Specific Learning Disability - Team Determination of Eligibility (9A)
Page help

  Incomplete Incomplete
 
 
Student ,   Birthdate   [x] [ ] Initial evaluation
 
School -   Date Date   [x] [ ] 3-year re-evaluation
 

 
I. Presence of Severe Discrepancy. (Select either A or B and then complete items II through IV.)
 
A. The IEP Team finds a severe discrepancy between measures of intellectual ability and one or more of the following areas of achievement:

Oral
Expression
Written
Expression
Listening
Comprehension

Mathematics
Calculation
Basic
Reading
Skills
Mathematics
Reasoning

Reading
Comprehension
Reading
Fluency
   

B. Standard measures do not reveal a severe discrepancy, but the IEP Team finds that a severe discrepancy does exist based upon the additional documentation provided in the attached report.
 
  (Complete and attach Specific Learning Disability Discrepancy documentation form)
 

 
II. The discrepancy identified in Item I (above) is directly related to a processing disorder.

  Check appropriate area(s)
    Sensory
Motor
Skills
  Visual
Processing
  Auditory
Processing

    Attention   Cognitive Abilities, (including association, conceptualization and expression)
 

 
III. If ANY of the items below (A-E) are checked “Yes”, the student MAY NOT be identified as having a specific learning disability.
  A. The discrepancy is due primarily to limited school experience or poor school attendance.
 

  B. The discrepancy is a result of environmental, cultural difference or economic disadvantage.
 

  C. The discrepancy is due primarily to mental retardation or emotional disturbance.
 

  D. The discrepancy is due primarily to a visual, hearing, or motor disability.
 

  E. This discrepancy can be corrected through other regular or categorical services offered within the regular Instructional program.
 
  F. The discrepancy is due to limited English proficiency.
 
  G. The discrepancy is due to lack of appropriate instruction in reading and math.
 
 

 
  IV. The Student has a specific learning disability.
 

 
V. Basis for determination of eligibility
  Psychoeducational Evaluation utilizing multiple measures. See attached psychoeducational report.

  Other (specify)
 

       
VI. Relevant behavior related to academic functioning, noted during observation
 
 
  See attached Psychoeducational report.  
 

 
VII. Educationally relevant medical findings, if any (describe)
 
 

 
I agree with the conclusions stated above:
           
           
 

 

  School Psychologist Date   Special Ed. Admin./Designee Date
           
           
 

 

  Special Education Teacher Date   General Education Teacher Date
           
           
 

 

  LSH Specialist Date   Reading Teacher Date
           
           
 

 

  Parent/Guardian Date   Other Date
           
 
My assessment of this student differs from the above report as follows: Statement (attach additional pages as necessary)
 
 
 

     
  Signature and Title Date