INDIVIDUALIZED EDUCATION PROGRAM (IEP)

COVER PAGE

Student Name_______Ricky Harris___________________________ Date 5/1/03_ Page _1__ of _6__

Student ID Number__7812____________________________Grade__5_____

DOB __2/8/93__ Age* ____10____ Disability (ies) (if identified) ___Specific Learning Disability

Parent/Guardian Name__Mrs. Jean Harris�� Home Address: ��1010 Elmwood,�� Grandview�� 20002-3333 _

Phone # (H) 211-694-9-3003___________________________ Phone # (W) (____)__________________

Most recent eligibility date���������������.������������� ���������� _12_/__10_/__00_

Most recent re-evaluation date ��������������������.������ ���_____/_____/_____

Next re-evaluation must occur before this date ���������������������������������..�� � ���..__ __/_____/_____

Date of IEP meeting����������������������. ���..��.. ����. ������5/������ 1/����� 03

This IEP will be reviewed no later than this date������������������ ��� �.. ����� 5/����� 1/���� 04

Date parent notified of IEP meeting���������������������.�... ���� ��������4/������ 5/���� 03

Date student notified of IEP meeting (if transition will be discussed)���������� ��... ... �._ _/_____/_____

Copy of IEP given to parent/student by (Name)__Mrs. Jean Harris_ ___ On (Date)__5/1/03___

IEP Teacher/Manager_Elizabeth Parker__ Phone Number (211) 694-9897

___________________________________________________________________________________________________

PARTICIPANTS INVOLVED:

The list below indicates that the individual participated in the development of this IEP and the placement decision; it does not

authorize consent. Parent or student (age 18 or older) consent is indicated on the �Prior Notice/Consent� page.

NAME OF PARTICIPANT������������������������������������������������������������� POSITION�������������������� date

Elizabeth Parker���������������������������������������� Sp. Ed. Teacher/IEP manager�� ��5/1/03

Joanne Black����������������������������������������������������������������������������� Classroom teacher ���������������������May 1, 2003

Roberta Carr�������������������������������������������� School District Representative 5/1/03

Mrs. Jean Harris������������������������������������������ Mother��������� ����������������������May 1, �03

Parental Consent please check the appropriate boxes and sign.

� I received a NOTICE OF PROCEDURAL SAFEGUARDS

� I have had the opportunity to help develop this IEP.

� I agree with the goals and objectives of this IEP.

� I agree with the placement and service recommendations

I do not agree with the placement and service recommendations.\

Mrs. Jean Harris��� �����������������date ����May 1, �03

_{signature of parent/ guardian/surrogate/student}

*The student must be informed at least one year prior to turning 18 that the IDEA procedural safeguards (rights) transfer to him/her at age

18 and be provided with an explanation of those procedural safeguards .

Date informed _____/_____/_____

Virginia Department of Education � Sample IEP Form � May 2001 page 3 of 25

INDIVIDUALIZED EDUCATION PROGRAM (IEP)

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