Model Forms: Student Information Summary and Individualized Education Program (IEP)
January 2010
TO:
District Superintendents
Superintendents of Schools
Presidents of Boards of Education
New York City Board of Education
Principals of Public Schools
Chairpersons, Committees on Preschool Special Education
Chairpersons, Committees on Special Education
Approved Private Schools for Students with Disabilities
Approved Preschool Programs for Children with Disabilities
Other New York State Agencies
State-Operated and State-Supported Schools
Organizations, Parents and Individuals Concerned with Special Education
Impartial Hearing Officers
Commissioner's Advisory Panel for Special Education Services
Regional Special Education Technical Assistance Support Centers
Special Education Parent Centers
Early Childhood Direction Centers
FROM:
James P. DeLorenzo
SUBJECT:
New York State Model Forms: Student Information Summary Form and Individualized Education Program (IEP) - PDF 
(Memo only - 50 KB)
The New York State Education Department (NYSED) has developed model Student Information Summary (Attachment 1) and Individualized Education Program (IEP) forms (Attachment 2) for use with preschool and school-age students with disabilities.
Student Information Summary Form - Word 
(44 KB)
The Student Information Summary form is provided only as a model form that could, at a district's discretion, be completed to supplement a student's IEP. Information on the model Student Information Summary form is important information for the district to document, but is not required by law or regulation to be included in a student’s IEP (e.g., native language of student, need for interpreter, parent information, type of meeting, committee participants). School districts may modify the Student Information Summary form to add or replace the suggested fields as they deem appropriate.
Individualized Education Program Form - Word (323 KB)
The model IEP form will assist school districts to meet federal and State requirements for IEP development and to provide a consistent format for all IEPs developed in NYS beginning with the 2011-12 school year. While the IEP form is being released at this time as a 'model' form, this State form will be required for use by all local and State educational agencies for all IEPs developed for use in the 2011-12 school year and thereafter, pursuant to section 200.4(d)(2) of the Regulations of the Commissioner of Education. NYSED does not expect to make any further changes to the form except as required by changes to federal and/or State law and regulations. The State’s IEP form may be used in its current Word document format, or may be converted to another format, including a computerized format. Attachment 3 provides general directions for the use of this form as a word document and information regarding each section of the State’s model IEP form.
The State’s IEP form may be used in its current Word document format, or may be converted to another format, including a computerized format. However, for all IEPs developed for the 2011-12 school year, and thereafter, the State’s IEP form may not be modified to otherwise change its appearance or content. Attachment 3 provides general directions for the use of this form as a word document and information regarding each section of the State’s model IEP form.
Additional guidance on IEP development may be found at https://www.emsc.nysed.gov/specialed/publications/iepguidance.htm. The guidance document provides important information on federal and State requirements relating to IEPs that must be considered in developing instructionally relevant and legally correct IEPs for students with disabilities. Beginning in February 2010, the State will announce web-based seminars through Elluminate to provide additional training and information on the use of the State’s form. In addition, specialists from the Regional Special Education Technical Assistance Support Centers (RSE-TASC) will offer training in their respective regions of the State.
Questions regarding these forms may be directed to SEFORMS@nysed.gov. NYSED will review questions submitted and post a Question and Answer document on its web site at https://www.emsc.nysed.gov/specialed/formsnotices/ to respond, as appropriate, to questions received. Questions may also be directed to the Special Education Policy Unit at 518-473-2878.
Attachments
Student Information Summary Form - Word (44 KB)
Individualized Education Program Form - Word (323 KB)
General Directions to Use the State's Model IEP Form (Updated March 2010)