Early Intervention Individualized Evaluation Plan

Child ID#__________________

Child SS#__________________

Early Intervention Individualized Education Program

Seneca Highlands Intermediate Unit Nine

RD #3, Box 311A; Smethport, PA 16749; (814) 887-9287

Child's Name_______________________DOB____________Address__________________________Phone_______________

Parent/Guardian/Surrogate_______________________________Address/Phone (if different)___________________________

District of Residence_________________________Transition Year_______________Date of Last Eval.__________________

MDE DATE_________________IEP DATE________________ DATE FOR RE-EVAL___________________IEP REVIEW___________________

Name of Participant Relationship to child Signature (Signature indicates attendance, not agreement)

	Parent
	LEA
	Regular Ed. Teacher
	Special Ed. Teacher
	MDT Representative

(Note: This section is completed as the last step of the process.)

Projected Projected

EI Services Agency Address & Location of Hours/week Initiation Duration Contact

Phone Services Date of Service Person

Parents have a right to request mediation or a prehearing conference and a right to a due process hearing. More information is

included in the attached Procedural Safeguards Notice. I have received a copy of the Procedural Safeguards Notice.

At Initial__________ (parent’s initial) At IEP Review__________( )

Family Services Agency Address & Phone Projected Projected Direct Service Contact

Initiation Duration or Referral Person

**Exit Criteria**When IEP Team determines that the child is no longer eligible for services.

Child's Name_______________________________________

Special considerations the IEP Team must address before developing the IEP (each question must be answered)

A. Is the Child Blind or Visually Impaired? NO

______ YES - Team must provide instruction in Braille and use of

Braille/based on the child's current and future reading and writing

skills and needs and will be included in the development of the IEP.

_____ YES - Team does not need to address the need for Braille/Braille

instruction based on the child's current and future reading and writing

skills and needs.

B. Is the Child Deaf or Hard of Hearing? NO

______ YES - Team must address the child's language and

communication needs, opportunities for direct communication with

peers and professionals in the child's language and communication

mode, academic level, and full range of needs including opportunities

for direct instruction in the child's language and communication

mode in the development of the IEP.

C. Does the Child exhibit behaviors that NO

impede his/her learning or that of others? ______ YES - Team must develop strategies including positive

behavior interventions and supports in the IEP.

D. Does the Child have limited English NO

proficiency? ______ YES - Team must address the language needs of the child

in the development of the IEP.

E. Does the Child have communication NO

needs? ______ YES - Team must address the communication needs of

the child in the development of the IEP.

F. Does the Child require assistive NO

technology devices and services? (Any item, piece ______YES – Team must address the child’s assistive technology

of equipment, or product system acquired needs in the development of the IEP.

commercially, off the shelf, modified, or customized

that is used to increase, maintain or improve functional

capabilities of a child with a disability.)

G. Does the Child need transition to NO

school-age services? ______ YES - The child is within one year of transition. Team must

discuss transition and develop transition goals and objectives.

H. Does the child have any health concerns? NO

_____ YES - (If yes, team must address intervention strategies needed

to support the child's participation in programs and services.)

I. Does the family wish to include family NO

services? _____ YES - (If yes, team must list services and demographic information

on the services page of the IEP)

Early Intervention IEP

Child’s Name______________________________________________________________________

Present Levels of Performance

Describe the eligible young child’s Present Levels of Performance (include functional information on strengths and

needs; describe in clear terms what the child can and cannot do).

Social/Behavior (include information about attention span and behavior)

Motor

Self-Help

Communication

Cognition

With parental consent, describe what the family perceives as their strengths and needs as they relate to the goals

of the child. What are the family’s priorities for the child?

How does the eligible young child’s disability affect the child’s participation in the general education curriculum

and/or appropriate activities?

Early Intervention IEP

Child's Name____________________________________________ Goal Page_____________

Measurable Annual

Goal(s)

Benchmarks/Short-term Objectives:

*Expected level of achievement

*Evaluation schedule

*Method of Evaluation

Date and Result

of Review

Early Intervention IEP

Child’s Name___________________________________________________________