Parent/Guardian Survey For IEP
In preparation for your child’s Individualized Education Program (IEP), please answer the following questions so that together we may develop an appropriate program. If the question does not imply to your child, please feel free to put N/A.
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Child's name? *
What grade is your student in? *
Your Name *
Your Relationship to child *
Please share your thoughts on specific disability/problems/concerns that you have regarding your child. *
What accommodations have been tried with success or lack thereof by you, by other providers, school, etc. *
Has your child been retained? If so, what grade did he/she repeat? *
Did your child attend preschool? If so, where? *
How many schools has your child attended? Please list the schools. *
 Describe any recent changes that may affect your child’s school performance *
Do you have concerns with your child's social/emotional well-being? If so, please explain. *
Please list any medical information and/or health problems (e.g., medications, allergies, etc.). **Mark N/A if not medical information noted *
Please list any medications your child is taking including name of the medication, reason for medication, dosage, and when administered. **Mark N/A if none prescribed *
What are your child’s interests (activities he/she enjoys)? *
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