ࡱ> dfcb jbjb{x{x 4T 8l$tbZZZZ!|yp,Rj!i@!ZZpZZ r0p"p" IEP AMENDMENT  Student s Name:  FORMTEXT       DOB: FORMTEXT       Original IEP Date: FORMTEXT      Amendment Date: FORMTEXT      Amendment(s) to District s Offer Free Appropriate Public Education (FAPE)Special Education ServicesAddition Check if appropriateDeletion Check if appropriateFrequency / TimeSpecify Day/Week/ MonthLocation/SettingTitle of Service ProviderParent Consent to Services Yes No Yes No FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Do any of the above amendments change the percent (%) of time the student is inside general education?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, write new percentage (%) inside general education:  FORMTEXT     %Changes in Present Levels of Performance: FORMTEXT      Changes in Goals and/or Benchmarks: (attach SELPA form 4 A-C, as appropriate): FORMTEXT      Other Changes: FORMTEXT      Rationale for Changes: FORMTEXT      Parent/Guardian/Adult Student has agreed that a meeting is not needed for this amendment to the IEP  FORMCHECKBOX  No  FORMCHECKBOX  YesSignatures below document the agreement to amend the current IEP dated  FORMTEXT       and to agree to implement the changes described in this document. Parent/Guardian/Adult Student Date Signature of person responsible to notify IEP members Date District Representative/Administrative Designee Date Other Date  Other Date  Other Date     Sonoma County SELPA SELPA Form 52 Copy 1: File Copy 2: Parent Copy 3: Special Ed. Teacher/Specialist Copy 4: General Ed. 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