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Forms/School-Reports/FRM-SCH-001-IEP-Documentation-Form.md

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+# IEP Documentation and Liaison Form
+
+| Form ID | FRM-SCH-001 | Revision | 1.0 |
+|---------|-------------|----------|-----|
+
+---
+
+## Section 1: Student Information
+
+| Field | Entry |
+|-------|-------|
+| Student Name | |
+| Date of Birth | |
+| Current Age/Grade | |
+| School District | |
+| School Building | |
+| Medical Record Number | |
+
+## Section 2: Parent/Guardian Information
+
+| Field | Entry |
+|-------|-------|
+| Parent/Guardian 1 Name | |
+| Phone | |
+| Email | |
+| Parent/Guardian 2 Name | |
+| Phone | |
+| Email | |
+
+## Section 3: IEP Meeting Information
+
+| Field | Entry |
+|-------|-------|
+| IEP Meeting Type | ☐ Initial ☐ Annual ☐ Triennial ☐ Amendment ☐ Other: _____ |
+| Meeting Date | |
+| Meeting Location | |
+| Our Practice Participation | ☐ In-person ☐ Virtual ☐ By phone ☐ Written input only |
+| Practice Representative | |
+
+### IEP Team Members Present
+
+| Role | Name | Present |
+|------|------|---------|
+| Parent/Guardian | | ☐ |
+| Special Education Teacher | | ☐ |
+| General Education Teacher | | ☐ |
+| School Administrator/LEA Rep | | ☐ |
+| School Psychologist | | ☐ |
+| Speech-Language Pathologist | | ☐ |
+| Occupational Therapist | | ☐ |
+| Physical Therapist | | ☐ |
+| Developmental Pediatrician | | ☐ |
+| Student (age-appropriate) | | ☐ |
+| Other: _____________ | | ☐ |
+
+## Section 4: Eligibility Determination
+
+### IDEA Eligibility Category (Primary)
+- [ ] Autism
+- [ ] Developmental Delay (ages 3-9)
+- [ ] Emotional Disturbance
+- [ ] Intellectual Disability
+- [ ] Multiple Disabilities
+- [ ] Other Health Impairment
+- [ ] Specific Learning Disability
+- [ ] Speech or Language Impairment
+- [ ] Other: _______________
+
+### Additional Eligibility Categories (if applicable)
+
+
+
+
+### Evaluation Data Reviewed
+- [ ] Cognitive assessment
+- [ ] Autism diagnostic evaluation (ADOS-2, ADI-R)
+- [ ] Academic achievement testing
+- [ ] Speech-language evaluation
+- [ ] Occupational therapy evaluation
+- [ ] Physical therapy evaluation
+- [ ] Behavioral assessment
+- [ ] Medical information
+- [ ] Classroom observations
+- [ ] Parent input
+- [ ] Other: _______________
+
+## Section 5: Present Levels of Performance
+
+### Academic Performance Summary
+*(Strengths and areas of need)*
+
+
+
+
+### Functional Performance Summary
+*(Daily living skills, social-emotional, behavior, communication)*
+
+
+
+
+### How Disability Affects Educational Progress
+
+
+
+
+## Section 6: IEP Goals and Objectives
+
+### Goal #1
+**Area:** _______________
+
+**Goal Statement:**
+
+
+
+
+**Measurable Objectives:**
+1.
+2.
+3.
+
+**Progress Monitoring Method:**
+
+**Progress Reporting Schedule:**
+
+---
+
+### Goal #2
+**Area:** _______________
+
+**Goal Statement:**
+
+
+
+
+**Measurable Objectives:**
+1.
+2.
+3.
+
+**Progress Monitoring Method:**
+
+**Progress Reporting Schedule:**
+
+---
+
+*(Attach additional goals as needed)*
+
+## Section 7: Special Education Services
+
+| Service | Provider | Frequency | Duration | Location | Start Date |
+|---------|----------|-----------|----------|----------|------------|
+| | | | | | |
+| | | | | | |
+
+### Service Delivery Models
+- [ ] Co-teaching/Push-in
+- [ ] Pull-out (resource room)
+- [ ] Self-contained classroom
+- [ ] Related services in general education
+- [ ] Community-based instruction
+- [ ] Other: _______________
+
+## Section 8: Related Services
+
+| Service | Provider | Frequency | Duration | Location | Start Date |
+|---------|----------|-----------|----------|----------|------------|
+| Speech-Language Therapy | | | | | |
+| Occupational Therapy | | | | | |
+| Physical Therapy | | | | | |
+| Counseling | | | | | |
+| Behavioral Support | | | | | |
+| Social Work Services | | | | | |
+| Assistive Technology | | | | | |
+| Other: ____________ | | | | | |
+
+## Section 9: Accommodations and Modifications
+
+### Instructional Accommodations
+- [ ] Extended time
+- [ ] Reduced distractions
+- [ ] Preferential seating
+- [ ] Visual supports/schedules
+- [ ] Chunking of assignments
+- [ ] Repeated/simplified directions
+- [ ] Use of assistive technology
+- [ ] Sensory breaks
+- [ ] Other: _______________
+
+### Testing Accommodations
+- [ ] Extended time (specify: _____%)
+- [ ] Breaks during testing
+- [ ] Small group or separate setting
+- [ ] Read-aloud
+- [ ] Scribe
+- [ ] Use of calculator
+- [ ] Simplified language
+- [ ] Assistive technology
+- [ ] Other: _______________
+
+### Modifications to Curriculum
+- [ ] Modified assignments
+- [ ] Alternate assessments
+- [ ] Reduced workload
+- [ ] Simplified content
+- [ ] Other: _______________
+
+## Section 10: Behavioral Intervention Plan (BIP)
+
+### BIP Status
+- [ ] BIP in place
+- [ ] BIP not required
+- [ ] FBA (Functional Behavioral Assessment) needed
+
+### Target Behaviors (if BIP in place)
+
+
+
+
+### Behavioral Supports and Interventions
+
+
+
+
+## Section 11: Participation in General Education
+
+### Percentage of Day in General Education
+- [ ] 80% or more (inclusive)
+- [ ] 40-79%
+- [ ] Less than 40%
+- [ ] Separate setting
+
+### Justification for Removal from General Education (if applicable)
+
+
+
+
+## Section 12: Transition Planning (for students age 14+)
+
+### Post-Secondary Goals
+**Education/Training:**
+
+
+
+
+**Employment:**
+
+
+
+
+**Independent Living:**
+
+
+
+
+### Transition Services Needed
+- [ ] Instruction
+- [ ] Related services
+- [ ] Community experiences
+- [ ] Employment and post-school objectives
+- [ ] Daily living skills (if appropriate)
+- [ ] Functional vocational evaluation
+
+### Transition Service Providers
+
+| Service | Provider/Agency | Contact |
+|---------|----------------|---------|
+| | | |
+
+## Section 13: Extended School Year (ESY) Services
+
+### ESY Determination
+- [ ] ESY services recommended
+- [ ] ESY services not needed
+
+### ESY Services (if applicable)
+
+| Service | Frequency | Duration |
+|---------|-----------|----------|
+| | | |
+
+### Justification for ESY
+
+
+
+
+## Section 14: Assessment Participation
+
+### State/District Assessments
+- [ ] Regular assessment without accommodations
+- [ ] Regular assessment with accommodations
+- [ ] Alternate assessment
+
+### Alternate Assessment Justification (if applicable)
+
+
+
+
+## Section 15: Medical/Clinical Recommendations from Our Practice
+
+### Key Clinical Findings Relevant to Education
+
+
+
+
+### Recommendations for School-Based Supports
+1.
+2.
+3.
+
+### Suggested Accommodations Based on Diagnosis
+
+
+
+
+### Coordination with Medical/Therapeutic Services
+
+
+
+
+## Section 16: Parent Concerns and Input
+
+### Parent-Stated Priorities for IEP
+
+
+
+
+### Parent Concerns
+
+
+
+
+### Parent Agreement with IEP
+- [ ] Parent agrees with IEP
+- [ ] Parent has concerns (documented above)
+- [ ] Parent does not consent to IEP
+- [ ] Parent requests mediation/due process
+
+## Section 17: Follow-Up and Coordination
+
+### Our Practice Follow-Up Actions
+
+| Action | Responsible | Target Date | Status |
+|--------|-------------|-------------|--------|
+| | | | |
+| | | | |
+
+### Next IEP Review Date
+| Annual Review Due | |
+|-------------------|---|
+| Triennial Evaluation Due | |
+
+### Coordination Notes
+*(Communication with school, therapy coordination, etc.)*
+
+
+
+
+## Section 18: Documentation and Records
+
+### Records Provided to School
+- [ ] Diagnostic evaluation report
+- [ ] Cognitive assessment report
+- [ ] Medical documentation
+- [ ] Treatment recommendations
+- [ ] Progress notes
+- [ ] Other: _______________
+
+### Records Received from School
+- [ ] Current IEP
+- [ ] Progress reports
+- [ ] Teacher observations
+- [ ] School-based evaluation reports
+- [ ] Other: _______________
+
+## Section 19: Signatures and Approvals
+
+| Completed By | | Date | |
+|--------------|---|------|---|
+| Reviewed By (Provider) | | Date | |
+
+---
+
+## Section 20: Communication Log
+
+| Date | Contact Person | Topic | Method | Notes |
+|------|---------------|-------|--------|-------|
+| | | | ☐ Phone ☐ Email ☐ Meeting ☐ Letter | |
+| | | | ☐ Phone ☐ Email ☐ Meeting ☐ Letter | |
+| | | | ☐ Phone ☐ Email ☐ Meeting ☐ Letter | |
+
+---
+
+*Form FRM-SCH-001 Rev 1.0*