THIS IEP INCLUDES:

FORMCHECKBOX Transitions

FORMCHECKBOX Interim Service Plan

NEW YORK CITY

BOARD OF EDUCATION

INDIVIDUALIZED EDUCATION PROGRAM

CONFERENCE INFORMATION

CSE Case#   -     

Home District:    Service District:   

Date:   /   /     

Type:      

STUDENT INFORMATION *Age as of the date of the conference

Name:      

NYC ID#    -   -   

Date of Birth   /  /    

Gender FORMDROPDOWN

Address:      

Age:      

Phone: (   )    -    

English LAB      

Year     

Spanish LAB      

Year     

Grade FORMDROPDOWN

Language(s) Spoken/Mode of Communication FORMDROPDOWN

Primary Agency with whom student is involved      

Name of Contact       FORMTEXT      

Phone: (   )    -    

Agency Case#      

PARENT/GUARDIAN INFORMATION Relationship to Student

Name:      

FORMDROPDOWN

Address:      

Phone (Home): (   )    -    

Phone (Work): (   )    -    

Interpreter Required FORMCHECKBOX Yes FORMCHECKBOX No

Preferred Language/ Mode of Communication FORMDROPDOWN

SPECIAL MEDICAL/PHYSICAL ALERTS (Refer to Health & Physical Development Page for additional details.)

The student has FORMCHECKBOX medical conditions and/or FORMCHECKBOX physical limitations which affect his/her FORMCHECKBOX learning FORMCHECKBOX behavior and/or FORMCHECKBOX participation in school activities.

The student requires FORMCHECKBOX medication and/or FORMCHECKBOX health care treatment(s) or procedure(s) during the school day.

Other alerts:      

SUMMARY OF RECOMMENDATIONS Eligibility FORMCHECKBOX Yes FORMCHECKBOX No

Recommended Services Classification of Disability FORMDROPDOWN

FORMDROPDOWN      

Staffing Ratio

FORMDROPDOWN

Twelve Month School Year FORMCHECKBOX Yes FORMCHECKBOX No Recommended Services for the Twelve Month School Year

FORMDROPDOWN      

Staffing Ratio

FORMDROPDOWN

Other Recommendations (Check all that apply) *Details are provided in relevant sections of IEP

FORMCHECKBOX Program Accessibility

FORMCHECKBOX Adaptive Phys. Ed.*

FORMCHECKBOX Bilingual Instruction

FORMCHECKBOX Related Services

FORMCHECKBOX Assistive Technology

FORMCHECKBOX Monolingual Services with ESL

FORMCHECKBOX Monolingual Services without ESL

FORMCHECKBOX Special Education Transportation – Comment      

Students who are blind or visually impaired:

Students who are deaf or hard of hearing

Braille instruction needed FORMCHECKBOX Yes FORMCHECKBOX No

Language of Instruction      

Mode of Communication      

Copy for FORMCHECKBOX CSE FORMCHECKBOX Parent FORMCHECKBOX School FORMCHECKBOX Student FORMCHECKBOX Other Page 1

Student:

NYC ID# – –

CSE Case# –

Date of Conference: / /

CONFERENCE INFORMATION

Referral Type:

FORMCHECKBOX Initial

FORMCHECKBOX Annual Review

Conference Type:

FORMCHECKBOX EPC

FORMCHECKBOX Annual Review

FORMCHECKBOX Triennial

FORMCHECKBOX Requested Review

FORMCHECKBOX CSE Review

FORMCHECKBOX CPSE Review

Attendance at Conference

Please note that your signature reflects your participation at the conference and does not necessarily indicate agreement with the

Individualized Education Program.

Signature/Title

Role

(Indicate if Bilingual)

Signature/Title

Role

(Indicate if Bilingual)

      FORMTEXT      

Parent/Legal Guardian

Parent/Legal Guardian

District Representative

Special Education Teacher

Or Related Service Provider

General Education Teacher

Parent Member (CPSE/CSE)

Student

Other

Education Evaluator

School Psychologist

Other

School Social Worker

Other

Other

Use an asterisk(*) to signify the participant who interprets the instructional implications of evaluation results.

Use the letter (T) to signify participation by teleconference.

Conference Result

FORMCHECKBOX Initiate Service

FORMCHECKBOX Modify Service

FORMCHECKBOX Change Recommended Service

FORMCHECKBOX No Change

Indicate Modifications

Initiation, Duration and Review of IEP

Projected Date of Initiation of IEP   /  /    

Projected Date of Review of IEP   /  /    

Duration of Services      

Contacts with Parent/Legal Guardian

Date Notice of Meeting Sent   /  /    

Date IEP and Notice of Recommendation

Date of Follow-up (if any)   /  /    

FORMCHECKBOX Given to Parent   /  /    

Type of Follow-up FORMCHECKBOX Letter