I hereby petition the Radford City Public Schools, Office of Special Education, for modifications of the Individual Education Program (IEP) of:

(Student)

A. We request the current program to be modified to include/exclude the following:

Goal # Statement: Objective: 1. Objective: 1.

2. 2.

3. 3.

4. 4.

Criteria Level Procedure 5. Criteria Level/Procedure 5. 6. 6.

Teacher evaluation of goal achievement (to be completed prior to annual review):

Evaluation Schedule: Annual goals will be evaluated during the annual review. Short-term objectives will be monitored during each six weeks grading period. Short-term objective statement must specify criteria level. Enter one of the following progress codes per objective for each marking period. NI-Objective Not Initiated, P-Progressing in the Objectives, M-Objective Mastered, M/R-Objectives Mastered but needs review to maintain mastery, D-Having Difficulty with the objective.

B. Schedule change:

We hereby authorize the following schedule change in mainstream classes, due to schedule

conflicts, or to accommodate interests.

change to change to

Rationale:

C. We request a change in the Frequency and Duration of services as follows:

D. We hereby give permission for the current IEP to be extended until the end of the school year (__/__/__).

E. My signature verifies this request:

Parent/Guardian/Surrogate Date

Other Committee Members Present/Relationship Date