Individual Education Program Template
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6Enter District Name Here
Enter School Name Here
Individual Education Program (IEP)
Student’s Full Name:
SSID:
Date of Birth:
Grade:
School:
Disability:
Age:
Present Levels of Academic Achievement and Functional Performance, including how the
Education
disability affects the student’s involvement and progress in the general curriculum
Performance
(For preschool children include the effect on participation in appropriate activities; Beginning in the child’s
Areas Assessed
th
8
grade year or when the child has reached the age of 14, a statement of transition needs is included.)
Communication
Performance commensurate with similar age peers
Status
Academic
Performance commensurate with similar age peers
Performance
Health, Vision,
Not an area of concern at this time
Hearing, Motor
Abilities
Social and Emotional
Performance commensurate with similar age peers
Status
Performance commensurate with similar age peers
General Intelligence
th
Not an area of concern at this time (Checking this box is not an option when the student is in the 8
Grade or 14 years or older
because transition must be addressed for these students)
Check all areas of need as identified by the Admissions and Release Committee (More than one area may be checked.)
Instruction
Related services
Transition Needs
Community experiences
Employment
Daily Living Skills
Post School Adult Living Objectives
Functional Vocational Evaluation
Functional
Not an area of concern at this time
Vision/Learning
Media Assessment
P a g e
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Kentucky Individual Education Program
Revised 03/20/2012
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