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

IEP Documentation and Liaison Form

Form ID	FRM-SCH-001	Revision	1.0

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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:

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Goal #2

Area: _______________

Goal Statement:

Measurable Objectives: 1. 2. 3.

Progress Monitoring Method:

Progress Reporting Schedule:

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(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

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

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Section 20: Communication Log

Date	Contact Person	Topic	Method	Notes
			☐ Phone ☐ Email ☐ Meeting ☐ Letter
			☐ Phone ☐ Email ☐ Meeting ☐ Letter
			☐ Phone ☐ Email ☐ Meeting ☐ Letter

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Form FRM-SCH-001 Rev 1.0