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This form is to be completed and attached to the IEP Team Certification identification of Specific Learning Disability Form in order to
document the presence of a Specific Learning Disability in instances when the student does not exhibit a severe discrepancy between
ability and achievement as measured by standardized test. (Ed. Code Section 3030j Paragraph C)
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Statement of the area, the degree, and the basis and method used in determining the discrepancy: |
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1. Data from assessment instruments (ability and achievement): |
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2. Information provided by the parent: |
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3. Information provided by the pupil’s present teacher: |
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4. Summary of the pupil’s classroom performance: |
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a. Observations: |
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b. Work Samples: |
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c. Group Test Scores: |
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5. Consideration of the pupil’s age: |
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6. Additional Relevant Information: |
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