F20 Evaluation Team Report

EVALUATION TEAM REPORT (ETR)


PART A
Student Name: ____________________________________________________	Birthdate: _______________	Age: _____
Evaluator: __________________________________________
Areas of Assessment: ___________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
Summary of assessment(s), including results of the student's progress in the general curriculum & instructional implications to ensure progress. _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
Signature & Title of Evaluator: _________________________________________________		Date: _________


q Initial Evaluation
q Reevaluation
PART B
Disability Determination: ________________________________________________________________________
Basis for Eligibility Determination: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
Signature Block: Please note that filling the name, title and date in this section documents who the team members are & who is part of the evaluation team. A signature in this section documents that the person signing is certifying that this report reflects the team member's conclusion. If the report does not reflect a team member's conclusion please see "Statement of Disagreement" below.
____________________________ _______________________ Name Title	___________________________ Signature	_______________ Date (mm/dd/yyyy)
____________________________ _______________________ Name Title	___________________________ Signature	_______________ Date (mm/dd/yyyy)
____________________________ _______________________ Name Title	___________________________ Signature	_______________ Date (mm/dd/yyyy)
____________________________ _______________________ Name Title	___________________________ Signature	_______________ Date (mm/dd/yyyy)
____________________________ _______________________ Name Title	___________________________ Signature	_______________ Date (mm/dd/yyyy)
____________________________ _______________________ Name Title	___________________________ Signature	_______________ Date (mm/dd/yyyy)

Statement of Disagreement Any team member who disagrees with the eligibility determination must attach to this report a written statement explaining his/her reason for disagreeing with the team's determination.


PART C
Documentation for Determining the Existence of a Specific Learning Disability

Student's Name: ____________________________________	Birthdate: _______________	Age: _____
A. When provided with learning experiences & instruction appropriate for the student's age or to meet state-approved grade-level standards, the student does not achieve adequately for the child's age or to meet state-approved grade-level standards in one or more of the following areas:
q Oral Expression	q Reading Fluency Skills
q Listening Comprehension	q Reading Comprehension
q Written Expression	q Mathematics Calculation
q Basic Reading Skill	q Mathematics Problem Solving
Summarize assessment results & other data used by the evaluation team to support the determination.
AND
B. The student is not making sufficient progress to meet age or state-approved grade-level standards in one or more of the areas identified below when using a process based on the student's response to scientific, research-based intervention:
q Oral Expression	q Reading Fluency Skills
q Listening Comprehension	q Reading Comprehension
q Written Expression	q Mathematics Calculation
q Basic Reading Skill	q Mathematics Problem Solving
Summarize assessment results & other data used by the evaluation team to support this determination.
OR
C. The evaluation team has determined that the student exhibits a pattern of strengths & weaknesses in performance, achievement or both, relative to age, state-approved grade-level standards, or intellectual development, that is determined to be relevant to the identification of a specific learning disability, using appropriate assessments to evaluate the student consistent with the requirements of the IDEA at 34 C.F.R. 300.304 & 300.305.
Summarize assessment results & other data used by the evaluation team to support this determination.
AND
D. The team has determined that the student's lack of adequate achievement & sufficient progress for the student's age or to meet state-approved grade-level standards is not primarily the result of:
q Visual, Hearing, or Motor Disability	q Limited English Proficiency
q Mental Retardation	q Lack of Appropriate Instruction in Reading/Math
q Emotional Disturbance	q Environment of Economic Disadvantage
q Cultural Factors
Summarize assessment results & other data used by the evaluation team to support this determination.

E. OBSERVATION
1. The student has been obsserved in his or her learning environment which includes the regular classroom setting to document the student's academic performance & behavior in the student's areas of difficulty. In the case of a child of less than school age or out of school, an evaluation team member must observe the child in an environment appropriate for a child of that age.
Summarize assessment results & other data used by the evaluation team to support this determination.

2. Describe the relationship of the relevant behavior if any, noted during observation(s) to the student's academic functioning.
Summarize assessment results & other date used by the evaluation team to support this determination.

3. Describe the educationally relevant medical findings, if any.
Summarize assessment results & other date used by the evaluation team to support this determination.

F. NOTIFICATION OF PARENTS
The parent(s) was notified about:
1. The state's policies regarding the amount and nature of student performance data that would be collected & the general education services that would be provided.
q Yes q No
2. Strategies for increasing the child's rate of hearing: &
q Yes q No
3. The parent's right to request an evaluation.
q Yes q No

Effective date: 2/1/07
PR-06