Iep Participation Documentation printable pdf download

Iep Participation Documentation

Vermont Department of Vermont

Individualized Education Program (IEP)

IEP Case Manager: __________________________________ IEP Meeting Date: _______________

Student/Child's Name: _______________________________ Date of Birth: ____________________

Disability Category: ______________________________ Identification #: _____________________

School or Program: ____________________________________________ Grade Assigned: _______

Parent/Guardian: ____________________________________ Telephone #: ____________________

Address:___________________________________________________________________________

_________________________________________________________________________________

Initiation and Duration of IEP Services: _____________________ to: _____________________

_____________________ to: _____________________

Initiation and Duration of Extended Year Services:

_____________________ to: _____________________

Annual Review Date: _____________ Next 3-year Re-evaluation Date: ____________________

IEP Team Members

Printed Name/Position/Agency

Parent(s)/Guardian/Surrogate (circle one)

Name:

Student (when appropriate)

Name:

Special Education Teacher or Service Provider

Name:

Local Education Agency (LEA) Representative

Name:

Individual who can interpret the instructional

implications of evaluation results

Name:

Regular Education Teacher(s)

Name:

Transition Planning Participants/Other Agencies

Name:

Position/Agency:

Name:

Position/Agency:

Other Participants

Name/Position:

Page __ of __

Form 5

September 21, 2005

Individualized Education Program (IEP)

Page 1

Iep Participation Documentation