SAMPLE IEP 3 PDF

# LOS ANGELES COUNTY CHARTER SELPA ## INDIVIDUALIZED EDUCATION PROGRAM (IEP) - INFORMATION / ELIGIBILITY **Page 2 of 16** | | | | | | |---|---|---|---|---| | Student Legal Name: | Legal Suffix: |Date of Birth:| IEP Date: 5/26/2023 | | | Original SpEd Entry Date: 5/26/2023 | | Next Annual Pla...

# LOS ANGELES COUNTY CHARTER SELPA ## INDIVIDUALIZED EDUCATION PROGRAM (IEP) - INFORMATION / ELIGIBILITY **Page 2 of 16** | | | | | | |---|---|---|---|---| | Student Legal Name: | Legal Suffix: |Date of Birth:| IEP Date: 5/26/2023 | | | Original SpEd Entry Date: 5/26/2023 | | Next Annual Plan Review: 5/25/2024 | | | | Last Eligibility Evaluation: 5/26/2023 | | Next Eligibility Evaluation: 5/25/2026 | | | ### MEETING TYPE: - Initial - Plan Review - Eligibility Evaluation ### Additional Purpose of Meeting (if needed): - Transition - Pre-Expulsion - Interim - Other | **Age:** | **Grade:** | **Native Language:** | **Redesignated:** | **Interpreter:** | |---|---|---|---|---| | 11 year(s) 11 months | 06 Sixth grade | 01 Spanish | Yes No | Yes No | | **EL:** | **Student ID:** | **SSID:** | | | | Yes No | 11191 | 4946123002 | | | | Parent/Guardian: | | | | | |---|---|---|---|---| | | Home Phone: | | Home Phone: | | | | Work Phone: | | Work Phone: | | | | Cell Phone: | | Cell Phone: | | | | Email: | | Email: | | | Home Address: | | | | | | City: | | | | | | State/Zip: | | | | | ### District of Special Education Accountability: Prepa Tec-Los Angeles Middle School ### Residence School: - Yes - No - Ethnicity Intentionally Left Blank ### Hispanic Ethnicity: - Yes - No - Ethnicity Intentionally Left Blank ### Race (regardless of Ethnicity): - Race 1. 700 White - Race 2. - Race 3. - Race 4. - Race 5. - Race Intentionally Left Blank ### INDICATE DISABILITY/IES Note: For initial and triennial IEPs, assessment must be done and discussed by IEP Team before determining eligibility. * Low Incidence Disability | | | |---|---| | **Primary:** Specific Learning Disability (SLD) | **Secondary:** None | - Not Eligible for Special Education - Exiting from Special Education (returned to reg. ed/no longer eligible) ### Describe how student’s disability affects involvement and progress in general curriculum (or for preschoolers, participation in appropriate activities) specific learning disability due to attention processing affects the ability to filter out irrelevant background stimuli (i.e. visual or auditory distractions of any kind), resulting in an inability to focus and/or identify relevant information. This impacts her involvement and progress in the general education curriculum. ### FOR INITIAL PLACEMENTS ONLY Has the student received IDEA Coordinated Early Intervening Services (CEIS) using 15% of IDEA funding in the past two years? - Yes - No | **Date of Initial Referral for Special Education Services:** | **Person Initiating the Referral for Special Education service:** | |---|---| | 10/10/2022 | 10 Parent | | **Date District Received Parent Consent:** | **Date of Initial Meeting to Determine Eligibility:** | |---|---| | 11/14/2022 | 5/26/2023 |