CONFIDENTIAL

These are legal documents! The information contained within them is personal and confidential. Please file these documents in a secure location. If thrown away, please shred or properly tear the materials before discarding. Thank you! Ms. Palacios

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PASSPORT
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Student:

Eligibility:
ELD Level:
Attending School:

DOB:
Residence School:

ELL DYes D No

Transportation: DYes D No
Case carrier:

Future School:

Residence (verified)

Non-resident

phone:

email:

Summary of Individualized Education Program

Program: RSP Q SDP-SLD D OTHER: SDPPercent of time inside SPED:
%

Service Model: Q Collaborative

D Direct Instruction-Departme/7ta//zed

D Direct Instruction-Se/f contained

Description of RSP Services (ifapplicable)

Service Layers:

Co-Planning
times;

D Co-teaching '
minutes/week

Direct non-intensive

O Direct intensive

Total Service Minutes:

Service Providers: GenED Teacher D SpED Teacher both

Performance Area: D Reading

D Writing

D Math D Voc/ED

D Other
D N/A

Learning Center (direct instruction): Flexible Use (non-intensive) Elective (intensive)

IEP Goals:

D Reading
Behavior

Writing
ELL/ELD

DMath D DIS:

(Pre) Vocational / Educational

DDIS:
Time/Frequency:

D Other:

Related Services:

Assistive Technology: D Yes

No

Assessed Area of Need:

Behavior Support Plan: D Yes D No

Target behavior:

Adult Assistance: DYes DNo

Describe service need(s):

Reason: DHealth DBehavior

Suspensions: DYes DNo Total Days: Allocation: D Existing Personnel D Assigned Personnel

Location of service: D Classroom D Transportation

Strengths:
Area of need:

D Passing periods D PE

D Lunch, nutrition, activities

Current/Prior Interventions (Academic/ behavior):

Independent Reading Lvl (GE): STAR testing: D CST D CAPA Measure: D Informal DFornial
date:

Modifications (Level 3): D YES

NO

Testing accommodations (CDE Level2): D YES D NO D Timing/Scheduling D Presentation

D Response D Test Read Aloud (non-ELA portions)

(If yes, refer to IEP, Section K for details)

Instructional Accommodations (Academic / behavior)'.

Additional Supports (non-academic):

Health/Other Relevant concerns:
Additional information:

Articulation PASSPORT

Form developed by:

M. Kessler. 2006.

Notes: Phase remember, that for both kgal and ethical reasons, the status ofastudent receiving special educationalservices
cannot bedisclosed toother students, parents, ornon-instructional supportpersonnel Please refer tocomplete IEP document or
speak withcase carrier for specific information regarding a student's educational program.