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                        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