Individual Education Plan Sample
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3Individual Education Plan (IEP):
Annotated sample
Template
Designed for electronic use
Include the child’s
Individual Education Plan (IEP)
full details.
Child’s information
Days attending
Kindergarten
Family name
Given name
Date of birth
kindergarten
start date
Specify service
details, including
Mon, Tues and
Smith
John
3/1/2010
31/01/2013
alt Wed
the name of the
teacher or person
Service information
preparing this IEP.
Name of service
Browns Road Kindergarten
Address
34 Browns Road, Brisbane
Phone
07 3842 0978
Email address
Gather information
including:
IEP prepared by
Mary Harrison
• diagnosis and
Director/Teacher signature
Date
5/03/2013
any relevant
Medical and support information for child
medical notes
Down syndrome
• other support,
Diagnosis or disability
Intellectual impairment
including
Medical notes
health
John is unsteady when walking
John has medication daily for epilepsy
professionals
and educational
Occupational Therapist — Lana Jones,
Support staff/agencies
agencies.
Disability Services Queensland, Inclusion Support
Attendance at
Days and times
Fridays 9:00–2:30pm
Early Childhood
Development
ECDP contact
Sarah Green — Wynnum ECDP
Program (ECDP)
details
Gather information
from:
Contributors to IEP
• parents/carers
Name
Agency/Relation to child
Contact number
Signature
• all involved
Kay Smith
Mother
professionals.
Brad Smith
Father
Lana Jones
Occupational Therapist
Mary Harrison
Kindergarten teacher
Michelle Black
Kindergarten assistant
ECDP staff can
Sarah Green
ECDP teacher
assist kindergarten
teachers to write
the IEP.
John Smith’s Individual Education Plan
Page 1 of 3
Individual Education Plan (IEP): Annotated sample
Queensland Curriculum & Assessment Authority August 2014
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