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Sample Special Education Forms I-9

By Alan Washington,2014-05-07 21:40
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Sample Special Education Forms I-9

    Page ____ of ____ INDIVIDUALIZED EDUCATION PROGRAM:

    SUMMARY

    Form I-9 (Rev. 10/06)

Name of Student _____________________________

Projected beginning and ending date(s) of IEP services & modifications _________________ to

    ________________ (month/day/year)

     (month/day/year)

Physical education: ? Regular ? Specially designed

    Vocational education: ? Regular ? Specially designed

Include a statement for each of I, II, III and IV below to allow the student (1) to advance appropriately

    toward attaining the annual goals; (2) to be involved and progress in the general education curriculum; (3)

    to be educated and participate with other students with and without disabilities to the extent appropriate, and

    (4) to participate in extracurricular and other nonacademic activities. Include frequency, location, &

    duration (if different from IEP beginning and ending dates).

     I. Special education Frequency/ Location Duration

     Amount

II. Related services needed to benefit from special education including frequency, location, and

    duration (if different from IEP beginning and ending dates).

? None needed to benefit from special education

     Freq / Amt Location Duration

    ? Assistive Technology ? Audiology ? Counseling ? Educational Interpreting ? Medical Services for Diagnosis and Evaluation ? Occupational Therapy ? Orientation and Mobility (VI only) ? Physical Therapy ? Psychological Services ? Recreation ? Rehabilitation Counseling Services ? School Health Services ? School Nurse Services ? School Social Work Services ? Speech / Language ? Transportation ? Other: specify

Page ____ of ____ Form I-9

    III. Supplementary aids and services: aids, Freq / Amt Location Duration

    services, and other supports provided to or

    on behalf of the student in regular education

    or other educational settings.

    ? Yes ? No (If yes, describe)

    IV. Program modifications or supports for

    school personnel that will be provided.

    ? Yes ? No (If yes, describe)

Form I-9 Page ____ of ____

     V. Participation in Regular Education Classes

     ? The student will participate full-time with non-disabled peers in regular education

    classes, or for preschoolers, in age-appropriate settings.

     ? The student will not participate full-time with non-disabled peers in regular education

    classes, or for preschoolers, in age-appropriate settings. (If you have indicated a

    location other than regular education classes or age-appropriate settings in the case of a

    preschooler in I, II, or III above, you must check this box and explain why full-time

    participation with non-disabled peers is not appropriate.)

    VI. Participation in Extracurricular and Nonacademic Activities

    Will the student be able to participate in extracurricular and nonacademic activities with

    nondisabled students? ? Yes ? No

    (If yes, include under I., II., III., and IV. any special education, related services, supplementary

    aids and services, and program modifications or supports necessary to assist the student. If no,

    describe the extent to which the student will not be involved in extracurricular and nonacademic

    activities with nondisabled students)

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