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General Information about Eligibility Checklists in ENCORE

1. All eligibility checklists in ENCORE function the same.2. When yes or no is checked, other fields may become required, optional or unavailable.3. Actual data/information to support a specific point of criteria is entered in the text field.

This includes test scores, a summary and analysis of the observational data, and information from other sources (interviews), existing records and reports. Do not simply list data sources or assessment titles.

4. If reporting specific test scores, explain what the scores mean so that parents understand.5. When including information regarding behavior, describe the behavior and indicate the

frequency with which the behavior occurs.6. Any team member can and should enter information obtained from assessments or

sources into the appropriate fields on the eligibility checklist(s).7. The final eligibility decision is automatically checked based on responses to the points of

criteria.8. For more detailed information regarding eligibility criteria consult the Disability

Evaluation Guides on the 2013-14 SSIMS disk or DPI’s website.

Disclosure Statement:Statements in the text boxes are meant to give the user possible examples of types of information that might be included, however, not intended to be used directly or duplicated in student IEPs.

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ELIGIBILITY CHECKLIST AUTISM

Autism means a developmental disability significantly affecting a student's social interaction and verbal and non-verbal communication, generally evident before age 3 that adversely affects learning and educational performance. Other characteristics often associated with autism are engagement in repetitive activities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. The term does not apply if a student's educational performance is adversely affected primarily because he or she has an emotional disturbance.

1. This student displays difficulties or differences or both in interacting with people and events. The student may be unable to establish and maintain reciprocal relationships with people. The student may seek consistency in environmental events to the point of exhibiting rigidity in routines.

The following data was used to make this determination:

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When considering the disability of Autism for a student there are two important things to remember: 1. This is an educational diagnosis, not a medical diagnosis. 2. If a student already has a medical diagnosis of Autism, MPS will request the report, and consider the information. A medical diagnosis does not guarantee an educational diagnosis.

Summarize information from: Autism rating scales Previous evaluations Observations across multiple settings Interviews with individuals who have direct knowledge of the student

Questions to consider: Does the student form attachments to family members and others? Is the student able to share attention with another person to a third object or event? How aware is the student to the social environment as compared to the physical environment? Does the student learn from imitating what he or she sees others doing? Does the student engage in give-and-take, back-and-forth social interaction including conversation, turn-

taking in games, waiting their turn in group situations such as during group classroom discussions? Does the student understand the unstated, tacit rules of social interactions and social situations? What is the social quality of the student’s play? Does the student prefer to play alone? Does the student

engage in parallel play? Does the student play interactively and appropriately, or does the student dominate play with peers?

2. This student displays problems which extend beyond speech and language to other aspects of social communication, both receptively and expressively. The student's verbal language may be absent or, if present, lacks the usual communicative form which may involve deviance or delay or both. The student may have a speech or language disorder, or both, in addition to communication difficulties associated with autism.


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Summarize information from: Autism rating scales Previous evaluations Observations across multiple settings Interviews with individuals who have direct knowledge of the student

Questions to consider: Non Verbal Students:

Does the student understand cause and effect? Does the student exhibit communicative intent (the desire to communicate with another person, verbally or

non-verbally)? Does the student have a form of communication? How does this student get his or her wants met? Does this student repeat or echo words or phrases (echolalia)? Does this student demonstrate spontaneous use of core communicative functions such as requesting, protesting

or refusing, requesting help or assistance or indicating cessation (“all done”)? Does the student understand and follow verbal and nonverbal directions?

Verbal Students: Does the student spontaneously seek out others to initiate communication without prompting? Does this student demonstrate spontaneous use of core communicative functions such as requesting, protesting

or refusing, requesting help or assistance or indicating cessation (“all done”)? Does the student have reciprocal conversations? Does the student maintain a topic initiated by others? Does the student attend to communicative partner, for example, call out the person’s name, establish eye

contact, or demonstrate appropriate personal space? Does the student observe and understand nonverbal cues exhibited by others? Does the student exhibit appropriate nonverbal cues themselves, such as body language, tone of voice, vocal

inflection, eye gaze, personal space, etc.? Does the student show an interest/awareness in the needs and wishes of others? Does the student show awareness and ability to repair communication breakdowns? Does the student have the vocabulary and knowledge base to express his/her emotions/feelings in a variety of

situations? Does the student understand and follow verbal and nonverbal directions? Does the student understand and use figurative language such as idioms or slang?

3. The student exhibits at least one of the following characteristics:a. The student exhibits delays, arrests or regressions in motor, sensory, social or learning skills. The student may

exhibit precocious or advanced skill development, while other skills may develop at normal or extremely depressed rates. The student may not follow developmental patterns in the acquisition of skills.

b. The student exhibits abnormalities in the thinking process and in generalizing. The student exhibits strengths in concrete thinking while difficulties are demonstrated in abstract thinking, awareness and judgment. Perseverant thinking and impaired ability to process symbolic information may be present.

c. The student exhibits unusual, inconsistent, repetitive or unconventional responses to sounds, sights, smells, tastes, touch or movement. The student may have a visual or hearing impairment or both in addition to sensory processing difficulties associated with autism.

d. The student displays marked distress over changes, insistence on following routines and a persistent preoccupation with or attachment to objects. The student's capacity to use objects in an age-appropriate or functional manner may be absent, arrested or delayed. The student may have difficulty displaying a range of interests or imaginative activities or both. The student may exhibit stereotyped body movements.


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Summarize information from: Standardized tests, assessments and checklists Autism rating scales Observations across multiple settings Interviews with individuals who have direct knowledge of the student Sensory profiles/checklists Developmental history/assessments

Questions to consider: Does this student demonstrate exhibit precocious development in some areas (often concrete visual rote

learning skills) while exhibiting depressed rates in other areas? Has this student’s growth followed the typical developmental rates and sequences? (Often children on the

spectrum show splintering of skills with clear strengths and weaknesses.) Does this student process information in a concrete, literal manner? Does this student demonstrate difficulties understanding abstract and symbolic information or relationships? Does this student demonstrate difficulties with executive functioning skills such as attending, problem

solving, problem solving, organizing, prioritizing, and/or generalizing? Does this student exhibit hypersensitivity or hyposensitivity to sensory stimuli? Does this student tend to squint, close their eyes, or stare when asked to attend to visual stimuli? Does this student have unexpected or unusual reactions to textures? Does this student seek vestibular (movement) input by bouncing, rocking, spinning etc. OR Does the student

avoid that vestibular input? Does this student exhibit a limited diet, crave certain foods or flavors, or eat non-food items? Does this student avoid smells or smell things that typically do not have an odor? Does this student seem to have difficulty knowing where their body is in space, falling off chairs, banging

into people or objects, frequently hugging with force, enjoying heavy work activities such as pulling, pushing or carrying heavy items, or enjoy being wrapped tightly in a blanket?

Does this student demonstrate any ritualistic actions or behaviors? Does this student exhibit high anxiety over a change in routine? Does this student perseverate on thoughts, activities, actions or behaviors? Does this student have a restricted/ narrow range of interests or unusual interests when compared to peers? Does this student demonstrate repetitive motor or vocal patterns such as flapping, rocking, pacing, humming,

picking, chewing etc?

ELIGIBILITY CHECKLIST COGNITIVE DISABILITY

Cognitive disability means significantly subaverage intellectual functioning that exists concurrently with deficits in adaptive behavior and that adversely affects educational performance.

1. Intellectual FunctioningThis student has a standard score of two or more standard deviations below the mean.

OR This student has a standard score between one and two standard deviations below the mean; and This student has been documented as having a cognitive disability in the past; and This student's condition is expected to last indefinitely.


2. Adaptive Behavior This student has deficits (interpreted to mean two or more of the age related adaptive behavior areas) in adaptive behavior as demonstrated by a standard score of two or more standard deviations below the mean. Communication (from age 3-21) Self-direction (from age 6-21) Self-care (from age 3-21) Health and safety (from age 6-21) Social skills (from age 3-21) Applying academic skills in life (from age 6-21) Home living skills (from age 6-21) Leisure (from age 6-21) Appropriate use of resources in the community Work (from age 14-21) (from age 6-21)


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Summarize information from: Intellectual assessments (A standard deviation (SD) of 2.0 is typically a score of 70 or below.) Review of records/previous evaluations

Summarize information from: Developmental/adaptive assessments Interviews with individuals who have direct knowledge of the Student Review of records/previous evaluations

Questions to Consider: How does the child’s level of functioning at home compare to functioning at school? What opportunities has the child had to demonstrate the ability to perform or complete certain tasks? Has experience in areas been limited, which may lend itself to lower test scores?

3. Academic FunctioningThis student has a standard score of two or more standard deviations below the mean in at least two areas for the appropriate age group (in addition to a score of two or more standard deviations below the mean in the area of General Information for students age 6 through 21).

Check all that apply. Age 3 through 5 (at least two of the following) Academic readiness Comprehension of language or communication Motor Skills Age 6 through 21 (at least two of the following) Written Language Reading Mathematics AND Yes No General Information


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Summarize information from: Preacademic assessments Academic assessments Review of records/previous evaluations

ELIGIBILITY CHECKLIST EMOTIONAL BEHAVIORAL DISABILITY

Emotional behavioral disability means social, emotional or behavioral functioning that so departs from generally accepted, age appropriate ethnic or cultural norms that it adversely affects a student's academic progress, social relationships, personal adjustment, classroom adjustment, self-care or vocational skills.

1. This student exhibits social, emotional, or behavioral functioning that so departs from generally accepted age appropriate, ethnic or cultural norms that it adversely affects the student in at least one of the following areas:

Academic Progress Classroom Adjustment Social Relationships Self-Care Personal Adjustment Vocational Skills


2. Behaviors are severe, chronic and frequent.


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Summarize information from: Observations, parent interviews and teacher/other staff reports Formal and informal assessments

Questions to consider: To what degree does this child’s behavior affect the above checked areas?

Severe—behavior hampers normal functioning to a significant degree; behavior is a threat to the student or others; behavior causing a student to fail academically, get into trouble with the law, or repeatedly be in situations which result in disciplinary actions; impacts negatively on social interactions.Chronic—behavior that is markedly impacted by the length of time the behaviors of concern have been exhibited in relation to the age of the student. The behavior is not symptomatic of a developmental level or a situational stress (such as parents divorcing, serious illness or death in the family, a recent major move, serious injury or illness of the student, a parent remarrying, transition to a new level of school, mismatch with program style, a new sibling, family financial crisis).Frequent—consider predictability of the behavior and the effects of the environment. Since behavior occurs in a context, it is important to note factors that may affect the frequency such as others in the setting, prevention strategies, time of day, activities or assignments and so on. If the behavior is situational, it may be that environmental manipulations will resolve the issues.

Summarize information from: Discipline records/referrals Parent reports/questionnaires Observations

Questions to consider: Is the behavior in excess compared to peers with similar backgrounds? Is there an ongoing pattern? Is the behavior occurring much more than normal or expected?

3. Behaviors occur at school and in at least one other setting. Home Community


4. This student displays one or more of the following:

Inability to develop or maintain satisfactory interpersonal relationships Inappropriate affective or behavior response to a normal situation Pervasive unhappiness, depression or anxiety Physical symptoms, pains or fears associated with personal or school problems Inability to learn that cannot be explained by intellectual, sensory or health factors Extreme withdrawal from social interaction Extreme aggressive for a long period of time Other inappropriate behaviors that are so different from children of similar age, ability, educational experiences and opportunities that the student or other students in a regular or special education program are negatively affected


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Summarize information from: Parent reports/questionnaires Discipline records/referrals Report card information/comments Classroom teacher/other staff reports

Summarize information from: Discipline records/ referrals Observations Parent reports

Questions to consider: Does the student’s behavior result in poor grades, attendance, or levels of achievement when compared to

potential? Does the student’s behavior interfere with the ability to interact with peers and adults or manage his/her behavior

in a variety of environments? Does the student’s behavior interfere with his/her ability to read social cues? Does the student’s behavior negatively impact on his/her affect?

ELIGIBILITY CHECKLIST HEARING IMPAIRMENT

Hearing impairment, including deafness, means a significant impairment in hearing with or without amplification whether permanent or chronically fluctuating, that significantly adversely affects a student's educational performance including academic performance, speech perception and production or language and communication skills.

1. There is a significant impairment in hearing, as documented by a licensed audiologist and observational data from the parents and teacher of this student, which includes either a significant permanent impairment in hearing OR a significant pattern of chronically fluctuating impairment in hearing.


2. The impairment in hearing significantly adversely affects the following:

The student's educational performance, including academic performance, such as phonemic awareness, vocabulary, general word knowledge, independent reading with comprehension, reading for information, etc.


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Summarize information from: Audiology reports Teacher observations

Questions to consider: Has a report from an audiologist been made available? How does the student use his/her hearing in a variety of settings under various conditions?

Summarize information from: Teacher observations Student performance on classroom activities Student performance on formal and informal assessments Classroom-based assessments Formal and informal assessments Individualized achievement testing Speech/Language assessments

Questions to consider: Is there potential for the student to benefit from the use of amplification devices? What amplification devices has the student used in the classroom setting? Does the student communicate with non-disabled peers? If yes, how? What is the student’s academic performance level in the regular settings?

The student's speech perception and production, including the ability to listen with comprehension to spoken messages in a variety of settings, and the ability to produce speech that is intelligible to others.


The student's language and communication skills such as vocabulary comparable to age peers, general knowledge, ability to ask questions, apply information, communicate effectively with peers and adults in a variety of situations in order to have needs met, know the nuances of communication exchange (manners), etc.


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Summarize information from: Teacher observations Parent interviews Speech/Language assessments

Questions to consider: What language (spoken or sign) does the student appear to prefer? (not teacher preference) Does the student use speech or sign language to communicate? Is the child able to use preferred method of communication in both home and school or out in the community? What is the level of fluency the student has attained using the method of communication of choice?

Summarize information from: Teacher observations Student performance on classroom activities Student performance on formal and informal assessments Speech/Language assessments

Questions to consider: Is there potential for the student to benefit from the use of amplification devices? What amplification devices has the student used in the classroom setting? Does the student communicate with non-disabled peers? If yes, how? What is the level of grammatical, semantic and social skill being demonstrated in understanding and using

language (spoken and sign) when communicating with adults and peers.

ELIGIBILITY CHECKLIST OTHER HEALTH IMPAIRMENT

Other health impairment means having limited strength, vitality or alertness, due to chronic or acute health problems. The term includes but is not limited to a heart condition, tuberculosis, rheumatic fever, nephritis, asthma, sickle cell anemia, hemophilia, epilepsy, lead poisoning, leukemia, diabetes or acquired injuries to the brain caused by internal occurrences or degenerative conditions, which adversely affects a student's educational performance.

1. This student has a health problem.


2. This health problem is chronic or acute. Chronic (long standing, continuous over time or recurring frequently) Acute (severe or intense)


3. The student’s health problem results in limited strength, vitality or alertness. (y/n)

Limited strength (inability to perform typical or routine tasks at school) Limited vitality (inability to sustain effort or endure throughout an activity) Limited alertness (inability to manage and maintain attention, to organize or attend, to prioritize environmental stimuli, including a heightened alertness)


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Summarize information from: Interviews and previous information that support whether or not the student has a health problem. Diagnosis from a physician. Medical records/lead levels.

Summarize information from: Cumulative records. Discipline records/referrals. Parent reports/questionnaires. Medical records.

Summarize information from: Narrative information provided by reports from providers, teachers, staff and parents. Examples of behavior associated with the above listed health concerns.

Note: Only one area is required to be checked in order for this point of criteria to be answered yes.

4. This student’s educational performance in one or more of the following areas is adversely affected by the documented health problem.

Consider both academic and nonacademic skills and progress. Pre-academic or academic achievement Adaptive behavior Behavior Classroom performance Communication Motor skills Social/Emotional Functioning Vocational Other_____________________________________


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Summarize information from: Observations Formal/ informal/classroom assessments Related Service provider information. Areas listed above should have a direct connection to the health problem.

ELIGIBILITY CHECKLIST ORTHOPEDIC IMPAIRMENT

Orthopedic impairment means a severe orthopedic impairment that adversely affects a student's educational performance. The term includes, but is not limited to, impairments caused by congenital anomaly, such as a clubfoot or absence of some member; impairments caused by disease, such as poliomyelitis or bone tuberculosis; and impairments from other causes, such as cerebral palsy, amputations, and fractures or burns that cause contractures.

1. This student has a congenital anomaly.


2. This student has impairments caused by disease.


3. This student has impairments from other causes.


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Summarize information from: Medical reports Parent interview Observations Cumulative folder Previous evaluations



4. This student's educational performance in one or more of the following areas is adversely affected as a result.If yes, check ALL that apply. Consider academic achievement and functional performance.

Maintaining and changing positions Using Classroom Materials Hygiene/Self-care Clothing management Mobility Eating Classroom performance Pre- academic or academic achievement Social/Emotional functioning Communication Vocational skills Behavior Participation in physical education Safety issues Accessing the community


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Summarize information from: Academic achievement testing Classroom assessments Formal and informal assessments Observations Parent report Teacher report Previous evaluations

Question to consider:

Is there a direct connection between the area(s) identified above and the documented orthopedic condition?

ELIGIBILITY CHECKLIST SIGNIFICANT DEVELOPMENTAL DELAY

Significant developmental delay means children, ages 3, 4 and 5 years of age or below compulsory school attendance age, who are experiencing significant delays in the areas of physical, cognition, communication, social emotional or adaptive development.

1. Age The child is 3, 4 or 5 years old (Statutory limit)

2. Other Categories Criteria under the other categories have been considered before the criteria of SDD

NOTE: The IEP team must consider other disability areas before the area of SDD. If anyone on the team suspects another disability or if the data “looks like” another disability, it must be considered and the criteria page completed. (For example, if the student’s scores are in the range that could be considered a Cognitive Disability, then the eligibility checklist should be completed.)

3. Information Sources All of the following qualitative and quantitative measures have been used to document delays and their detrimental effect upon this student's life.

Developmental history, health history and other pertinent information from parents/others Observation of this student in his/her daily setting, or alternative justified, by an IEP Team member Results from norm-referenced instruments or if not feasible, criterion-referenced instruments

4. Significance of Delays This student has delays greater than 1.5 SD that significantly challenge this student in 2 or more of the following life activities. NOTE: Delays are evidenced through history, caregiver information, observation and instruments.

Physical: gross motor OR fine motor Cognitive Communication: expressive language OR receptive language Emotional OR social Adaptive


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Summarize information from: Formal standardized testing (A standard deviation (SD) of 1.5 is typically a score of 77 or below.) Observations Interviews with individuals who have direct knowledge of the student Birth to Three Agency records/Previous evaluations

Questions to consider: What are this student’s background experiences and prior knowledge? Can it reasonably be expected that this

student complete some of the tasks presented to him/her? Is this student truly a student with a disability or a student who has not had the opportunities and stimulation to

demonstrate the skills expected? Has this student been involved in birth to three intervention and started to show growth?

5. Turning 6 Before the Start of the Next School Year Current Age of Student______________ This student is turning 6 years old as of _________and before the start of the next school year and will no longer

qualify for special education services. This student is turning 6 years old as of _________and before the start of the next school year and will only

qualify for services in the area of Speech and Language disability.

SDD Aging Out

Students who have been identified as SDD (Significant Developmental Delay), and turn 6 during the course of the school year, may continue to receive special education services for the remainder of that school year unless an IEP team determines that the child no longer meets criteria for SDD. If the student turns 6 on or before September 1 (which is commonly referred to as ‘prior to the start of the next school year’), special education services under SDD cannot be continued into the following school year.

Students who have a Significant Developmental Delay (SDD) and turn 6 on September 2, 2013 through September 1, 2014, must be reevaluated during the current school year (typically during K5), even if it’s not time for a regularly scheduled three year reevaluation.

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ELIGIBILITY CHECKLIST SPECIFIC LEARNING DISABILITY

When the student is NOT currently identified as SLD

Specific learning disability means a disorder in one or more of the basic psychological processes involved in understanding or using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell or perform mathematical calculations, including conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia and developmental aphasia.

SLD REEVALUATION (Currently identified as SLD)NOTE: Do not check this box if the student is NOT currently identified with a learning disability!

1. Inadequate Classroom AchievementThis student does not achieve adequately for his/her age/grade after intensive intervention. Yes No

If yes, achievement is inadequate in the following area(s): Check all that apply. Oral Expression Basic Reading Skill Mathematics Calculation Listening Comprehension Reading Comprehension Mathematics Problem Solving Written Expression Reading Fluency Skills

See ER-2 form for the data used to make this determination.

NOTE: Areas checked in this section should match the data found on ER-2, Section G.

2. Insufficient ProgressThis student has made insufficient progress based on one of the following options. Yes No

A. Insufficient response to intensive scientific , research-based or evidence based intervention. The student

does not make sufficient progress to meet age or grade -level standards following at least two intensive scientific, research or evidence based interventions implemented with adequate fidelity and closely aligned to individual student needs. Note: All schools must use this criterion beginning December 1,2013.

If yes to Insufficient Progress, the response is insufficient in the following area(s): Check all that apply Oral Expression Basic Reading Skill Mathematics Calculation Listening Comprehension Reading Comprehension Mathematics Problem Solving Written Expression Reading Fluency Skills


B. Significant Discrepancy. The student has a significant discrepancy between ability and achievement. Note: This criterion may no longer be used beginning December 1,2013.

If yes to Insufficient Progress, there is a discrepancy in the following area(s): Check all that apply Oral Expression Basic Reading Skill Mathematics Calculation Listening Comprehension Reading Comprehension Mathematics Problem Solving Written Expression Reading Fluency Skills


NOTE: Only areas for which there have been intensive interventions can be considered. The team selects Option A, Insufficient response to intensive scientific, research-based or evidence based

intervention, for all referrals made on and after November 4, 2013 except from private schools not implementing RtI.

The team selects Option B, Significant Discrepancy, when students are evaluated in MPS who have been referred BEFORE November 4, 2013. This option will also be used with students attending private schools not implementing RtI.

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3. Exclusionary FactorsThis student does not meet general education expectations primarily because of : Check all that apply.

Environmental, cultural or economic factors Limited English proficiency Lack of appropriate instruction in oral expression, listening comprehension, written expression, basic reading skill, reading comprehension, reading fluency skills, mathematics calculation, mathematics problem solving Other disability_______________________________________

The following data was used to make this determination:Summarize information from:

teacher observations information from student records ESL data information from parents references to data documenting other disability criteria found elsewhere in the evaluation report

Questions to consider: Has the student been transient? How many times has the student moved? What is the student’s attendance rate? Did poor attendance cause the student’s delay in progress? Has there been a traumatic event or significant change in the family that caused the delay in progress? Has the student been receiving appropriate instruction? Have there been intensive, culturally responsive

interventions to address academic delays? Are there major factors outside of school that could be impacting student performance in school? What is the student’s native language and culture?

Is the student proficient in his/her native language?

Has the student failed to develop age appropriate native language skills despite appropriate instruction?

What is the gap between the student’s proficiency in English and his/her native language; and what is the impact on learning?

Has the student failed to gain English language skills despite instruction?

Is there a difference in the student’s performance by subject area?

Are the student’s learning difficulties pervasive in both his/her native language and English?

Are the expectations of the student’s home culture consistent with school expectations?

Can any social or psychological factors (e.g., refugee or immigrant status; mental health concerns; racial or ethnic bias) be identified?

Did someone with expertise in the student’s dominant culture and language participate in the IEP team?

Was someone with expertise in the student’s dominant culture and language involved in conducting and interpreting the evaluation data?

Are the majority of students in the aggregate grade or age group achieving grade level standards in the area(s) of concern for the referred student?

How does the referred student’s performance compare to the performance of the aggregate group?

If the student is a member of an economic, limited English proficient, or cultural subgroup, how does the performance of the subgroup compare to the performance of the aggregate grade or age group?

How does the referred student’s performance compare to that of other members of the subgroup? Is the referred student’s performance significantly different?

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ER-2: ADDITIONAL DOCUMENTATION REQUIRED WHEN A STUDENT IS EVALUATED FOR SPECIFIC LEARNING DISABILITIES

When the student is NOT currently identified as SLD SLD REEVALUATION (Currently identified as SLD)

NOTE: Do not check this box if the student is NOT currently identified with a learning disability!

For students being evaluated for a specific learning disability, address each of the following:

A. Information demonstrating that the student was provided appropriate instruction in regular education.Summarize information from:

Attendance records Report cards WKCE and MAP results and aligned standards Grade level assessments

Questions to consider: Was core (universal) instruction provided regularly? What was the student’s attendance like? What was the rate of attendance over a period of years? Was differentiated instruction provided? How was the instruction differentiated? How often? How did the student perform on state or district-wide assessments? How did the student perform in the classroom?

B. Information demonstrating that the student received repeated assessments of achievement reflecting student progress.

Summarize information from: Response to Intervention data MAP assessment data (WKCE, or any annual assessment, is NOT used here.) Ongoing standards-based assessments

Questions to consider: Is there a systematic process for documenting progress? What kind of progress was documented following instruction based on objective assessments? Were the assessments multiple, on-going measures provided at regular intervals?

C. Information demonstrating that the student's parents were provided information on the above assessments of achievement of this student.

Summarize information from: E-mails Written notes/descriptions of progress data Progress reports Parent meetings/conferences where progress data is shared

Questions to consider: Was the parent provided with a report on the student’s progress based on the repeated assessments?

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D. Relevant behavior noted during observation of the student in his or her learning environment (including the regular classroom) and the relationship of that behavior to the student's academic functioning (if using observational data of the student's academic performance and behavior done prior to the referral for the evaluation, see ER-1).

Summarize information from: Observations

Questions to consider: Were there any relevant behaviors observed that impact the student’s learning in the area(s) of concern?

E. Educationally relevant medical findings.

If none, check “None”. Otherwise, briefly describe any relevant medical findings considered by the team.

Summarize information from: Parent information Medical reports, if any

F. The student received intensive intervention, which was applied in a manner highly consistent with its design, closely aligned to pupil need, and culturally appropriate.

Summarize information from: Observations during interventions Information from teacher applying interventions Can be referenced elsewhere in the report

Questions to consider: What interventions were implemented? What were the areas of concern being addressed? Were the interventions applied in a manner that was highly consistent with its design, aligned to the need,

culturally appropriate, focused on single or small number of discrete skills, AND provided for a substantial number of minutes?

G. Inadequate classroom achievement. The student's achievement relative to his or her age, or to meeting state approved grade level standards in one or more of the following: oral expression, listening comprehension, written expression, basic reading skills, reading fluency skills, reading comprehension, mathematics calculations and mathematics problem solving.

Summarize information from: Individually administered academic achievement tests WKCE and MAP assessments cannot be considered here, since they are not individually administered. Testing observations

Questions to consider: Were individualized achievement tests administered AFTER the interventions were applied? Based on the performance on the achievement testing, was the student’s performance 1.25 standard deviations

below the mean after the intensive intervention (WJ-III SS≤81)? Were the assessments administered according to the standardized system established by the test publisher? Is there any reason to believe that the results of the assessment are invalid or unreliable?

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H. Insufficient progress.

For schools using Response to Intervention:The student does not make sufficient progress to meet age or state approved grade level standards in one or more of the eight areas of potential specific learning disabilities when using a process based on the student's response to intensive scientific, research-based or evidence-based interventions.

Check the box for this criteria option if the referral is received after November 4, 2013, except if the student is attending a non-public school not using RtI.

Documentation will include a brief summary of interventions used, progress monitoring results, and reasons the team believes progress is insufficient.

Summarize information from: Progress monitoring data Observations of the student engaged in the intervention activities for each of the areas being considered

Questions to consider: What scientific, research-based or evidence-based interventions have been used? Have there been two or more of those interventions for each of the areas being considered? What are the results of progress monitoring procedures? Why has the student made or not made sufficient progress with the interventions used?

If regression procedure is not used, document why it was not appropriate to use the regression procedure and document that significant discrepancy exists, including a variable pattern of achievement or ability, in at least one of the eight potential areas of specific learning disabilities using other empirical evidence.

I. The effects of a visual, hearing or physical (motor) disability, cognitive disability, emotional disturbance, cultural factors, environmental or an economic disadvantage, or limited English proficiency on the student's achievement level.

Document the effects of the listed factors, if any. This would support the determination if there are any exclusionary factors on the criteria checklist.

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Check this box if the regression procedure is not used and document the reasons that the procedure was inappropriate for use in the evaluation.

Summarize information from: Testing observations Documentation to explain reasoning when the regression formula is not used

Questions to consider: Were individualized achievement tests administered AFTER the interventions were applied? Were the assessments administered according to the standardized system established by the test publisher? Is there any reason to believe that the results of the assessment are invalid or unreliable?

J. If the student participated in a process that assesses the student's response to scientific, research-based intervention, include a statement for each of the following: N/A N/A for SLD Reevaluation

Check “N/A” ONLY if the student did not participate in an RtI process and the Significant Discrepancy procedure is being used as documented in Section H.

THIS SHOULD ONLY APPLY TO STUDENTS WHOSE NOTICES OF REFERRAL WENT OUT BEFORE NOVEMBER 4, 2013 OR WHO WERE ATTENDING A NON-PUBLIC SCHOOL THAT DOES NOT USE RtI.

1. The instructional strategies used with the student.

If “N/A” is checked above, leave this box blank.

Summarize information from: Information from Teacher Observations of applied interventions Data collected in the progress monitoring procedure Can be referenced elsewhere in the report

Questions to consider:1. What interventions were implemented?2. What were the areas of concern being addressed?

2. The student-centered data collected in response to the instructional strategies used with the student.

If “N/A” is checked above, leave this box blank.

Summarize information from: Data collected in the progress monitoring procedure Can be referenced elsewhere in the report

Questions to consider: How was the progress monitored and the data recorded? What are the data collected in the progress monitoring procedure?

3. How and when the student's parents were informed about the amount and nature of this student's performance data that would be collected and the general education services that would be provided, the strategies to be used to increase this student's rate of learning, and their right to request an evaluation.If “N/A” is checked above, leave this box blank.

Summarize information from: Documentation of correspondence providing information to the parent Data collected in the progress monitoring procedure Can be referenced elsewhere in the report

Questions to consider: Were the parents informed of the student’s progress? Were the parents informed of the interventions being used to address areas of concern? Were the parents informed of their right to request an evaluation before the interventions were

applied?

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The IEP team assures that the decision of whether this student has a specific learning disability was based on information from a variety of sources and not on any single measure or assessment as the sole criterion. Each IEP team participant must sign below and indicate whether he/she agrees with the conclusions regarding whether or not the student is a student with a specific learning disability. If this does not reflect his/her conclusions, then that IEP team participant must also attach a statement with his/her conclusions

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If the parent is the member that disagrees, this box can be used to document the parent’s statement or a statement can be attached and the reference can be added here.

ELIGIBILITY CHECKLIST SPECIFIC LEARNING DISABILITY

When the student IS currently identified as SLD

Specific learning disability means a disorder in one or more of the basic psychological processes involved in understanding or using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell or perform mathematical calculations, including conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia and developmental aphasia.

Check this box ONLY if the student is CURRENTLY identified with a learning disability!

1. Inadequate Classroom Achievement

For SLD Reevaluation:This student does not meet general education expectations due to needs resulting from SLD. (Yes or No)


Teacher observations Report cards WKCE and MAP results and aligned standards Grade level assessments IEP goal progress reports Current intervention progress information

Questions to consider: Can the student meet general education expectations in general education environments when provided with

reasonable options, interventions, adaptations, or other general education strategies? Does the student’s specific learning disability continue to interfere with his or her participation in general

education classes or ability to meet general education standards? Is the student’s achievement within the range of performance of other students in the same grade? Does the student continue to exhibit significant achievement delays and is the student failing to make

progress in the general education curriculum? Can the student independently use supports and accommodations, such as e-books, video lectures, peer note

takers, scanners, text readers, or other assistive technology to assist the student in meeting general education requirements?

2. Insufficient Progress

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3. Exclusionary FactorsThis student does not meet general education expectations primarily because of : Check all that apply.

Environmental, cultural or economic factors Limited English proficiency Lack of appropriate instruction in oral expression, listening comprehension, written expression, basic

reading skill, reading comprehension, reading fluency skills, mathematics calculation, mathematics problem solving

Other disability_______________________________________


teacher observations information from student records ESL data information from parents references to data documenting other disability criteria found elsewhere in the evaluation report

Questions to consider: Has the student been transient? How many times has the student moved? What is the student’s attendance rate? Did poor attendance cause the student’s delay in progress? Has there been a traumatic event or significant change in the family that caused the delay in progress? Has the student been receiving appropriate instruction? Have there been intensive, culturally responsive

interventions to address academic delays? Are there major factors outside of school that could be impacting student performance in school? What is the student’s native language and culture?

Is the student proficient in his/her native language?

Has the student failed to develop age appropriate native language skills despite appropriate instruction?

What is the gap between the student’s proficiency in English and his/her native language, and what is the impact on learning?

Has the student failed to gain English language skills despite instruction?

Is there a difference in the student’s performance by subject area?

Are the student’s learning difficulties pervasive in both his/her native language and English?

Are the expectations of the student’s home culture consistent with school expectations?

Can any social or psychological factors (e.g., refugee or immigrant status; mental health concerns; racial or ethnic bias) be identified?

Did someone with expertise in the student’s dominant culture and language participate in the IEP team?

Was someone with expertise in the student’s dominant culture and language involved in conducting and interpreting the evaluation data?

Are the majority of students in the aggregate grade or age group achieving grade level standards in the area(s) of concern for the referred student?

How does the referred student’s performance compare to the performance of the aggregate group?

If the student is a member of an economic, limited English proficient, or cultural subgroup, how does the performance of the subgroup compare to the performance of the aggregate grade or age group?

How does the referred student’s performance compare to that of other members of the subgroup? Is the referred student’s performance significantly different?

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ER-2: ADDITIONAL DOCUMENTATION REQUIRED WHEN A STUDENT IS EVALUATED FOR SPECIFIC LEARNING DISABILITIES

When the student IS currently identified as SLD

Do not check this box if the student is NOT currently identified with a learning disability!

For students being evaluated for a specific learning disability, address each of the following:A. Information demonstrating that the student was provided appropriate instruction in regular education.

B. Information demonstrating that the student received repeated assessments of achievement reflecting student progress.

C. Information demonstrating that the student's parents were provided information on the above assessments of achievement of this student.

D. Relevant behavior noted during observation of the student in his or her learning environment (including the regular classroom) and the relationship of that behavior to the student's academic functioning (if using observational data of the student's academic performance and behavior done prior to the referral for the evaluation, see ER-1).

Summarize information from: Observations

Questions to consider: Were there any relevant behaviors observed that impact the student’s learning in the area(s) of concern?

E. Educationally relevant medical findings.

If none, check “None”. Otherwise, briefly describe any relevant medical findings considered by the team.

Summarize information from: Parent information Medical reports, if any

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F. The student received intensive intervention, which was applied in a manner highly consistent with its design, closely aligned to pupil need, and culturally appropriate.

G. Inadequate classroom achievement.

H. Insufficient progress.

I. The effects of a visual, hearing or physical (motor) disability, cognitive disability, emotional disturbance, cultural factors, environmental or an economic disadvantage, or limited English proficiency on the student's achievement level. Document the effects of the listed factors, if any. This would support the determination if there are any exclusionary factors on the criteria checklist.

J. If the student participated in a process that assesses the student's response to scientific, research-based intervention, include a statement for each of the following:

The IEP team assures that the decision of whether this student has a specific learning disability was based on information from a variety of sources and not on any single measure or assessment as the sole criterion. Each IEP team participant must sign below and indicate whether he/she agrees with the conclusions regarding whether or not the student is a student with a specific learning disability. If this does not reflect his/her conclusions, then that IEP team participant must also attach a statement with his/her conclusions.

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Note: If the parent is the member that disagrees, this box can be used to document the parent’s statement or a statement can be attached and the reference can be added here.

ELIGIBILITY CHECKLIST SPEECH OR LANGUAGE IMPAIRMENT

Speech or language impairment means an impairment of speech or sound production, voice, fluency, or language that significantly affects educational performance or social, emotional or vocational development.

1. Language

This student scores at or below 1.75 SD on formal test measures.There is documentation that this delay impairs oral communication in the student's natural environment.

The following data was used to make this determination:Indicate method to document: Language sample Checklist Interview Observation ReportOther: ___________________________________________________________________________

Formal testing was not appropriate or informal measures were used to assess language functioning. List reason(s) below.

Two informal measures were used. There is evidence of a communication delay. List two types of measures below.


2. Speech or Sound Production

There is documentation of delayed speech or sound production.

If yes, one of the following must be checked:

This student scores at or below 1.75 SD on a test of articulation or phonology. This student has consistent speech sound errors when 90% of typically developing children produce the sound correctly. This student presents with one or more disordered phonological processes occurring at least 40% of the time. This student scores in the moderate to profound range on a test of phonological processes.

The delay in speech or sound production significantly affects the intelligibility of the student's speech.


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Summarize information from: Formal/informal assessments Classroom observations Parent report Teacher interview Student interview


3. Voice

There is documentation of a vocal impairment without short-term physical factors or respiratory virus or infection.


4. Fluency

This student demonstrates speaking behaviors characteristic of a fluency disorder.


5. Impact

The delay(s), impairment or disorder identified above significantly affects educational performance, social, emotional or vocational development.


6.7.

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Questions to consider: Is the student willing to participate in class discussions? Is the student able to make wants and needs known? Does the student communicate with peers? How often? Do peers understand him/her? How is the impairment or disorder affecting the student’s educational performance, social/emotional

functioning, or vocational development?

6. Exclusions

The IEP team could not identify a speech/language impairment for the following reason(s):

Speech or language delays are mild, transitory or developmentally appropriate. Speech or language performance is consistent with developmental levels unless the student requires speech or language services in order to benefit from his or her educational program(s). Speech or language skills are a result of dialectical differences or learning English as a second language. Auditory processing delays exist in isolation and do not result in an impairment of oral communication skills. A tongue thrust is present that does not result in an impairment in speech or sound production. Elective or selective mutism or school phobia are present without a delay in oral communication skills.


Additional data:

Check box to confirm.

A speech and language pathologist was an IEP team participant and attended IEP meetings when the team discussed eligibility for a speech and language impairment and/or the need for speech and language services.

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Summarize information from: Formal/informal assessments Observations Review of records

Summarize nformation and Observations from Others

ELIGIBILITY CHECKLIST TRAUMATIC BRAIN INJURY

Traumatic brain injury means an acquired injury to the brain caused by an external physical force resulting in total or partial functional disability or psychosocial impairment, or both, that adversely affects a student's educational performance. The term applies to open or closed head injuries resulting in impairments in one or more areas, such as cognition; speech and language; memory; attention; reasoning; abstract thinking; communication; judgment; problem solving; sensory, perceptual and motor abilities; psychosocial behavior; physical functions; information processing; and executive functions, such as organizing, evaluating and carrying out goal directed activities. The term does not apply to brain injuries that are congenital or degenerative, or brain injuries induced by birth trauma.

1. This student has an acquired injury to the brain that occurred following a period of normal development. The acquired injury may not be due to congenital causes (such as PKU or Down Syndrome) or degenerative causes (such as Multiple Sclerosis or Muscular Dystrophy) or induced by birth trauma (such as perinatal stroke).

The following data was used to make this determination, including a description of the nature of the acquired injury, if present, and source(s) of evidence: (If medical information from a licensed physician is available, the IEP team must consider it.)

2. This student's acquired brain injury was caused by an external physical force from a strike or blow to the head or from movement of the brain within the skull. (For example: due to a bike or car accident, a fall, a sports injury, an object like a nail penetrating the brain, or whiplash to the head)


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Summarize information from: Medical reports Parent interviews Accident reports

Questions to consider: Was there a significant injury to the student’s head? What was the extent or severity of the injury?

Summarize information from: Medical reports Parent interviews Accident reports

Questions to consider: What was the cause of the injury? How did the injury occur?

3. This student's educational performance (consider both academic and nonacademic skills and progress) is adversely affected due to total or partial functional disability and/or psychosocial impairment in one or more of the following areas.

If yes, check all that apply. Cognition Speech & Language Memory Attention Reasoning Abstract Thinking Communication Judgment Problem solving Sensory, Perceptual and Motor Abilities Physical functions Information processing Psychosocial Behavior (psychological or social functioning) Executive functions (e.g. organizing, evaluating and goal-directed activities)


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Summarize information from: School records Teacher observations Test performances Behavior records Comparisons of performances before and after the injury Behavior and skills demonstration

Questions to consider: How was the student performing in the classroom prior to the brain injury? How is the student currently performing on classroom tasks? How has the student’s classroom performance or behaviors changed following the brain injury?

ELIGIBILITY CHECKLIST VISUAL IMPAIRMENT

Visual impairment means, even after correction, a student's visual functioning significantly adversely affects his or her educational performance.

1. A certified teacher of the visually impaired conducted a functional vision evaluation, including:Yes No Review of medical informationYes No Formal/informal testsYes No Educational implications and curricular needs


2. An ophthalmologist or optometrist has documented at least one of the following (check all that apply): Central visual acuity of 20/70 or less in the better eye after conventional correction Reduced visual field to 50 degrees or less in the better eye Other ocular pathologies that are permanent and irremediable Cortical visual impairment A degenerative condition that is likely to result in a significant loss of vision in the future


3. An orientation and mobility specialist, or teacher of the visually impaired in conjunction with an orientation and mobility specialist, evaluated this student to determine if there are related mobility needs in home, school, or community environments.

The evaluation was conducted by: An orientation and mobility specialist A teacher of the visually impaired in conjunction with an orientation and mobility specialist


NOTE: Before a teacher of the visually impaired is added to the team, an ocular report must be requested and received

documenting the current visual functioning. A teacher of the visually impaired and an orientation and mobility specialist must be a part of this team.

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A certified teacher of the visually impaired conducts a functional vision evaluation. Summarize the medical information, results of formal and informal tests of visual functioning, and the implications of the visual impairment on the educational and curricular needs of the student.

An ocular report must be submitted from the ophthalmologist or optometrist to document this information. Summarize the results of the ocular report, including the name of the ophthalmologist or optometrist and the date of the report. Indicate in this box “See attached ocular report”.

Note: Scan and attach a copy of the ocular report in ENCORE.

An orientation and mobility specialist, or teacher of the visually impaired in conjunction with an orientation and mobility specialist, evaluates the child to determine if there are related mobility needs in home, school, or community environments.

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