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School Age
Students Name:
Bic Mitchum
10-13-2015
IEP Implementation Date (Projected Date when Services and Programs Will Begin):
Anticipated Duration of Services and Programs:
Date of Birth:
Age:
Grade:
10-14-2015
10-13-2016
5-25-2000
15 Yrs. 4 Mos.
9th
2019
Mastery Charter School-Gratz Campus
Philadelphia County
Phone (Home):
215-800-0000
Phone (Work):
610-555-5555
Other Information:
The LEA and parent have agreed to make the following changes to the IEP without convening an IEP meeting, as documented by:
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April 2014
Date of Revision(s)
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Participants/Roles
April 2014
Printed Name
Signature
Parent/Guardian/Surrogate
Gillette Mitchum
Gillette Mitchum
Student*
Bic Mitchum
Bic Mitchum
Christine Rock
Christine Rock
Jennifer Cooper
Jennifer Cooper
Phillip Smith
Philip Smith
Maggie Gleason
Maggie Gleason
Parent/Guardian/Surrogate
Career/Tech Ed Rep***
Community Agency Rep
Teacher of the Gifted****
Speech & Language Therapist
*
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:
Colin Bussisere-Nichols: Algebra 1
Christopher Irving: Leveled Literacy
April 2014
I have received a copy of the Procedural Safeguards Notice during this school year. The Procedural Safeguards Notice provides information about my rights,
including the process for disagreeing with the IEP. The school has informed me whom I may contact if I need more information.
Signature of Parent/Guardian/Surrogate:
Gillette Mitchum
April 2014
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April 2014
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 students reading and writing skills, needs, and appropriate reading and writing media (including an
evaluation of the students 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
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 students language and communication mode; academic
level; full range of needs, including opportunities for direct instruction in the students 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
Yes
Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction (SDI), annual goals, etc.)
No
Student needs must be addressed in the IEP (i.e., present levels, specially designed instruction, annual goals, etc.)
No
April 2014
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The IEP team must address the students language needs and how those needs relate to the IEP.
No
April 2014
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):
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April 2014
April 2014
a series of benchmark
Performance Level
Below Basic
Below Basic
Below Basic
Below Basic
*Benchmark testing for RP1 2015, has not yet been administered to Bic. Benchmark
testing begins October 21,2015
CURRENT GRADES
*African-American History
Algebra 99 %
Leveled Literacy Intervention 95%
Corrective Reading 98%
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April 2014
MATH: Bic will answer 33 or more digits correctly in 2 out of 3 trials to equate to a beginning
of 5th grade level equivalency in his math computation skills, as measured by Computation
Digits Correct given three times per report period. These computation areas include: Division,
Multiplication, Addition and Subtraction of Fractions. Baseline: On the fourth grade Basic Math
Computation Digits Correct Test, Bic got 24 digits correct which correlates into a grade
equivalency of the beginning of fourth grade (50th percentile).
UPDATE:
On August 26, 2015 Bic was administered the STAR Math Assessment. Bic's results indicate
that he is working at a 4.6 (Grade Equivalent). Bic's test performance is comparable to that of
an average fourth grader after the sixth month of the school year.
TEACHER INPUT
Colin Bussiere-Nichols (Algebra 1):
Mr. Bussiere-Nichols completed a Teacher Input Form for Bic on 10/7/15. According to Mr.
Bussiere-Nichols, Bic is currently passing Algebra 1 with a 98%. Mr.Bussiere-Nichols shared
that Bic is well behaved in class and is "always happy". Mr. Bussiere-Nichols added that "Bic is
one of the hardest working students I have ever seen". Mr. Bussiere-Nichols also shared that
Bic completes his homework, classwork and independent work in on time daily.
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April 2014
SPEECH: Bic will improve articulation skills and increase his speech intelligibility by appropriately
producing /r/, /r/-blends, and /l/-blends in all positions (i.e. initial, medial, and final) of single
words, phrases, sentences, in reading, and conversation with 80% accuracy across 3 targeted
therapy sessions. Baseline: Bic is able to produce the /r/ sound in single words with 50% accuracy.
UPDATE:
Bic attends small group speech therapy sessions, where he works on improving the articulation of
his target sounds, which are /r/, /r-blends/ and /l-blends/.
In regards to his articulation skills, Bic has made significant improvements towards his goal during
this past IEP term. Per his progress reporting results from Report Period 4 of last school year, Bic
has mastered the articulation of the /r/ phoneme in all positions at the word level. During a
structured
task, at the sentence level, Bic is articulating the /r/ phoneme in the initial position with 100%
accuracy. However, his accuracy decreases to 45% when the /r/ is in the medial and final position
of words at the sentence level. He requires cues to utilize correct tongue positioning consistently
when attempting to co-articulate the /r/ sound with other sounds within a sentence. He has also
made significant improvement with his articulation of /r-blends/ and /l-blends/ at the structured
sentence level as well, especially during a reading task. He is able to articulate /r-blends/ and /lblends/ at the sentence level with 84%, but can be inconsistent with this at times. It is
recommended that Bic continue to work on his articulation of /r/, /r-blends/ and /1-blends/, at the
single sentence to conversational level with emphasis placed on self-monitoring and selfcorrection of his articulation in order to increase his awareness of his speech and improve overall
intelligibility.
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April 2014
Post-Secondary Education
Bic shared that after high school he would like to attend a 4 year college or university. Bic
acknowledged that he needs to improve his overall reading, math and speech/language to gain
entry into college.
Employment
Bic shared that he would like to work in the field of technology. According to Bic he would like to
research jobs in the area of technology and work on learning how to write a resume to better
assist him in obtaining gainful employment.
Independent Living
In regards to independent living, Bic shared he would like to live independently after graduating
college. An independent living goal is not appropriate at this time.
Areas of need in regards to obtaining employment and continuing education after the completion
of high
school are:
*Increase his basic academic skills and speech
*Increase knowledge about various job fields as related to Bic's interests and increase skills
related to these jobs as appropriate.
*Bic research various jobs in technology outlining salaries, degree/certificates needed, and other
job qualifications.
At this time, no outside agencies are being utilized to assist Bic in his transition goals.
TEACHER INPUT
Christopher Irving (Leveled Literacy):
Mr. Irving completed a Teacher Input Form for Bic on 10/7/15. According to Mr. Irving "Bic always
follows directions and is very cooperative. He seems eager to participate in small group
discussions and helps others regularly. Academically Mr. Irving added that Bic excels at talking
about his reading, and it appears that Bic is thinking about what he has read. In addition, Bic
seems to struggle with reading accuracy and fluency. Mr. Irving also added that Bic works well
independently, in small groups and has good organizational skills. However, Bic does not turn in
his homework assignments on time.
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April 2014
How the students disability affects involvement and progress in the general education curriculum:
Bics diagnosis of Specific Learning Disability affects his involvement in the general education
curriculum. Bic requires small group speech and language intervention to remediate his deficits.
Bic receives a 30 minute session once a week in a small group setting with a Speech Therapist as
well as reading support through a school wide reading intervention program. Bic also participates
in a Math Intervention program daily. Bic participates with the support of specially designed
instruction, accommodations, and curricular modifications in all other subjects with his nondisabled peers.
Strengths
-Respectful
-Potential to participate in class discussions
-Cooperative and willing to work hard/participate
-Positive
-Timed tasks
-Memory tasks with visual cues
-Basic Math calculation and word problem skills
April 2014
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 students 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 students 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 students needs taking into account the students strengths, preferences, and interests.
POST SCHOOL GOALS Based on age appropriate assessment, define and project the appropriate measurable postsecondary goals that address education
and training, employment, and as needed, independent living. Under each area, list the services/activities and courses of study that support that goal.
Include for each service/activity the location, frequency, projected beginning date, anticipated duration, and person/agency responsible.
For students in Career and Technology Centers, CIP Code:
No CIP code is needed
10/12/2015 - 10/11/2016
Algebra 1, Math Foundations, AA History, Corrective Reading, Leveled Literacy, Art, Freshman Seminar
Service/Activity
Location
Frequency
Projected Beginning
Date
Anticipated
Duration
Person(s)/Agency
Responsible
Regular Education
Classroom
daily
10/12/2015
10/11/2016
Special Education
/ Regular Education
Teacher
Regular Education
Classroom
10/12/2015
10/11/2016
Special Education
/ Regular Education
Teacher
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April 2014
Special Education
Classroom
Special
Education/Regular
Education Classroom
Gymnasium
weekly
10/12/2015
10/11/2016
Speech Therapist
daily
10/12/2015
10/11/2016
Regular
Education/Special
Education Teacher
10/12/2015
10/11/2016
Case Manager
Employment Goal:
10/12/2015 - 10/11/2016
Algebra 1, Math Foundations, AA History, Corrective Reading, Leveled Literacy, Art, Freshman Seminar
Service/Activity
Location
Frequency
Projected Beginning
Date
Anticipated
Duration
Person(s)/Agency
Responsible
Regular
Education/Special
Education Classroom
daily
10/12/2015
10/11/2016
Classroom teacher
Regular
Education/Special
Education Classroom
daily
10/12/2015
10/11/2016
Regular
Education/Special
Education Teacher
Special Education
Classroom
10/12/2015
10/11/2016
Case Manager
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April 2014
Special Education
Classroom
10/12/2015
10/11/2016
Case Manager
Special Education
Classroom
10/12/2015
10/11/2016
Case Manager
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April 2014
Bic has a goal of living independently after he graduates high school. Bic will about obtain this goal with little
assistance.
Service/Activity
Location
Frequency
Projected Beginning
Date
Anticipated
Duration
Person(s)/Agency
Responsible
Regular
Education/Special
Education Classroom
daily
10/12/2015
10/11/2016
Regular
Education/Special
Education Teacher
Special Education
Classroom
10/12/2015
10/11/2016
Case Manager
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April 2014
Math
Science
Reading
Writing
ELA*
*ELA will replace the Reading and Writing PSSAs in 2014-15 for grades 3-8.
Keystone Exam (Replaces the 11th grade PSSA in high school; Student must participate by 11 th grade)
Tested Subject Without Accommodations
With Accommodations
Accommodations to be Provided
Extended time
Algebra 1
X
Small-group setting
Read aloud test directions and requested test items
Refocusing prompts
Simplified directions
Literature
X
Extended time
Small-group setting
Simplified directions
Read aloud test directions and requested test items
Refocusing prompts
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April 2014
Written narrative notes (requires prior approval in accordance with PDE guidance)
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April 2014
Domains
With Accommodations Unable to Participate Accommodations to be Provided or Rationale for Inability to
Participate in Selected Domains
Listening
Reading
Writing
Speaking
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:
Without Accommodations
Listening
Reading
Writing
Speaking
Domains
With Accommodations Unable to Participate Accommodations to be Provided or Rationale for Inability to
Participate in Selected Domains
Local Assessments
Local assessment is not administered at this students grade level; OR
Student will participate in local assessments without accommodations; OR
X
-- Extended time
-- Small-group setting
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April 2014
Standardized or Norm
Reference Tests
Criterion-Referenced
Tests
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Report of Progress
April 2014
SHORT TERM OBJECTIVES Required for students with disabilities who take alternate assessments aligned to alternate achievement standards (PASA).
Short term objectives / Benchmarks
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April 2014
Location
Frequency
Anticipated Duration
daily
10/14/15
10/13/16
weekly
10/14/15
10/13/16
Due to Bics
communication needs he
will be given visual,
auditory, kinesthetic cues,
modeling, sound drills and
speech games along with
self-monitoring.
Speech Support
Classroom
daily
10/14/15
daily
10/14/15
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10/13/16
10/13/16
April 2014
10/14/15
Math Class
10/13/16
daily
B. RELATED SERVICES List the services that the student needs in order to benefit from his/her special education program.
Service
Location
Frequency
Anticipated Duration
C. SUPPORTS FOR SCHOOL PERSONNEL List the staff to receive the supports and the supports needed to implement the students IEP.
School Personnel to
Receive Support
School Staff
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Support
Location
On-going
communication
between parent and Across All Settings
Mastery Charter
School.
Frequency
Projected Beginning
Date
Anticipated Duration
weekly
10/14/15
10/13/16
April 2014
Case Manager
Regular Education
Teacher
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On-going
communication
between parent and
All Major and Minor
Mastery Charter
Subject Areas
School's special
education
department.
daily
10/14/15
10/13/16
Ongoing support
and communication
between general
education teachers
and special
education
department.
daily
10/14/15
10/13/16
April 2014
Support Service
Not Applicable
Support Service
Not Applicable
Support Service
Not Applicable
E. EXTENDED SCHOOL YEAR (ESY) The IEP team has considered and discussed ESY services, and determined that:
Student IS eligible for ESY based on the following information or data reviewed by the IEP team:
OR
X As of the date of this IEP, student is NOT eligible for ESY based on the following information or data reviewed by the IEP team:
Extended School Year (ESY) services have been discussed and it has been determined that Bic is not eligible for ESY
services because he is able to make progress in the general education curriculum with the support of specially
designed instruction and accommodations and modifications made to the curriculum. Bic's ability to recoup previously
learned information after a period of time away from school is self-sufficient.
The Annual Goals and, when appropriate, Short Term Objectives from this IEP that are to be addressed in the students ESY Program are:
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April 2014
If the IEP team has determined ESY is appropriate, complete the following:
ESY Service to be Provided
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Location
Frequency
Anticipated Duration
April 2014
It is the responsibility of each public agency to ensure that, to the maximum extent appropriate, students with disabilities, including those in public
or private institutions or other care facilities are educated with students who are not disabled. Special classes, separate schooling or other removal of
students with disabilities from the general educational environment occurs only when the nature or severity of the disability is such that education in
general education classes, EVEN WITH the use of supplementary aids and services cannot be achieved satisfactorily.
What supplementary aids and services were considered? What supplementary aids and services were rejected? Explain why the supplementary
aids and services will or will not enable the student to make progress on the goals and objectives (if applicable) in this IEP in the general
education class.
What benefits are provided in the general education class with supplementary aids and services versus the benefits provided in the special
education class?
What potentially beneficial effects and/or harmful effects might be expected on the student with disabilities or the other students in the
class, even with supplementary aids and services?
To what extent, if any, will the student participate with nondisabled peers in extracurricular activities or other nonacademic activities?
Explanation of the extent, if any, to which the student will not participate with students without disabilities in the regular education class:
Bic will not participate with students without disabilities in the general education classroom
when he is receiving speech and language services.
Explanation of the extent, if any, to which the student will not participate with students without disabilities in the general education curriculum:
Bic will not participate when he receives small group speech and language intervention for 30
minutes, once per week and when he has check-ins with his case manager. He participates in
all other general education curriculum classes including research based reading intervention
and math intervention.
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April 2014
Supplemental: Special education supports and services provided by special education personnel for more than 20% of the day but less than
80% of the school day
Full-Time: Special education supports and services provided by special education personnel for 80% or more of the school day
Emotional Support
Learning Support
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April 2014
Physical Support
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April 2014
Is this school the students neighborhood school (i.e., the school the student would attend if he/she did not have an IEP)?
Yes
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April 2014
SECTION A: For Students Educated in Regular School Buildings with Non Disabled Peers Indicate the Percentage of time INSIDE the regular classroom for this student:
Time spent outside the regular classroom receiving services unrelated to the students disability (e.g., time receiving ESL services) should be considered time inside the regular classroom.
Educational time spent in age-appropriate community-based settings that include individuals with and without disabilities, such as college campuses or vocational sites, should be counted as time
spent inside the regular classroom.
Calculation for this Student:
Column 1
Column 2
Calculation
Indicate Percentage
(Column 1 Column 2) x
100 = %
(5/7) x 100
Percentage Category
SECTION B: This section required only for Students Educated OUTSIDE Regular School Buildings for more than 50% of the day select and indicate the Name of School or
Facility on the line corresponding with the appropriate selection: (If a student spends less than 50% of the day in one of these locations, the IEP team must do the calculation
in Section A)
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Column 2
Calculation
Indicate Percentage
Section A: The percentage of time student
spends inside the regular classroom:
Example 1
5.5
6.5
Example 2
(3 5) x 100 = 60%
Example 3
(1 5) x 100 = 20%
For help in understanding this form, an annotated IEP is available on the PaTTAN website at www.pattan.net Type Annotated Forms in the Search feature on the website. If you do not have access
to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215.
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April 2014