Form 5a - Offer Of Special Education And Related Services
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1STATE SELPA IEP TEMPLATE
OFFER OF FAPE - SERVICES
Student Name _____________________
Date of Birth ___/___/________
IEP Date ___/___/________
The service options that were considered by the IEP team (list all) ________________________________________________________
______________________________________________________________________________________________________________
(In selecting LRE, describe the consideration given to any potential harmful effect on the child or quality of services that the child needs)
Supplementary Aids, Services & Other Supports for School Personnel, or For Student, Or On Behalf Of the Student
Aids, Services, Program
Accommodations/Modifications,
And/Or Supports
Start Date
End Date
Frequency
Duration
Location
Student
___/___/______ ___/___/______
___/___/______ ___/___/______
Personnel
Student
___/___/______ ___/___/______
___/___/______ ___/___/______
Personnel
Student
___/___/______ ___/___/______
___/___/______ ___/___/______
Personnel
Special Education Transportation
Yes
No
SPECIAL EDUCATION AND RELATED SERVICES
Service
Start Date ___/___/______
End Date ___/___/______
Provider
Individual
Group
Sec Transition
Frequency
Duration
Location
Comments:
Service
Start Date ___/___/______
End Date ___/___/______
Provider
Individual
Group
Sec Transition
Frequency
Duration
Location
Comments:
Service
Start Date ___/___/______
End Date ___/___/______
Provider
Individual
Group
Sec Transition
Frequency
Duration
Location
Comments:
Extended School Year (ESY)
Yes
No
Service
Start Date ___/___/______
End Date ___/___/______
Provider
Individual
Group
Sec Transition
Frequency
Duration
Location
Programs and services will be provided according to where student is in attendance and consistent with the district of service calendar
and scheduled services, excluding holidays, vacations, and non-instructional days unless otherwise specified.
Revised 07/2013
Form 5A
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Parent category: Education