EvaluationReportandEligibilityDetermination.doc

PURPOSE: The evaluation report documents assessment results and review of data that assists in determining whether a student is eligible for special education, and provides information to the IEP team to assist with IEP development. The evaluation process should be sufficient in scope to determine: (1) whether a student has a disability, (2) whether the disability adversely affects his/her performance in the general education curriculum, and (3) the nature and extent of the student’s need for specially designed instruction and any necessary related services. Based on the review of the evaluation results, the evaluation group and the parent determine whether the student is eligible for special education. If the evaluation group believes the student may have a specific learning disability, the supplementary report for SLD contains the additional requirements to be included as part of the eligibility determination. EVALUATION REPORT Student name: Student ID No.: Birthdate: Grade: Age: Race/Ethnicity: School district: School building: Eligibility determination date: Three-year reevaluation due date: Primary language of student: Primary language at home: Parent(s) name(s): Parent interpreter needed? Yes No Surrogate parent: Yes No If yes, name: Adult student: Yes No Primary staff contact name: Title: Initial Evaluation Reevaluation Background Information (reason for referral or presenting concerns, such as relevant medical/developmental history, sensory loss, teacher recommendations, academic/preacademic history, current placement in general education, instructional history, grade retention, any previous interventions implemented and their results, and other factors, including parent concerns and any additional information provided by the parent(s)):  Evaluation Procedures and Results (record findings from the review of existing data and any additional assessments conducted, including the date and source (specific