XC:
LaSalle/Putnam County Educational Alliance for Special Education 1009 Boyce Memorial Drive
Ottawa, IL. 61350
PHONE/TDD: (815) 433-6433
FAX: (815) 433-6164 Email:
[email protected]
INDIVIDUAL SERVICES PLAN REPORT Name of Student
Last
First
Middle
Birthdate
Age
Name of Parent/Guardian
Relationship
Date of Meeting
Present Grade
Address
Phone Number
District of Residence
District Responsible for Services
Address
Phone Number
School Attending
PURPOSE OF CONFERENCE
Change District of Responsibility
Initial Eligibility Determination
Develop Initial ISP
Re-evaluation
Annual ISP Review
To Consider Continuation of Services
Educational Setting Change
To Consider Change of Services
Program Services Change
To Consider Termination of Services
Transition Planning Graduation Transfer IEP to ISP
Manifestation Determination Other (Specify)
Disability Requiring Special Education Primary: Secondary: Secondary: From Eligibility Determination Dated: (If eligibility is being determined, complete at end of the Determination)
LANGUAGE (Information available from referral)
Language(s) spoken in the home:
Language(s) used by child:
Cultural background:
Language used for evaluation:
Interpreter for parent communication:
Yes
No
Mode of Communication used by student: Special Education Services: IF THE STUDENT WILL BE RECEIVING SPECIAL EDUCATION SERVICES, COMPLETE THE FOLLOWING SECTIONS AT THE END OF THE CONFERENCE. Special Ed/L.R.E. Setting(s): Case Manager(s): Location: (*FOR DISTRICT COMPLETION) SPECIAL EDUCATION FUNDING AND CHILD TRACKING SYSTEM (FACTS) (See codes on reverse side) (1) (2) *ETHNIC (3) *LANGUAGE (4) *RELATED & OTHER SERVICES (5) (6) *SEX ORIGIN -Primary *TERM *BEGIN DATE
(FOR L.E.A.S.E. OFFICE USE ONLY) (7) FUND (8) DISABILITIES (MAX OF 2)
(9) EE
(10) RBP
(11) SECTION 14-7.03 ELIG T P G
(Cover Page) Individual Services Plan (ISP) Forms for Private/Parochial Students
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Student
Date
GENERAL CONSIDERATION IN THE DEVELOPMENT OF THE ISP PARENTAL VISION/EDUCATIONAL CONCERNS
STUDENT STRENGTHS
State how the disability affects the student’s involvement and progress in the general curriculum or for preschool children, as appropriate, how the disability affects the child’s participation in appropriate activities. This should reflect the adverse effects identified in the student’s most recent evaluation and eligibility determination.
RESULTS OF RECENT ASSESSMENT DATA/PROGRESS INFORMATION
CONSIDERATIONS OF SPECIAL FACTORS Check the boxes to indicate if the student requires a particular device or service due to special factors. Medication/Medical Information:
YES
YES
NO
DATE Glasses
Vision Screening:
Hearing Aides
Hearing Screening:
PASSED
FAILED
NO Assistive Technology Devices & Services Blind/Visually Impaired-Braille Instruction Deaf/Hearing Impaired Language/Communication Needs Limited English Proficiency-Language/Communication Needs Behavior-Positive Interventions/Supports/Strategies Supports for school personnel
For boxes checked “yes”, specify device and/or services required. Include any related services indicated as part of the educational services. If a Functional Assessment or Behavioral Intervention Plan is developed, attach completed forms.
[PAGE S-1]
Save Individual Services Plan (ISP) Forms for Private/Parochial Students
Student
Date
SUPPLEMENTARY AIDS AND SERVICES/PROGRAM ACCOMODATIONS Document the supplementary aids and services and/or program accommodations that the student requires to participate in regular education classes and activities with non-disabled peers: A. Instruction
D. Self-Management
B. Materials
E. Testing
C. Grading
F. Communication
Intermittent services necessary in order to meet the student’s educational/health needs such as vision/hearing screenings, diagnostic testing with prior parental consents as required, social service/crisis intervention, etc. will be provided on an as-needed basis.
STATE AND DISTRICT-WIDE ASSESSMENTS State
District Participate in the entire State assessment with no accommodations Participate in the entire State assessment with accommodations Participate in part(s) of the State assessment; Specify components: Participate in the State Alternate Assessment
Participate in the entire district wide assessment with no accommodations Participate in the entire district wide assessment with accommodations Participate in part(s) of the district wide assessment; specify components: Not Participate in the District Wide Assessment
If the student is completing the assessment(s) with accommodations, specify the needed accommodations below. If there are differences in subjects, specify test next to the accommodation. Extended time; Subject Alternate setting, Subject Tests presented orally; Subject Instructions in other modes; Subject Use of tests in large print or Braille; Subject
Use of audiocassette for directions; Subject Assistive devices; Subject Assistance w/writing; Subject Other; Subject
If the student will not participate in part or all of the assessment(s), specify why the assessment is not appropriate: State:
District:
Document the alternate assessment to be given: Illinois Alternate Assessment
District: (Options might include: portfolio, goal attainment, CBM’s standardized individual achievement.)
Additional Considerations:
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[PAGE S-2] Individual Services Plan (ISP) Forms for Private/Parochial Students
ANNUAL GOALS AND BENCHMARKS/OBJECTIVES
Student Name
METHOD/SETTING
Goal
Date of Birth
TITLE of IMPLEMENTOR(S)
Regular Education Consultation Direct Sp. Ed. Service Other
ISP Date
Present Level of Performance
Peer Performance/Learning Standard
Measurable Annual Goal
How will Progress be Measured?
checklist
curriculum-based measure
structured observation
rubric
log/journal
Other
Benchmark/Objective #1
Benchmark/Objective #3
Benchmark/Objective #2
Benchmark Objective #4
Progress Report Statement to Parents
portfolio
Date:
Comments:
is is not moving at a pace to reach the annual goal Progress Report Statement to Parents Date: Comments:
is is not moving at a pace to reach the annual goal Progress Report Statement to Parents Date: Comments:
is is not moving at a pace to reach the annual goal Progress Report Statement to Parents Date: Comments:
is
is not moving at a pace to reach the annual goal [PAGE S-3] Individual Services Plan (ISP) Forms for Private/Parochial Students
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Name of Student:
Date: Educational Services Current Program
Areas of Participation
Sp Ed MPW In In RegEd SpEd
Begin Date
Future Program End Date
Sp Ed MPW In In RegEd SpEd
Begin Date
End Date
Location/Frequency Comments
Related Services
CP
FP
Total Special Ed Minutes/Week:
CP
FP
Instructional Minutes:
MPW Provided just in SpEd Setting:
CP
FP
% of Time Receiving SpEd Services:
Bell to Bell Minutes:
% Used to Determine LRE (EE):
Transportation Requirements If special transportation is required, indicate the:
Is special assistance required?
Type:
Type:
Provider:
□
Yes
□
No
Provider:
Special Education Placement
The placement shall be appropriate to the student’s needs and least restrictive of the student’s interaction with non-disabled children, based on the student’s I.E.P. and located as close as possible to the student’s home, unless the I.E.P. requires some other arrangement, in the school he/she would attend if not disabled; and consistent with the findings of the case study evaluation. When determining the placement, consider any potentially harmful effect, either on the student or the quality of services that he/she needs. Accept
Reject
□ □ □ □ □ □ □ □ □
□ □ □ □ □ □ □ □ □
Reasons Placement Options Were Rejected Regular Education Regular Education with Modifications Regular Education with Speech/Language Services Resource (Sp. Ed. less than 50% of day)
□ Monitor □ Itinerant Self-Contained (Sp. Ed. more than 50% of day) Private/Public Day Residential Other:
Extended School Year Type:
□
Yes
□
No
Extended school year services are needed. If yes, the I.S.P. must indicate the: Amount of Service: Duration:
[PAGE S-4]
Save Individual Services Plan (ISP) Forms for Private/Parochial Students
Student
Date
ISP Participants Signature indicates attendance Agree
NAME/TITLE
Disagree
Date
Date
NAME/TITLE
Parent/Guardian
Principal/LEA Representative
Parent/Guardian
School Psychologist
Student
School Social Worker
Regular Education Teacher
Director/Coordinator
Regular Education Teacher
Private School Representative
Special Education Teacher
Other
Speech-Language Pathologist
Other
Special Education Teacher
Other
Agree
Disagree
Date
Date
Participants must check agree/disagree boxes for L.D. eligibility only. Any participant who disagrees with the teams’ decision must submit a separate statement to include in the student’s record presenting his/her conclusions.
Yes
No
Yes
No
Explanation of Procedural Safeguards was provided to the parents with the notice of the conference. Date Mailed Parents given copy of Conference Summary.
Yes
No
Parents given copy of the district’s behavioral intervention policies.
Yes
NA
Parents given copy of the district’s behavioral intervention procedures (Initial ISP only)
Yes
No
I agree to waive the requirement of a ten (10) calendar day interval before implementation of this ISP.
PARENT/GUARDIAN CONTACTS MADE: Date
(To be completed if parent/guardian is not present) Type
[Signature Page] Individual Services Plan (ISP) Forms for Private/Parochial Students
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