1. education
2. special education

STUDENT INFORMATION AND SERVICES
Ventura County Special Education Local Plan Area (SELPA) Individualized Education Program (IEP)
Sample, Steve
Student
D.O.B.
Age
2/1/1997
Parent/Guardian/Surrogate
Case Manager
Address
Case Manager Phone
Phone Home ___________ Cell ____________Work
Case Manager Email
E-mail:
School Attending
Parent/Guardian
Home School
Address
Residency
Phone Home ___________ Cell ____________Work
Native Language
E-mail:
✔
 EO
Dates
Initial entry (0-22)
Initial IEP
Next Review
9/2/2013
(3-4 year olds)
Secondary (If any) None
Teacher (Elem. only)
Student ID #
Phoenix (COE)
District of Service (DOS) County Office of Education (VCOE)
District of Responsibility County Office of Education (VCOE)
English
 Eligible for Migrant Program
Agency Services (outside of IEP)
 Deafness (LI)
 Visual Impairment (LI)
 Orthopedic Impairment(LI)
 Hard of Hearing (LI)
 Deaf/Blindness (LI)
LI = Low Incidence
Ethnicity/Race
Hispanic/Latino No
Race:________________
White
___________________
___________________
___________________
Health / Behavior
 N/A
 Specialized Physical Health Care Service(s)
 Health &/or Emergency Care Plan Date ____________
 Behavior Intervention Plan
Date ____________
9/1/2013
✔
Special Transportation
No
✔1 2 3 4 5
If yes, specify level: 
 Yes 
✔
Special Requirements:
 Not Eligible (explanation/comments)
Emergency Drop off:
Special Education Services and/or Related Services
All services on this IEP will continue until next review unless otherwise specified under End Date.
Begin
Date
Sample 3
SSID#
Phoenix (COE)
Parent or legal guardian
Eligibility (Check Primary)
 Other Health Impairment
 Multiple Disability
Traumatic Brain Injury
 Established Medical Disability
Change Placement
 Regional Center (RC)
 CCS
 Mental Health (DMH)
 Social Services  Rehabilitation (DR)
 Other Agency
Exit Date
9/1/2013
Other Review
Meeting Date
Meeting Purpose
 None
✔
Exit Reason
* Contingent upon full IEP team approval of plan.
 Intellectual Disabilities
 Speech/Language Impairment
 Specific Learning Disability
 Autism
 Emotional Disturbance
Grade 10th Sex M
 IFEP  EL (see ELD page)  RFEP
9/1/2014
Next Triennial
Implementation (this plan)*
16 yr. 7 mo.
End
Date
(current yr)
(optional)
Location
In General Education
____
0 Percent of the school day that the student is in the
general education classroom/setting (ages 3-22).
Physical Education
 General
 Adapted
 Modified General
 Exempt
 Specially Designed
 N/A
✔
Out of District Transfer
Transfer to: County Office of Education (VCOE)
Date:
9/2/2013
Service:
Service:
Service:
Service:
Dismissed From
Frequency
Total
Minutes
Provider
1.Primary Specialized Academic Instruction
All Subjects
9/2/2013
________
________
__________________
Separate
school
____________
Weekly
_______
1960
_____________
VCOE
2. Individual counseling
ISES
9/2/2013
________
________
Separate
school
__________________
Monthly
____________
_______
90
VCOE
_____________
3. Counseling and guidance
ISES
9/2/2013
________
________
Separate
school
__________________
Monthly
____________
90
_______
VCOE
_____________
4. Social work services
ISES
9/2/2013
________
________
Separate
school
__________________
Monthly
____________
_______
60
VCOE
_____________
________
________
__________________
____________
_______
_____________
_____________
5.
6.
________
________
__________________
____________
_______
7.
________
________
__________________
____________
_______
_____________
_____________
8.
________
________
__________________
____________
_______
9.
________
________
__________________
____________
_______
_____________
10.
________
________
__________________
____________
_______
_____________
11.
________
________
__________________
____________
_______
_____________
12.
________
________
__________________
____________
_______
_____________
Note: Services will only be provided on regular school days, per the student’s school calendar, unless otherwise specified. For services with a frequency of “weekly,” services may not be provided if school is not in session on the day(s)
student is scheduled to receive services. For services with a frequency of "monthly" the total minutes will be prorated for months with less than 4 weeks of school. Services with “yearly” frequency include minutes provided during ESY.
■
■
■
■
■ District Office 
Copy to: 
General Education/Cumulative File 
Case Manager 
Parent/Adult Student 
Related Services  Agency  Other
LEAST RESTRICTIVE ENVIRONMENT
Ventura County SELPA IEP
Student Name
Sample, Steve
D.O.B.
2/1/1997
9/1/2013
Meeting Date
Promotion and Retention Standards (Grades 2-8)  Regular district criteria  Individualized criteria, specify (reading for gr. 2 & 3; English/language arts and math for all other grades):
Special Factors Affecting Learning and Placement
Do any of the following special factors apply? If yes, describe interventions, strategies and/or supports.
✔
 Yes  No Behavior interferes with learning (of self or others): Social emotional goals
 Yes ✔
 No Language needs of English Learner (EL):
 Yes ✔
 No Braille instruction for students with blindness or visual impairment:
 Yes ✔
 No Communication needs, including students who are deaf or hard of hearing :
 Yes ✔
 No Assistive technology devices and services:
 Yes 
✔ No Low Incidence Equipment to be acquired:
Behavior Intervention Plan
Program Considerations
The IEP Team considered the following factors to determine the least restrictive environment for the student:
• The level of his/her individual needs as reflected on this IEP
• Placement with age-appropriate peers and participation with students without disabilities to
the maximum extent appropriate in non-academic and extracurricular activities
• Removal from general education only when the nature or severity of the educational needs
are such that education in general classes with supplementary aids and services cannot be
• Any potential harmful effect on the social and personal needs, the level of educational
achieved satisfactorily
functioning, or the quality of services which s/he needs
✔

Check each program option discussed:
 General education class(es) with special education monitoring, consultation, collaboration,
accommodations or modifications
 General education class(es) with special education services provided individually or in small groups in
the classroom
 General education class(es) with special education services provided individually or in small groups
outside the classroom
 Special education class(es) with part-time integration for academics in general education classroom

Special education class(es) with integration into non-academic and/or
extracurricular activities in general education classrooms or settings.

✔ Full-time special education class(es) in a public school
 Full-time special education class(es) in a Nonpublic School (NPS)
 Home/hospital instruction
 (For preschoolers only) Related Services only
 Other:
Offer of Free Appropriate Public Education (FAPE) - Describe student’s overall school program, including supports needed for extracurricular activities (if any):
Steve will attend Phoenix school, a self-contained school designed to support special education students with intensive social/emotional needs. Phoenix provides specialized academic
instruction in all subjects in a highly structured environment. Social/emotional services are provided on campus by therapists who are available a majority of the school day. "Time in"
counseling, which is an as-needed, brief intervention/support to resolve conflict or assist with coping strategies, is available on an immediate basis during school hours. ESY will be provided
for 19 days. Transportation from home to school daily. Student will receive Intensive Social/Emotional Services to address his/her social emotional &/or behavioral goals. These services will
be provided by a licensed clinical professional, known as an Intensive School-Based Therapist (ISBT). The ISBT will work with educational staff, student & family as appropriate to address
underlying issues, make community referrals, & develop strategies to address the needs at school. ISES services will be available during the the summer months between school sessions.
the student needs a more highly structured classroom.
If placement in other than general education, provide rationale:
Due to emotional difficulties,
If placement in other than home school, provide rationale: Requires self-contained program away from the comprehensive campus.
Other placement rationale: N/A
Additional supports for student: None at this time
Supports needed for school personnel (i.e. consultation, training, planning time): Consultation with Intensive School-Based Therapist as needed
Consultation with school nurse
Support needed for transition between programs (i.e. special education to general education; preschool to kindergarten; middle school to high school):
Student to visit new school
Extended School Year ✔
 Yes  No
If yes, fill out the services box below.
Special Education Services and/or Related Services
 See Meeting Summary for additional/more specific information regarding the ESY program.
Frequency Minutes
1.Specialized Academic Instruction
All Subjects
Daily
________
240
________
2.Individual counseling
ISES
Monthly
________
90
________
3.Counseling and guidance
ISES
Monthly
________
90
________
4. Social work services
ISES
Frequency Minutes
________
Monthly
60
_____
5.
________
_____
6.
________
_____
7.
________
_____
WORKSHEET FOR SPECIALIZED OUT OF DISTRICT PROGRAM
Ventura County Special Education Local Plan Area (SELPA)
Student Name Sample, Steve
___________ D.O.B.
The team agrees student will be placed in
2/1/1997
Meeting Date 9/1/2013
Phoenix – VCOE
Rationale for placement:
Sam requires a separate campus away from the comprehensive campus with intensive social-emotional services provided on-site due to his intensive social-emotional-behavioral needs.
(OR ANYTHING SIMILAR TO THIS WORDING)
______________________________________________________________________________________________________________________________
Progress reports toward goals will be reported to parents
 Method:
Mailed
_________
 Months:
Quarterly
___
It is the goal of the Ventura County SELPA to educate students in settings as close to the home community as soon as possible. Steps to assist student in
returning to a less restrictive school placement:
DISTRICTS ARE TO SELECT FROM THE FOLLOWING THOSE THAT ARE APPLICABLE FOR THIS PARTICULAR STUDENT:
 Review with student behavioral expectations in less restrictive environment.
 Student to make list of rationale for his/her readiness to return to district with ISBT or case manager.
 As student begins to show attainment of the skills/competencies below, Phoenix staff will communicate with representative from District of Residence.
 Meeting will then be held with the student, family, district of residence, and Phoenix staff to discuss the student’s readiness to return to district.
o Or it could be a monthly or quarterly meeting to check in.
 Next, transition plan (for student to return to district) to be developed with student, family, district of residence and Phoenix staff.
 Student and/or family to visit options/class/campus in district of residence that student would be transitioning to.
 Student to attend comprehensive campus in district of residence for a partial day before full transition back to district.
Skills/competencies student should display before returning to a less restrictive school placement:
 90% attendance over one semester
 90% class work completion over one semester
 Highest behavioral level (STAR level; based on points) over one semester

PLEASE WRITE 2 SKILLS THAT ARE SPECIFIC TO YOUR STUDENT THAT YOU WANT TO SEE IN ORDER FOR THE STUDENT TO RETURN TO DISTRICT

These skills and competencies should be reflected in goals when appropriate.
Frequency of IEP review:
Annually
____________
Copies of Progress Reports and Behavior Emergency Reports to be forwarded to:
(Name)
District contact info
(Title)
(Location)
(Address/Fax)
Copy to: District Office:  DOR DOS Cumulative File Case Manager Parent/Adult Student Intensive School-Based Therapist  Related Services  Other
AGREEMENT/ATTENDANCE
Ventura County SELPA IEP
Student Name
D.O.B.
Sample, Steve
Meeting Date
2/1/1997
9/1/2013
The following components of the IEP were explained and discussed at this meeting. Parent/Adult Student initials below indicate agreement with respective provisions in this
IEP document unless specified below.
Parent/Adult Student Rights – Within the last year, I have received a copy of and understand the rights afforded to me. I understand that this program will be reviewed
annually and that I may request a review of this program at any time.
Assessment Reports – I have received copies of all the reports discussed.
N/A
N/A
Progress toward previous goals was reviewed, and I received a copy of the Progress Report.
This IEP was prepared, reviewed and communicated with me in understandable language, including abbreviations. I have had the opportunity to provide input in developing
this program. The district facilitated parent involvement as a means of improving services and results for my child.
N/A
Eligibility – I agree with the eligibility determination.
Annual Goals – I agree with the goals in this IEP except as noted below.
N/A
Services – I agree with the services stated in this IEP except as noted below.
Progress Reports – I was informed that the custodial parent/adult student will receive written reports of progress toward goals concurrent with general education reporting
periods at the school of attendance. Exception(s):
N/A
Parent/Adult Student offered translation  Declined  Accepted:
Language
High School / Postsecondary Only:
I was informed that all special education rights will be/were transferred to student upon reaching age of majority.
I was informed that graduation from high school with a regular diploma ends the district’s obligation to provide a free, appropriate public education.
I give the district permission to exchange information with and invite to the next IEP meeting the adult agencies specified on the Transitioning From Public School page.
N/A
Parent/Adult Student Participation: _____ Attended _____ Teleconferenced _____ Invited /Did not attend;
Approval: _____ Agree with IEP _____ Agree except as noted below:
This IEP will be implemented except for areas of disagreement noted above. Comments, if any:
Parent/Guardian/Surrogate/Representative
Date
Parent/Guardian
Date
Student
Date
 Private School – This IEP represents the
District’s offer of a Free Appropriate Public Education. As parents have chosen to enroll student/continue
County Office of Education (VCOE)
enrollment in a private school in the
District, any services to be offered will be in accordance with the private school guidelines of the district
in which the private school is located. Parents were given information for contacting district where private school is located.
Signatures of other IEP team members. (Indicate members with Excusal Form on record.)
Special Education Teacher
Date
School Psychologist
Date
Interpreter
Date
General Education Teacher
Date
Occupational Therapist
Date
School Counselor
Date
Speech-Language Pathologist
Date
School Nurse
Date
Title/Agency
Date
LEA (District) Representative
Date
Title/Agency
Date
LEA (District) Representative
Date
For more information about special education and your rights, please contact your district Special Education Office or visit the SELPA website at www.venturacountyselpa.com