State Selpa Iep Template
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1STATE SELPA IEP TEMPLATE
Offer of FAPE
EDUCATIONAL SETTING
Page ____ of ____
Name
IEP Date _____/_____/_____
Physical Education
General
Specially Designed
Other
District of Service
School of Attendance
School Type
Federal Setting
Federal Preschool Setting _______________________
All special education services provided at student’s school of residence?
Yes
No (rationale)
_______% of time student is outside
the regular class & extracurricular & non academic activities
_______% of time student is
in
the regular class & extracurricular & non academic activities
Student will not participate in the regular class & extracurricular & non academic activities
because
Other Agency Services
California Children’s Services (CCS)
Regional Center
Probation
Department of Rehabilitation
Department of Social Services (DSS)
County Mental Health (CMH)
Other
Student Eligible for Mental Health Services under Chapter 26.5?
Yes
No
Mental Health Services Included on the IEP?
Yes
No
Promotion Criteria
District
Progress on Goals
Other
Parents will be informed of progress
Quarterly
Trimester
Semester
Other
How?
Progress Summary Report
Other
ACTIVITIES TO SUPPORT TRANSITION
(e.g., preschool to kindergarten, special education and/or NPS to general education class, 8
– 9
grade)
th
th
GRADUATION PLAN
(Grade 8 and Higher)
Projected graduation date and/or secondary completion date ___/___/___
To participate in high school curriculum leading to a Diploma
To participate in high school curriculum leading to a Certificate of Completion
Revised 7/10
Form 5B
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