TOOL 1: Sample ILP Instrument
Date Updated
Date of most recent update to ILP instrument:
Sections #s
updated:
Dates of prior ILP instrument updates:
1) Student Personal Information
Student name:
School mentor name:
Projected high school
graduation year:
School name:
Student date of birth:
Grade level:
Address:
Email:
Phone 1:
Phone 2:
2) Parent/Guardian/Other Caring Adult Information
Name 1:
Relationship:
Address:
Email:
Phone 1:
Phone 2:
Name 2:
Relationship:
Address:
Email:
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
Phone 1:
Phone 2:
Name 3:
Relationship:
Address:
Email:
Phone 1:
Phone 2:
3) Other Student Plans
Check off the other types of student plans that are in place, and provide the date of the most recent version for each applicable plan.
Student Plan
Date of Most Recent Version
 504 Education Plan
 Individualized Education Plan (IEP)
 Transition Planning Form (TPF)
 Education Proficiency Plan (EPP)
 CVTE Career Plan (Career Plan)
 Individual Student Success Plan (ISSP)
 Other:
 Other:
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
4) Student Identified Strengths
Provide an overview of your self-identified strengths in the personal/social, academic, and workplace readiness domains.
Personal/Social:
Academic:
Workplace
Readiness:
5) Student Identified Barriers to Success
Check all boxes that apply to you and identify any steps to be taken to reduce barriers.
Potential Barriers
Notes and Next Steps to Reduce Barriers
 Low Income
 Language
 Disability
 Unemployment
 Housing/ Homelessness
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
Potential Barriers
Notes and Next Steps to Reduce Barriers
 Gang Involvement
 Substance Abuse
 Domestic Violence
 Pregnancy or Parenting
 Physical Health
 Mental Health
 Lack of Guardian Support
 Other:
 Other:
 Other:
6) State Agency Involvement
List any involvement with state agencies. Examples include Department of Youth Services, Department of Transitional Assistance,
Department of Children and Families, and Department of Mental Health.
Agency Name
Contact Person
Contact Information
Permission to
Contact (Y/N)
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
7) Career Interests
List your career interests (this may include results from interest inventories), career opportunities associated with the career interest
area, and the education or training necessary to obtain that career. Create a separate row for each potential career opportunity – so
one career interest area may have several rows with different career opportunities.
Career Interest Area
Example: Early Childhood
Career Opportunity
Elementary school teacher
Post-Secondary Education or Training Required
4 year degree program
8) Short Term Student Goals
Provide at least one short term (1-2 month) goal for each domain (academic, personal/social, and workplace readiness). For each
short-term goal, include action steps to reach this goal, including the description of activities, supports that will be needed or
provided, and the timeline. Retain prior short-term goals for student review and reflection.
Short Term Goal – Academic Domain
Goal Description:
Step 1
Activity Description:
Supports:
Timeline:
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
Step 2
Activity Description:
Supports:
Timeline:
Step 3
Activity Description:
Supports:
Timeline:
Short Term Goal – Personal/Social Domain
Goal Description:
Step 1
Activity Description:
Supports:
Timeline:
Step 2
Activity Description:
Supports:
Timeline:
Step 3
Activity Description:
Supports:
Timeline:
Short Term Goal – Workplace Readiness Domain
Goal Description:
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
Step 1
Activity Description:
Supports:
Timeline:
Step 2
Activity Description:
Supports:
Timeline:
Step 3
Activity Description:
Supports:
Timeline:
9) Long Term Student Goals
Provide at least one long term (post-secondary) goal related to future education, career, and personal/life goals. For each long-term
goal, include some immediate action steps to reach this goal, including the description of activities, supports that will be needed or
provided, and the timeline. Retain prior long-term goals for student review and reflection.
Long Term Goal 1
Goal Description:
Step 1
Activity Description:
Supports:
Timeline:
Step 2
Activity Description:
Supports:
Timeline:
Step 3
Activity Description:
Supports:
Timeline:
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
Long Term Goal 2
Goal Description:
Step 1
Activity Description:
Supports:
Timeline:
Step 2
Activity Description:
Supports:
Timeline:
Step 3
Activity Description:
Supports:
Timeline:
Long Term Goal 3
Goal Description:
Step 1
Activity Description:
Supports:
Timeline:
Step 2
Activity Description:
Supports:
Timeline:
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
Step 3
Activity Description:
Supports:
Timeline:
10) Middle School Courses Information
Provide an overview of the middle school courses taken and the associated grades.
Subject Area
Grade 6
Grade 7
Grade 8
English
Math
Science
History/ Social Studies
Physical Education
Art
Technology
Other:
Other:
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
11) High School Courses Information
Provide an overview of the courses taken, including the course titles, course grade (GR), and course credits earned (CR). Note in the
course title if the course is taken for dual credit, is an AP course, etc.
Subject
Area
Title
GR
CR
Title
GR
CR
Title
GR
CR
Title
GR
CR
Title
GR
English
Math
Science
Social
Sciences
Foreign Lang
Health
Arts
Physical Ed
Elective
Elective
Other
Other
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
CR
12) High School Roadmap
For each subject area, provide the total number of credits required for graduation, the total applicable credits earned to date, and
the total credits remaining to be earned in the subject area. If applicable, provide a short description of the course(s) options to
fulfill the required credits. This table can be used a simple roadmap to graduation for students, families, and staff.
Subject
Area
English
Total Credits
Needed for
Graduation
Total
Applicable
Credits Earned
Total Credits
Remaining
Description of Course Options to Fulfill Required Credits
Math
Science
Social
Sciences
Foreign
Lang
Health
Arts
Physical Ed
Electives
Other
Yes/No/Unsure
Notes
Are you expecting to complete MassCore – the Massachusetts
recommended course of study – by your high school graduation date?
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
13) Tier 2 and Tier 3 Supports or Interventions
Document the Tier 2 and Tier 3 supports and interventions (academic and non-academic) that you are participating in (or in which
you previously participated). Tier 2 interventions and supports are moderately intensive and are targeted toward small groups of
students with similar needs who would benefit from similar interventions or supports. Tier 3 interventions and supports are the
most intensive and are provided to individual students with the highest levels of need.
Check off the grade levels in which you participated in that intervention or support.
Support or Intervention Name
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10 Grade 11 Grade 12
14) Assessment Results
Provide an overview of your results on state, local, and other assessment results.
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
State Assessment: ELA
State Assessment: Math
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
State Assessment: Science
State Assessment: ACCESS for ELLs
Local Assessment:
Local Assessment:
Other: PSAT
Other: SAT
Other:
15) Extracurricular Activities
Document the extracurricular activities in which you are engaged, including those provided in school, and well as those offered out
of school.
Grades 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
In school
Out of
school
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
16) Career Development Education Activities
Career Development Education encompasses three stages – Awareness, Exploration, and Immersion – that help students move from
the cognitive to the experiential. Document your participation in activities and/or courses that provide career awareness,
exploration, or immersion opportunities.
•
•
•
Awareness stage examples include: career interest inventories, exploring labor market information through websites and
publications, listening to career speakers, and/or participation in career days or fairs.
Exploration stage examples include participation in workshops or classes with a career focus, “job shadowing,” informational
interviews with local professionals, and/or producing a career-related research or capstone project.
Immersion stage examples include internships, entrepreneurial enterprises, or other work-based learning opportunities.
Grades 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Career
Awareness
Activities
Career
Exploration
Activities
Career
Immersion
Activities
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education
17) Reflections
Reflections from the student, parent/guardian, and school should happen at the beginning and at the end of the school year. The
reflection at the beginning of the year focuses all parties on the work and the specific goals for the upcoming year. The year-end
reflection is an honest assessment of successes and challenges encountered throughout the school year. The end-of-year reflection
may identify action steps for the next year.
Stakeholder
Student
Reflection
Parent/Guardian
Name:
School Mentor
Name:
TOOL 1: Sample ILP Instrument, excerpt from the Massachusetts Guide for Implementing Individual Learning Plans published by the MA Department of Elementary and Secondary
Education