# IEP at a glance · blank working reference

Permitted learner reference: __________

Maintained plan location / authorized access route: __________

Actual plan version: __________

Plan effective date: __________

Plan review date: __________

Summary prepared / checked date: __________

Intended staff reader: __________

Designated school contact route: __________

Annual-goal wording / source reference: __________

Other service or assessment provisions / source reference: __________

For each supplied instruction:
- Setting / task: __________
- Responsible role: __________
- Exact action: __________
- Timing / condition / limit: __________
- Source section and exact wording reference: __________
- Question to confirm: __________

Checked against maintained plan by / date: __________

Actual implementation / observation record reference: __________

Keep actual records in the approved school environment; this reference does not replace the full plan.