Evaluation+Report

EVALUATION REPORT (ER)
 * **Student Name:** |||||||||||| **Student Birth Date:** ||
 * **Age:** |||||||||||| **Grade:** ||
 * **Date of Report:** |||||||||||| **Date Report Provided to Parent/Guardian/Surrogate:** ||
 * **School Student is Attending:** |||||||||||| **Local Education Agency (LEA):** ||
 * **County of Residence:** |||||||||||| **Current Educational Program:** ||
 * **Name of Parent/Guardian/Surrogate:** ||
 * **Address:** ||||||  |||||| **Phone: (H)** ||||||   ||
 * ||||||, |||||| **Phone: (W)** ||||||  ||
 * **Other Information:** ||

If determining eligibility for Specific Learning Disability (SLD), the SLD component near the end of this document must be completed and used to complete Sections 5 and 6. ||
 * Complete Sections 1 through 6 for all students.
 * 1. REASONS(S) FOR REFERRAL: ||
 * **2. SOURCES OF EVALUATION DATA** – In interpreting evaluation data, the school must draw upon a variety of data sources, including those listed below, and carefully consider the information obtained. Document the information obtained from the sources below. ||
 * || **A. Evaluations and information provided by the parent of the student (or documentation of LEA’s attempt to obtain parental input):** ||
 * **B. Observations-Include teacher observations and observations by related services providers, when appropriate:** ||
 * **C. Recommendations by teachers:** ||
 * **D. The student’s physical condition (include health, vision, hearing); social or cultural background; and adaptive behavior relevant to the student’s suspected disability and potential need for special education:** ||
 * **E. Assessments: Include, when appropriate, current classroom based assessments; aptitude and achievement tests, local and/or state assessments; behavioral assessments; vocational technical education assessment results; interests, preferences, aptitudes (for secondary transition); etc:** || ||
 * **3. IF AN ASSESSMENT IS NOT CONDUCTED UNDER STANDARD CONDITIONS, DESCRIBE THE EXTENT TO WHICH IT VARIED FROM STANDARD CONDITIONS** (including if the assessment was given in the student’s native language or other mode of communication): ||
 * **4. DETERMINING FACTORS** – A student must not be found to be eligible for special education and related services if the determining factor for the student’s disability is any of those listed below. Respond Yes or No to, and provide evidence for, each determining factor below. ||
 * || Yes No ||   || Lack of appropriate instruction in reading, including the essential components of reading instruction. Provide evidence: ||
 * Yes No ||   || Lack of appropriate instruction in math. Provide evidence: ||
 * Yes No ||   || Limited English proficiency. Provide evidence: || ||
 * **NOTE: IF DETERMINING ELIGIBILITY FOR SPECIFIC LEARNING DISABILITY, COMPLETE THE DETERMINATION OF SPECIFIC LEARNING DISABILITY COMPONENT AT THE END OF THIS DOCUMENT BEFORE COMPLETING SECTIONS 5 and 6.
 * **4. DETERMINING FACTORS** – A student must not be found to be eligible for special education and related services if the determining factor for the student’s disability is any of those listed below. Respond Yes or No to, and provide evidence for, each determining factor below. ||
 * || Yes No ||   || Lack of appropriate instruction in reading, including the essential components of reading instruction. Provide evidence: ||
 * Yes No ||   || Lack of appropriate instruction in math. Provide evidence: ||
 * Yes No ||   || Limited English proficiency. Provide evidence: || ||
 * **NOTE: IF DETERMINING ELIGIBILITY FOR SPECIFIC LEARNING DISABILITY, COMPLETE THE DETERMINATION OF SPECIFIC LEARNING DISABILITY COMPONENT AT THE END OF THIS DOCUMENT BEFORE COMPLETING SECTIONS 5 and 6.
 * **NOTE: IF DETERMINING ELIGIBILITY FOR SPECIFIC LEARNING DISABILITY, COMPLETE THE DETERMINATION OF SPECIFIC LEARNING DISABILITY COMPONENT AT THE END OF THIS DOCUMENT BEFORE COMPLETING SECTIONS 5 and 6.

Complete Sections 5 and 6 for all students.** || Complete A or B or C. || Primary disability category: Secondary disability category(s), if any: ||
 * **5. SUMMARY OF FINDINGS/INTERPRETATION OF EVALUATION RESULTS** – Considering all available evaluation data, record the team’s analyses of the student’s functioning levels. ||
 * || **A. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT – Describe the student’s present levels, strengths, and the resulting academic needs, when appropriate. Include communicative status, motor abilities, and transition needs as appropriate. For students with limited English proficiency (LEP), include current level(s) of English language proficiency in reading, writing, speaking and understanding/listening:** ||
 * **B. PRESENT LEVELS OF FUNCTIONAL PERFORMANCE – Describe the student’s present levels, strengths, and the resulting functional and developmental needs, when appropriate:** ||
 * **C. BEHAVIORAL INFORMATION – Include social and emotional status and behavioral strengths and needs, when appropriate:** || ||
 * **6. CONCLUSIONS** – Determination of Eligibility and Educational Needs
 * **C. BEHAVIORAL INFORMATION – Include social and emotional status and behavioral strengths and needs, when appropriate:** || ||
 * **6. CONCLUSIONS** – Determination of Eligibility and Educational Needs
 * || A. ||  || The student does not have a disability and therefore is NOT ELIGIBLE for special education. ||
 * OR ||
 * B. ||  || The student has a disability but does not need specially designed instruction, and therefore is NOT ELIGIBLE for special education. ||
 * OR ||
 * C. ||  || The student has a disability AND is in need of specially designed instruction, and therefore IS ELIGIBLE for special education. ||
 * || 1. || Disability Category
 * || 2. || Recommendations for consideration by the IEP team to enable the student to participate as appropriate in the general education curriculum (including special considerations the IEP team must consider before developing the IEP, measurable annual goals, specially designed instruction, and supplementary aids and services): || ||


 * **Evaluation Team Participation** |||||| **Agreement and Disagreement required ONLY when evaluating students for specific learning disability.** ||
 * **Evaluation Team Participants*** |||||||||||| **Title** |||||| **Agree/Disagree**** ||
 * ||||||||||||  |||||| Yes  No ||
 * ||||||||||||  |||||| Yes  No ||
 * ||||||||||||  |||||| Yes  No ||
 * ||||||||||||  |||||| Yes  No ||
 * ||||||||||||  |||||| Yes  No ||
 * ||||||||||||  |||||| Yes  No ||
 * * A certified school psychologist is required for evaluation of the following disability categories: Autism, Emotional Disturbance, Mental Retardation, Multiple Disabilities, Other Health Impairments, Specific Learning Disability or Traumatic Brain Injury. A certified school psychologist is not required for Deaf-blindness, Deaf and Hard of Hearing, Speech/Language Impairment, Visual Impairment, and Orthopedic Impairment.


 * For specific learning disability only, if a team member disagrees with the team’s conclusion related to the identification of the student as having a specific learning disability, the member must submit a separate statement presenting the member’s dissent to the LEA. This information must be attached to the //Evaluation Report//. Please submit this statement to:||  ||   ||   ||   ||   ||
 * LEA Representative Name ||  || Phone Number ||   || Email Address ||

A copy of the //Procedural Safeguards Notice// is available upon request from your child’s school. This document explains your rights, and includes state and local advocacy organizations that are available to help you understand your rights and how the special education process works.

For help in understanding this form, an annotated //Evaluation Report// is available on the PaTTAN website at www.pattan.net Type “Annotated Forms” in the Search feature on the website. If you do not have access to the Internet, you can request the annotated form by calling PaTTAN at 800-441-3215. ||


 * **DETERMINATION OF SPECIFIC LEARNING DISABILITY** ||
 * **NOTE: This component must be completed when determining eligibility for Specific Learning Disability. The information must be attached to and/or incorporated into Sections 5 and 6 of the completed Evaluation Report.** ||
 * **Provide documentation for items 1-10.** ||
 * || **1.** |||| **The student does not achieve adequately for the student’s age or does not meet State-approved grade-level standards in one or more of the following areas when provided with learning experiences and scientifically based instruction appropriate for the student’s age or State-approved grade level standards and level of English language proficiency: oral expression, listening comprehension, written expression, basic reading skill, reading fluency skills, reading comprehension, mathematics calculation, and mathematics problem-solving.** ||
 * **2.** |||| **Check below to identify the process(es) used to determine eligibility.** ||
 * ||  || **Response to Scientific Research-Based Intervention (RtI). Document the criteria below.
 * ||  || **Response to Scientific Research-Based Intervention (RtI). Document the criteria below.

The student does not make sufficient progress to meet age or State-approved grade-level standards in one or more of these areas: oral expression, listening comprehension, written expression, basic reading skill, reading fluency skills, reading comprehension, mathematics calculation, and mathematics problem-solving:** ||
 * ||  || **Severe Discrepancy between Intellectual Ability and Achievement. Document the criteria below.

The student exhibits a pattern of strengths and weaknesses in performance, achievement or both relative to age, standards or intellectual development:** || .
 * **3.** |||| **The instructional strategies used and the student-centered data collected:** ||
 * **4.** |||| **The educationally relevant medical findings, if any:** ||
 * **5.** |||| **The effects of the student’s environment, culture, or economic background:** ||
 * **6.** |||| **Data demonstrating that prior to referral or as part of the referral process for a specific learning disability, the student’s regular education instruction was delivered by qualified personnel, including the English as a Second Language (ESL) program, if applicable:** ||
 * **7.** |||| **Data based documentation of repeated assessments of achievement at reasonable intervals, reflecting progress during instruction, which was provided to the parents:** ||
 * **8.** |||| **An observation in the student’s learning environment (including the regular classroom setting) to document the student’s academic performance and behavior in the areas of difficulty. Note the relationship of that behavior to the student’s academic functioning:** ||
 * **9.** |||| **Other data, if needed, as determined by the evaluation team:** ||
 * **10.** |||| **Include a statement for each item below to support the conclusions of the evaluation team that the findings are not primarily a result of** ||
 * ||  || **Visual, hearing, motor disability:** ||
 * ||  || **Mental retardation:** ||
 * ||  || **Emotional disturbance:** ||
 * ||  || **Cultural factors:** ||
 * ||  || **Environmental or economic disadvantage:** ||
 * ||  || **Limited English proficiency:** || ||
 * **10.** |||| **Include a statement for each item below to support the conclusions of the evaluation team that the findings are not primarily a result of** ||
 * ||  || **Visual, hearing, motor disability:** ||
 * ||  || **Mental retardation:** ||
 * ||  || **Emotional disturbance:** ||
 * ||  || **Cultural factors:** ||
 * ||  || **Environmental or economic disadvantage:** ||
 * ||  || **Limited English proficiency:** || ||
 * ||  || **Limited English proficiency:** || ||