INDIVIDUALIZED EDUCATIONAL PROGRAM (IEP) SAMPLE
Name of Student: Gender: M F Age: DOB: Grade: Identification:
Date: School: Teacher: SERT: Placement:
Assessment Information:
Historical Information
Academic Information
Psychological Information
Special Information
Health History
Vision/Hearing
Name of Student: School: Date: Specialist: Page # 2
Strengths/Weaknesses
G Behavioural
G Academic
Behavioural Objectives: what, when, who, how, success indicator,
G Long Term
G Short Term
Methods, Materials, and Techniques (designate who will implement)
Assessment of Effectiveness
