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Summary of Evaluation/Eligibility Worksheet-Specific Learning Disability

This document summarizes a student's evaluation for specific learning disability (SLD) eligibility. It includes results of required screenings, evaluations, progress monitoring data, and academic observations. Based on this information, the team identified the student's strengths and needs, including evidence of a significant delay in an academic area. The team also considered whether a pattern of strengths and weaknesses is relevant to SLD identification. Finally, the team determined whether any other factors are the primary cause of the student's delays or if they require specially designed instruction.

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Heidi Jorx
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147 views3 pages

Summary of Evaluation/Eligibility Worksheet-Specific Learning Disability

This document summarizes a student's evaluation for specific learning disability (SLD) eligibility. It includes results of required screenings, evaluations, progress monitoring data, and academic observations. Based on this information, the team identified the student's strengths and needs, including evidence of a significant delay in an academic area. The team also considered whether a pattern of strengths and weaknesses is relevant to SLD identification. Finally, the team determined whether any other factors are the primary cause of the student's delays or if they require specially designed instruction.

Uploaded by

Heidi Jorx
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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Method of eligibility:

DEC 3-SLD (1 of 3) Discrepancy RtI

SUMMARY OF EVALUATION/ELIGIBILITY WORKSHEET-SPECIFIC LEARNING DISABILITY


Student: Student Name School: School Name Date
00 / 00 / 2000 00 / 00 / 2000 00 / 00 / 2000

DOB: 00 / 00 / 2000 Grade: Grade Data Source/Summary of Results


Pass Pass Fail Fail

Required Screenings and Evaluations


Hearing Screening: Vision Screening:

dB (Intensity Level) Hz (Frequencies) Far R 20/ L 20/ Near R 20/ L 20/

Speech/Language Screening: 00 / 00 / 2000 Review of Existing Data: 00 / 00 / 2000 Summary of conference(s) with parent(s): 00 / 00 / 2000 Research-based interventions to address academic skill deficiencies (progress monitoring data): 00 / 00 / 2000 Social/Developmental History: 00 / 00 / 2000 Academic, Functional and Behavioral Observation(s): 00 / 00 / 2000 *Educational Evaluation 00 / 00 / 2000 *Psychological Evaluation (Including Intellectual Evaluation) 00 / 00 / 2000 Other: *Required when using the discrepancy method to determine eligibility.

As a result of the required screenings, evaluations, progress monitoring data, and review of existing information, what do we now know about the student? Include characteristics of a specific learning disability consistent with the definition. Strengths:
Needs:

Final 2-11

DEC 3-SLD (2 of 3) Student: Student Name School: School Name DOB: 00 / 00 / 2000 Grade: Grade

Based on information from multiple sources, provide documentation of significant delays in the following:
The child does not achieve adequately for the childs age, intellectual development or to meet State-approved grade-level standards in one or more of the following areas when provided with learning experiences and instruction appropriate for the childs age or State-approved grade level-standards: Listening Comprehension Basic Reading Skills Mathematics Calculation Select one of the following: The child does not make sufficient progress to meet age or State-approved grade-level standards in one or more of the areas identified above when using a progress based on the childs response to scientific, research-based instruction. Give specific examples to show evidence of insufficient progress. Oral Expression Reading Fluency Skills Mathematical Problem Solving Written Expression Reading Comprehension Skills None (not eligible)

OR The child exhibits a pattern of strengths and weaknesses in performance, achievement, or both, relative to age, State-approved grade-level standards or intellectual development, that is determined by the group to be relevant to the identification of a specific learning disability, using appropriate assessments. Describe the pattern. Show evidence of progress monitoring data, a 15-point discrepancy, or an alternative to the discrepancy analysis.

OR Not Applicable (not eligible)

Final 2-11

DEC 3-SLD (3 of 3) Student: Student Name School: School Name


Select one of the following: The following factors have been ruled out a the primary cause of the disability: sensory or motor deficits, intellectual or serious emotional disabilities, Limited English proficiency, environmental, cultural, or economic influences, or lack of appropriate instruction in reading or math.

DOB: 00 / 00 / 2000 Grade: Grade

OR Describe which factor(s) listed above cause the academic delay. The child cannot be eligible in the category of SLD.

What is the adverse effect, if any, on educational performance? Include a statement of the relationship of the behavior noted during the observation to the students academic functioning. Also, address the effort of any applicable educationally relevant medical findings. What evidence exists that the student requires specially designed instruction? IEP TEAM MUST COMPLETE ELIGIBILITY DETERMINATION.

Final 2-11

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