Specific Learning Disability
Team Determination of Eligibility (9A)
Student
,
Birthdate
School of att.
School of att.
Date
Date
Purpose of Meeting*
Purpose of Meeting*
Other:
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.
Yes
No
Yes
No
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.
Yes
No
Yes
No
A. The discrepancy is due primarily to limited school experience or poor school attendance.
Yes
No
Yes
No
B. The discrepancy is a result of environmental, cultural difference or economic disadvantage.
Yes
No
Yes
No
C. The discrepancy is due primarily to mental retardation or emotional disturbance.
Yes
No
Yes
No
D. The discrepancy is due primarily to a visual, hearing, or motor disability.
Yes
No
Yes
No
E. This discrepancy can be corrected through other regular or categorical services offered within the regular Instructional program.
Yes
No
Yes
No
F. The discrepancy is due to limited English proficiency.
Yes
No
Yes
No
G. The discrepancy is due to lack of appropriate instruction in reading and math.
Yes
No
Yes
No
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