Oregon Standard Individualized Education Program Page 7
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7Student’s Name:
Date:
School District:
Service Summary (this section may be continued on additional page(s), if necessary)
Specially Designed Instruction
Anticipated Amount/Frequency
Anticipated Location
Starting Date
Ending Date
Provider e.
g. LEA, ESD, Regional
Starting Date
Ending Date
Related Services
Anticipated Amount/Frequency
Anticipated Location
Provider
Starting Date
Ending Date
Anticipated Amount/Frequency
Anticipated Location
Provider
Supplementary Aids/Services; Modifications;
Accommodations
Starting Date
Ending Date
_______________________________
Anticipated Amount/Frequency
Anticipated Location
Provider
_______________________________________
Supports for School Personnel
___________________________
Nonparticipation Justification
Does the student need to be removed from participating with nondisabled students in the regular classroom, extracurricular, or nonacademic activities for the
provision of special education services, related services, or supplementary aids and services?
Yes_________
No___________
If yes, document the amount/ extent of the removal:__________________________________________
If yes, provide explanation justifying the removal:
Extended School Year (ESY) Services
ESY services will be provided for this student:
__ Yes: ESY services to be provided are described on Services Summary Page
__ No
__ To be considered: Will meet to consider ESY by
(date)
Form 581-5138a-P
Page 7 of 7
1/2011: Oregon Standard IEP for students age 15 and younger when IEP is in effect
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