 6 day cycle 02/12/16
02/02/17
Home/School An average of 5 X 10 min sessions per week
delivered over a total of approximately180

sessions within the IEP School Year.
02/12/16 02/02/17
02/12/16 02/02/17
School daily; during academic and nonacademic time
periods
02/12/16 02/02/17
*The District and parents agree that the frequency denoted in
the column above excludes the summer break (i.e the period of
time between the last student day of the current school year and
the first student day of the next school year) and holiday
breaks when school is closed (i.e. Thanksgiving, Winter break,
spring break etc.) unless specifically noted.
2. Is this Student eligible for School Based Access billing?
Yes: Please indicate services Speech, OT, Transportation,
Personal Care Aide
No
C. SUPPORTS FOR SCHOOL PERSONNEL – List the staff to
receive the supports and the supports needed to implement
the student’s IEP.
.
School Personnel to
Receive Support Support Location Frequency Beginning Date
Anticipated

Duration
All staff who work
with the student
Specially designed instruction will be distributed
to staff members who work with the student
Regular
school
1st week of
each course.
02/12/16 02/02/17
D. GIFTED SUPPORT SERVICES FOR A STUDENT
IDENTIFIED AS GIFTED WHO ALSO IS
IDENTIFIED AS A STUDENT WITH A DISABILITY –
Support services are required to assist a gifted student to benefit
from gifted education (e.g., psychological services, parent
counseling and education, counseling services, transportation to
and from gifted
programs to classrooms in buildings operated by the school
district).
Support Service NA
Support Service NA
Support Service NA

EXTENDED SCHOOL YEAR – The IEP team has considered
and discussed ESY services, and determined that:
1) Consideration
This is the Student’s first IEP – the team has not yet had the
opportunity to collect data over breaks in programming.
ESY for the current school year was already reviewed on date
of meeting (Note must be before February 28th if the student
is identified with MR, AUT, SED)
The IEP team discussed the following considerations for ESY:
Yes No Yes No
Do present education levels (Section
II above) show progress on Annual
goals and objectives.
Do the parents report negative changes in
adaptive behaviors?
Does the student demonstrate self
sufficiency & independence?
Is there data indicating that successive
interruptions in educational program resulted
in withdrawal from the learning process?

Are there any medical reports
indicating difficulties which may be
exacerbated during breaks?
Did the student receive ESY services in the
Past?
2) Determination
As of 02/03/16 the IEP team has determined student is NOT in
need of ESY services for the following reason(s):
The student is Eligible for ESY for the following reason(s):
3) Reasons for determination
For the IEP team to discuss at the time of the IEP meeting.
Special Education teachers working with Zach recommend ESY.
Zach has demonstrated severe difficulty with behavior
following an extended break from school.
The Annual Goals and, when appropriate, Short Term
Objectives from this IEP that are to be addressed in the
student’s
ESY Program are:
Annual Goal to Maintain Short Term Objectives

If the IEP Team has determined ESY is appropriate complete
the following:
ESY Service to
be provided
Location Frequency Projected Beginning
Date
Anticipated Duration
Implementation
of his PBSP
School-based Up to 30 hours
of instruction
June 2016 August 2016
VII. EDUCATIONAL PLACEMENT
A. QUESTIONS FOR IEP TEAM – The following questions
must be reviewed and discussed by the IEP team prior to
providing the explanations regarding participation with students
without disabilities.

Individualized Education Program (Aug 2014 revision) Page 1 .docx

Individualized Education Program (Aug 2014 revision) Page 1 .docx

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Individualized Education Program (Aug 2014 revision) Page 1 .docx