Specific Learning Disability Discrepancy Documentation Report
(Individualized Education Program Team Certification)
  Student Name ,
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)

Statement of the area, the degree, and the basis and method used in determining the discrepancy:

1. Data from assessment instruments (ability and achievement):
2. Information provided by the parent:
3. Information provided by the pupil’s present teacher:

4. Summary of the pupil’s classroom performance:
    a. Observations:
 
    b. Work Samples:
 
    c. Group Test Scores:
 

5. Consideration of the pupil’s age:
6. Additional Relevant Information: