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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*