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oneotstuen tastes); i, Individual Student General Supervision File Review Checklist 2017-2018 Revised 9-18-2017 Date of Birth Grade _‘D Category of Eligibility Lonay dove LWrgairmnevct te ves (ne) Current Eligibility Report Date ol Current Annual ep Date _41{2i | DOLt Secondary Transition Student Yes (8) Preschool Student Yes Please refer to the directions for additional guidance on eac! reviewed by SAVON Holo lsat FA School Item Yes | No | NA Evaluat n/Eligi ‘Written Notice or Parental Consent for Initial Assessment was obtained prior to 5 administrating assessments or evaluation on initial evaluation. (joes 300.9 and 300.300 AND X 300.503) y 1. Reviewer Comments 1: Documentation of consent for Reevaluation OR reasonable attempts is present for a 2, | 3-year re-evaluation. OR Documentation of written notice for a reevaluation % consisting only of a review of existing new data ita 3008 ané 300.503). Reviewer Comments 2: 2, _ | Elbty was determined bya team (all required participants), including the parent. | T Hi Reviewer Comments 3 ‘2, | Acomprehensive evaluation was conducted and all areas of concern identified on a the Consent for Assessment are reflected in the Eligibility Report. (00 503,13) T Reviewer Comments 4: 5 Eligibility Category Autism Spectrum Disorder Hearing Impairment Specific Learning Disability 1 Deaf-Blindness intellectual Disability ‘PAspeech/Language impairment: Language O Deafness O Multiple Disabilities O Speech/Language Impairment: Speech Be O Developmental Delay Orthopedic impairment. CO Traumatic Brain Injury 1 Emotional Disturbance Other Health Impairment C1 Visual impairment including blindness Evaluations and Assessment show that the student meets the State eligibility criteria for disability category identified wea s00.0a(e\), 300.3061), KX Check box for SLD eligibility and complete SLD checklist, Reviewer Comments 5: Name of Student (Last, First): 6. _ | Eligibility Report appropriately addresses adverse effect. Reviewer Comments 6: 7. __| Eligibility Report appropriately addresses need for specially designed instruction x an Reviewer Comments 7: Limited English Proficiency: A language proficiency score was obtained and appropriate assessments were selected based on the student's level of proficiency. Reviewer Comments 8: Individualized Education Program IEP Team Members in attendance: student (ane ‘when appropriate) (WER 300 32(0)7) and (2003235) Guardian (ioen | Hschoot osriee Administrator or | Teacher (aoeA 30032310141) | Designee 300.s21 aaa) (Woen 300.323/aK2) Peon | pen Education Teacher {W0eA 300323(0)3) Reviewer Comments 9. Comments: |EP includes appropriate Present Levels of Academic Achievement and Functional 10. _| Performance (PLAAFP) and Appropriate corresponding Goal(s). Please see criteria checklist below: Present Level(s) of Academic Achievement and Functional Performance (PLAAFP) and Goal Aligned to tt Each skill area will have a corresponding goal(s). Checked boxes indicate criteria was met: A hay that PLAAFP INA strenath and needs ofthe child (DEA sLesabmny tects otement 3 in generated. fun: _| 0324s (0A 3003208310) Aonual bat Mhsaseine | GLiarested | Ghciteriaor | Drroceaure eg. Ona prove, | Sischedule aay “Blgeterences an (en stator | Levelof ssobserved,ascharted,ona_| weelyy, monthly | acceptable daho 300.324(a)(ii) performance | Performance | rubric 300.320()(3)() 300.320(0)13)) Standard ‘Skill Area. ‘i Sentese | BLstrenath and needs oF the child (loca “$A Disability affects involvement in general ed. Yar, _| sooaaasionn. (nen 3003208) Annwalseat | siesscine | Ttargeted | kcrteraor | Sprocedureeg One probe, Ph schedule—daity, | ChReterencesan ita stitor | tevelof as observed ascharted,ona | week, monthly | acceptable kdaho 3022(0¥8 | performance | Performance | rubrie200 3204131) 300320(18K0) Standard ‘Silane Strength and needs of the child (IDEA ‘BLoisabilty affects involvement in general ed. Math [fovoszaan, (WOEA 360.320(0)4)0) ‘annual 623 NG) aasetine Targeted | Ahcrterisor | (grcedureeg, One probe, | GAgchedulecay, | References on {ea Skitor | Levelof ‘ssobserved, as charted, ona | weeldy, monthly | ‘acceptable Idaho 20022408) _ | performance | periormance | rubric 500.3201096) Seoa20aN3i Standard Sui Area TG Strength and needs ofthe child bex THloistintyartects involvement in generl ed Ftadivey | Socas2aaie, {DEA 300:3204a)(2)0) Romaatest | sLanseine — [tarscted [ipicetere or | Dprocedure eg. On probe, ‘Blschedute—daiy, | G{Reterences an (ea sxitor | Levet of sscbservedaschared,one | weekty, monthly | acceptable tdaho 200328101) performance | Performance | rubric 300391131) 30032011000) Standard Reviewer Comments 10. Comments: Name of Student (Last, First): 14. IEP includes a statement about Written Progress Reports iota 300.320()/340) Reviewer Comments 11: da The IEP includes a description of the special education and related services being provided to the student including: Please see criteria checklist below: Checked boxes indicate criteria was met: Service 1 [special Education and/or Related | GLGie of Professional | Offrequency of ‘ocation | BLstarcdate | Praag vate Deaihiv} Service wer 2000 320/246) Staff Responsible Dea | service 309320(0y7) | 300320(aN7) | 30032040) | 300320(a)7) 3003206}4) Service 2 | c{ special education and/arReated | Rite of Profesional | Sécequency of | ftocation KYsrare date | End date Math | Service ioeas000320(% Staff Responsible 08a | service oa200xn) | 3003204aN7) | 30032019 | 30032097) * so0320(ee) Service 3 | spec téucaton and/or Related | Slate of Professional | lrrequencver | BKtgeation | BZStan date | DfEna date writs Service (IDEA 3000,320(3)(4) ‘Staff Responsible IDEA | service 300.320(a)(7) | 300-320(aX7} | 300.320{aM(7) | 300.3204a)(7) Lang 30032004) Service 4 |-§{ special education and/or Related | Pi Title of Professional Perequency of GKrocation | BLstart date | pend date LAID | sence ten 0c0320(844 Staff Responsible Dea | service s0os2qiann) | 300320taN7) | 30032019) | a03zcah7) Hwa Py 3003206048) Service 5'| © special taueation and/or Related. | Cie of Profesional | Frequencyor | Chtecation | Dstandate | enddoe Service (Osa 300022019K4) Stet Responsiie ota | service scosaciai7) | s00sz0taK7 | sonszota7) | a003z0K7) 30022006) Reviewer Comments 12: 13. Services show a direct relationship to other components of the IEP. 4 Reviewer Comments 13: | 14, The IEP team has explained the extent, if any, to which a student will not participate in general education and has provided a rationale for that placement decision (ora 300.3201aN5)- Reviewer Comments 14: 15. The Least Restrictive Environmental Code is reflective of the time documented on the IEP service grid. soo.szoays) Reviewer Comments 15: 16. When applicable, ESY is addressed as a consideration and services are identified in the IEP (10e4 300.205), Reviewer Comments 16: 7. When behavior impedes student's learning or the learning of others, itis addressed in the IEP. (Positive behavior supports incorporated within the IEP or Behavior L Intervention Plan attached) a8 crn o0.32eo2 and 30.5200)10) Reviewer Comments 17: 18. |EP lists accommodations/adaptations the student requires to be involved and make progress in the general education curriculum to the maximum extent possible, wea 300 320(a-0) & 300.2201)6)0 . KL LK Reviewer Comments 18 19. Participation is addressed for each individual statewide assessment. (10a 300320(a)6H). Reviewer Comments 19: Name of Student (Last, First); 20, _ | Written Notice was provided and included an explanation for all required K | components related to the contents of the IEP. 3s crn aoosos(oie) 35 crn 3005031017) Reviewer Comments 20: Additional Comments: {f you identified this student as a Secondary Transition Student, a Preschool Student, or a student Specific Learning Disability please fill out the relevant additional checklist.

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