Rev. 08/30/02
Copies to: Special Ed Office, Bldg. Conf. File, Parent
Harvey County Special Education Cooperative
308 East 1st Street
Newton, KS 67114-3846
 
EVALUATION/REEVALUATION ELIGIBILITY REPORT
(This information is confidential and is only available to authorized personnel.)

Initial Evaluation   Reevaluation (Section A and C only)   Report date:

Student's Name: 

Date of Birth:   Grade: School:

 
SECTION A: EVALUATION DATA SUMMARY

General Education Interventions or Screening Results:

Record Review:

Interview:

Observation: (Include relevant behavior noted during the observation and the relationship of the behavior to the student's academic functioning.)

Tests:

Any educationally relevant medical findings:

 
B. BASIS FOR INITIAL ELIGIBILITY DETERMINATION
Question 1: Does the response of the presenting concern to general education interventions (or for preschool children, results of screening and evaluation) indicate the need for intense or sustained resources?

Data Sources Used to Support Response: 

GEI/Screening   Record Review   Interview   Observation   Testing

Discussion of how the data led you to the response:

Question 2: Are the resources needed to support the student to participate and progress in the general education curriculum (for preschool children, to participate in activities appropriate for children of the same age) beyond those available through general education and other resources?

Data Sources Used to Support Response: 

GEI/Screening   Record Review   Interview   Observation   Testing
Discussion of how data led you to the response:

Question 3: Is there evidence of a severe discrepancy between the performance of the student and his/her peers or evidence of a severe discrepancy between the student's ability and performance in the area(s) of concern?

Data Sources Used to Support Response: 

GEI/Screening   Record Review   Interview   Observation   Testing
Discussion of how data led you to the response:

If the child is suspected of having a Specific Learning Disability, is the severe discrepancy primarily the result of:
Visual, hearing or motor impairment?

Mental retardation or emotional disturbance?

Environmental, cultural or economic disadvantage?

Question 4: Is the presence of an exceptionality substantiated by convergent data from multiple sources?

Data Sources Used to Support Response: 

GEI/Screening   Record Review   Interview   Observation   Testing
Discussion of how data led you to the response:

EXCLUSIONARY FACTORS
Is the determinant factor for eligibility due to:
A lack of instruction in reading or mathematics?

Limited English Proficiency?

 
SECTION C: BASIS FOR CONTINUING ELIGIBILITY DETERMINATION
Question 1: Does the student continue to be a child with an exceptionality?

Data Sources Used to Support Response: 

GEI/Screening   Record Review   Interview   Observation   Testing
Discussion of how data led you to the response:

Question 2: Does the student continue to need special education and related services?

Data Sources Used to Support Response: 

GEI/Screening   Record Review   Interview   Observation   Testing
Discussion of how data led you to the response:

It is the judgment of the undersigned members of the evaluation team, including parents, that an evaluation addressing all areas of concern has been completed and:

The student is eligible for special education

Meets the criteria as a child with an exceptionality (specify)

and

Special education services are necessary to enable your child to receive educational benefits in accordance with his/her abilities or capabilities.

The student is not eligible for special education

Does not meet the criteria as a child with an exceptionality

or

Special education services are not necessary to enable your child to receive education benefits in accordance with his/her abilities or capabilities.

 

SIGNATURES:
Name Position Date Agree Disagree*

             
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* Any member of this team dissenting from the final team recommendations must submit in writing his/her recommendations and the reasons for disagreeing with the decision.