Amendment To The Iep Without Convening An Iep Team Meeting Form

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AMENDMENT TO THE IEP
WITHOUT CONVENING AN IEP TEAM MEETING
Hancock County Schools
The following change(s) amend the student’s IEP dated ______________.
Student’s Full Name ____________________________
Date of Amendment________________________
Date of Birth _____________________________
School ______________________________________
Parent/Guardian _______________________________
Grade ___________________________________
Address _____________________________________
WVEIS#__________________________________
Phone ___________________________________
City/State____________________________________
The parent/adult student was contacted by the undersigned district personnel on _________ (date) and agreed to
make a change(s) to the student’s IEP without convening an IEP Team meeting. The district’s proposed change(s)
to the student’s IEP pertain(s) to ____________________________________________________________ based
on____________________________________________________________________________________.
The
reason(s) for the proposed change(s) is/are ___________________________________________________
_____________________________________________________________________________________________.
The district also considered ______________________________________________________________; however,
____________________________________________________________________. Other factors relevant to this
change include ________________________________________________________. The documented change(s)
(addition(s), deletion(s) or substitution(s)) is/are outlined in detail below.
For each Part of the IEP affected by the change, document the corresponding change(s) and the initiation date(s).
Part
Change
Initiation
The parent/adult student has been advised a copy of the revised IEP with the amendments incorporated would be
provided upon request. Enclosed please find: ___ a copy of the Amendment; or
___ a copy of the Amendment and the student’s revised IEP.
Signature _______________________________________
Title/Position ________________________________
Exceptional students and their parents have protections under the procedural safeguards. A copy of the Procedural Safeguards Brochure and
assistance with understanding the provisions of the procedural safeguards may be obtained by contacting the Director of Special Education at
_______________, as appropriate, the local Parent Educator Resource Center at ___________________ and/or the West Virginia Department of
Education, Office of Special Programs at 304.558.2696 or 1.800.642.8541.
NOTE: This form must be attached to the IEP being amended and all service providers responsible for
implementing these changes must be informed of the change(s).
New: 08/2013

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