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:

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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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