ࡱ> U@ Cbjbj r8:t eeePflf$ uhhL8i8i8ijjj8`~`޶$%Rwl-kjjkk8i8i/oookF8i8iokooouZDw8ih PB3`ekjv8x E0uw>il@4Dw  Dwj0Cj"oejj8jjj  d[`o  ` SERVICE PLAN COMPONENTS [Completed for Chapter 193 and IDEA students] STUDENT INFORMATION A section may be added at the beginning of the Services Plan format to include pertinent student information as determined necessary by the school district of attendance.  SERVICE PLAN PARTICIPANTS Please sign in the appropriate space. A signature in this section of the Services Plan documents participation in the meeting and does not mean agreement with the Plan.  Student, if appropriate or required Date Parent Date General Education Teacher Date Special Education Teacher or Special Education Provider Date Child Study Team Member Date Case Manager (May be the CST member above.) Date Public School Representative (May be the CST member or other appropriate public school personnel.) Date Specialist Date Other Date PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE [Completed for Chapter 193 and IDEA students] Consider relevant data. List sources of information used to develop the Services Plan. Describe the present levels of academic achievement and functional performance including how the childs disability affects his or her involvement and progress in the general education curriculum. For preschool children*, as appropriate, describe how the disability affects the childs participation in appropriate activities. Include other educational needs that result from the students disability. * IDEA only STATEMENT OF TRANSITION SERVICE NEEDS [IDEA students only. Completed if the district of attendance determines that services will be provided.]Beginning at age 14, or younger if appropriate, develop the long-range educational plan for the students future. Review annually. Statement of the students interests and preferences :PostSecondary GOALS Outcomes (vision for the future) [Idea students only. Completed if the district of attendance determines that services will be provided.]Post Secondary Education: (Including but not limited to, college, vocational training and continuing and adult education) Employment/Career: Community Participation: (Including but not limited to, recreation and leisure activities, and participation in community organizations) Daily Living: COURSES OF STUDY [IDEA students only. Completed if the district of attendance determines that services will be provided. ]Considering the student's strengths, interests, preferences, and desired post secondary goals, list the specific courses of study for the next school year. When appropriate, identify the courses of study projected for future years.Grade___ Courses of Study (List course names): Grade___ Projected Courses of Study (List course names): Grade___ Projected Courses of Study (List course names): Grade___ Projected Courses of Study (List course names): STATEMENT OF TECHNICAL CONSULTATION [Idea students only. Completed if the district of attendance determines that services will be provided.]%Technical consultation (information/advice) is needed from Division of Vocational Rehabilitation Services or other agency or agencies. List the name of any agency from which technical consultation is needed:  STATEMENT OF TRANSITION SERVICES NEEDED TO ATTAIN MEASURABLE POSTSECONDARY GOALS: COORDINATED ACTIVITIES/STRATEGIES AND AGENCY LINKAGES TO ADULT SERVICES [IDEA students only. Completed if the district of attendance determines that services will be provided.]Beginning at age 16, or younger, if appropriate, complete the following multi-year plan for promoting movement from school to the students desired post-school goals. The students needs, strengths, interests and preferences in each area (instruction, community experiences, etc.) must be considered, and responsibilities should be shared among participants (student, parent, school staff, outside agencies, employers, etc.).Activities/Strategies Related to Measurable Postsecondary Goals Expected Date of ImplementationPerson or Agency Arranging and/or Providing Services Instruction Post Secondary Education/Training Related Services Community Experiences  STATEMENT OF TRANSITION SERVICES NEEDED TO ATTAIN MEASURABLE POSTSECONDARY GOALS: COORDINATED ACTIVITIES/STRATEGIES AND AGENCY LINKAGES TO ADULT SERVICES (Continued) [IDEA students only. Completed if the district of attendance determines that services will be provided.] Activities/Strategies Related to Post-Secondary OutcomesExpected Date of ImplementationPerson or Agency Arranging and/or Providing ServicesEmployment Adult Living Objectives Daily Living Skills Functional Vocational Evaluation  Name of the school staff person who will be the liaison to post-secondary resources: [IDEA students only. Completed if the district of attendance determines that services will be provided.]  TRANSFER OF RIGHTS AT AGE OF MAJORITY [Completed for Chapter 193 and IDEA students.]OPTION I: At least three years before the student reaches age 18, a statement that the student and the parent(s) have been informed of the rights that will transfer to the student on reaching the age of majority, unless the parents obtain guardianship [N.J.A.C. 6A:14-3.7(e)14]. The district of attendance may use the following description to document that the student and parents have been informed of the rights that will transfer. The team may include this statement at age 14 when transition planning begins.  On (Date), (Name of Student) will turn age 18 and become an adult student. The following rights will transfer to (Name of Student): The public education agency must receive written permission from (Name of Student) before it conducts any assessments as part of an evaluation or reevaluation and before implementing a services plan for the first time. The public education agency must send a written notice to (Name of Student) whenever it wishes to change or refuses to change his/her evaluation, eligibility or services plan. You, the parents, may not have access to (Name of Student)s educational records without his/her consent, unless he/she continues to be financially dependent on you. The public education agency will continue to provide you, the parents, with notice of meetings and of any proposed changes to your adult childs program. Any time (Name of Student) disagrees with his/her evaluation or eligibility, he/she is the only one who can request mediation or a due process hearing to resolve any disputes arising in those areas. If (Name of Student) wishes, he/she may write a letter to the school giving you, the parents, the right to continue to act on his/her behalf in these matters. OPTION II: At least three years before the student reaches age 18, a statement that the student and the parent(s) have been informed of the rights that will transfer to the student on reaching the age of majority unless the parents obtain guardianship [N.J.A.C. 6A:14-3.7(e)14]. The public education agency may inform the student and the parents by letter of the rights that will transfer. If a letter is used, complete the following: __________________________ was informed in writing on ______________of the rights that will transfer to him/her at age eighteen. (Name of Student) (Date) __________________________ was/were informed in writing on ______________ of the rights that will transfer at age eighteen. (Name of Parent[s]) (Date)  ACADEMIC AND/OR FUNCTIONAL AREA: [Completed for Chapter 193 and IDEA students.] ANNUAL MEASURABLE ACADEMIC AND/OR FUNCTIONAL GOAL: BENCHMARKS OR SHORT-TERM OBJECTIVES CRITERIA EVALUATION PROCEDURE           MODIFICATIONS AND SUPPLEMENTARY AIDS AND SERVICES [Completed for Chapter 193 and IDEA students.]State any modifications to be provided by the public education service provider.State any supplementary aids and services to be provided by the public education service provider.   SUPPORTS FOR SCHOOL PERSONNEL [IDEA students only. Completed if the district of attendance determines that services will be provided.] State any supports to be provided for school personnel on behalf of the student.  PROGRESS REPORTING [Completed for Chapter 193 and IDEA students.] State how the parents will be regularly informed of their students progress toward the annual goals. METHOD SCHEDULE  For the services being provided, explain the extent, if any, to which the student will not participate with non-disabled peers in the general education class and in extracurricular and nonacademic activities: Please explain the extent to which the student is removed from the general education class to receive IDEA or Chapter 193 services.  STATEMENT OF SPECIAL EDUCATION AND RELATED SERVICES [Completed for Chapter 193 and IDEA students.]State the special education services by instructional area. For in-class programs: Also state amount of time the resource teacher is present in the class. For IDEA only: If the district of attendance determines that extended school year services will be provided, it should be noted on this page. Dates the services will begin and endFrequencyLocationDuration                              State the related servicesDates the services will begin and endFrequencyLocationDuration                      NOTICE REQUIREMENTS FOR THE SERVICES PLAN [Completed for Chapter 193 and IDEA students.]This form describes the information required in each of the components of written notice for a services plan meeting. The written notice includes the services plan as a description of the proposed action and a description of the procedures and factors used in determining the proposed action.Describe the proposed action and explain why the public education agency has taken such action: The attached services plan describes the proposed program that was developed: _____as a result of an initial evaluation and determination of eligibility. _____as a result of an annual review. _____as a result of a reevaluation. _____in response to a parental request. _____other:__________________________________________________________  Describe any options considered and the reasons those options were rejected: Describe the procedures, tests, records or reports and factors used in determining the proposed action: The sources of information used to develop the proposed services plan are listed in the present levels of performance. If applicable, describe any other factors that are relevant to the proposed action: PROCEDURAL SAFEGUARDS STATEMENT [Completed for Chapter 193 and IDEA students.] As the parent of an eligible student with disabilities enrolled in a nonpublic school or as an eligible adult student enrolled in a nonpublic school, you have rights regarding identification, evaluation, and classification including the right to mediation and/or a due process hearing. You may request a complaint investigation to determine whether the responsible district of attendance followed appropriate procedures regarding the determination of services and the development of a services plan, and whether the services were provided in accordance with the services plan. A description of the rights afforded to the parents of eligible nonpublic school students is contained in the document, Parental Rights in Special Education (PRISE). This document is published by the ӣƵ Department of Education. A copy of PRISE is provided to you upon referral for an initial evaluation, when a disciplinary action that constitutes a change in placement is imposed by your school district, and the first time a due process hearing or complaint investigation is requested. In addition, a copy will be provided to you at your request. To obtain a copy of PRISE, please contact: ___________________________________________________________________ School district of attendance Office or Personnel Phone Number For help in understanding your rights, you may contact any of the following: ___________________________________________________________________ School district of attendance Representative Phone Number Statewide Parent Advocacy Network (SPAN) at (800) 654 - 7726. Protection and Advocacy, Inc., at (800) 922 - 7233. ___________________________________________________________________ County Supervisor of Child Study Phone Number  CONSENT FOR INITIAL IMPLEMENTATION: [Completed for Chapter 193 and IDEA students.] Your signature is required to give consent before the proposed services plan can start. You have the right to consider the attached services plan before giving consent. Once your written consent is given, services will begin. I, we have received a copy of the proposed services plan and give consent for the services to start. ___________________________________________________________________ Signature Date  ANNUAL REVIEW [Applicable to Chapter 193 and IDEA students.]To implement the proposed services plan based on the annual review, the responsible public education agency must provide the parent with 15 days notice prior to implementation. When the 15 days have passed, the program may be implemented without obtaining the parents signature. For Chapter 193 Services OnlyFor nonpublic school students to receive services under Chapter 193, an additional form is attached. This form, 4071 must be signed and returned to the school to authorize the funding of the services.  ANNUAL SERVICES PLAN SIGN-OFF: This form is used when the proposed services plan is intended to be implemented before the 15 day notice period has expired. The parents signature is required to document agreement to start the services sooner.  [Applicable to Chapter 193 and IDEA students.] You have the right to consider the proposed services plan for up to 15 calendar days. To have the services start before the 15 days expire, you must sign below. 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