Title
|
|
|
Part A
|
|
|
Name of Student *
|
|
|
Date of Birth (mm/dd/yyyy) *
|
|
|
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 and Title of Evaluator *
|
|
|
Date (mm/dd/yyyy) *
|
|
|
Part B
|
|
|
Initial Evaluation or Reevaluation? *
|
|
|
Disability Determination *
|
|
|
Basis for Eligibility Determination *
|
|
|
Signature Block: Note that filing the name, title, & date in this section documents who the team members are & who is part of the evaluation team.
|
|
|
Signature Block: 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.
|
|
|
1. Name *
|
|
|
1. TItle *
|
|
|
1. Signature *
|
|
|
1. Date (mm/dd/yyyy) *
|
|
|
2. Name *
|
|
|
2. Title *
|
|
|
2. Signature *
|
|
|
2. Date (mm/dd/yyyy) *
|
|
|
3. Name *
|
|
|
3. Title *
|
|
|
3. Signature *
|
|
|
3. Date (mm/dd/yyyy) *
|
|
|
4. Name *
|
|
|
4. Title *
|
|
|
4. Signature *
|
|
|
4. Date (mm/dd/yyyy) *
|
|
|
5. Name *
|
|
|
5. Title *
|
|
|
5. Signature *
|
|
|
5. Date (mm/dd/yyyy) *
|
|
|
6. Name *
|
|
|
6. Title *
|
|
|
6. Signature *
|
|
|
6. Date (mm/dd/yyyy) *
|
|
|
Statement of Disagreement: Any team member who disagrees with the eligibility determination must attach to this report a written statement explainging 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 *
|
|
|
Date of Birth (mm/dd/yyyy). *
|
|
|
Age. *
|
|
|
a. When provided w/ learning experiences/instruction appropriate to child's age or to meet state-approved grade-level standards, the child does not achieve adequately for the child's age or to meet state-approved GLS in 1+ areas (check all that apply) *
|
|
|
a. Summarize assessment results & other data used by the evaluation team to support this determination. *
|
|
|
AND
|
|
|
b. The child is NOT making sufficient progress to meet age or state-approved grade-level standards in 1+ of the areas identified below when using a process based on the child's response to scientific, research-based intervention. (check all that apply) *
|
|
|
b. Summarize assessment results & other data used by the evaluation team to support this determination. *
|
|
|
OR
|
|
|
c. The evaluation team determined that the child exhibits a pattern of strengths & weaknesses in performance, &/or achievement, relative to age, state-approved grade-level standards, or intellectual development, that is determined to be relevant to the...
|
|
|
c. continued... identification of a specific learning disability, using appropriate assessments to evaluate the child consistent with the requirements of the IDEA at 34 C.F.R. 300.304 & 300.305.
|
|
|
c. Summarize assessment results & other data used by the evaluation team to support this determination. *
|
|
|
AND.
|
|
|
d. The team has determined that the child's lack of adequate achievement & sufficient progress for the child's age or to meet state-approved grade-level standards is NOT primarily the result of (check all that apply) *
|
|
|
d. Summarize the assessment results & other data used by the evaluation team to support this determination. *
|
|
|
e. OBSERVATION
|
|
|
1. The child has been observed in his/her learning environment which includes the regular classroom setting to document the child's academic performance & behavior in the child's areas of difficulty.
|
|
|
1. continued... 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.
|
|
|
1. 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 child's academic functioning. *
|
|
|
2. Summarize assessment results & other data used by the evaluation team to support this determination. *
|
|
|
3. Describe the educationally relevant medical findings, if any. *
|
|
|
3. Summarize assessment results & other data used by the evaluation team to support this determination. *
|
|
|
f. NOTIFICATION TO PARENTS
|
|
|
The parent(s) was notified about
|
|
|
1. The state's policies regarding the amount & nature of child performance data that would be collected & the general education services that would be provided. *
|
|
|
2. Strategies for increasing the child's rate of learning *
|
|
|
3. The parent's right to request an evaluation *
|
|
|
Effective date: 2/1/07
|
|
|
|
|