1. Initial Evaluation/Eligibility Team Report
    2. EVALUATION DATA SUMMARY
      1. BASIS for INITIAL ELIGIBILITY DETERMINATION
      2. Data sources used to support response:
      3. Data sources used to support response:
      4. Data sources used to support response:
      5. Data sources used to support response:



Initial Evaluation/Eligibility Team Report
 

 
Student’s Name: ________________________________________ Date of Birth: ____________________
 
Enrolling School: _______________________________________ Grade: _________________________
 
Report Date:________________________________
 



EVALUATION DATA SUMMARY

General education interventions or screening results:
 
 
 
Record review:
 
 
Interview:


Observation: (include relevant behavior noted during the observation and the relationship of the behavior to the student’s academic functioning.)
 
 
Tests:
 
 
Any educationally relevant medical findings:
 
 
 



BASIS for INITIAL ELIGIBILITY DETERMINATION

Question 1: Does the response of the presenting concern to general education interventions
(or for pre-school children, results of screening and evaluation) indicate the need for intense
or sustained resources?               Yes No



Data sources used to support response:
GEI/Screening Record Review Interview Observation Testing
Discussion of how data led you to the response:
 
 
 
 
 
 
 
 
Question 2: Are the resources needed to support the student to participate and progress in the general education curriculum (for pre-school children, to participate in activities appropriate for children the same age) beyond those available through general education and other resources?   Yes No



Data sources used to support response:
GEI/Screening Record Review Interview Observation Testing
Discussion of how data led you to the response:
 
 
 
 
 
 
 
Question 3: Is there evidence of a severe discrepancy between the performance of the student and
his/her peers or evidence of a severe discrepancy between the student’s ability and performance in the area(s) of concern?               Yes No



Data sources used to support response:
GEI/Screening Record Review Interview Observation Testing
Discussion of how data led you to the response:
 
 
 
 
 
If child is suspected of having a learning disability, the severe discrepancy is not primarily the result of:
     Visual, hearing or motor impairment       Yes No
     Mental retardation or emotional disturbance     Yes No
     Environmental, cultural or economic disadvantage   Yes No
 
Question 4: Is the presence of an exceptionality by convergent data from multiple
sources?                 Yes No



Data sources used to support response:
GEI/Screening Record Review Interview Observation Testing
Discussion of how data led you to the response:
 
 
 
 
Exclusionary Factors
Has the child experienced a history of:
   A lack of instruction in reading, including instruction using eh essential
components of reading instruction or mathematics?     Yes No
   If yes, explain:
 
 
 
 
   Limited English Proficiency?           Yes No
   If yes, explain:
 
 
 
 
   Are there other factors than the two above that have contributed to the unique
   educational needs of the child?         Yes No
   If yes, explain:
 
 
 
It is the judgment of the undersigned members of the evaluation team, including parents, that an evaluation addressing all areas of concern has been completed and:
       The student is eligible for special education because:
The criteria as a child with an exceptionality, as determined by district eligibility indicators, has been met
   and
Special education services are necessary to enable this student to receive educational benefits in accordance with his/her abilities or capabilities
 
The student is not eligible for special education because:
The criteria as a child with an exceptionality, as determined by district eligibility indicators, has not been met
 or
Special education services are not necessary to enable this student to receive educational benefits in accordance with his/her abilities or capabilities

(Check all criteria met)
 
AM:
Communication Social Interaction Before Age of 3
 
DB:
Vision Loss Hearing Loss
 
DD:
1.5 SD Delay Diagnosed Condition Assessment Unreliable
 
ED:
Interpersonal relationships Behavior/Emotions Physical Symptoms/Fears Time/Degree
 
GI:
Aptitude Achievement Products
 
HI:
Hearing Loss Educational Impact
 
LD:
Aptitude-Achievement Discrepancy Processing Deficit Exclusions
 
MD:
At Least Two Disabilities Severe Educational Needs
 
MR:
Aptitude Adaptive Behavior Achievement
 
OHI:
Health Condition Limited Strength Limited Vitality Limited Alertness
 
OI:
Orthopedic or Health Impairment Educational Impact
 
SL:
Language Voice Fluency Articulation/Phonology
 
TBI:
Injury to brain from external source Impaired Functioning
 
VI:
Vision Loss Education Impact

 
RECOMMENDATIONS: The following are areas of discrepancy/areas eligible for special education services.
1.__________________________________________ 2._______________________________________
 
3.__________________________________________ 4._______________________________________
 
5.__________________________________________ 6._______________________________________
 
Signature of Team Member    Date      Position
 
_________________________________ ___________________ ____________________________
 
_________________________________ ___________________ ____________________________
 
_________________________________ ___________________ ____________________________
 
_________________________________ ___________________ ____________________________
 
_________________________________ ___________________ ____________________________
 
_________________________________ ___________________ ____________________________
 
DISSENTING TEAM MEMBER (S) SIGNATURE AND ATTACHED STATEMENT REPRESENTING HIS/HER CONCLUSIONS:
 
Signature of Team Member    Date      Position
 
_________________________________ ___________________ ____________________________
 
_________________________________ ___________________ ____________________________
 
Attachments _______ Yes ______ No
 

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