Test Student Proposed IEP

HOUSTON INDEPENDENT SCHOOL DISTRICT

ADMISSION, REVIEW, AND DISMISSAL/INDIVIDUALIZED EDUCATION
PROGRAM (ARD/IEP) TEAM REPORT

Student Information

Name: Daniel Test ID#: School: Test School School Phone: 1234567891
TEST123231123

Date of Birth: 05/01/2008 Grade: 8 Home School: Bellaire Hs

Parent/Guardian/Adult Student/Surrogate Parent: Mr. Test

Email: [email protected]
Date: 05/20/2022

ARD/IEP Team Meeting Information

Parent is in attendance. Parent was unable to attend the ARD/IEP meeting.

Yes No An interpreter/translator was needed and used to assist in conducting the meeting for parent(s) with deafness or

whose native language is other than English. If Yes, specify the language or other mode of communication.

Justification:

no interpreter was needed; the home language is English

The meeting is audiotaped by: Not Applicable Parent School District Adult Student

I. PURPOSE OF MEETING Promotion Manifestation Determination Review
Secondary Services IEP Course Review - Failure
Annual Graduation Additional Evaluations
ESY Re-Evaluation (REED)
Identification IEE Other
Evaluation Placement
Discipline
Transition
Dismissal
Program (IEP)

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 1

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

II. INFORMATION REVIEWED AND CONSIDERED

State Assessment Results:
Assessment results should be entered here. State assessment results are available for grade 3-8 state assessments in English
Language Arts (ELA) and Math, New York State Regents exams, SAT, Advanced Placement exams, and the National Assess-
ment of Educational Progress (NAEP).

District Wide Assessment Results:
District wide assessment results should be entered here- state results are available for grade 3-8 state assessments in English
Language Arts (ELA) and Math, New York State Regents exams, SAT, Advanced Placement exams, and the National Ass-
essment of Educational Progress (NAEP).Test results are available for grade 3-8 state assessments in English Language Arts
(ELA) and Math, New York State Regents exams, SAT, Advanced Placement exams, and the National Assessment of Educat-
ional Progress (NAEP).Test results are available for grade 3-8 state assessments in English Language Arts (ELA) and Math, New
York State Regents exams, SAT, Advanced Placement exams, and the National Assessment of Educational Progress (NAEP).
This is only a test!!!!!!!!!!!!!!

Strengths of the Student
Information from the parent(s) for enhancing the education of the student:
Parental involvement can make a positive difference at all age levels. Parental involvement tends to be the greatest with
young children and tends to taper off as children get older. Studies have shown, however, that the involvement of par-
ents of middle and high school students is equally important. In high school, for example, a parent's encouragement can
influence whether a child stays in school or drops out. Similarly, a child may consider going to college more seriously
when parents show interest in the child's academic achievements and talk with the child about the benefits of a college
education.
Age appropriate transition and functional vocational evaluation information:
Age-appropriate transition assessments are tools that help students identify their strengths, interests, skills, and/or knowl-
edge needed to reach their goals for life after high school.

Additional Evaluation Data
No additional evaluation(s) data is requested.
Yes, additional evaluation(s) data is requested (e.g., 3-year evaluation, ARD/IEP Team request, parent request, teacher
request).

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 2

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

III. ELIGIBILITY DETERMINATION

A. Determining Disability Condition Criteria

Based on the evaluation data reviewed, the ARD/IEP Team has determined that the student:

does not meet the disability condition criteria to rec- meets the disability condition criteria to receive special

eive special education and related services. STOP! education and related services.

AND
Yes No by reason of the disability/disabilities has a need for special education and related services.

B. Determining Eligibility to Receive Special Education and Related Services

Determinant factor analysis is not applicable.

C. No Yes Based on disability condition criteria and determinant factor analysis, it has been determined that this stud-
ent is eligible for special education services under the following disability categories:
(1) - 10 Autism
(2) - 03 Auditory Impairment
(3) - 04 Visual Impairment
(4) - 09 Speech Impairment

D. Special education services are reviewed at least annually and at each review, the ARD/IEP Team determines whether a stud-
ent continues to need these services or should be dismissed from receiving special education.
ARD/IEP Begin Date: 05/20/2022
ARD/IEP End Date: 05/18/2023
Special education services are projected to begin on 05/20/2022 and will be reviewed again on 05/18/2023

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 3

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

IV. Present Levels of Academic Achievement and Functional Performance
A. PLAAFP 34 CFR §300.320

The present levels of academic achievement and functional performance in the IEP describe what the student knows and is able
to do.

Student Profile:
PLAAFP statements are intended to identify strengths and weaknesses of the student and all of the student's disability related
needs. It is a concise summary of the information and data previously collected and known about the student. The ARD Team
must consider the impact the disability has on the student's ability to learn and function as their non-disabled peers

State what the student can do in measurable terms. Document relevant student profile data. User must enter at least 350 charac-
ters here.

Describe how the student's disability(ies) affect(s) the student's involvement and progress in the general education cur-
riculum.
PLAAFP statements are intended to identify strengths and weaknesses of the student and all of the student's disability related
needs. It is a concise summary of the information and data previously collected and known about the student. The ARD Team
must consider the impact the disability has on the student's ability to learn and function as their non-disabled peers

Describe how the student's disability(ies) affect(s) the student's involvement and progress in the general education curriculum.
User must enter at least 350 characters here.

Academic/Functional/Other (Provide academic/functional information for each area identified in the current evaluation that
interferes with the student's progress in the general education curriculum.)

Accommodations:

Accommodation Category Accommodation
Other Classroom Based Accommodations Allow for preferential seating
Other Classroom Based Accommodations Alternate quiet and active time
Designated Supports Calculation Aids
Designated Supports Oral/Signed Administration
Designated Supports Supplemental Aids
Other Classroom Based Accommodations Offer choices
Other Classroom Based Accommodations Allow frequent breaks for movement
Articulation Implement IEP classroom goals in collaboration with speech therapist.

Summary of Curriculum(s) Reading ELA Math Science Social Elective/ All
Accommodation Studies Other

Allow for preferential seating
Alternate quiet and active time
Calculation Aids
Oral/Signed Administration
Supplemental Aids
Offer choices
Allow frequent breaks for movement
Implement IEP classroom goals in collaboration
with speech therapist.

B. Goals and Objectives 34CFR §300.320

Progress on the previous year's annual goals and benchmark/short-term objectives:
Describe progress made from previous annual goals and/or objectives

Does the student require short-term objectives?

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 4

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

Yes, the student requires short-term objectives because (a) the student requires modifications and accommodations to clas-
sroom instruction, assignments, and assessments to access and demonstrate progress in the grade-level TEKS; or (b) the
student has a significant cognitive disability, is receiving instruction that is linked to the grade level curriculum through
prerequisite skills; or some measurable goals are more effectively implemented or measured when short-term objectives are
included.

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 5

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

ANNUAL GOAL: B

Academic Performance

Curriculum/Service Area

Measurable Annual Goal:
Develop Annual Goal to address each academic need of the student here. Progress will be determined using the following meas-
urement criteria: Percent Accuracy. Daniel's baseline score was 50.0 (%) on 05/20/2022. Daniel will achieve 800.0 (%) by
05/18/2023.

Goal Objective(s)
· When required/appropriate, develop short-term objectives to assist in mastering Annual Goals here. Progress will be

determined using the following measurement criteria: Percent Accuracy. Daniel's baseline score was 55 Percent on
05/20/2022. Daniel will achieve 75 Percent by 05/18/2023.

TEKS Standards: This goal reflects a modification to the TEKS standards or the level at which the child is accessing the
TEKS through prerequisite skills. The student's expectations for this subject area are reflected in the student's goals/objectives.

Implemented By: Special Education Teacher, General Education Teacher, Speech Therapy Service Provider, Certified Teacher
for Students with VI, Certified Teacher for Students with AI

Schedule of Evaluation
Time frame when this goal will be monitored for progress: Every 6 weeks, Every 3 weeks (secondary)

ESY Criteria: Student does not have a need for ESY

Transition: Is this goal designed to support Transition for this student? Yes

Academic and Functional concerns: Is this goal designed to address Academic and Functional concerns? Yes

Behavior

Behavior

Measurable Annual Goal:
Develop Annual Goal to address each behavior need of the student here. Progress will be determined using the following
measurement criteria: Percent Accuracy. Daniel's baseline score was 40 (%) on 05/20/2022. Daniel will achieve 70 (%) by
05/18/2023.

Goal Objective(s)
· Develop short term objectives to address each behavior need of the student here Progress will be determined using the fol-

lowing measurement criteria: Percent Accuracy. Daniel's baseline score was 40 Percent on 05/20/2022. Daniel will ach-
ieve 70 Percent by 05/18/2023.

Implemented By: Special Education Teacher, General Education Teacher

Schedule of Evaluation
Time frame when this goal will be monitored for progress: Concurrent with the issuance of progress reports and report cards

ESY Criteria: Student does not have a need for ESY

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 6

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

Academic and Functional concerns: Is this goal designed to address Academic and Functional concerns? Yes

Speech/Language

Speech

Measurable Annual Goal:
Speech Therapist will develop Annual Goal to address the speech/language needs of the student here. Progress will be determ-
ined using the following measurement criteria: Percent Accuracy. Daniel's baseline score was 40 (%) on 05/20/2022. Daniel will
achieve 70 (%) by 05/18/2023.

Goal Objective(s)
· Speech Therapist will develop short term objectives to address the speech/language needs of the student here. Progress

will be determined using the following measurement criteria: Percent Accuracy. Daniel's baseline score was 40 Percent on
05/20/2022. Daniel will achieve 70 Percent by 05/18/2023.

Implemented By: Speech Therapy Service Provider

Schedule of Evaluation
Time frame when this goal will be monitored for progress: Concurrent with the issuance of progress reports and report cards

ESY Criteria: Student does not have a need for ESY
Academic and Functional concerns: Is this goal designed to address Academic and Functional concerns? Yes

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 7

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

C. Supplementary Aids and Personal Care Services 34 CFR §300.42; 19 TAC §89.62-63
The student requires the following supplementary aids and personal care services:

Supplementary Aids

Aids, Services, and Other Supports Provided to the Student

Area of Needs Goal Start Date End Date
05/18/2023
Instructional Accommodations 1 05/20/2022 05/18/2023

Behavioral Support Services 1 05/20/2022

Goal Number Associate Goals

1 Develop Annual Goal to address each academic need of the student here.

Campus Resources

Describe the campus resources available to assist with supplementary aids and services (i.e., Toileting - modified toilet seat; Feeding -
wedge pillow, neck roll to support head; Instructional Accommodations – multiplication chart).
Describe the campus resources available to assist with supplementary aids and services

Personal Care Services:

Are Personal Care Services required for this student: Yes

Personal Care Service assistance is required due to the student's disabilities that are listed below:

Disability Health Condition/Medical Diagnosis Psychiatric, Developmental, or Behav-

ioral Diagnosis

· 10 Autism · Autistic Spectrum, Pervasive

· 03 Auditory Impairment

· 04 Visual Impairment

· 09 Speech Impairment

Personal Care Services:
· Supervision/Monitoring: Personal Care Services is required throughout the school day in a group setting, in addition to one-

on-on basis (Individual Care). Daniel, has behavioral limitation such as (provide details of limitation here ) due to his/her 10
Autism, 03 Auditory Impairment, 04 Visual Impairment and 09 Speech Impairment that affects activities of daily living.

Personal care services are provided to prevent:
Elopement, Maintaining safety for students and others, Behavior, Attending Tasks

Additional Comments
Additional comments regarding personal care services can be entered here

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 8

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

NOTICE OF TRANSFER OF RIGHTS AT AGE OF MAJORITY
Complete the Notice of Transfer of Parental Rights form beginning no later than one year before the student reaches the age of
18. The student and parent must be informed of the student's rights under IDEA, if any will transfer or was transferred to the
student on reaching the age of 18.

D. Transition Information 34 CFR §300.42
No Yes Is the student enrolled in grade 6 or higher?

Personal Graduation Plan 08/22/2022 Anticipated date of graduation: 2026
Date student will enter / entered grade 9:

Yes No The ARD/IEP Team has determined that this student will likely graduate within four years of entering the ninth
grade.

Diploma Type
Distinguished Level of Achievement and Performance Acknowledgements

Distinguished Level of Achievement requires:
Successful completion of (1) the Foundation program (22 credits), (2) Curriculum requirements for at least one endorsem-
ent (at least 26 credits), 4 math credits - must include Algebra II, and 4 science credits.

Performance Acknowledgement requires:
1. Outstanding performance in one of the following: (a) In dual credit courses (12 college hours GPA of 3.0),
(b) In bilingual and bi-literacy (in two or more languages), (c) AP test score of 3+ or IB exam score of 4+, and (d) On
the PSAT, ACT-Plan, SAT or ACT
2. For earning a nationally or internationally recognized business or industry certification or licensure.

STEM 1 - Student is pursuing 08/22/2022 06/05/2026

Graduation Options

The ARD Committee has determined that this student will graduate and be awarded a high school diploma based on the following (mark
applicable boxes):

The LEA must provide the student with a Summary of Performance and the parent(s) and adult student with a PRIOR WRITTEN
NOTICE.

Option One: Regular Graduation
Yes No
The student has/is expected to satisfactorily completed the State's or HISD's (whichever is greater) minimum
Yes No curriculum and credit requirements for graduation (under the foundation program, recommended or distinguis-
hed achievement high school program curriculum requirements) applicable to students in general education
The student has/is expected to achieve satisfactory performance on at least 3 of 5 required state assessment,
and/or the student's cohort is eligible for individual graduation committee.

Option Three: The student has/is expected to satisfactorily complete the State's or HISD's (whichever is greater) minimum
Yes No curriculum and credit requirements for graduation (under the minimum high school program curriculum requ-
irements) applicable to students in general education with/without curriculum modifications.
Yes No Did the student participate in required state assessments?
Yes No The student has/will successfully complete their IEP
Yes No Does the student have full time employment with sufficient self-help skills?

Graduation Code:

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 9

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

No Yes Is the student 14 years of age (12 years of age for students with Autism or as determined by the ARD/IEP
Team)?

Transition Services
Review of additional information that supports transition planning (indicate below) :
Attendance Records

Development of Post-Secondary Goals

1. Describe the steps taken to ensure the student's preferences and interests are considered:
Describe the steps taken to ensure the student's preferences and interests are considered

2. Insert student comments from the Student Input Form:
Insert student comments from the Student Input Form

3. Insert parent comments from the Parent Input Form:
nsert parent comments from the Parent Input Form

4. The course of study needed to assist the student in reaching the transition goals and related objectives will include:

Consideration of Employment Goals and Objectives in the Development of the IEP
Yes No The ARD/IEP Team determined that it IS appropriate to integrate into the ARD/IEP employment goals and
objectives. If YES, address in ANNUAL GOALS section.

RELATED/MEDICAL/HEALTH SERVICES/SUPPORTS NEEDED TO FULFILL POST-SECONDARY GOALS
Currently Receiving:
None

Services/Accommodations needed to fulfill post-secondary goals and employability training

Student Need Service-Support

document services/accommodations student will need document services/supports student will need

Consideration of Independent and Adult Living Goals and Objectives in the Development of the IEP
Yes No The ARD/IEP Team determined that it IS appropriate to integrate into the ARD/IEP independent and/or adult
living goals and objectives. If YES, address in ANNUAL GOALS section.

Consideration of Student and Parental Involvement in the Student's Transition
Yes No Appropriate student involvement in the student's transition to life outside the public school system should be
integrated in the ARD/IEP.
If YES, The ARD/IEP Team will integrate in the IEP as follows:
Annual Goals
Special Education

Consideration of Postsecondary Education Options in the Development of the IEP
Yes No The ARD/IEP Team determined that it IS appropriate to integrate into the ARD/IEP services to facilitate post-
secondary education options
If YES, The ARD/IEP Team will integrate in the IEP as follows:
Annual Goals
Special Education

Consideration of the Availability of Age-Appropriate Instructional Environments

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 10

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

Yes No The ARD/IEP Team determined that it IS appropriate to integrate into the ARD/IEP services to facilitate post-
secondary education options
If YES, The ARD/IEP Team will integrate in the IEP as follows:
Special Education

Post-secondary Goals
Provide recommendations to assist the student in meeting postsecondary goals; include modifications or accommodations that
helped the student to reach any prior short term goals.

Transition - Employment
After graduation from high school ____ will ______.

Transition - Education
After graduation from high school ____ will ______.

Transition - Independent Living Skills
After graduation from high school ____ will ______.

Transition - Recreation and Social Skills
After graduation from high school ____ will ______.

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 11

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

E. The ARD/IEP Team has determined that progress toward IEP goals may be facilitated by the following (check all that ap-

ply) 34 CFR §300.38

Not Applicable Special Education Class

CTE General Education Class with accommodations

General Education Class Other

Provision of Related Services

Yes No The ARD/IEP Team reviewed achievement on each of the previous year's goals and short-term objectives on
the IEP, including a discussion of how the student' s disability affects involvement and progress in the general
education setting. NOTE: This is applicable to all but initial ARD/IEP meetings)

Yes No N/A Previous IEP goals and if applicable, objectives from ARD/IEP meeting held on , remain in effect.

Student Assessment: State STAAR

F. Behavior Considerations
Yes No The student exhibits significant behavioral challenges which adversely affect his/her educational performance
or the learning of others. If yes, complete Development of the Behavior Support and Intervention Plan form
which modifies the ISD Code of Student Conduct while considering the use of positive behavioral intervent-
ions, strategies, and supports (including supplementary aids and services, additional special education services,
and/or related services).

Yes No The student understands school rules as outlined in the district's Code of Student Conduct. If yes, the ISD
discipline policy will be followed including accommodations from the Student's Development of the Behav-
ior Support and Intervention Plan (if appropriate). If no, complete the student's Development of the Behavior
Support Plan.

G. Physical competencies, as it affects participation in instructional settings and physical education:

Normal Vision without Glasses Normal Hearing Good General Health

Describe other Physical Limitations / Medications:
Describe other Physical Limitations / Medications

H. Assistive technology considerations based on the Texas 4 Step Model:
Yes No Does the student need assistive technology to receive a free and appropriate public education?

I. Communication Needs:
Document any communication needs of the student here .

J. Individual Family Service Plan
Yes No N/A Copy of student's Individual Family Service Plan (IFSP) is attached and has been considered in
the development of the initial IEP for preschool students who have been served in Early Childhood
Intervention (ECI) Programs.

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 12

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

K. For a Student with Autism or Pervasive Developmental Disorder
Not Applicable
The student has a diagnosis of Autism or another pervasive developmental disorder.

Based on peer-reviewed research-based educational programming practices, to the extent practicable, the ARD/IEP Team
determines whether the following strategies are needed.

Social Skills Supports and Strategies
The ARD/IEP Team has considered the use of social skills supports and strategies based on social skills assessment/ cur-
riculum and provided across settings, and determined that the student DOES need services as part of his/her IEP
Describe:
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TEST TEST TEST TEST

The ARD/IEP Team will address this need in the IEP as follows: Supplementary Aids and Services

Extended Day Services Special Education Related Services Annual Goals BSIP
ESY

Positive Behavior Support Strategies
The ARD/IEP Team has considered the use of positive behavior support strategies based on relevant information and determ-
ined that the student DOES need services as part of his/her IEP
Describe:
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TEST TEST TEST TEST

The ARD/IEP Team will address this need in the IEP as follows: Supplementary Aids and Services

Extended Day Services Special Education Related Services Annual Goals BSIP
ESY

In-Home and Community-Based Training
The ARD/IEP Team has considered in-home and community-based training or viable alternatives that assist the student with
acquisition of social/behavioral skills and determined that the student DOES NOT need services as part of his/her IEP
The basis for this determination is:
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TEST TEST TEST TEST

Staff-To-Student Ratio
The ARD/IEP Team has considered the suitable staff-to-student ratio appropriate to identified activities and as needed to
achieve social/behavioral progress based on the student's developmental and learning level that encourages work towards
individual independence and determined that the student DOES need specified staff-to-student ratio as part of his/her IEP
Describe:
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TEST TEST TEST TEST

The ARD/IEP Team will address this need in the IEP as follows: Supplementary Aids and Services

Extended Day Services Special Education Related Services Annual Goals BSIP
ESY

Learning Levels From To
Acquisition - learning new information TEST TEST

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 13

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

Fluency - information learned, increase speed and ac- TEST TEST
curacy
Maintenance - preserving what's been learned TEST TEST
Generalization - using information in a broader sense TEST TEST

Minimal Unstructured Time
The ARD/IEP Team has considered the use of daily schedules reflecting minimal unstructured time and active engagement in
learning activities and determined that the student DOES need services as part of his/her IEP
Describe:
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TEST TEST TEST TEST

The ARD/IEP Team will address this need in the IEP as follows: Supplementary Aids and Services

Extended Day Services Special Education Related Services Annual Goals BSIP
ESY

Communication Interventions
The ARD/IEP Team has considered the use of communication interventions, including language forms and functions that en-
hance effective communication across settings and determined that the student DOES need services as part of his/her IEP
Describe:
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TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST TEST
TEST TEST TEST TEST

The ARD/IEP Team will address this need in the IEP as follows: Supplementary Aids and Services

Extended Day Services Special Education Related Services Annual Goals BSIP
ESY

Extended Educational Programming
The ARD/IEP Team has considered extended educational programming and determined that the student DOES need extended
educational programming as part of his/her IEP
Describe:
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TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST TEST
TEST TEST TEST TEST

The ARD/IEP Team will address this need in the IEP as follows: Supplementary Aids and Services

Extended Day Services Special Education Related Services Annual Goals BSIP
ESY

Teaching Strategies
The ARD/IEP Team has considered teaching strategies based on peer reviewed research-based practices for students with
ASD and determined that the student DOES need teaching strategies specified in his/her IEP
Describe:
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TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST TEST
TEST TEST TEST TEST

The ARD/IEP Team will address this need in the IEP as follows: Supplementary Aids and Services

Extended Day Services Special Education Related Services Annual Goals BSIP
ESY

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 14

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

Futures Planning
Beginning at any age, the ARD/IEP Team has considered futures planning (for integrated living, work, community, and edu-
cational environments) that considers skills necessary to function in current and post-secondary environments, and determined
that the student DOES need services as part of his/her IEP
Describe:
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TEST TEST TEST TEST

The ARD/IEP Team will address this need in the IEP as follows: Supplementary Aids and Services

Extended Day Services Special Education Related Services Annual Goals BSIP
ESY

Parent / Family Training
The ARD/IEP Team has considered parent/family training and support provided by qualified personnel with experience in
ASD and determined that services ARE NOT needed as part of the student's IEP
The basis for this determination is:
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TEST TEST TEST TEST

Professional Educator and Staff Support
The ARD/IEP Team has considered professional educator/staff support and determined that services ARE NOT needed as
part of the student's IEP
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TEST TEST TEST TEST

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 15

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

N. Determination of Services for a Student who is Deaf or Hard of Hearing
N/A Yes The ARD/IEP Team provided to the parent(s) the State-adopted brochure that contains written information
about programs offered by Texas School for the Deaf (TSD)

Yes No The ARD/IEP Team provided to the parent(s) the State-adopted brochure that contains written information ab-
out programs offered by Texas School for the Deaf (TSD)

The language and communication needs of the student
The DHH provider will document the language and communication needs of the student should be entered here

The student has the following opportunities for direct communications with peers and professional personnel in the stud-
ent's language and communication mode
The DHH provider will document opportunities for direct communications with peers and professional personnel in the student's
language and communication mode

The full range of needs, including opportunities for direct instruction in the student's language and communication mode
The DHH provider will document the full range of needs, including opportunities for direct instruction in the student's language
and communication mode

O. Determination of Services for a Student who is Blind or Visually Impaired

The ARD/IEP Team provided to the parent(s) the State-adopted brochure that contains written information about
programs offered by Texas School for the Blind and Visually Impaired (TSBVI)

Yes No Based on an evaluation of the student's FULL AND INDIVIDUAL EVALUATION, the student is functionally
blind. If YES, each person assisting in the development of the IEP must receive information describing the
benefits of Braille instruction

Yes No Instruction in Braille or the use of Braille for the student is appropriate. If YES, the student will be provided
with reading and writing instruction in Braille and the use of Braille that is sufficient to enable the student to
communicate with the same level of proficiency as other students of comparable ability who are at the same
grade, as follows:
Instructions:
If YES, the student will be provided with reading and writing instruction in Braille and the use of Braille
that is sufficient to enable the student to communicate with the same level of proficiency as other students of
comparable ability who are at the same grade

For a student who is functionally blind, describe the appropriate learning media based on the FUNCTIONAL VISION
EVALUATION and LEARNING MEDIA ASSESSMENT:
For a student who is functionally blind, describe the appropriate learning media based on the FUNCTIONAL VISION
EVALUATION and LEARNING MEDIA ASSESSMENT

Provide a detailed description of the arrangements made to provide the student with the following:

Orientation and Mobility Training Document Orientation and Mobility Training; ; users must enter at least

75 characters

Instruction in Braille Document Instruction in Braille; users must enter at least 75 characters

Instruction for Large Print Document Instruction for Large Print; users must enter at least 75

characters

Other training to compensate for serious visual loss Other training to compensate for serious visual loss; users must enter at

least 75 characters

Access to special media and special tools, appliances, Access to special media and special tools, appliances, aids, or devices

aids, or devices commonly used by individuals with ;enter 75 characters

serious visual impairments

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 16

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

Describe the plans and arrangements made for contacts with and continuing services to the student beyond regular school
hours (if needed) to ensure the student learns the skills and receives the training
Describe the plans and arrangements made for contacts with and continuing services to the student beyond regular school hours
(if needed) to ensure the student learns the skills and receives the training

Detailed explanation of the various service resources available in the community and throughout the State provided to the
student
Provide detailed explanation of the various service resources available in the community and throughout the State provided to the
student

Describe the training the student will receive in the expanded core curriculum (as required for the student to succeed in

classroom settings and derive lasting, practical benefits from the education in the LEA) as follows:

Compensatory Skills Document training provided; users must enter at least 75 characters for

training

Communicative Skills Document training provided; users must enter at least 75 characters for

training

Orientation and Mobility Document training provided; users must enter at least 75 characters for

training

Social Adjustment/Interaction Document training provided; users must enter at least 75 characters for

training

Vocational or Career Counseling Document training provided; users must enter at least 75 characters for

training

Career Education Document training provided; users must enter at least 75 characters for

training

Independent Living Skills Document training provided; users must enter at least 75 characters for

training

Recreation and Leisure Skills Document training provided; users must enter at least 75 characters for

training

Use of Assistive Technology Document training provided; users must enter at least 75 characters for

training

Sensory Efficiency Skills Document training provided; users must enter at least 75 characters for

training

Self-Determination Document training provided; users must enter at least 75 characters for

training

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 17

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

ARD/IEP SUPPLEMENT: Benefits of Braille Instruction
IDEA 1414 (D)(3)(iii)

In 1991, House Bill 2277, the "Braille Bill" was passed into law by the Texas State Legislature. One provision of the bill,
contained in Chapter 506, states that: "each person assisting in the development of a functionally blind child's individualized
education program shall receive information describing the benefits of Braille instruction."

It has been determined that Daniel Test is functionally blind. The following information is being provided to you as a participant
in the development of this child's individualized education program (IEP).

Instruction in Braille for use as reading and writing medium provides the following benefits:

· Braille allows reading and writing skills to be developed.
· Because literacy is based on the ability to read and write, Braille is the only media available for obtaining literacy for

people who use their tactile sense as the primary means of gathering information.
· Braille allows the child who is functionally blind to have the same "written" materials in the classroom as sighted peers.
· Braille allows for instruction in correct written language usage such as structuring sentences, spelling, formatting para-

graphs and editing.
· Braille allows the selection of a book for the pleasure of reading independently at any time or place without additional

equipment.

To benefit from Braille instruction, a child should demonstrate the following strengths:

Letter Awareness
To use any medium for literacy, a child should be able to demonstrate an understanding of the concept of the alphabet, that
letters are combined to form words that words are combined to make sentences, and that sentences express thoughts.

Tactual Discrimination and Shape Recognition
A Braille cell consists of a small, raised, six-dot configuration. The position and arrangement of the dots within this configurat-
ion indicate which letter is being represented. The shape that the dots form is the tactual identifier for the reader to recognize the
letter. A potential Braille user should be able to demonstrate an understanding of basic shapes and be able to tactually discrimi-
nate likenesses or differences between objects.

Number Concepts
The dots that comprise the Braille cell are numbered one through six according to their position within the configuration. In
addition to the shape the dots make to indicate individual letters, the numbered position of the dots (2,4,5,6 = w) is learned to
be able to produce each letter using a Braille writer. Potential Braille user should be able to demonstrate an understanding of the
numbering system and be able to demonstrate application of at least the numbers one through six.

Spatial Concepts
An understanding of and ability to demonstrate basic directional concepts in relation to a page facilitates the production of and
reading of Braille. The basic directional concepts include: top (beginning), middle, bottom (end), left, right, up, down, across,
back/backward.

Motor Skills
To be able to produce Braille, a child should be able to demonstrate the ability to use both hands in cooperation to perform
keyboarding functions using a 6-key configuration. In order to tactually read Braille efficiently, a child should demonstrate
the ability to move at least one hand laterally with one finger of the hand tactually following (tracking) lines of raised dots
completely from left to right, to the end of each line.

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 18

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

P. Behavior Support and Intervention Plan (BSIP) Yes, the student requires a BSIP.
No, the student does not require a BSIP

Behavior Support and Intervention Plan

Information Provided by the Parent
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Circumstances in the Student's Life
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Evaluation(s) Performed by the HISD
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Evaluation(s) Performed by Outside Agencies
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Current Classroom Based Assessments and Observations
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Teacher and/or Related Service Provider Information
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Discipline Records
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Attendance Records
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Previous Functional Behavior Assessment / Behavior Support Plan
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Other
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TESTTEST TEST TEST TEST TEST

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 19

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

Challenging Behaviors
Off Task, Incomplete Assignments, Disruption Inside the Classroom, Disruption outside the classroom, Tardy / Truant, Un-
prepared for Class, Emotional Outburst / Tantrum, Leaves Assigned Area, Noncompliance, Negative Verbalization, Negative
Physical, Social Isolation / Withdrawl, Substance Abuse

Rating Intervention/Consequence Effectiveness 0-Not Used 1-Not Effective 2-Sometimes Effective 3-Effective

Antecedents/Positive Supports 2 Preferential Seating and Proximity Control
0 Verbal Prompting Redirection 0 Physical Prompting / Redirection
2 Corrective Feedback 3 Develop Behavior Chart or Contract
2 Reduce Length / Number of Directives 3 Counseling or Conferencing / Processing
2 Visual Prompt / Cue / Signal 0 Provide Manipulitives
0 Written or Visual Schedule

Reinforcers/Rewards 2 Tangible Reward (specify): Hot Chips, Free time to visit his favorite teacher
3 Private Praise 3 Earned Activity / Privilege (specify): Free time to visit his favorite teacher
1 Public Praise 3 Job Responsibility (specify): Classroom manager passing out materials
2 Positive Note Home
3 Class / School Reward System

Consequences 1 Removal from Group / Class
3 Planned Ignoring 3 Sent to Office
0 In Building Suspension 3 Off Campus Suspension
2 Loss of Incentive or Privilege 0 Lunch Detention
0 Public Correction

Behavior Support and Intervention Plan for Behavior 1
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Antecedents
Independent Seat Work, Changing Classes, Sensory Issues, 1:30 pm After lunch

Consequences
Teacher Attention, Failure to Earn Reward, Sent to Office

Functions of the Behavior
Delay / Avoid Task, Communication

PREVENTION TEACHING REINFORCEMENT
Antecedents/Changes to Environment Behaviors/Skill Building Consequences/Staff Responses
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TESTTEST TEST TEST TES TESTT- TESTTEST TEST TEST TES TESTT- TESTTEST TEST TEST TES TESTT-
EST TEST TEST TES TESTTEST TEST EST TEST TEST TES TESTTEST TEST EST TEST TEST TES TESTTEST TEST
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EST TEST TEST TEST TEST EST TEST TEST TEST TEST EST TEST TEST TEST TEST

Behavior Support and Intervention Plan for Behavior 2
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TEST TEST TES TESTTEST TEST TEST TES TESTTEST TEST TEST TES TESTTEST TEST TEST TES TESTTEST TEST
TEST TES TESTTEST TEST TEST TEST TEST

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 20

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

PREVENTION TEACHING REINFORCEMENT
Antecedents/Changes to Environment Behaviors/Skill Building Consequences/Staff Responses
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Implementing the Plan:
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Monitoring the Plan:
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Evaluating the Plan:
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TESTTEST TEST TEST TES TESTTEST TEST TEST TEST TEST

Assurances:
A student's placement may be changed for more than 10 days for violating the Code of Student Conduct to the same extent the
rules allow discipline of a non-disabled student, if an ARD/IEP Team has determined that the misconduct is not a manifestation
of the student's disability; however, the student must still be provided a Free and Appropriate Public Education (FAPE) during
the period of any removal.

Either the parent of a disabled student or an adult student who disagrees with any decision regarding placement or with the man-
ifestation determination, or HISD if it believes that maintaining the current placement of the student is substantially likely to
result in injury to the student or to others, may request a hearing regarding placement from the Texas Education Agency.

Placement During Appeals: When an appeal has been requested by either the parent or HISD:

(a) the student shall remain in the interim alternative educational setting pending the decision of the hearing officer or until the
expiration of 45 school days in the case of a removal for weapons, drugs, or serious bodily injury, whichever occurs first,
unless the parent and the State of Texas or HISD agree otherwise; and

(b) the State of Texas or HISD shall arrange for an expedited hearing, which shall occur within 20 school days of the date the
hearing is requested and shall result in a determination within 10 school days after the hearing.

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 21

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

V. SCHEDULE OF INSTRUCTIONAL AND RELATED SERVICES:

Transportation as a Related Service:
Is special transportation required? No Yes

Justification:
The student has a limited mobility or cognitive......

The student will be unable to receive special education services unless special transportation is provided because
The student has limited mobility or cognitive skills which impede safe travel on a regular school bus.

Transportation provided by (Describe how transportation will be provided):
HISD, complete HISD Transportation Registration Form online.

What type of transportation service is required?
Wheelchair Bus Start Date: 04/27/2022 End Date: 04/26/2022

Instructional / Related Services: 34 CFR §300.320

Total Instructional/Related Service hours should be reflected in Total Special Education hours.

Related Services / Other Instructional Services - Semester: Spring 2021-2022

Itinerant Visually Impaired Teacher Services - Direct

Educational Needs Duration Amount / Location Goal Type of
Frequency Service Del-
ivery
TEST TEST TEST TEST 30 minute(s) 1 per Week Flexible locat- Direct
TESTTEST TEST TEST TEST ions on campus
TEST TEST TESTTEST TEST

Itinerant Auditory Impaired Teacher Services - Direct

Educational Needs Duration Amount / Location Goal Type of
Frequency Service Del-
TEST TEST TEST TEST 30 minute(s) Flexible locat- ivery
TESTTEST TEST TEST TEST 1 per Week ions on campus Direct
TEST TEST TESTTEST TEST

In-Class Support- English Language Arts - Direct

Educational Needs Duration Amount / Location Goal Type of
Frequency 1 Service Del-
Providing reading vocabulary; 30 minute(s) General ivery
comprehension strategies 3 per Week education Direct

In-Class Support- Math - Direct Duration Amount / Location Goal Type of
Educational Needs Frequency 1 Service Del-
General ivery
TEST TEST TEST TEST TEST 60 minute(s) 2 per Week education Direct
TEST TEST TEST TEST TEST
TEST TESTTEST TEST

Subtotal hours per week for semester Spring 2021-2022 = 0.00

ID Associate Goals
1 Develop Annual Goal to address each academic need of the student here.
1 Develop Annual Goal to address each academic need of the student here.

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 22

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

Related Services / Other Instructional Services - Semester: Fall 2022-2023

Itinerant Visually Impaired Teacher Services - Direct

Educational Needs Duration Amount / Location Goal Type of
Frequency Service Del-
ivery
TEST TEST TEST TEST 30 minute(s) 1 per Week Flexible locat- Direct
TESTTEST TEST TEST TEST ions on campus
TEST TEST TESTTEST TEST Amount / Type of
Frequency Service Del-
Itinerant Auditory Impaired Teacher Services - Direct ivery
Direct
Educational Needs Duration Location Goal
Type of
TEST TEST TEST TEST 30 minute(s) 1 per Week Flexible locat- Service Del-
TESTTEST TEST TEST TEST ions on campus ivery
TEST TEST TESTTEST TEST Amount / Direct
Frequency
In-Class Support- English Language Arts - Direct Type of
Service Del-
Educational Needs Duration Location Goal ivery
Direct
Providing reading vocabulary; 30 minute(s) 3 per Week General 1
comprehension strategies Duration education Goal
Amount /
In-Class Support- Math - Direct Frequency Location
Educational Needs

math problem solving calculat- 60 minute(s) 2 per Week General
ion; Small group instruction on education
IEP goals and general education
curriculum.

Subtotal hours per week for semester Fall 2022-2023 = 0.00

ID Associate Goals
1 Develop Annual Goal to address each academic need of the student here.

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 23

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

Related Services / Other Instructional Services - Semester: Spring 2022-2023

Itinerant Visually Impaired Teacher Services - Direct

Educational Needs Duration Amount / Location Goal Type of
Frequency Service Del-
ivery
TEST TEST TEST TEST 30 minute(s) 1 per Week Flexible locat- Direct
TESTTEST TEST TEST TEST ions on campus
TEST TEST TESTTEST TEST

Itinerant Auditory Impaired Teacher Services - Direct

Educational Needs Duration Amount / Location Goal Type of
Frequency Service Del-
TEST TEST TEST TEST 30 minute(s) Flexible locat- ivery
TESTTEST TEST TEST TEST 1 per Week ions on campus Direct
TEST TEST TESTTEST TEST

In-Class Support- English Language Arts - Direct

Educational Needs Duration Amount / Location Goal Type of
Frequency Service Del-
TEST TEST TEST TEST 30 minute(s) General ivery
TESTTEST TEST TEST TEST 3 per Week education Direct
TEST TEST TESTTEST TEST

In-Class Support- Math - Direct Duration Amount / Location Goal Type of
Educational Needs Frequency Service Del-
General ivery
TEST TEST TEST TEST 60 minute(s) 2 per Week education Direct
TESTTEST TEST TEST TEST
TEST TEST TESTTEST TEST

Subtotal hours per week for semester Spring 2022-2023 = 0.00

Instructional Services - Semester: Spring 2021-2022

Reading 7

Grade Class support Duration Amount / Frequency Location
assigned ICS 60 minute(s) 5 per Week
G General Education
Location

Subtotal hours per week for semester Spring 2021-2022 = 0.00

Instructional Services - Semester: Fall 2022-2023

Reading 7

Grade Class support Duration Amount / Frequency Location
assigned ICS 60 minute(s) 5 per Week
G General Education
Location

Subtotal hours per week for semester Fall 2022-2023 = 0.00

Instructional Services - Semester: Spring 2022-2023

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 24

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

Reading 7

Grade Class support Duration Amount / Frequency Location
assigned ICS 60 minute(s) 5 per Week
G General Education
Location

Subtotal hours per week for semester Spring 2022-2023 = 0.00

Accelerated Instruction/Intensive Program of Instruction

Accelerated Instruction under the Student Success Initiative (SSI) TEC §28.0211 requires a school district to provide stud-
ents in third through eighth grade who do not perform satisfactorily on a state assessment with accelerated instruction in the
applicable subject area.

Was the student successful on all state administered assessments (including alternate Yes No N/A
assessments)? Yes No
Parent gives permission for student to be served in an intervention group with more
than three students?

The school district in which the student attends school shall provide to the student accelerated instruction in the applicable sub-
ject area, including reading instruction for a student who fails to perform satisfactorily on a reading assessment instrument.

After a student fails to perform satisfactorily on an assessment instrument a an Accelerated Learning Committee (ALC) shall
be established to prescribe the accelerated instruction the district shall provide to the student before the start of the next school
year. The Admission Review Dismissal committee (ARDC) shall serve as the ALC for special education students.

The Accelerated Learning Committee (ALC) shall be composed of the principal or the principal's designee, the student's par-
ent or guardian, and the teacher of the subject of an assessment instrument on which the student failed to perform satisfactorily.

The district shall notify the parent or guardian of the time and place for convening the Accelerated Learning Committee (ALC)
and the purpose of the committee. TEC §28.0211(c) An accelerated instruction group administered by a school district under this
section may not have a ratio of more than 3 students for each teacher, although parents have the option to waive the 3:1 requ-
irement.

Check each area on which the student did not perform satisfactorily.
Reading Mathematics Writing Science Social Science

Accelerated Instruction/Intensive Program of Instruction

Assessment Area Reading Date Services Provided Type of Service Del-
Frequency / Duration Service Locat- ivery
ion Begin Date: Direct
Num Sessions: 2 per General Edu- 04/27/2022
Week cation Location End Date:
Session length: 45 per 04/26/2023
minute(s)

Specific Support/Assistance to be Provided

STAAR Tutorials TEST
Accelerated learning is:
deeper learning through complex and meaningful problems and projects
moving forward into grade-level content, with support
prioritizing high-level skills and content and creating teaching and learning pathways

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 25

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

determining the most efficient and effective way to help students experience grade-level learning based on where they are today
access to grade-level content despite the absence of some knowledge and skills from previous grades
identifying the most crucial knowledge and skills that students need and integrating those into lessons
a long-range plan, building on a foundation of assets, not deficiencies
assuming all students can learn literally anything with the right instruction and support
scaffolding up, not down

Dyslexia Services
The need for Dyslexia Services has been evaluated.
The student will receive Standard Protocol Dyslexia Interventions for 60 minutes per week.

The student will be unable to receive special education services unless special transportation is provided because of one or more
of the following reasons:
The student has limited mobility or cognitive skills which impede safe travel on a regular school bus.

Special Transportation Considerations

Is special seating required Yes No

Student's height: 5'11''
Student's weight: 160

If yes, please specify:

Whole seat for one person
Seat belt

Using the codes below, please describe any health and/or behavioral concerns that may affect safe transportation of this student
and describe any precautions that should be taken to ensure the safety of this student.

Verbal
Non Verbal

Student's Before School Pick-Up Address
Does the student need to be picked up? No

Student's After School Delivery Address
Does the student need to be picked up? No

Coordination between General Education and Special Education

Responsibility for monitoring student performance in Gen- Position/Title: case manager
eral Education:
Frequency: Schedule of evaluation: 6 weeks
Frequency: Schedule of evaluation of participation in 3 weeks
extracurricular activities:
Criteria for participation in extracurricular activities: same as non disabled peers
Progress Report/Report Card,Goals and/or goals and objectives are
Parent Coordination: updated and sent home,Parent Conference

Schedule of Compensatory Services:

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 26

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

Are Compensatory Services required? No Yes

Has the student been determined eligible for compensatory services as a result of a previously denied evaluation request? No Yes
Details: Academic

Has the student been determined eligible for compensatory services as a result of a lack of implementation of the IEP? No Yes
Details: Failure to Provide Services

Has the student been determined eligible for compensatory services as a result of delayed evaluation timelines? No Yes

ADDITIONAL COMMENTS:
TESTTESTTEST
If the LEA doesn't give your child all of the special education services listed in her IEP (including academics, speech therapy, language,
physical therapy, occupational therapy, social work, and any other related service or therapy), you may be able to get compensatory
education. For example, if your child's IEP says she should get 60 minutes per week of speech therapy, and she gets no speech therapy
for three weeks, your child should get 180 extra minutes (60 minutes per week times three weeks) of speech therapy to make up for that
time she missed. This is compensatory special education. It is not acceptable under IDEIA for the school district to try to say that they
don't have to provide speech therapy if the speech teacher is ill or absent.

Compensatory Service Details

Service Added Educational Duration Amount / Location Goal Type of
Speech/Language Needs Frequency Service Del-
ivery
TEST TEST 30 minute(s) 3 / Week Flexible locat- Direct
TEST Create ions on campus
opportunities
for success.
Providing clas-
sroom accom-
modations that
Daniel is to
receive.

Compensatory Service Tracking

Compensatory Service Original Hours Owed Hours Completed Hours Remaining
Speech/Language 120 80 40

VI. STUDENT ASSESSMENT:

The decision to use a particular accommodation with any student should be made on an individual basis and should take into
consideration (a) the needs of the student and (b) whether the student routinely receives the accommodation in instruction and
testing. If a student receives special education services, all testing accommodations that are not part of the standard assessment
procedures must be documented in the student's IEP. Refer to the Texas Education Agency manual, Revised ARD Committee
Decision-Making Process for the Texas Assessment Program.

State and District Assessments

Note: Exemption from standardized testing may hinder acceptance into post-secondary and higher education.

Student is not classified as LEP/EL Student is classified as LEP/EL
Student is not taking a state assessment

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 27

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

For students taking STAAR Alternate 2, parents have been notified the student's achievement will be based on alternate
achievement standards.

Indicate the grade level and school year the student will be enrolled at time of testing. 2021-2022, 2022-2023
school year

District Assessment
Provide a statement describing the District Assessment(s) in which the student will participate.

Renaissance, Benchmarks
he table at the top of the page, but have not provided at least 25 characters in response to the statement "Provide a statement
describing the District Assessment(s) in which the student will participate"

Grade: 8 Assessment Participation Level Accommodations
Participation Area Decision
STAAR Student will take this version of the Calculation Aids
Grade 8 - STAAR Math test with accommodations Oral/Signed Administration
Supplemental Aids

Rationale: 2. Receives TEKS-based instruction routinely implemented allowable accommodations

Grade 8 - STAAR Reading STAAR Student will take this version of the Oral/Signed Administration

test with accommodations Supplemental Aids

Rationale: 2. Receives TEKS-based instruction routinely implemented allowable accommodations

Grade 8 - STAAR Science STAAR Student will take this version of the Calculation Aids

test with accommodations Oral/Signed Administration

Supplemental Aids

Rationale: 2. Receives TEKS-based instruction routinely implemented allowable accommodations

Grade 8 - STAAR Social Studies STAAR Student will take this version of the Supplemental Aids
test with accommodations

Rationale: 2. Receives TEKS-based instruction routinely implemented allowable accommodations

EXTENDED SCHOOL YEAR (ESY)

Are Extended School Year Services Recommended? Yes

Based on data reviewed, the student is at risk for losing previously mastered critical skills when school is not in session and will have
difficulty regaining those skills within a reasonable amount of time when school resumes. Documented evidence of regression is required.

The loss of acquired critical skills would be particularly severe or substantial without regard to the length of the recoupment period.

Documentation to support recommendations:
TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST

Identify areas of regression or where the student reasonably may be expected to exhibit severe or substantial regression:
TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST

These skills of concern are specified in the student's current goals and objectives (Choose specific goals and objectives aligned
with the above areas of regression):
TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST

Transportation is needed
The student has adaptive needs: Touch Monitor, Keyguard

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 28

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

The student has special dietary needs: Food Allergy, No dairy, peanut allergy
The student has health/medical needs: Medication, Tube feeding, Hoyer lift
The student has communicative needs: Single button communication device (i.e., switch), Communication board with pictures, words,
or objects
The student has supplementary aids/services needs: Hoyer lift, Epilepsy or seizure disorder

The following may result during the first eight weeks of the next school year if ESY is not provided:
Significant loss of acquired skills necessary for the student to appropriately progress in the general curriculum
Significant loss of self-sufficiency in self-help skill areas as evidenced by an increase in the number of direct service staff and/or
amount of time required to provide special education or related services

The ARD committee determined that the student will require an extended school year program and that the student's
placement will be:
Instructional Program: Self-Contained
Duration of Extended School Year Services between 06/16/2021 and 07/16/2021 4 Hours 4 Days per week; for 4 weeks

VII. CONSIDER EDUCATIONAL ALTERNATIVES:

Services which may be appropriate and for which the student is eligible were reviewed and discussed. Identify the general and
special education alternatives and supplementary aids and services previously tried (t) or considered (c). 34 CFR §300.115

Efforts to Modify and Supplement the Stud- Options provided Rate Options provided Rate Effect on Class Rate
ent's Participation in the General Education
Setting results (Meaningful, results (Meaningful, Options Provided

General education classroom core instructional Minimum, and No Ben- Minimum, and No Ben- (Positive, Negative,
interventions (Tier I)
Targeted group interventions (Tier II) efit) Academic efit) Non-Academic None)
Intensive, individual interventions other than sp-
ecial education (Tier III) Meaningful Benefit Meaningful Benefit Positive

Meaningful Benefit Meaningful Benefit Positive
Meaningful Benefit Meaningful Benefit Positive

Yes No Were these efforts to modify and supplement the student's participation in the general education setting
successful?

Yes No Will the student receive an educational benefit from full inclusion in the general education setting (including
nonacademic benefit)?

VIII. CONSIDER LEAST RESTRICTIVE ENVIRONMENT AND CONSIDERATION OF RELATED FACTORS:

34 CFR §300.114 Note: Least Restrictive justifications should be completed before identifying the campus and / or instructional
setting of the child who is to receive special education services.

The student will have available an instructional day commensurate with that of students without disabilities.

A. The ARD/IEP Team recommends that the student receive ALL instruction and services in the general education setting with
supplementary aids and services, based on a review of assessment data, new IEP, instructional modifications/supports neces-
sary to implement IEP, and previous efforts/considerations (Complete supplement forms if applicable - Supplementary Aids and
Services, Development of the BSIP, PGP, etc.).

Yes No

B. For students receiving special education services not on his/her home campus: (Address all) If additional space is ne-
eded use the deliberations page.

The ARD/IEP Team assures that the student's educational placement is as close as possible to his/her home campus.

Yes No Student is excluded from non-academic and extracurricular activities.

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 29

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

In addressing the least restrictive environment, the ARD/IEP Team considered the potential harmful effects on the student and
on the quality of services provided to the student with disabilities if the student is removed from general education clas-
ses. Describe potential harmful effects: 34 CFR §300.116

Effects on the student: Lack of opportunity for social interaction

Effects on the quality of services: Wide differences in development levels causing social isolation

IX. ASSURANCES: (check all applicable items)

The ARD/IEP Team assures that the decision to provide educational services:

A. is not based on deficiencies identified as directly attributable to a different culture or lifestyle or lack of educational opp-
ortunities. 34 CFR §300.306 (c)

Yes No Basis for Assurance: Review of Parent / Child Information

B. for national origin minority group child or linguistically different student, is not based on criteria which were developed sol-
ely on command of the English Language. 34 CFR §300.306 (a) and (b)

Yes No N/A Basis for Assurance:
Assessment Conducted in Native Language and English
Use of Interpreter/Translator

C. The ARD/IEP Team assures that all instruction and related services specified on the IEP will be provided to the student at no
cost. Fees normally charged to students without disabilities or their parents as a part of the general education program may be
charged (i. e., art or laboratory fees). 34 CFR §300.17

Yes No

D. The ARD/IEP Team assures that this student is being educated with students his/her age who do not have disabilities to the
maximum extent appropriate to his/her overall educational needs, including academic and developmental areas such as language
and socialization. 34 CFR §300.114

Yes No

X. PLACEMENT DETERMINATION: INSTRUCTIONAL SETTING / PROGRAM The student's educational placement is
based on his/her IEP. 34 CFR §300.116; §300.118

Semester Location Instructional Setting Placement
Spring 2021-2022 HISD Campus Mainstream with Direct, Indirect, and/or 40
Support Services
Fall 2022-2023 HISD Campus Mainstream with Direct, Indirect, and/or 40
Support Services
Spring 2022-2023 HISD Campus Mainstream with Direct, Indirect, and/or 40
Support Services

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 30

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

XI. DELIBERATIONS:

ARD/IEP Team

The deliberations page documents and summarizes the decisions made during the ARD/IEP meeting. This written summary is

not intended to be an exact recording or script of all conversations or comments made during the meeting.

Yes No N/A Student led a portion of the ARD/IEP Team Meeting.

Yes No N/A Discussion of supplements and additional forms included on the IEP is recorded in the

deliberations.

Yes No Has the student been determined eligible for compensatory services as a result of a previously

denied evaluation request?

Meeting start time: 9:15 am Meeting end time: 11:15 am

MEETING INFORMATION
Purpose of the Meeting
The ARD/IEP Team agreed to review the following: Annual, Transition, ESY, Other, Program (IEP), Placement
Procedural Safeguards
The parent was provided with a copy of the Procedural Safeguards on 05/20/2022
INFORMATION REVIEWED AND CONSIDERED

Full Initial Individual Evaluation Summary/Full Individual Evaluation Summary
Evaluation Specialists will enter the evaluation report summary details here

Evaluation Information

Psychological Evaluation, Evaluation Date: 02/25/2019
Evaluation Specialists will enter the evaluation report summary details here

TRANSITION

Daniel Test will graduate with the following diploma type: DLAPA
Determination of Services for a Student who is Deaf or Hard of Hearing
The ARD/IEP Team provided to the parent(s) the State-adopted brochure that contains written information about
programs offered by Texas School for the Deaf (TSD)

INSTRUCTIONAL AND RELATED SERVICES
Curriculum Setting
Daniel Test spends the following amount of time in the general education and special education setting:
Spring 2021-2022: 7.33 in General Education, and 0.00 hours in Special Education per day.
Fall 2022-2023: 7.33 in General Education, and 0.00 hours in Special Education per day.
Spring 2022-2023: 7.33 in General Education, and 0.00 hours in Special Education per day.

Refer to the Instructional and Related Services section of this ARD/IEP document for a semester specific breakdown.

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 31

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

Related Services/Other Instructional Services Specific Support/Assistance to be Provided
Itinerant Visually Impaired Teacher Services - TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST
Direct TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST
TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST
Itinerant Auditory Impaired Teacher Services - TESTTEST TEST TEST TEST TEST TEST TEST
Direct TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST
TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST
In-Class Support- English Language Arts - Direct TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST
TESTTEST TEST TEST TEST TEST TEST TEST
In-Class Support- Math - Direct TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST
TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST
Itinerant Visually Impaired Teacher Services - TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST
Direct TESTTEST TEST TEST TEST TEST TEST TEST
Itinerant Auditory Impaired Teacher Services - TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST
Direct TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST
In-Class Support- English Language Arts - Direct TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST
TESTTEST TEST TEST TEST TEST TEST TEST
In-Class Support- Math - Direct TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST
TESTTEST TEST
Itinerant Visually Impaired Teacher Services - TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST
Direct TESTTEST TEST
Itinerant Auditory Impaired Teacher Services - TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST
Direct TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST
In-Class Support- English Language Arts - Direct TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST
TESTTEST TEST TEST TEST TEST TEST TEST
In-Class Support- Math - Direct TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST
TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST
TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST
TESTTEST TEST TEST TEST TEST TEST TEST
TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST
TESTTEST TEST
TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST
TESTTEST TEST
TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST
TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST
TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST
TESTTEST TEST TEST TEST TEST TEST TEST
TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST TEST
TEST TEST TESTTEST TEST TEST TEST TEST TEST TESTTEST TEST
TEST TEST TEST TEST TESTTEST TEST TEST TEST TEST TEST
TESTTEST TEST TEST TEST TEST TEST TEST

PARTICIPATION IN STATE ASSESSMENTS

Student Assessment

Participation is State Assessments
OTHER, STR

EDUCATIONAL ALTERNATIVES

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 32

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

The ARD/IEP Team determined the appropriate educational placement for Daniel Test will have the following instructional sett-

ing codes.

Semester Placement

Spring 2021-2022 40

Fall 2022-2023 40

Spring 2022-2023 40

Additional Comments:
** This is a sample outline. Users are to use this section to capture all information discussed during the meeting **

The purpose of this meeting is a Promotion/Annual. Members in attendance include (list name and title)
Indicate parent/guardian and student participation: Parent and student was/was not in attendance. Neither Parent nor student was
in attendance. Parent granted committee permission to proceed without her. After 3 unsuccessful documented attempts to invite
parent, with no response, the committee was able to proceed.

The Procedural Safeguards were sent with Notice of Meeting. Contact information was provided if questions.
Student continues to meet the eligibility criteria for OHI ( ADHD) and Learning Disabled, according to FIE dated /TEST/ DATE
(If new FIE, allow evaluation specialist to input statement)

Insert Admin./Teacher/Related Service Provider statements:
Identify which State Assessments will be administered and if with/without accommodations

Discuss implementation of any current supplements and results; update/develop supplements as needed

Transportation will be provided by parent or HISD. Assistive technology devices and services have been considered by the ARD
committee and are found to be unnecessary. Technology available in the classroom is sufficient.

The Least Restrictive Environment will be the General ed class with provided accommodations and Support Facilitation. Student
will receive ICS in Reading and Math.
ESY is/is not recommended at this time because student is progressing in all academic areas.

Minutes were read and approved. The ARD forms were signed and meeting was adjourned.

This entire document represents the actions of this ARD/IEP Team. 34 CFR §300.322
Report (ECI or private school students who meet requirements) received today by parent/surrogate parent/adult student.

Recorded by: Signature Title

Copy of report mailed/sent by: Special Ed Prog Spclst-12M 05/20/2022
Title Date
5354
Name

Fax Generated on '05/20/2022'

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15/-.000E8055

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 33

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

XII. SIGNATURE OF ARD/IEP TEAM AND OTHER PARTICIPANTS:
34 CFR §300.345(f); 19 TAC §89.1050(a)(e)

Fax Generated on '05/20/2022'

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Signature And Title Role Participation Time Agreement
Members Excused
From Me-
eting

Sean John: Date:
Dean of Students
Administrator Participated via video conference Agree

Mr. Test: Date:

Father Parent Participated via video conference Agree

Digitally signed by Lashunda Johnson: LJ Date: 2022-05-17 10:45:02
Special Ed Prog Spclst-12M Special Education
Participated via video conference
Teacher(Case Manager)

Beverly Hardy: Date:
Speech Therapist 10M
In Person (Do not sign
electronically)

Jennifer LopezTest: Date:
General Education Teacher General Education Teacher Participated via video conference

Rochelle Abernathy: Date:
Tchr, Special Ed Deaf 10M
In Person (Do not sign
electronically)

Samantha Voll: Date:
Teacher of the Visually
Impaired In Person (Do not sign
electronically)

Daniel Test: Date:
Student
Participated via video conference

ARD/IEP Team signatures indicate that members were present at the ARD/IEP meeting, participated in the discussion, and un-
derstood what was discussed. Each member further understands that a check of agreement indicates that he/she agrees to the
decisions reached at the ARD/IEP meeting. Indicate specific positions, i.e., Teacher of the: Visually Impaired, Deaf/Hard of
Hearing, or Career and Technical Education. LPAC representative is required at the ARD/IEP meeting of ANY student who has
limited English proficiency (LEP) 34 CFR §300.571

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 34

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

The parent understands that the ARD/IEP Team will reconvene on the 3rd date if all documented attempts to accommodate
the parent's schedule are unsuccessful. The parent must be provided with Prior Written Notice each time refusal/proposed init-
iation or changes to the identification, evaluation, educational program, or educational placement of the child/adult student or the
provision of a free appropriate public education. Prior Written Notice must be given at least 5 school days in advance of the
action(s) that HISD proposes or refuses to take.

Please take a moment to participate in a brief survey to assist the Office of Special Education Services to provide outstanding
services to students with disabilities. There are three ways to complete the survey:
1. Complete an online survey at your child's school following an ARD/IEP meeting,
2. Complete an online survey anytime at https://www.surveymonkey.com/s/HISD_Parent_Survey, or
3. Call us at (713) 556-7025 and we will mail you a survey to complete and return to us.

PARENT/STUDENT RIGHTS: 34 CFR §300.500-300.529
Yes No A copy of the *Procedural Safeguards (Rights) is provided to the parent/student with the notice of this
ARD/IEP meeting.
Parent/adult student was not present.

The IEP report will be sent to him/her with a cover letter on 05/20/2022 by Case Manager
Given at the time of ARD/IEP meeting to: parent name
*Procedural Safeguards are sent with IEP report to: parent name

If a 10-day recess is implemented and the ARD/IEP Committee still cannot reach a mutual agreement, then the parent/adult student must be provided with Prior Written
Notice: Notice of Proposal or Refusal, and implement the IEP which it has determined to be appropriate for the student. When an IEP is implemented with which the
parent/adult student disagrees, the District shall provide Prior Written Notice to the parent/adult student.

Note: After five (5) years of inactive status or graduation, specific special education student records will be destroyed and will no longer be available. *Notice of
Procedural Safeguards: Rights of Parents of Students with Disabilities

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 35

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District Office of Special Education Services
ARD/IEP SUPPLEMENT: Prior Written Notice
34 CFR §300.503 & 19 TAC §89.1050

Guidance: Prior Written Notice

What is Prior Written Notice?
Prior written notice contains the seven required items and meets state and federal requirements. Prior written notice is intended
to provide a clear record for the student, parent, and District of the decisions that have been or will be made, the basis for those
decisions, and the actions that will or will not be taken. Prior written notice records any proposals or refusals with regard to sp-
ecial education matters.

Prior written notice must be provided in language understandable to the general public and in the native language of the adult
student/parent or other mode of communication used by the adult student/parent, unless it is clearly not feasible to do so. If the
native language/mode of communication of the adult student/parent is not a written language, the District must take steps to en-
sure that the prior written notice is translated orally or by other means to the adult student/parent in their native language/mode
of communication, ensuring that the adult student/parent understands the content of the prior written notice.

If prior written notice is provided after an ARD/IEP meeting, the adult student/parent has the right to use up to five days to rev-
iew documents, including a newly developed IEP, to make the most appropriate school-related decisions for himself/herself or
his/her child. In accordance with state and federal laws, HISD must wait 5 days to implement an IEP after the ARD/IEP meet-
ing. If the adult student/parent agrees to waive the 5 day waiting period, the IEP can be implemented immediately. The agreem-
ent or disagreement is voluntary.

Prior Written Notice Is Also Needed When Agreement during An ARD/IEP Meeting Is Not Reached:
If, during an ARD/IEP meeting, the ARD/IEP Team does not reach mutual agreement, the adult student/parent will be offered
a single 10 day recess in order to allow the adult student/parent and the District the opportunity to reach mutual agreement. If
after the 10 day recess the ARD/IEP Team does not reach mutual agreement, the District shall provide an additional prior written
notice and may implement the IEP it determined to be appropriate for the child/adult student. However, a written statement of
the basis for the disagreement must be included in the IEP, and the parent who disagrees must be offered the opportunity to write
a statement of disagreement.

The District and the adult student/parent may request IEP facilitation by an independent facilitator under the Texas Education
Agency (TEA) program that provides IEP facilitators by completing and submitting the TEA's required form within five days of
the ARD/IEP meeting that ended in disagreement.

The District may offer IEP facilitation, which is different from the TEA's program that provides IEP facilitators, or may incorp-
orate elements of IEP facilitation into an ARD/IEP meeting.

This prior written notice is provided to: 05/20/2022

Mr. Test Date

Parent/Adult Student

Note : An adult student/parent may elect to receive the prior written notice by electronic mail.

Campus to Complete this Section

Identify and Describe the Action the District Will Take:
The District must provide prior written notice to the adult student/parent at least five school days, unless he/she agrees to a
shorter timeframe, before it:

Proposes or refuses to initiate or change the identification of the child/adult student
Proposes or refuses to initiate or change the evaluation of the child/adult student
Proposes or refuses to initiate or change the educational placement of the child/adult student
Proposes or refuses to initiate or change the provision of a free appropriate public education (FAPE) to the child/adult
student

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 36

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District Office of Special Education Services
ARD/IEP SUPPLEMENT: Prior Written Notice
34 CFR §300.503 & 19 TAC §89.1050

Ceases to provide special education and/or related services to the child/adult student due to adult student/parent's revocation
of consent for services.
Implements an individualized education program (IEP) with which the parent/adult student disagrees.

Note: The District must provide the adult student/parent with prior written notice regardless of whether the adult student/parent
agreed to the change or requested the change.

Explanation of Action
1. Describe the action proposed/refused by HISD

Describe the action proposed/refused by HISD. Information discussed must be entered, do not leave blank.

2. Explain why action was proposed/refused by HISD

Explain why action was proposed/refused by HISD. Information discussed must be entered in this section, do not leave
blank.

3. Describe each evaluation procedure, assessment record, or report HISD used/will use as a basis for the proposed/refused
action

Describe each evaluation procedure, assessment record, or report HISD used/will use as a basis for the proposed/refused
action. Information discussed must be entered in this section, do not leave blank.

4. Option(s) the HISD team considered/proposed and reason(s) option(s) refused

Option(s) the HISD team considered/proposed and reason(s) option(s) refused. Information discussed must be entered in
this section, do not leave blank.

5. Describe any other factors relevant to HISD’s proposal/refusal

Describe any other factors relevant to HISD's proposal/refusal. Information discussed must be entered in this section, do
not leave blank.

Action When Evaluation is Requested
When an adult student/parent submits a written request to the District for an initial evaluation, the District must, not later than
the 15th day after the date of receipt, provide the parent/adult student:

· Prior written notice of its proposal to conduct an evaluation, a copy of the Notice of Procedural Safeguards, and an opp-
ortunity to give consent

· Prior written notice of its refusal to conduct an evaluation and a copy of the Notice of Procedural Safeguards

Campus Comment, if Applicable
Any campus comments can be entered in this section.

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 37

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District Office of Special Education Services
ARD/IEP SUPPLEMENT: Prior Written Notice
34 CFR §300.503 & 19 TAC §89.1050

Parent/Adult Student to Complete This Section

Sources for parent/adult students to contact to obtain assistance in understanding the prior written notice provisions:
Houston ISD - Office Special Education Services

Phone: (713) 556-7025 Website: http://www.houstonisd.org/Page/58432

Dr. S. Lachlin Verrett, Executive Director, Special Education Services
Shawna Punch, Senior Manager, Special Education Services

Mary Kay Kinnett, Director for Speech-Language Services and Special Education Evaluations

Region IV Education Service Center Texas Workforce Solutions
7145 Tidwell Road Vocational Rehabilitation Services

Houston, Texas 77092, (713) 462-7708 6220 Westpark, Suite 110
www.esc4.net/specialeducation Houston, Texas 77057, (713) 267-8510

www.twc.state.tx.us

The Arc of Greater Houston Arc of Greater Houston - Familias Hispanas del Arc
3737 Dacoma, Suite E Spanish Support Group
4410 Navigation Blvd.
Houston, Texas 77092, (713) 957-1600
www.aogh.org Houston TX 77011, (713) 957-1600 ext. 117
Email Contact: [email protected]

Disability Rights, Texas Learning Disabilities Association of Texas
1500 McGowen St., Suite 100 P.O. Box 831392
Houston TX 77004, (713) 974-7691
Toll-Free Intake Line for New Callers: 1-800-252-9108 Richardson, TX 75083-1392
www.ldatx.org
www.disabilityrightstx.org
Email Contact: [email protected]

Special Kids, Inc. Texas Project First
9001 Airport Blvd., Suite 707 www.texasprojectfirst.org
Houston, Texas 77036, (713) 783-KIDS (5437) 1-855-SPEDTEX (1-855-773-3839)

www.specialkidsinc.com
Email Contact: [email protected]

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 38

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District Office of Special Education Services
ARD/IEP SUPPLEMENT: Prior Written Notice
34 CFR §300.503 & 19 TAC §89.1050

If you have questions regarding this prior written notice, you may contact:

Special Education Senior Manager Program Specialist
Your signature below indicates that you understand the content of this Notice.

Parent/Adult Student Signature Date Interpreter/Translator Signature Date

Your signature below indicates that you waive the required five school days waiting period for the prior written notice.

Parent/Adult Student Signature Date Interpreter/Translator Signature Date

Parent/Adult Student Survey

Please participate in a brief survey to assist the Office of Special Education Services to provide quality services to students with
disabilities.

There are three ways to complete the survey:
1. Complete an online survey at your campus/your child's school following an ARD/IEP meeting
2. Complete an online survey anytime at https://www.surveymonkey.com/s/HISD_Parent_Survey
3. Call us at (713) 556-7025 and we will mail you a survey to complete and return

Fax Generated on '05/20/2022'

@15/-.000E8055@
15/-.000E8055

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 39

Name: Daniel Test, TEST123231123 ARD/IEP Meeting Date: 05/20/2022

Houston Independent School District
Office of Special Education Services

ARD/IEP Notice to Access of Medicaid Reimbursement

The Houston ISD must give you an annual written notice (information received in writing) that it will access your or your child's public
benefits or insurance. First, the Houston ISD is required to (a) seek your one-time consent to exchange information with and to submit
bills to Medicaid for reimbursement, and (b) inform you of why the consent is requested. After it obtains this one-time consent, the
Houston ISD will not be required to obtain any further parental consent in the future before it accesses your or your child's public
benefits or insurance regardless of whether there is any change in the type, amount, or cost of services to be billed to the public benefits
or insurance program (e.g. Medicaid). The Houston ISD must provide the notice in understandable language, and translated into your
native language or other mode of communication, unless it is not feasible to do so. The following constitutes prior written notice.

Description of the action(s) the Houston ISD proposes to take: The Houston ISD proposes to access your or your child's eligible public
benefits or insurance (e.g. Medicaid) to assist the district in providing the highest quality of services to the children served by Houston
ISD.

Explanation of why the Houston ISD is proposing to take the action(s): The money collected from Medicaid will be used to expand and
enhance medical and related services for children served by Houston ISD.

Description of each evaluation procedure, assessment, record, or report the Houston ISD used as a basis for the proposal: Records or
information about the health services and related services that are provided to you or your child will be used to determine reimbursement
amounts. Individual health plans, doctors' orders, medical reports, Medicaid eligibility reports, and the individualized education program
(IEP) report are among the documents that the district may use to determine reimbursement eligibility.

Description of other options considered by the ARD/IEP committee and the reasons why those options were rejected: The Houston ISD
always considers the available resources to provide services specified in the IEP at no cost to you regardless of whether you consent to
Houston ISD billing Medicaid for reimbursement; however, reimbursement from Medicaid for the health and related services that you
or your child receives at school will greatly expand and enhance medical and related services for you or your child.

Description of other factors that are relevant to the Houston ISD's proposal: It is important to understand that your or your child's Medicaid
eligible health care services outside of the school setting will not be limited or decreased if the Houston ISD bills Medicaid for school
related services. Medicaid has no lifetime maximum amount of services to children which are eligible for reimbursement. If the service
your child receives is not eligible for reimbursement, Medicaid will not be billed.

Sources for the parents to contact to obtain assistance in understanding the provisions of Part B of the Individuals with Disabilities
Education Act (IDEA):

Houston Independent School District
Office of Special Education Services
4400 West 18th Street
Houston, Texas 77092
Phone No.: (713) 556-7025
Fax No.: (713) 556-7589

Region IV – Education Service Center
7145 West Tidwell
Houston, Texas 77092-2096
Phone No.: (713) 462-7708
Fax No.: (713) 744-6514

Education Service Center Contact
Ginger Gates, Director
(713) 744-6586
[email protected]

Copy to: Special Education Eligibility Folder Parent and/or Student Special Education Page 40