Division of Students with Disabilities & English Language Learners

PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL NEEDS

DOCUMENTATION OF STUDENT'S CURRENT PERFORMANCE AND ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS

EVALUATION RESULTS (INCLUDING FOR SCHOOL-AGE STUDENTS, PERFORMANCE ON STATE AND DISTRICT-WIDE
ASSESSMENTS)
SKIP THIS: WOULD BE A SUMMARY OF TEST SCORES

PRESENT LEVELS OF PERFORMANCE (INCLUDE ACADEMIC, SOCIAL, BEHAVIORAL, PHYSICAL, ADAPTIVE OR LIFE SKILLS, AS
WELL AS MANAGEMENT OR SUPPORT NEEDS)
Eric can successfully decode unknown grade level words with prompting and/or pre-teaching. Eric can successfully determine the main idea of a text, but
struggles to find relevant details and make connections. Eric has shown to do very well in math class. Eric does well with visual representations of concepts
and step-by-step instructions that break down more abstract ideas, as shown by his interest in Biology class. Eric is very good at thinking globally and
identifying big ideas, and can benefit from explicit directions when it comes to more detail-oriented tasks like analyzing.
Eric is reading at 10 grade level for sight words, and at a 5.6 grade level for more unfamiliar words. Erics decoding can interfere with his ability to
comprehend readings from content areas and demonstrate his full level of knowledge. In addition, sometimes Erics self-efficacy affects his ability to persist
with more difficult decoding and phonics tasks, also not allowing him to show his full potential.
Eric benefits from instruction that takes this into account, and targeted strategies, so that he can show the full potential of his abilities. When given concrete
phonics strategies, and isolated practice, Eric can successfully navigate grade level words. Eric also benefits from use of a word-processing device, so that he
can construct written responses that demonstrate his true capabilities without handwriting being an obstacle to his composition. Eric is capable in math, and
would benefit from opportunities to demonstrate this capability more frequently, especially in cooperative learning/peer tutoring situations as it would positive
reinforce his academic capability and self-perception.

District 75
400 First Avenue, New York, New York, 10010

PRESENT LEVELS OF PERFORMANCE AND INDIVIDUAL NEEDS

DOCUMENTATION OF STUDENT'S CURRENT PERFORMANCE AND ACADEMIC, DEVELOPMENTAL AND FUNCTIONAL NEEDS

EFFECT OF STUDENT NEEDS ON INVOLVEMENT AND PROGRESS IN THE GENERAL EDUCATION CURRICULUM OR, FOR A
PRESCHOOL STUDENT, EFFECT OF STUDENT NEEDS ON PARTICIPATION IN APPROPRIATE ACTIVITES
Due to Erics phonics and literacy needs he benefits from placement in general education classes that provide a Special Education co-teacher who can ensure
his needs are being met and that he is receiving literacy strategy support in core content areas.

STUDENT NAME:
STUDENT NEEDS RELATING TO SPECIAL FACTORS
BASED ON THE IDENTIFICATION OF THE STUDENT'S NEEDS, THE COMMITTEE MUST CONSIDER WHETHER THE STUDENT NEEDS A PARTICULAR DEVICE OR
SERVICE TO ADDRESS THE SPECIAL FACTORS AS INDICATED BELOW, AND IF SO, THE APPROPRIATE SECTION OF THE IEP MUST IDENTIFY THE PARTICULAR
DEVICE OR SERVICE(S) NEEDED:

Does the student need strategies, including positive behavioral interventions, supports and other strategies to address behaviors that impede the student's
learning or that of others?

Yes xNo

Does the student need a behavioral intervention plan? xNo

Yes

For a student with limited English proficiency, does {.he,she} need a special education service to address {.his,her} language needs as they relate to the IEP?
Yes xNo

Not Applicable

For a student who is blind or visually impaired, does {.he,she} need instruction in Braille and the use of Braille?
Yes xNo
Not Applicable
Does the student need a particular device or service to address {.his,her} communication needs? xYes No (Word processing device)
In the case of a student who is deaf or hard of hearing, does the student need a particular device or service in consideration of the student's language and
communication needs, opportunities for direct communications with peers and professional personnel in the student's language and communication mode,
academic level, and full range of needs, including opportunities for direct instruction in the student's language and communication mode?
Yes xNo
Not Applicable
Does the student need an assistive technology device and/or service? xYes No (Student needs a word-processing device)
If yes, does the Committee recommend that the device(s) be used in the student's home?

Yes xNo

District 75
400 First Avenue, New York, New York, 10010

STUDENT NEEDS RELATING TO SPECIAL FACTORS

BASED ON THE IDENTIFICATION OF THE STUDENT'S NEEDS, THE COMMITTEE MUST CONSIDER WHETHER THE STUDENT NEEDS A PARTICULAR DEVICE OR
SERVICE TO ADDRESS THE SPECIAL FACTORS AS INDICATED BELOW, AND IF SO, THE APPROPRIATE SECTION OF THE IEP MUST IDENTIFY THE PARTICULAR
DEVICE OR SERVICE(S) NEEDED:

STUDENT NAME:

NYC ID:

BEGINNING NOT LATER THAN THE FIRST IEP TO BE IN EFFECT WHEN THE STUDENT IS AGE 15 (AND AT A YOUNGER AGE IF DETERMINED APPROPRIATE)
MEASURABLE POSTSECONDARY GOALS
LONG-TERM GOALS FOR LIVING, WORKING AND LEARNING AS AN ADULT
STTUDENT WILL PURSUE A 4 YEAR DEGREE, POSSIBLY IN ENGINEERING OR ROBOTICS.

EDUCATION/TRAINING: 2 or 4 year degree.

EMPLOYMENT: Engineering profession
INDEPENDENT LIVING SKILLS (WHEN APPROPRIATE): n/a
TRANSITION NEEDS
In consideration of present levels of performance, transition service needs of the student that focus on the student's courses of study, taking into account the
students strengths, preferences and interests as they relate to transition from school to post-school activities:
Student will pursue career options as related to the Engineering and Robotics field. Student will complete an internship that reflects these career interests as
well as participate in a robotics club to develop and hone these interests.

STUDENT NAME:

NYC ID:

MEASURABLE ANNUAL GOALS

District 75
400 First Avenue, New York, New York, 10010

THE FOLLOWING GOALS ARE RECOMMENDED TO ENABLE THE STUDENT TO BE INVOLVED IN AND PROGRESS IN THE GENERAL
EDUCATION CURRICULUM, ADDRESS OTHER EDUCATIONAL NEEDS THAT RESULT FROM THE STUDENT'S DISABILITY, AND PREPARE
THE STUDENT TO MEET HIS/HER POSTSECONDARY GOALS.
ANNUAL GOALS
WHAT THE STUDENT WILL BE EXPECTED TO ACHIEVE BY
THE END OF THE YEAR IN WHICH THE IEP IS IN EFFECT

SCHEDULE
WHEN PROGRESS WILL BE
MEASURED

1. Eric will be able to answer five grade-level textdependent inference questions.

1. Progress will be
checked by the end of
the year, and checked
every ten weeks over a
two week period.

2. Eric will be able to successfully decode at least 10

unfamiliar words in a grade-level text.

2. Progress will be
checked by the end of
the year, and checked
every ten weeks over a
four week period.

3. Eric will be able to construct a written paragraph that

includes three relevant details of a grade level text.

3. Progress will be
checked by the end of
the year, and checked
every ten weeks over a
two week period.

METHOD & CONDITION

HOW PROGRESS WILL BE
MEASURED

CRITERIA
MEASURE TO DETERMINE IF
GOAL HAS BEEN ACHIEVED

1. 4 out of 5 times.
1. Using a concept map
and a grade-level text.

2. 4 out of 5 times.
3. 4 out of 5 times.

2. Using his preferred

decoding strategy from
an approved list.
3. Using a word
processing device.

SHORT-TERM INSTRUCTIONAL OBJECTIVES AND/OR BENCHMARKS (INTERMEDIATE STEPS BETWEEN THE STUDENT'S PRESENT
LEVEL OF PERFORMANCE AND THE MEASURABLE ANNUAL GOAL):
ANNUAL GOAL 1
By the end of the year, Eric will be able to answer five grade-level text-dependent inference questions, based on a grade-level informational text, using a
concept map, at least 4 out of 5 times over the course of a two week period.
District 75
400 First Avenue, New York, New York, 10010

BENCHMARK GOAL
Eric will answer 2 text-dependent
inference questions, based on a
grade-level informational text.
Eric will answer 3 text-dependent
inference questions, based on a
grade-level informational text.
Eric will answer 4 text-dependent
inference questions, based on a
grade-level informational text.

SCHEDULE
Progress will be measured the over
the last two weeks of marking
period 1.
Progress will be measured the over
the last two weeks of marking
period 2.
Progress will be measured the over
the last two weeks of marking
period 3.

METHOD & CONDITION

Using a concept map and a gradelevel text.

CRITERIA
4 out of 5 times

Using a concept map and a gradelevel text.

4 out of 5 times

Using a concept map and a gradelevel text.

4 out of 5 times

ANNUAL GOAL 2
By the end of the year, Eric will be able to successfully decode at least 10 unfamiliar words in a grade-level text, using his preferred decoding strategy
from an approved list, over the course of a 4-week period, 4 out of 5 times.
BENCHMARK GOAL
Eric will be able to successfully
decode at least 2 unfamiliar words
in a grade-level text.
Eric will be able to successfully
decode at least 4 unfamiliar words
in a grade-level text.
Eric will be able to successfully
decode at least 7 unfamiliar words
in a grade-level text.

SCHEDULE
Progress will be monitored the over
the course of the last 4 weeks of
marking period 1.
Progress will be monitored the over
the course of the last 4 weeks of
marking period 2.
Progress will be monitored the over
the course of the last 4 weeks of
marking period 3.

METHOD & CONDITION

Using his preferred decoding
strategy from an approved list.

CRITERIA
4 out of 5 times.

Using his preferred decoding

strategy from an approved list.

4 out of 5 times.

Using his preferred decoding

strategy from an approved list.

4 out of 5 times.

ANNUAL GOAL 3
By the end of the year, Eric will be able to construct a written paragraph that includes three relevant details of a grade level text, using a word processing
device, with a success rate of at least 4 out of 5 times over a 2 week period.
BENCHMARK GOAL
Eric will be able to construct a
written paragraph that includes

SCHEDULE
Progress will be monitored the over
the course of the last 2 weeks of

METHOD & CONDITION

Using a word processing device

District 75
400 First Avenue, New York, New York, 10010

CRITERIA
At least 1 out of 5 times.

three relevant details of a grade

level text.
Eric will be able to construct a
written paragraph that includes
three relevant details of a grade
level text.
Eric will be able to construct a
written paragraph that includes
three relevant details of a grade
level text.

marking period 1.
Progress will be monitored the over
the course of the last 2 weeks of
marking period 2.

Using a word processing device

At least 2 out of 5 times.

Progress will be monitored the over

the course of the last 2 weeks of
marking period 3.

Using a word processing device

At least 3 out of 5 times.

REPORTING PROGRESS TO PARENTS

Identify when periodic reports on the student's progress toward meeting the annual goals will be provided to the students parents:
8 times a year: 4 mid-marking period, and 4 quarterly marking period
STUDENT NAME:

NYC ID:
RECOMMENDED SPECIAL EDUCATION PROGRAMS AND SERVICES

SPECIAL EDUCATION
PROGRAM/SERVICES

SERVICE DELIVERY
RECOMMENDATIONS*

FREQUENCY
HOW OFTEN
PROVIDED

DURATION
LENGTH OF SESSION

LOCATION
WHERE SERVICE WILL BE
PROVIDED

PROJECTED
BEGINNING /
SERVICE
DATE(S)

SPECIAL EDUCATION PROGRAM:

ICT- INTEGRATED
COTEACHING IN
ENGLISH AND SOCIAL
STUDIES
20:2

5 TIMES PER
WEEK PER
COTAUGHT
CLASS
(10X/WEEK)
TOTAL

45 MINUTE SESSIONS

ENGLISH AND SOCIAL

STUDIES CLASSROOM

9/1/15

RELATED SERVICES:

SPEECH

2X WEEK

45 MINUTE SESSIONS

GENERAL EDUCATION
CLASSROOM

9/1/15

SUPPLEMENTARY AIDS AND

SERVICES/PROGRAM

TAPED LECTURES,
AUDIO VERSIONS OF

AS NEEDED

AS NEEDED

District 75
400 First Avenue, New York, New York, 10010

GENERAL EDUCATION
CLASSROOM

9/1/15

RECOMMENDED SPECIAL EDUCATION PROGRAMS AND SERVICES

MODIFICATIONS/ACCOMMODATIONS:

TEXT, SCAFFOLDED
COOPERATIVE
LEARNING
OPPORTUNITIES (PEER
SUPPORTS),
PRETEACHING OF
VOCABULARY,

ASSISTIVE TECHNOLOGY DEVICES

AND/OR SERVICES:

ACCESS TO IPAD OR
WORD PROCESSOR

ALL CLASSES
ALL DAYS
1.

1.CO-PLANNING TIME
2. ASSITIVE TECH
SUPPORTS FOR SCHOOL PERSONNEL ON TRAINING
BEHALF OF THE STUDENT:
3.FLIPPPED CLASSROOM
PD

2.
3.

5 TIMES
A WEEK
PER
CLASS
AS
NEEDED
AS
NEEDED

ALL DAY

1.
2.
3.

MINUTES
VARIABLE
VARIABLE

GENERAL EDUCATION
CLASSROOM AND AT
HOME

9/1/15

VARIABLE

9/1/15

* Identify, if applicable, class size (maximum student-to-staff ratio), language if other than English, group or individual services, direct and/or indirect
consultant teacher services or other service delivery recommendations.
SKIP THIS

NYC ID:

12-MONTH SERVICE AND/OR PROGRAM - Student is eligible to receive special education services and/or program during July/August:
Yes

No

If yes:
Student will receive the same special education program/services as recommended above.
OR
Student will receive the following special education program/services:

District 75
400 First Avenue, New York, New York, 10010

SPECIAL EDUCATION
PROGRAM/SERVICES

SERVICE DELIVERY
RECOMMENDATIONS

FREQUENCY

DURATION

LOCATION

PROJECTED
BEGINNING /
SERVICE
DATE(S)

Location

Projected
Beginning /
Service Date(s)

Name of school/agency provider of services during July and August:

For a preschool student, reason(s) the child requires services during July and August:

Special Education Program/services

Service Delivery
Recommendations

Frequency

Duration

Name of school/agency provider of services during July and August:

For a preschool student, reason(s) the child requires services during July and August:
PROVIDE A LIST OF TESTING AND OTHER ACCOMMODATIONS THAT THIS CHILD SHOULD HAVE

NYC ID:

TESTING ACCOMMODATIONS (TO BE COMPLETED FOR PRESCHOOL CHILDREN ONLY IF THERE IS AN ASSESSMENT PROGRAM FOR NONDISABLED
PRESCHOOL CHILDREN): INDIVIDUAL TESTING ACCOMMODATIONS, SPECIFIC TO THE STUDENTS DISABILITY AND NEEDS, TO BE USED CONSISTENTLY BY
THE STUDENT IN THE RECOMMENDED EDUCATIONAL PROGRAM AND IN THE ADMINISTRATION OF DISTRICT-WIDE ASSESSMENTS OF STUDENT
ACHIEVEMENT AND, IN ACCORDANCE WITH DEPARTMENT POLICY, STATE ASSESSMENTS OF STUDENT ACHIEVEMENT.
TESTING ACCOMMODATIONS

1.
2.
3.
4.

CONDITIONS*

IMPLEMENTATION RECOMMENDATIONS**

Tests read aloud

Condition: All tests
Implementation Recommendations: 2 times
Access to word processing device
Condition: Tests with writing components Implementation Recommendations: as needed
Extended Time
Condition: All Tests
Implementation Recommendation: double times
Tests Administered in a quiet location Condition: All tests Implementation Recommendation: room with low-level distraction

District 75
400 First Avenue, New York, New York, 10010

TESTING ACCOMMODATIONS (TO BE COMPLETED FOR PRESCHOOL CHILDREN ONLY IF THERE IS AN ASSESSMENT PROGRAM FOR NONDISABLED
PRESCHOOL CHILDREN): INDIVIDUAL TESTING ACCOMMODATIONS, SPECIFIC TO THE STUDENTS DISABILITY AND NEEDS, TO BE USED CONSISTENTLY BY
THE STUDENT IN THE RECOMMENDED EDUCATIONAL PROGRAM AND IN THE ADMINISTRATION OF DISTRICT-WIDE ASSESSMENTS OF STUDENT
ACHIEVEMENT AND, IN ACCORDANCE WITH DEPARTMENT POLICY, STATE ASSESSMENTS OF STUDENT ACHIEVEMENT.

*Conditions Test Characteristics: Describe the type, length, purpose of the test upon which the use of testing accommodations is conditioned, if
applicable.
**Implementation Recommendations: Identify the amount of extended time, type of setting, etc., specific to the testing accommodations, if applicable.
FILL OUT IF APPROPRIATE

NYC ID:

BEGINNING NOT LATER THAN THE FIRST IEP TO BE IN EFFECT WHEN THE STUDENT IS AGE 15 (AND AT A YOUNGER AGE, IF DETERMINED APPROPRIATE).
COORDINATED SET OF TRANSITION ACTIVITIES
NEEDED ACTIVITIES TO FACILITATE THE
STUDENTS MOVEMENT FROM SCHOOL TO
POST-SCHOOL ACTIVITIES

Instruction

SERVICE/ACTIVITY

Robotics Class

Elective
Related Services

SCHOOL DISTRICT/AGENCY RESPONSIBLE

Home School building

none
Community Experiences
Club opportunities

Development of Employment and Other Postschool Adult Living Objectives

Career-oriented internship

Robotics Club

Robotics Internship

District 75
400 First Avenue, New York, New York, 10010

Local University Chapter

Local Engineering Firm

BEGINNING NOT LATER THAN THE FIRST IEP TO BE IN EFFECT WHEN THE STUDENT IS AGE 15 (AND AT A YOUNGER AGE, IF DETERMINED APPROPRIATE).
COORDINATED SET OF TRANSITION ACTIVITIES
NEEDED ACTIVITIES TO FACILITATE THE
STUDENTS MOVEMENT FROM SCHOOL TO
POST-SCHOOL ACTIVITIES

SERVICE/ACTIVITY

SCHOOL DISTRICT/AGENCY RESPONSIBLE

Acquisition of Daily Living Skills (if applicable)

n/a
Functional Vocational Assessment (if applicable) n/a

ASSUME THIS CHILD WILL PARTICIPATE IN ASSESSMENTS

NYC ID:

PARTICIPATION IN STATE AND DISTRICT-WIDE ASSESSMENTS

(TO BE COMPLETED FOR PRESCHOOL STUDENTS ONLY IF THERE IS AN ASSESSMENT PROGRAM FOR NONDISABLED PRESCHOOL STUDENTS)

xThe student will participate in the same State and district-wide assessments of student achievement that are administered to general education
students.
The student will participate in an alternate assessment on a particular State or district-wide assessment of student achievement.
Identify the alternate assessment:
Statement of why the student cannot participate in the regular assessment and why the particular alternate assessment selected is appropriate for the student:

ASSUME AN INCLUSIVE PLACEMENT

NYC ID:

District 75
400 First Avenue, New York, New York, 10010

PARTICIPATION WITH STUDENTS WITHOUT DISABILITIES

REMOVAL FROM THE GENERAL EDUCATION ENVIRONMENT OCCURS ONLY WHEN THE NATURE OR SEVERITY OF THE DISABILITY IS
SUCH THAT, EVEN WITH THE USE OF SUPPLEMENTARY AIDS AND SERVICES, EDUCATION CANNOT BE SATISFACTORILY ACHIEVED.
FOR THE PRESCHOOL STUDENT:
Explain the extent, if any, to which the student will not participate in appropriate activities with age-appropriate nondisabled peers (e.g., percent of the
school day and/or specify particular activities):
FOR THE SCHOOL-AGE STUDENT:
Explain the extent, if any, to which the student will not participate in regular class, extracurricular and other nonacademic activities (e.g., percent of the
school day and/or specify particular activities): n/a Student is in gen. ed. 100% of the time

If the student is not participating in a regular physical education program, identify the extent to which the student will participate in specially-designed
instruction in physical education, including adapted physical education: n/a

EXEMPTION FROM LANGUAGE OTHER THAN ENGLISH DIPLOMA REQUIREMENT:

No xYes - The Committee has determined that the student's disability adversely affects his/her ability to learn a language and recommends the student
be exempt from the language other than English requirement.

FILL OUT ONLY IF APPROPRIATE

NYC ID:

District 75
400 First Avenue, New York, New York, 10010

SPECIAL TRANSPORTATION
TRANSPORTATION RECOMMENDATION TO ADDRESS NEEDS OF THE STUDENT RELATING TO HIS/HER DISABILITY

xNone
Student needs Special Transportations Accommodations/Services as follows:
TRANSPORTATION ACCOMMODATIONS

TRANSPORTATION SPECIFIC ACCOMMODATIONS

PLACEMENT RECOMMENDATION

Placement Recommendation:
Non-Public School

Day

Residential

District 75
400 First Avenue, New York, New York, 10010

SUMMARY
STUDENT INFORMATION
Student Name: Eric Holder
NYC ID:
DOB:
Gender: Made
Parents Language(s) Spoken/Mode Communication:
IEP INFORMATION
Date of IEP Meeting: 2/03/15
IEP Amendment:

Yes xNo

Reconvene of IEP Meeting:

Yes xNo

SUMMARY OF RECOMMENDATIONS
Classification of Disability: Visual Perceptual/Visual Motor Deficit (Dysgraphia and Dyslexia)
Defer to CBST:
Recommended Services: Co-taught classes, speech
Special Education Programs
Related Services
12-Month Services: no
Special Education Programs
Related Services

The student will participate in the same State and district-wide assessments of student achievement that are administered to general education students.
The student will participate in an alternate assessment on a particular State or district-wide assessment of student achievement
Alternate assessment:

District 75
400 First Avenue, New York, New York, 10010

If there is a no provider available in this language, service is recommend in English pending availability of a bilingual provider:
The student should be placed in an interim monolingual class:
Recommended for:

No

without bilingual paraprofessional?

ESL Only xNot recommended for ESL/Bilingual

Does have a Behavioral Intervention Plan?

Yes xNo

Recommended for Specialized Transportation: xNone

School Type:
Medical Alert: The student has
The student requires

with bilingual paraprofessional?

Yes

Student needs specialized transportation

medical conditions and/or

medical and/or

physical limitations which affect {.his,her}

learning,

behavior and/or

participation in school activities.

health care treatment(s) or procedure(s) during the school day.

PROMOTION CRITERIA
Current Year

xStandard
Modified :
xEnglish Language Arts ("ELA") must meet % of the grade Standards
must be mastered as evidenced by student work, teacher observation,
assessments/grades, and attendance.

xMath must meet % of the grade Standards must be mastered as evidenced

by student work, teacher observation, assessments/grades, and attendance.

Next Year

xStandard
Modified :
xEnglish Language Arts ("ELA") must meet % of the grade Standards
must be mastered as evidenced by student work, teacher observation,
assessments/grades, and attendance.

xMath must meet % of the grade Standards must be mastered as evidenced

by student work, teacher observation, assessments/grades, and attendance.

Parent Concerns:
Parents are concerned that Eric is unable to work to full potential due to difficulties in reading and writing in multiple subject areas.

District 75
400 First Avenue, New York, New York, 10010

OTHER PROGRAMS CONSIDERED

X General Education
Related Service Only
X Special Education Teacher Support Services [SETSS]
Integrated Co-Teaching Services
Special Class in a Community School
Special Education Teacher Support Services [SETSS] Provided by a Specialized School
Special Class in a Specialized School
Special Class in a Specialized School [Deaf/Hard of Hearing]
Special Class in a Specialized School [Visual Impairment]
Home Instruction
Other Please Specify:

Reason for Rejection:

District 75
400 First Avenue, New York, New York, 10010

NYC ID:

YOU DID IT!!!

District 75
400 First Avenue, New York, New York, 10010