Tool Search: Eligibility Report

Evaluations are used to document the student's educational needs and the student's determination of eligibility for special education. This document describes each editor, the section(s) of the print format that include the entered information, a description of each field on the editor, and any special considerations and instructions for using the editor and fields.

An evaluation must be created whether or not the student is determined to have a disability. A copy of the evaluation summary report, including the documentation of eligibility, is given to the student’s parents by the school

The current format of this document is the WI Eligibility Report 2022. Evaluation formats are selected in Eval Types.

Editor Home

The Editor Home lists the editors available on the student's Evaluation and the Modification and Completion information.

Editor Home

Header	Description
Name	The name of the editor.
Status	The state of the editor. Statuses can be: In Progress indicates a user has entered and saved data in that editor. Not Started is the default status for all editors. Complete indicates a user has clicked the Complete button on the editor. This does not lock the editor from further editing, but indicates the user considers the editor to be finished. Not Needed indicates a user has clicked the Not Needed button on the editor. This is usually done for editors that do not apply to the student.
Modified By	The date and the user by whom the editor was last edited.
Completed By	The date and the user who clicked the Complete button for that editor.

General Evaluation Information

The following table lists the buttons available for the editors:

Button	Description
Save	Different editors have different save options. Click the arrow next to the Save & Stay button to view all saving options for any given editor. Save captures progress and navigates the user to the Editor Home or to the List Screen for List editors. See the Editor Types section for additional information. Save & Stay captures progress and keeps the user on the current editor. This save button is the default save option and usually found within the detail screen of List editors, such as Goals and Objectives. Save & Next captures progress and navigates the user to the next editor. Save & New captures progress and creates a new record. This save button is usually found within the detail screen of a list editor, such as Goals and Objectives. See the Editor Types section for additional information.
Refresh	Retrieves a new copy of data from the student's record. This includes enrollment, student, parent/guardian, and team member information. This also returns any accidentally deleted people records. Manually entered fields do not change when the refresh button is clicked. The user must Save after clicking Refresh to capture changes. A side panel displays listing all applicable Enrollment records for the student. See the Enrollments tool documentation for additional information.
Cancel	Navigates the user to the Editor Home screen or to the List Screen for List editors.
Status i.e. Complete, Not Needed, etc.	Changes the status of the editor. Complete indicates the editor is finished. This makes the editor read-only. However, this does not lock the editor from further editing. To further edit after an editor is marked Complete, the user must click In Progress. Not Needed indicates the editor does not apply to the student's evaluation. This makes the editor read only. However, this does not lock the editor from further editing. To further edit after an editor is marked Not Needed, click the In Progress button. In Progress only displays when the editor is in the Complete or Not Needed status and allows additional edits to be made.
Print	Prints the entire evaluation.
Editors	Opens a side panel listing all the available editors and their status. Select an editor from this list to navigate to that editor or click Close to collapse the side panel.
Previous	Navigates the user to the previous editor.
Next	Navigates the user to the next editor.

Editor Types

There are two types of editors available: List or Basic editors. When navigating to a Basic editor, the list of fields within the editor display. List editors display a list of all records within that editor. Clicking an existing record or the New button opens the detail view for an individual record. An example list editor is the Individual Student Data editor.

Padlock Icon

Only one user at a time can actively work on an editor. A person with a padlock icon displays in the Editors side panel, Editor Home, and List Screen of list editors indicating which editors currently have users working on them. Hovering over the icon displays the name of the user who has checked out the editor, including the current user (you).

Editors that are currently being edited are read only for all other users. The name of the person working on the editor displays in the header. Once the editing user navigates away from an editor, that editor becomes available for others to work on.

Template Banks

Certain fields within several editors have a paper icon Image of the paper icon displays next to their name. When the icon is clicked, a side panel displays with the available library of predetermined text for that field. Template Banks are managed in System Administration.

Editors

The following section lists each editor and describes each field on the editor.

Eligibility Report Header

The Evaluation Header editor lists general information about the Evaluation.

Eligibility Report Header Editor

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Field	Description	Validation
Eligibility Determination Date Required	The date the eligibility determination was made.	N/A
Evaluation Type Required	The type of evaluation. Options include: Initial Reevaluation Waiver	When Initial or Reevaluation are selected, (RE-3) Waiver editor is Not Needed. When Waiver is selected, ALL ER-1 editors, (ER-3) and (ER-4) are marked as Not Needed and the (RE-3) Waiver editor is available and required in order to Complete the evaluation.
Consent Date	The date consent was given.	N/A
Referral Date	The date the referral was received.	This date auto-populates to the Date Referral Received from the most recent, locked Referral.
For students transferring between public agencies: Evaluation Report reviewed and adopted (if applicable) by	A description of who reviewed and adopted the transfer student's evaluation.	N/A
Evaluation Adopted On	The day the evaluation for transfer students was adopted on.	N/A
For students transferring between public agencies: IEP reviewed and adopted (if applicable) by	A description of who reviewed and adopted the transfer student's plan.	N/A
IEP Adopted On	The day the plan for transfer students was adopted on.	N/A
Indicator 11 Reporting Purposes Only
Evaluation Delay Reason	The reason the evaluation was delayed. Options include: Transfer Child Unavailable Initial SLD Eval Other	This field is only available when Initial is selected as the Evaluation Type.
Evaluation Late Reason *Required	The reason the evaluation was late.	*This field is available and required when Other is selected from Evaluation Delay Reason.

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Enrollment Information

The Enrollment Information editor reports Special Education information from the student's Enrollment.

The Refresh button retrieves a fresh copy of data from the student's record.

Enrollment Information Editor

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Field Name	Description	Ad hoc/Database Location	Validation
Primary Impairment Required	The primary disability of the student. Options available are the same as those at Student Information > General > Enrollments > SPED > Primary Impairment.	Learner Planning > Learning Plans > disability1 Locked Attribute Dictionary: Enrollment.disability1	When Waiver is selected as the Evaluation Type from the Eligibility Report Header, this field pulls in from the Enrollment tool as read only on the UI and displays on Print under Identified Impairment. When Initial or Reevaluation is selected as the Evaluation Type from the Eligibility Report Header, this field does not pull from the Enrollment tool.
Secondary Impairment	The second disability of the student, if applicable. Options available are the same as those at Student Information > General > Enrollments > SPED > Primary Impairment.	Learner Planning > Learning Plans > disability2 Locked Attribute Dictionary: Enrollment.disability2	This field is read-only.
Third Impairment	The third disability of the student, if applicable. Options available are the same as those at Student Information > General > Enrollments > SPED > Primary Impairment.	Learner Planning > Learning Plans > disability3 Locked Attribute Dictionary: Enrollment.disability3	This field is read-only.
Fourth Impairment	The fourth disability of the student, if applicable. Options available are the same as those at Student Information > General > Enrollments > SPED > Primary Impairment.	Learner Planning > Learning Plans > disability4 Locked Attribute Dictionary: Enrollment.disability4	This field is read-only.
Fifth Impairment	The fifth disability of the student, if applicable. Options available are the same as those at Student Information > General > Enrollments > SPED > Primary Impairment.	Learner Planning > Learning Plans > disability5 Locked Attribute Dictionary: Enrollment.disability5	This field is read-only.
Grade	The student's current grade.	Enrollment > Grade enrollment.grade	This field auto-populates from selected Enrollment on Refresh. User can also manually edit the values if needed.
School Name	The name of the school associated with the student's Enrollment record.	Learner Planning > Learning Plans > servingSchoolName	This field auto-populates from selected Enrollment on Refresh. User can also manually edit the values if needed.
School Phone	The phone number of the school associated with the student's Enrollment record.	N/A	This field auto-populates from selected Enrollment on Refresh from System Administration > Resources > School > (School Name that matches Enrollment record) > Phone. User can also manually edit the values when needed.
District of Residence	The student's district of residence.	Learner Planning > Learning Plans > residentDistrictNumber	This field is read-only. This field auto-populates from selected Enrollment on Refresh from Enrollment > Resident District.
Serving District	The student's district of service.	Learner > Active Enrollment > Core > servingDistrict	This field is read-only. This field auto-populates from selected Enrollment on Refresh from Enrollment > Serving District.
District Information These fields are read-only.
District Number	The district number associated with the Enrolled school.	System Administration > Resources > District Information > State District Number	N/A
District Name	The district name associated with the Enrolled school.	System Administration > Resources > District Information > Name	N/A
District Address	The district address associated with the Enrolled school.	System Administration > Resources > District Information > Address	N/A
District Phone	The district phone number associated with the Enrolled school.	System Administration > Resources > District Information > Phone	N/A
District SPED Address	The district special education address associated with the Enrolled school.	System Administration > Resources > District Information > SPED Address	N/A
District SPED Phone	The district special ed phone number associated with the Enrolled school.	System Administration > Resources > District Information > SPED Phone	N/A

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Student Information

The Student Information editor displays basic information about the student such as demographic information. This is a read-only editor.

The Refresh button retrieves a fresh copy of data from the student's record.

Student Information Editor

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Field	Description	Ad Hoc/Location
Last Name	The student's last name.	Census > People > Demographics > Last Name identity.lastName
First Name	The student's first name.	Census > People > Demographics > First Name identity.firstName
Middle Name	The student's middle name.	Census > People > Demographics > Middle Name identity.middleName
Suffix	The student's suffix.	Census > People > Demographics > Suffix Name identity.suffix
Race, Ethnicity	The student's state defined race.	Census > People > Demographics > State Race/Ethnicity
Gender	The student's gender.	Census > People > Demographics > Gender identity.gender
Birthdate	The student's birthdate.	Census > People > Demographics > Birth Date identity.birthDate
Student Number	The student's identification number.	Census > People > Demographics > Student Number identity.studentNumber
Student's Primary Language	The student's first language. The values available in this list are available in a locked attribute dictionary, Language List (Definition.iso639-2Language).	Census > People > Demographics > Home Primary Language identity.homePrimaryLanguage
Interpreter Needed	Indicates the student requires an interpreter. Options are Yes or No.	N/A
WISEid	The student's state ID number.	Census > People > Demographics > State ID identity.stateID
Address	The student's address. This field becomes a dropdown when more than one address exists for the student. The primary household displays by default.	Census > Households > Address Info address.number; address.street; address.tag; address.prefix; address.dir; address.apt; address.city; address.state; address.zip
Case Manager Information These fields are read-only.
Name	The first and last name of the team member.	Student Information > Special Ed > General > Team Members
Title	The role of the team member.	Student Information > Special Ed > General > Team Members
Phone	The phone number of the team member.	Student Information > Special Ed > General > Team Members

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Parent/Guardian Information

The Parent/Guardian Information editor populates based on the guardian checkbox on the student's Relationships tool. The editor includes Demographics information for the student's guardian.

The Delete button next to each parent/guardian can be used to remove a parent/guardian from the IEP.

The Refresh button retrieves a new copy of parent/guardians' data. This also returns any accidentally deleted people. Manually entered fields do not change when the refresh button is clicked. The user must Save after clicking Refresh to capture changes.

When the Private Flag is marked on the Team Members tool for the parent/guardian, all contact information on this editor for that person is cleared out and a note on the editor display, "One or more records has been marked Private in the Team Members Tab. Contact information was not imported for those records and will appear blank below." On the printed document it reads, "Unpublished" in each of those areas.

When the Educational Surrogate Flag is marked on the Team Members tool, that person displays on the Parent/Guardian Information editor with "Educational Surrogate Parent" next to their name as the relationship and all other fields are hidden from the screen as well as on the printed document.

Parent/Guardian Information Editor

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Field	Description	Ad Hoc	Validation
Last Name	The last name of the parent/guardian.	Census > People > Demographics > Last Name identity.lastName	This field populates from Census. This is part of the header for the parent/guardian.
First Name	The first name of the parent/guardian.	Census > People > Demographics > First Name identity.firstName	This field populates from Census. This is part of the header for the parent/guardian.
Middle Name	The suffix of the parent/guardian.	Census > People > Demographics > Suffix Name identity.suffix	This field populates from Census. This is part of the header for the parent/guardian.
Suffix	The suffix of the parent/guardian.	Census > People > Demographics > Suffix Name identity.suffix	This field populates from Census. This is part of the header for the parent/guardian.
Relationship	The relation of the parent/guardian to the student.	Census > People > Relationships	This field populates from Census. This is part of the header for the parent/guardian.
Print Sequence	The print order of the parent/guardian(s) on the IEP.	N/A	When no Sequence is selected, parent/guardian(s) print in the order displayed in the UI. When any Sequences are selected, only parent/guardian(s) with a sequence number prints in the order defined.
Address	The parent/guardians' address.	Census > Households > Address Info address.number; address.street; address.tag; address.prefix; address.dir; address.apt; address.city; address.state; address.zip	This field populates from Census. When there are multiple addresses for a person, the drop down with an option to select which address displays. When there is only one address, the drop down only has one option. The populated address is the one marked Primary.
Home Phone	The home phone number of the parent/guardian.	Census > People > Demographics > Household Phone	This field populates from Census.
Work Phone	The work phone of the parent/guardian.	Census > People > Demographics > Work Phone	This field populates from Census.
Cell Phone	The cell phone of the parent/guardian.	Census > People > Demographics > Cell Phone	This field populates from Census.
Email	The primary email address for the parent/guardian.	Census > People > Demographics > Email	This field populates from Census.
Primary Language	The parent/guardian's first language.	Census > People > Demographics > Home Primary Language identity.homePrimaryLanguage	This field populates from Census. The values available in this list are available in a locked attribute dictionary, Language List (Definition.iso639-2Language).
Interpreter Needed	Indicates the student requires an interpreter. Options are Yes or No.	N/A	The values available in this dropdown are hard coded.

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(I-3) Team Meeting Cover Page

The Team Meeting Cover Page editor lists the team meetings held regarding the student and the participants of the meeting. Team Meetings display based on the Meeting Date. The Print in Plan slider must be marked On for the team meeting record to appear on the printed document.

Team members added on the Team Members tool can be added to team meetings. Team members can be added manually on this editor, but are not saved in the system and have to be created each time they are included in a meeting.

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Team Meeting List Screen

Column Name	Description	Description
Padlock Icon	The user currently editing the team meeting record.	N/A
Meeting Date	The date of the meeting.	This is pulled from the Meeting Date field on the Team Meeting detail screen.
Meeting Location	The location of the meeting.	This is pulled from the Meeting Location field on the Team Meeting detail screen.
Print in Eval	Indicates this meeting prints on the evaluation.	This field defaults to marked. Any action taken with this slider automatically updates on the Print in Plan slider on the Team Meeting list screen.

Team Meeting Detail Screen

Select an existing record or click New to view the Team Meeting detail screen.

Team Meeting Detail Screen

Field Name	Description	Validation
Team Meeting
Print in Eval	Indicates this meeting prints in the Evaluation.	This field defaults to marked. Any action taken with this checkbox automatically updates on the Print in Plan slider on the Team Meeting list screen.
Meeting Date Required	The date of the meeting.	This field auto-populates with the Eligibility Determination Date from the Eligibility Report Header editor.
Meeting Time	The time of the meeting.	N/A
Meeting Location	The location of the meeting.	N/A
Invite Date	The date the invitation for the meeting was sent to participants.	N/A
Purpose of Meeting
Evaluation and Reevaluation	Indicates which type of evaluation being discussed at the meeting. Options include: Evaluation including determination of initial eligibility for special education Reevaluation including determination of continuing eligibility for special education	N/A
Individualized Education Plan (IEP) (if student is eligible)	Indicates which type of IEP being discussed at the meeting. Options include: Develop an initial IEP Develop an annual IEP Review/revise IEP Transition - the consideration of post-secondary goals and transition services (Required for students beginning at age 14).	N/A
Placement (must be determined when the IEP is developed or reviewed/revised)	Indicates the type of placement discussed. Options include: Determine initial placement Determine continuing placement	N/A
Other	Options include: Review existing information to determine needs for additional assessments or other evaluation materials (IEP team meeting optional) Conduct a manifestation determination (check appropriate boxes under IEP & Placement if changes in either are contemplated) Determine setting for service during disciplinary change in placement (must check appropriate boxes under IEP & Placement) Other	N/A
Specify *Required	A text field used to specify the reason for the meeting.	*This field displays and is required when Other is selected above.
If a purpose of this meeting is IEP development, review, and/or revision related to the academic, developmental and functional needs of the child, the IEP team considered the results of:
Initial or most recent evaluation	Indicates the IEP team considered the initial or most recent evaluation in their determination. Options include: Yes Not Applicable	The values available in this dropdown are hard coded.
Statewide Assessments	Indicates the IEP team considered any statewide assessment in their determination. Options include: Yes Not Applicable	The values available in this dropdown are hard coded.
District-wide assessments	Indicates the IEP team considered any district-wide assessments in their determination. Options include: Yes Not Applicable	The values available in this dropdown are hard coded.
Documented Efforts If a parent did not attend or participate in the meeting by other means and did not agree to the time and place of the IEP team meeting, document three efforts to involve the parent(s)/guardian(s) +
Date	The date the attempt was made.	This field is duplicated a total of three times to document the three attempts.
Method	The method of contact.	This field is duplicated a total of three times to document the three attempts.
Result	The result of the attempt.	This field is duplicated a total of three times to document the three attempts.
Comments	Any additional comments needed to document the attempts.	N/A
Attendance
First Name Required	The name of the participant.	The Team Member names listed are read-only and are pulled from the person's District Assignment. Team members can be added using the Add button.
Last Name Required	The last name of the participant.	The Team Member names listed are read-only and are pulled from the person's District Assignment. Team members can be added using the Add button.
Role	The title of the participant.	N/A
LEA	The Local Education Agency contact.	At least one Team Member must be marked as LEA.
Invited	Indicates the participant was invited.	This determines whether or not the team member prints on the IEP.
Attended	Indicates the participant attended the meeting.	Team Members also display on the printed document when this is marked, even if the Invited checkbox has not been marked for them.

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(ER-1) Info from Existing Data

The Info from Existing Data editor reviews existing data from various sources regarding the student academic achievement in reading and other subjects.

Info from Existing Data Editor

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Field	Description
A. Information Provided By
Parent(s)/Family	Indicates information was provided by the student's parent/guardian(s).
Teachers, Related Service Providers	Indicates information was provided by the student's teachers and/or related service providers.
Other Sources	Indicates information was provided by other sources.
B. Summary of Previous Evaluations and Assessments
Classroom-based, District-wide or State Assessment Results	A description of the assessment results.
Other Evaluations and Assessments	A description of the other evaluations and assessments used.

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(ER-1) Previous Interventions

The Previous Interventions editor records the previous interventions taken for the student and the effect of the intervention on the student's literacy and other areas.

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Previous Interventions List Screen

Column Name	Description
Padlock Icon	The user currently editing the team meeting record.
Sequence	The order of the records.
Previous Interventions	A description of the previous interventions
Effect of the Interventions	A description of the impact of the intervention.

Previous Interventions Detail Screen

Select an existing record or click New to view the Previous Interventions detail screen.

Previous Interventions Detail Screen

Field	Description
Sequence Required	The order of the records.
Previous Interventions	A description of the previous interventions
Effect of the Intervention	A description of the impact of the intervention.

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(ER-1) Additional Assessments

The Additional Assessments editor records the results from additional assessments and other sources relating to the student's academic achievement and functional performance.

Additional Assessments Editor

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Field	Description	Validation
Information from additional assessments or other evaluation materials was gathered	Indicates additional assessment materials were gathered. Options include Yes or No.	The values available in this dropdown are hard coded.
Academic	A description of the academic additional assessment materials gathered.	N/A
Functional	A description of the functional additional assessment materials gathered.	N/A
III. Information regarding all areas of concern identified in the referral and any additional areas identified during the review of existing data are documented under Information from Existing Data and/or Information from Additional Assessments.	Indicates all areas of concern have been identified. Options include Yes or No.	The values available in this dropdown are hard coded.

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(ER-1) Eligibility Determination

The Eligibility Determination editor provides a collection of checklists for each disability the student is determined to have. Checklists include the considerations and questions to be addressed for each disability.

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Eligibility Determination List Screen

Column Name	Description
Padlock Icon	The user currently editing the team meeting record.
Sequence	The order of the records.
Checklist	The type of disability.
Date Form Completed	The date the documentation was completed.
Eligible	Indicates the student is eligible for special education services.
Print in Eval	Indicates this meeting prints on the evaluation.

Eligibility Determination Detail Screen

Select an existing record or click New to view the Eligibility Determination detail screen.

Eligibility Determination Detail Screen

Field	Description	Validation
Checklist Required	The type of disability. See the sections below: Autism Blind and Visually Impaired Deaf and Hard of Hearing Deafblind Emotional Behavioral Disability Intellectual Disability Orthopedic Impairment Other Health Impairment Significant Developmental Delay Specific Learning Disability - Initial Evaluation Specific Learning Disability - Re-Evaluation Specific Learning Disability - Initial Evaluation Using Significant Discrepancy Speech or Language Impairment Traumatic Brain Injury	The values available in this dropdown are hard coded.
Disability Category Criteria Determination Required	The type of evaluation. Options include Initial Evaluation or Re-evaluation.	The values available in this dropdown are hard coded.
Print in Eval	Indicates this meeting prints on the evaluation.	This field defaults to marked. Any action taken with this slider automatically updates on the Print in Plan slider on the Eligibility Determination list screen.
Eligible	Indicates the student is eligible for special education services.	N/A
Date Form Completed Required	The date the documentation was completed.	N/A
Sequence *Required	The order of the records.	When Eligible: Field is required, Numbers must be unique and greater than 0. When Not Eligible: Field is NOT required and blank values are ok. When numbers are used they must be unique and greater than 0.

Autism

Field	Description	Validation
The 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. Required	Indicates the student displays difficulties in interacting with others or events. Options are Yes or No.	The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence	A description of the evidence for the above determination.	N/A
The 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.	Indicates the student displays difficulties with social communication.	N/A
Explain or Reference Data or Evidence	A description of the evidence for the above determination.
SECTION II. OTHER CHARACTERISTICS (At least one must be answered Yes)
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. Required	Indicates the student displays pauses in motor, sensory, social or learning skills. Options are Yes or No.	The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence	A description of the evidence for the above determination.	N/A
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. Required	Indicates this student displays difficulties in thinking processes and generalizing. Options are Yes or No.	The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence	A description of the evidence for the above determination.	N/A
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. Required	Indicates the student displays unusual, inconsistent, repetitive or unconventional responses to sounds, sights, smells, tastes, touch or movement. Options are Yes or No.	The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence	A description of the evidence for the above determination.	N/A
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. Required	Indicates the student displays distress over changes, insistence on following routines, and a persistent preoccupation with or attachment to objects. Options are Yes or No.	The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence	A description of the evidence for the above determination.	N/A
SECTION III. EDUCATIONAL PERFORMANCE (Must be answered Yes)
There is an adverse effect on the student's learning, academic achievement or functional performance. Required	Indicates there is an adverse impact on the student's academic achievement or functional performance. Options are Yes or No.	The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence	A description of the evidence for the above determination.	N/A
SECTION IV. EXCLUSIONARY FACTOR
The student's educational performance is not primarily adversely affected due to an emotional behavioral disability (check to confirm that this is true).	Indicates the student's performance is not impacted due to an emotional behavioral disability.	N/A
SECTION V. DISABILITY CATEGORY CRITERIA DETERMINATION
The documentation of the criteria above demonstrates developmental disability significantly affecting a student's social interaction and verbal and nonverbal communication that adversely affects learning and educational performance. The student meets the disability category criteria under Autism. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education. Required	Indicates the student meets the criteria for Autism. Options are Yes or No.	The values available in this dropdown are hard coded.

Blind and Visually Impaired

Field	Description	Validation
A teacher of the Blind and Visually Impaired PI 34.051 conducted a functional vision evaluation, including all of the following	Indicates a licensed teacher of the Blind and Visually Impaired PI conducted a functional vision evaluation. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Review of medical information from an ophthalmologist or optometrist	Indicates a review of medical information from an ophthalmologist or optometrist was conducted.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when the associated checkbox is marked.
Formal / informal tests of visual functioning	Indicates formal or informal functional visual tests were conducted.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when the associated checkbox is marked.
Determination of the educational implications and curricular needs	Indicated a determination of the implications and the curriculum needs of the student was made.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when the associated checkbox is marked.
The student's vision functioning adversely affects educational performance	Indicates the student's vision functionality adversely impacts their educational performance.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when the associated checkbox is marked.
SECTION II. ORIENTATION AND MOBILITY NEEDS
An orientation and mobility specialist evaluated the student to determine if there are related orientation and mobility needs in home, school, or community environments *Required	Indicates a specialist evaluated the student to determine mobility needs. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
The student has orientation and mobility needs *Required	Indicates the student has orientation or mobility needs. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or reference data or evidence and include a description of the orientation or mobility needs *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
SECTION III. DISABILITY CATEGORY CRITERIA DETERMINATION
Initial Evaluation: The documentation of the criteria above demonstrates even after correction a student's visual functioning adversely affects educational performance. The student meets the disability category criteria under Blind and Visually Impaired. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education. *Required	Indicates the student meets the criteria for Blin and Visually Impaired. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Reevaluation: The student was previously found eligible as meeting the disability category under Blind and Visually Impaired and continues to have a disability that adversely affects the student's educational performance. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to continue to be eligible for special education *Required	Indicates the student has previously met the criteria for Blind and Visually Impaired and continues to have a disability that adversely affects the student's educational performance. Options are Yes or No.	*This field is required when Re-evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Re-evaluation is selected.

Deaf and Hard of Hearing

Field	Description	Validation
A teacher of the deaf or hard of hearing licensed under s. PI 34.050 was a member of the IEP team when determining eligibility. *Required	Indicates a licensed teacher of the deaf/hard of hearing licensure was a member of the IEP team. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
The IEP team reviewed a current evaluation conducted by an audiologist licensed under ch. 459, Wis. Stats. when determining eligibility. *Required	Indicates the IEP team reviewed current evaluation data when determining the student's eligibility. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
There is a decreased ability to detect sound in one or both ears with or without amplification, whether permanent or chronically fluctuating. *Required	Indicates the student has a decreased ability to detect sound in one or both ears. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
The student's decreased ability to detect sound has an adverse effect on the student's educational performance. *Required	Indicates the student's decreased ability has an adverse impact on their educational performance. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
SECTION II. EDUCATIONAL PERFORMANCE (At least one must be answered Yes)
There is an adverse effect on academic performance *Required	Indicates there is an adverse impact on the student's academic performance. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
There is an adverse effect on speech perception *Required	Indicates there is an adverse impact on the student's speech perception. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
There is an adverse effect on speech production *Required	Indicates there is an adverse impact on the student's speech production. Options are Yes or No.	*This field is required when Initial Evaluation is selected.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
There is an adverse effect on communication including language acquisition or expression *Required	Indicates there is an adverse impact on the student's communication. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
SECTION III. DISABILITY CATEGORY CRITERIA DETERMINATION
Initial Evaluation: The documentation of the criteria above demonstrates a decreased ability to detect sound in one or both ears with or without amplification, whether permanent or chronically fluctuating, which adversely affects the student's educational performance. The student meets the disability category criteria under Deaf and Hard of Hearing. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education. *Required	Indicates the student meets the criteria for Deaf and Hard of Hearing. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Reevaluation: The student was previously found eligible as meeting the disability category under Deaf and Hard of Hearing and continues to have a disability that adversely affects the student's educational performance. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to continue to be eligible for special education. *Required	Indicates the student has previously met the criteria for Deaf and Hard of Hearing and continues to have a disability that adversely affects the student's educational performance. Options are Yes or No.	*This field is required when Re-evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Re-evaluation is selected.

Deafblind

Field	Description	Validation
Conducted a comprehensive evaluation that includes completion of the criteria forms for Deaf and Hard of Hearing and Blind and Visually Impaired. must be answered Yes *Required	Indicates the IEP team conducted a comprehensive evaluation including forms for Deaf and Hard of Hearing and Blind and Visually Impaired. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
The student meets one of the following conditions *Required	Indicates the student meets one of the following conditions. Options are Yes or No.	*The dropdown is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Condition Met	The specific condition met. Options include: Meets the criteria for Deaf and Hard of Hearing specified in PI 11.36 (4) and Blind and Visually Impaired specified in PI 11.36 (3). Met Deaf and Hard of Hearing criteria and has a documented clinical or functional vision loss. Met Blind and Visually Impaired criteria and has a documented clinical or functional hearing loss. Has a documented diagnosis of a progressive medical condition that will result in concomitant hearing and vision losses (e.g., Usher's Syndrome).	Only one option may be selected.
Explain or Reference Data or Evidence to Support *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
SECTION II. EDUCATIONAL IMPACT (All three must be answered Yes)
There is an adverse effect on communication. *Required	Indicates there is an adverse impact on the student's communication skills.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected"
There is an adverse effect on developmental performance. *Required	Indicates there is an adverse impact on the student's developmental performance.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
There is an adverse effect on educational performance. *Required	Indicates there is an adverse impact on the student's educational performance.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
SECTION III. DISABILITY CATEGORY CRITERIA DETERMINATION
Initial Evaluation: The documentation of the criteria above demonstrates concomitantly deaf or hard of hearing and blind or visually impaired, the combination of which causes severe communication and other developmental and educational needs such that the individual disability-related needs of the student extend beyond the instruction and supports required for a student who is solely deaf or hard of hearing or blind or visually impaired. The student meets the disability category criteria under Deafblind. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education. *Required	Indicates the student meets the criteria for Deafblind.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Reevaluation: The student was previously found eligible as meeting the disability category under Deafblind and continues to have a disability that adversely affects the student's educational performance. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to continue to be eligible for special education. Document the need for specially designed instruction on the ER-1. *Required	Indicates the student has previously met the criteria for Deafblind and continues to have a disability that adversely affects the student's educational performance.	*This field is required when Re-evaluation is selected. The values available in this dropdown are hard coded.
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required when Re-evaluation is selected.

Emotional Behavioral Disability

Field	Description	Validation
The student exhibits at least one of the following Required	Indicates the student displays one or more of the following emotional behaviors. Options are Yes or No.	The values available in this dropdown are hard coded.
Behaviors that interfere with the development and maintenance of age and grade appropriate interpersonal relationships	Indicates the student displays behaviors that interfere with development and maintenance of interpersonal relationships.	N/A
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required if the associated checkbox is marked.
Observable affective or behavioral responses during routine daily activities inconsistent with the norms of the student or the student's community	Indicates the student displays behaviors inconsistent with the norms of the student or the student's community.	N/A
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required if the associated checkbox is marked.
Pervasive unhappiness, depression or anxiety	Indicates the student displays pervasive unhappiness, depression or anxiety.	N/A
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required if the associated checkbox is marked.
Physical symptoms or fears associated with personal or school problems	Indicates the student displays physical symptoms or fears associated with personal or school problems.	N/A
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required if the associated checkbox is marked.
Insufficient progress toward meeting age or grade level academic standards that cannot be explained by intellectual, sensory, or health factors	Indicates the student displays insufficient progress toward meeting academic standards.	N/A
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required if the associated checkbox is marked.
Isolation from peers or avoidance of social interactions impacting the student's access and engagement in instructional activities	Indicates the student isolates from peers which impacts their access and engagement in instructional activities.	N/A
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required if the associated checkbox is marked.
Patterns of behaviors across settings and individuals presenting risks to the physical safety of the student or others.	Indicates the student displays patterns of behavior that present risks to the physical safety of the student or others.	N/A
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required if the associated checkbox is marked.
The behaviors occur in an academic setting in school, in a non-academic setting in school and in the student's home or community. all must be checked *Required	Indicates the behaviors occur in an academic setting, non-academic setting, and in the student's home or community. Options are Yes or No.	The values available in this dropdown are hard coded.
Academic setting in school	Indicates the behaviors occur in an academic setting.	N/A
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required if the associated checkbox is marked.
Non-academic setting in school	Indicates the behaviors occur in a non-academic setting.	N/A
Explain or reference data or evidence *Required	A description of the evidence for the above determination.	*This field is required if the associated checkbox is marked.
Home or Community	Indicates the behaviors occur at home or in the student's community.	N/A
The student demonstrates frequent and intense observable behaviors which adversely affect the student's educational performance, either Required	Indicates the student displays behaviors which adversely affects the student's education performance. Options are Yes or No.	The values available in this dropdown are hard coded.
Onset of Behavior	Indicates when the onset of the behavior occurred. Options include: Over a long period of time; or Of sudden onset due to an emerging mental health condition which includes a diagnosis by a licensed mental health professional.	Only one option may be selected.
Explain or reference data or evidence Required	A description of the evidence for the above determination.	N/A
SECTION II. REQUIREMENTS
The IEP team conducted a comprehensive evaluation and considered current data from the following. Required	Indicates the IEP conducted a comprehensive evaluation. Options are Yes or No.	The values available in this dropdown are hard coded.
Data Considered from all must be checked	The method of data considered. Options include: The results of evidence-based positive behavioral interventions implemented within general education settings. (Document evidence-based positive behavioral interventions under previous interventions and their effects on the evaluation report, ER-1.) Systematic observations of the student in both academic and non-academic settings documenting intensity, frequency, rate or duration of observable target behaviors, as well as other ecological factors that may be impacting the student's behavior. Interviews of the student and parent or family that include gathering information regarding the student and family's norms and values, as well as other ecological factors that may impact the student's behavior. Interviews of the student's teachers that include gathering information regarding the student's strengths and ecological factors that may impact the student's behavior. Interview of an LEA staff member, identified by the student when possible, as having the most positive or a positive relationship with the student, that includes gathering information regarding the student's strengths and ecological factors that may impact the student's behavior. The LEA staff member may have been interviewed as one of the interviews of the student's teachers and may be a member of the IEP team. Review of educational information maintained by the LEA, including health, academic and disciplinary records. Results of standardized behavior rating scales, which are normed using nationally representative samples: From a minimum of two sources from school OR documented why the team was unable to gather valid rating scale results from two sources on the ER-1. From at least one source from the home or community. The IEP team confirmed that normative data reflects the child’s background OR documented that it did not in the ER-1.	Multiple options may be selected.
If needed, explain or reference data or evidence not already provided under Section I Required	A description of the evidence for the above determination.	N/A
SECTION III. ADDITIONAL REQUIREMENTS (Both must be checked)
The IEP team considered the effects of any known history of trauma or mental health disorder on the student's functioning and did not identify or refuse to identify emotional behavioral disability based solely on a known history of trauma or mental health disorder. Required	Indicates the IEP team considered the impact of the student's known history.	N/A
Summarize Discussion Required	A summary of the IEP's discussion.	N/A
The IEP team discussed and determined, based on information and data collected, whether behaviors are a result of a difference between the norms of the child's family and community or an emotional behavioral disability. The IEP team did not identify a student as a student with an emotional behavioral disability when there is evidence that the difference is the primary causal factor of the behaviors. Required	Indicates the IEP team considered and determined whether or not the behaviors are an emotional behavioral disability.	N/A
Summarize Discussion Required	A summary of the IEP's discussion.	N/A
SECTION IV. DISABILITY CATEGORY CRITERIA DETERMINATION
The documentation of the criteria above demonstrates a condition in which the student demonstrates frequent and intense observable behaviors, either over a long period of time or of sudden onset due to an emerging mental health condition which adversely affects the student's educational performance. The student meets the disability category criteria under Emotional Behavioral Disability. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education. Required	Indicates the student meets the criteria for an Emotional Behavioral Disability. Options are Yes or No.	The values available in this dropdown are hard coded.

Intellectual Disability

Field	Description	Validation
The student has a standard score of 2 or more standard deviations below the mean on at least one individually administered intelligence test that takes into account the student's mode of communication and is developed to assess intellectual functioning using this mode. More than one intelligence test may be used to produce a comprehensive result.	Indicates the student has a standard score or 2 or more standard deviations below the mean on an intelligence test. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
SECTION II. ADAPTIVE FUNCTIONING
The student has significant limitations in adaptive behavior as demonstrated by a standard score of 2 or more standard deviations below the mean on standardized or nationally normed measures, as measured by comprehensive, individual assessments that include interviews of the parents, tests, and observations of the student in adaptive behavior which are relevant to the student's age, in at least one of the following *Required	Indicates the student has a significant limitations in adaptive behavior. Options are Yes or No.	This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Conceptual Skills	Indicates the student has a limitation in the area of conceptual skills.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This field is required if the associated checkbox is selected.
Social Adaptive Skills	Indicates the student has a limitation in the area of social adaptive skills.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This field is required if the associated checkbox is selected.
Practical Adaptive Skills	Indicates the student has a limitation in the area of practical adaptive skills.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This field is required if the associated checkbox is selected.
An overall composite score on a standardized measure of conceptual, social, and practical skills	Indicates the student has a limitation in all the areas above.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This field is required if the associated checkbox is selected.
SECTION III. EDUCATIONAL PERFORMANCE (One yes/no question must be answered yes.)
The student is age 3 through 5 and has a standard score of two or more standard deviations below the mean on standardized or nationally-normed measures, as measured by comprehensive, individual assessments, in both of the following areas *Required	Indicates the student (age 3-5) has a significant limitations in educational performance. Options are Yes or No.	This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Language Development and Communication	Indicates the student has a limitation in the area of language development and communication.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This field is required if the associated checkbox is selected.
Cognition and General Knowledge	Indicates the student has a limitation in the area of cognition and general knowledge.	N/A
Explain or Reference Data or Evidence *Required OR	A description of the evidence for the above determination.	This field is required if the associated checkbox is selected.
The student is age 6 to 21 and has a standard score of 2 or more standard deviations below the mean on standardized or nationally-normed measures, as measured by comprehensive, individual assessments in all of the following areas. *Required	Indicates the student (age 6-21) has a significant limitations in educational performance. Options are Yes or No.	This field is required when "Initial Evaluation" is selected" The values available in this dropdown are hard coded.
Written Language	Indicates the student has a limitation in the area of written language.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This field is required if the associated checkbox is selected.
Reading	Indicates the student has a limitation in the area of reading.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This field is required if the associated checkbox is selected.
Mathematics	Indicates the student has a limitation in the area of mathematics.	N/A
Explain or Reference Data or Evidence *Required OR	A description of the evidence for the above determination.	This field is required if the associated checkbox is selected.
Reliable and valid assessment results are not possible due to functioning level or age (for ages 3 to 5 or 6 to 21) , and a standardized developmental scale or body of evidence including informal measures was used. *Required	Indicates assessment results are not possible due to the student's functioning level or age. Options are Yes or No.	This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This field is required when Initial Evaluation is selected.
SECTION IV. DISABILITY CATEGORY CRITERIA DETERMINATION
Initial Evaluation: The documentation of the criteria above demonstrates significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills and manifested during the developmental period that adversely affects the student's educational performance. The student meets the disability category criteria under Intellectual Disability (all sections above must be checked Yes). A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education. *Required	Indicates the student meets the criteria for an Intellectual Disability. Options are Yes or No.	This field is required when Initial Evaluation is selected The values available in this dropdown are hard coded.
Reevaluation: The student was previously found eligible as meeting the disability category criteria under Intellectual Disability and continues to have a disability that adversely affects the student's educational performance. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to continue to be eligible for special education. *Required	Indicates the student has previously met the criteria for an Intellectual Disability and continues to have a disability that adversely affects the student's educational performance. Options are Yes or No.	This field is required when Re-evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This field is required when Re-evaluation is selected.

Orthopedic Impairment

Field	Description	Validation
Does the student have a congenital anomaly? *Required	Indicates the student has a congenital anomaly. Options are Yes or No.	*This is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is required when Initial Evaluation is selected.
Does the student have impairments caused by disease? *Required	Indicates the student's impairments were caused by a disease. Options are Yes or No.	*This is required when Initial Evaluation is selected.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is required when Initial Evaluation is selected.
Does the student have impairments from other causes? *Required	Indicates the student's impairments have additional cause(s). Options are Yes or No.	*This is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is required when Initial Evaluation is selected.
Examples of other conditions which may qualify a student for Orthopedic Impairment include, but are not limited to, arthrogyposis, spina bifida, juvenile arthritis, muscular dystrophy, and osteogenesis imperfecta. These are only examples and are provided as those noted in federal and state law have been mostly eradicated in the United States. NOTE: A diagnosis from a licensed physician is not* required for the IEP team to consider Orthopedic Impairment.* However, medical diagnosis and medical information are helpful.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is required when Initial Evaluation is selected.
SECTION II. EDUCATIONAL PERFORMANCE (Must be answered Yes)
Is the student's educational performance in one or more of the following areas adversely affected as a result? *Required	Indicates the student's educational performance is impacted. Options are Yes or No.	*This is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
If yes, check ALL that apply. Consider academic achievement and functional performance.	The area of impact. Mark all that apply: Maintaining and changing positions Using classroom materials Hygiene/self-care Clothing management Mobility Eating Classroom performance Per-academic or academic achievement Social/Emotional functioning Communication Vocational skills Behavior Participation in physical education Safety issues Accessing the community Other	N/A
Describe *Required	A description of any other areas of impact.	*This is available and required when Other is available.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is required when Initial Evaluation is selected.
SECTION III. DISABILITY CATEGORY CRITERIA DETERMINATION
Initial Evaluation: The documentation of the criteria above demonstrates a severe orthopedic impairment that adversely affects the student's educational performance. The student meets the disability category criteria under Orthopedic Impairment. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education. *Required	Indicates the student meets the criteria for Orthopedic Impairment. Options are Yes or No.	*This is required when "Initial Evaluation" is selected. The values available in this dropdown are hard coded.
Reevaluation: The student was previously found eligible as meeting the disability category criteria under Orthopedic Impairment and continues to have a disability that adversely affects the student's educational performance. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to continue to be eligible for special education. *Required	Indicates the student previously met the criteria for Orthopedic Impairment and continues to have a disability that adversely affects the student's educational performance. Options are Yes or No.	This is required when "Re-evaluation" is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This is required when "Re-evaluation" is selected.

Other Health Impairment

Field	Description	Validation
Does the student have a health problem? *Required	Indicates the student has a health condition. Options are Yes or No.	*This is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is required when Initial Evaluation is selected.
Is the health problem chronic or acute? *Required	Indicates the health condition is chronic or acute. Options are Yes or No.	*This is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Chronic (long-standing, continuous over time, or recurring frequently)	Indicates the health condition is chronic.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is available and required when the associated checkbox is marked.
Acute (severe or intense)	Indicates the health condition is acute.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is available and required when the associated checkbox is marked.
Does the student's health problem result in limited strength, vitality, or alertness? If yes, check ALL that apply. *Required	Indicates the health condition results in limited strength, vitality, or alertness. Options are Yes or No.	*This is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Limited strength (inability to perform typical or routine tasks at school)	Indicates the health condition results in limited strength.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is available and required when the associated checkbox is marked.
Limited vitality (inability to sustain effort or endure throughout an activity)	Indicates the health condition results in limited vitality.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is available and required when the associated checkbox is marked.
Limited alertness (inability to manage and maintain attention, to organize or attend, to prioritize environmental stimuli, including a heightened alertness)	Indicates the health condition results in limited alertness.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is available and required when the associated checkbox is marked.
SECTION II. EDUCATIONAL PERFORMANCE
Is the student's educational performance in one or more of the following areas adversely affected as a result? *Required	Indicates the student's educational performance is adversely affected. Options are Yes or No.	*The dropdown is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
If yes, check ALL that apply. Consider academic achievement and functional performance.	The area of impact. Mark all that apply: Pre-academic or academic achievement Adaptive behavior Behavior Classroom performance Communication Motor skills Social/Emotional Functioning Vocational skills Other	N/A
Describe *Required	A description of any other areas of impact.	*This field is available and required when the associated Other is selected.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is required when Initial Evaluation is selected.
SECTION III. DISABILITY CATEGORY CRITERIA DETERMINATION
The documentation of the criteria above demonstrates limited strength, vitality or alertness, due to chronic or acute health problems which adversely affects the student's educational performance. The student meets the eligibility criteria under the disability category of Other Health Impairment. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education.	Indicates the student meets the criteria for an Other Health Impairment. Options are Yes or No.	The values available in this dropdown are hard coded.

Significant Developmental Delay

Field	Description	Validation
AGE: Is the child age 3 through 9 years old? *Required	Indicates the student is between 3 and 9 years old. Options are Yes or No.	*This is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
OTHER SUSPECTED IMPAIRMENTS: Have all other suspected impairments been considered before identifying the category of significant developmental delay? *Required	Indicates all other suspected impairments have been considered. Options are Yes or No.	*This is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
SIGNIFICANCE OF DELAYS: Are delays of at least 1.5 standard deviations below the mean present that significantly challenge the child in 2 or more of the following major life activities? *Required	Indicates delays present that significantly challenge the child in 2 or more of the following major life activities. Options are Yes or No.	*This is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Physical activity in gross motor skills, such as the ability to move around and interact with the environment with appropriate coordination, balance and strength; or fine motor skills, such as manually controlling and manipulating objects such as toys, drawing utensils, and other useful objects in the environment	Indicates the student has a delay in the area of gross or fine motor skills.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is available and required when the associated checkbox is marked.
Cognitive activity, such as the ability to acquire, use and retrieve information as demonstrated by the level of imitation, discrimination, representation, classification, sequencing, and problem-solving skills often observed in a child's play.	Indicates the student has a delay in the area of cognitive activity.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is available and required when the associated checkbox is marked.
Communication activity in expressive language, such as the production of age-appropriate content, form and use of language; or receptive language, such as listening, receiving and understanding.	Indicates the student has a delay in the area of expressive or receptive language.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is available and required when the associated checkbox is marked.
Emotional activity such as the ability to feel and express emotions, and develop a positive sense of oneself; or social activity, such as interacting with people, developing friendships with peers, and sustaining bonds with family members and other significant adults.	Indicates the student has a delay in the area of emotional or social activity.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is available and required when the associated checkbox is marked.
Adaptive activity, such as caring for their own needs and acquiring independence in age-appropriate eating, toileting, dressing and hygiene tasks.	Indicates the student has a delay in the area of adaptive activities or acquiring independence skills.	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is available and required when the associated checkbox is marked.
The delays demonstrate an adverse effect on the child's daily life, including learning, academic achievement or functional performance. *Required	Indicates the delays demonstrate an adverse effect on the student's daily life. Options are Yes or No.	*This is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This is required when Initial Evaluation *is selected.
SECTION II. ASSESSMENT REQUIREMENTS
Are all of the following qualitative and quantitative measures being used to document delays and their detrimental effect upon the child's life? *Required	Indicates all of the following measures are being used to document delays and the impact on the student's life. Options are Yes or No.	*This is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Developmental and health history, including results from vision and hearing screening and other pertinent information from parents and, if applicable, other caregivers or service providers.	Indicates the student's health history was considered.	N/A
Describe Source of Information *Required	A description of the sources of information.	*This is available and required when the associated checkbox is marked.
Observation of child in daily living environment or, such as the child's home, with a parent or caregiver, or an early education or care setting which includes peers who are typically developing. If observation in these settings is not possible, observation in an alternative setting is permitted.	Indicates observations of the student's daily life were considered.	N/A
Include Dates and Settings of Observations *Required	A description of the dates and settings of the observations.	*This is available and required when the associated checkbox is marked.
Results from norm-referenced instruments were used to document significant delays of at least 1.5 standard deviations below the mean in 2 or more of the developmental areas which correspond to the major life activities.	Indicates results from norm-referenced instruments were considered.	N/A
Describe Source of Information *Required	A description of the sources of information.	*This is available and required when the associated checkbox is marked.
If it clearly was not appropriate to use norm-referenced instruments, other instruments, such as criterion referenced measures, were used to document the significant delays.	Indicates results from norm-referenced instruments were not considered and other instruments were used.	N/A
If a norm-references instrument was not used, explain why *Required	A description of why norm-referenced instruments were not used.	*This is available and required when the associated checkbox is marked.
SECTION III. DISABILITY CATEGORY CRITERIA DETERMINATION
Initial Evaluation: The documentation of the criteria above demonstrates the child is experiencing significant delays in the areas of physical, cognition, communication, social-emotional, or adaptive development that adversely affects the child's major life activities. The child meets the disability category criteria under Significant Developmental Delay. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education. *Required	Indicates the student meets the criteria for Significant Developmental Delay. Options are Yes or No.	*This is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Reevaluation: The student was previously found eligible as meeting the disability category criteria under Significant Developmental Delay and continues to have a disability that adversely affects the student’s educational performance. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to continue to be eligible for special education. *Required	Indicates the student previously met the criteria for Significant Developmental Delay and continues to have a disability that adversely affects the student’s educational performance. Options are Yes or No.	*This is required when Re-evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This is required when Re-evaluation is selected.

Specific Learning Disability - Initial Evaluation

Field	Description	Validation
The student does not make sufficient progress to meet age or grade-level standards following at least two intensive, scientific research-based or evidence-based interventions implemented with adequate fidelity and closely aligned to individual student needs.	Indicates the student does not make sufficient progress after two interventions. Options are Yes or No.	The values available in this dropdown are hard coded.
Data Used to Support Insufficient Progress Determination Check the area(s) considered and whether the student did or did not make sufficient progress below.
Basic Reading Skill	Indicates the student's basic reading skills were considered.	N/A
Progress *Required	The student's progress in their basic reading skills. Options include: The student did not demonstrate sufficient progress The student demonstrated sufficient progress	*This field is available and required when the associated checkbox is marked. The values available in this dropdown are hard coded.
Decision Rule - The student's rate of progress was *Required	Indicates the student's rate of progress in their basic reading skills. Options include: The same or less than same age peers. Greater than same age peers, but will not result in the student reaching the average range of achievement as same age peers in a reasonable period of time. Greater than same age peers, but the intensity of resources to obtain this rate of progress cannot be maintained in general education.	*This field is available and required when the associated checkbox is marked. Only one value may be selected.
Progress Monitoring Data - Briefly summarize data collected. Attach supporting data as appropriate. *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is marked.
Reading Comprehension	Indicates the student's reading comprehension was considered.	N/A
Progress *Required	The student's progress in their reading comprehension skills. Options include: The student did not demonstrate sufficient progress The student demonstrated sufficient progress	*This field is available and required when the associated checkbox is marked. The values available in this dropdown are hard coded.
Decision Rule - The student's rate of progress was *Required	Indicates the student's rate of progress in their reading comprehension skills. Options include: The same or less than same age peers. Greater than same age peers, but will not result in the student reaching the average range of achievement as same age peers in a reasonable period of time. Greater than same age peers, but the intensity of resources to obtain this rate of progress cannot be maintained in general education.	*This field is available and required when the associated checkbox is marked. Only one value may be selected.
Progress Monitoring Data - Briefly summarize data collected. Attach supporting data as appropriate. *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is marked.
Reading Fluency Skills	Indicates the student's reading fluency was considered.	N/A
Progress *Required	The student's progress in their reading fluency skills. Options include: The student did not demonstrate sufficient progress The student demonstrated sufficient progress	*This field is available and required when the associated checkbox is marked. The values available in this dropdown are hard coded.
Decision Rule - The student's rate of progress was *Required	Indicates the student's rate of progress in their reading fluency skills. Options include: The same or less than same age peers. Greater than same age peers, but will not result in the student reaching the average range of achievement as same age peers in a reasonable period of time. Greater than same age peers, but the intensity of resources to obtain this rate of progress cannot be maintained in general education.	*This field is available and required when the associated checkbox is marked. Only one value may be selected.
Progress Monitoring Data - Briefly summarize data collected. Attach supporting data as appropriate. *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is marked.
Mathematics Calculation	Indicates the student's mathematics calculations skills were considered.	N/A
Progress *Required	The student's progress in their mathematics calculations skills. Options include: The student did not demonstrate sufficient progress The student demonstrated sufficient progress	*This field is available and required when the associated checkbox is marked. The values available in this dropdown are hard coded.
Decision Rule - The student's rate of progress was *Required	Indicates the student's rate of progress in their mathematics calculations skills. Options include: The same or less than same age peers. Greater than same age peers, but will not result in the student reaching the average range of achievement as same age peers in a reasonable period of time. Greater than same age peers, but the intensity of resources to obtain this rate of progress cannot be maintained in general education.	*This field is available and required when the associated checkbox is selected. Only one value may be selected.
Progress Monitoring Data - Briefly summarize data collected. Attach supporting data as appropriate. *Required	A description of the evidence for the above determination.	This field is available and required when the associated checkbox is marked.
Mathematics Problem Solving	Indicates the student's mathematics problem solving skills were considered.	N/A
Progress *Required	The student's progress in their mathematics problem solving skills. Options include: The student did not demonstrate sufficient progress The student demonstrated sufficient progress	*This field is available and required when the associated checkbox is marked. The values available in this dropdown are hard coded.
Decision Rule - The student's rate of progress was *Required	Indicates the student's rate of progress in their mathematics problem solving skills. Options include: The same or less than same age peers. Greater than same age peers, but will not result in the student reaching the average range of achievement as same age peers in a reasonable period of time. Greater than same age peers, but the intensity of resources to obtain this rate of progress cannot be maintained in general education.	*This field is available and required when the associated checkbox is marked. Only one value may be selected.
Progress Monitoring Data - Briefly summarize data collected. Attach supporting data as appropriate. *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is marked.
Written Expression	Indicates the student's writing expression skills were considered.	N/A
Progress *Required	The student's progress in their written expression skills. Options include: The student did not demonstrate sufficient progress The student demonstrated sufficient progress	*This field is available and required when the associated checkbox is marked. The values available in this dropdown are hard coded.
Decision Rule - The student's rate of progress was *Required	Indicates the student's rate of progress in their written expression skills. Options include: The same or less than same age peers. Greater than same age peers, but will not result in the student reaching the average range of achievement as same age peers in a reasonable period of time. Greater than same age peers, but the intensity of resources to obtain this rate of progress cannot be maintained in general education.	*This field is available and required when the associated checkbox is marked. Only one value may be selected.
Progress Monitoring Data - Briefly summarize data collected. Attach supporting data as appropriate. *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is marked.
Oral Expression	Indicates the student's oral expression was considered.	N/A
Progress *Required	The student's progress in their oral expression skills. Options include: The student did not demonstrate sufficient progress The student demonstrated sufficient progress	*This field is available and required when the associated checkbox is marked. The values available in this dropdown are hard coded.
Decision Rule - The student's rate of progress was *Required	Indicates the student's rate of progress in their oral expression skills. Options include: The same or less than same age peers. Greater than same age peers, but will not result in the student reaching the average range of achievement as same age peers in a reasonable period of time. Greater than same age peers, but the intensity of resources to obtain this rate of progress cannot be maintained in general education.	*This field is available and required when the associated checkbox is marked. Only one value may be selected.
Progress Monitoring Data - Briefly summarize data collected. Attach supporting data as appropriate. *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is marked.
Listening Comprehension	Indicates the student's listening comprehension skills were considered.	N/A
Progress *Required	The student's progress in their listening comprehension skills. Options include: The student did not demonstrate sufficient progress The student demonstrated sufficient progress	*This field is available and required when the associated checkbox is marked. The values available in this dropdown are hard coded.
Decision Rule - The student's rate of progress was *Required	Indicates the student's rate of progress in their listening comprehension skills. Options include: The same or less than same age peers. Greater than same age peers, but will not result in the student reaching the average range of achievement as same age peers in a reasonable period of time. Greater than same age peers, but the intensity of resources to obtain this rate of progress cannot be maintained in general education.	*This field is available and required when the associated checkbox is marked. Only one value may be selected.
Progress Monitoring Data - Briefly summarize data collected. Attach supporting data as appropriate. *Required	A description of the evidence for the above determination.	This field is available and required when the associated checkbox is selected.
The instructional strategies used with the student, including intensive intervention, were applied in a manner highly consistent with the design, closely aligned to pupil need, and culturally appropriate.	Indicates the instructional strategies were applied in a manner highly consistent with the design, closely aligned to pupil need, and culturally appropriate.	N/A
The student's parent(s) were informed about the amount and nature of their child's performance data collected; the general education services provided; progress monitoring data collected; the strategies for increasing their child's rate of learning, including the intensive interventions used; and their right to request an evaluation.	Indicates the student's parent/guardian(s) were informed about the data collected, services provided, progress monitoring data, strategies, and their rights to request an evaluation for their student.	N/A
Additional Notes	Any additional comments regarding the determination and/or documentation.	N/A
2. Inadequate Classroom Achievement
The student does not achieve adequately for their age or grade-level after intensive intervention.	Indicates the student does not achieve adequately for their age or grade-level after intensive intervention. Options are Yes or No.	The values available in this dropdown are hard coded.
If “Yes,” achievement is inadequate in the following area(s) *Required	The area in which the student's achievement is inadequate. Options include: Oral Expression Basic Reading Skill Mathematics Calculation Listening Comprehension Reading Comprehension Mathematics Problem Solving Written Expression Reading Fluency Skills	*This field is available and required when the associated dropdown is Yes. Mark all that apply.
Data Used to Support Determination:	A description of the evidence for the above determination.	N/A
If the 1.25 standard deviation (SD) requirement was not used to make this determination, provide the reason why valid and reliable standard scores could not be maintained and documentation of inadequate achievement using other empirical evidence	A description of the reasons for the determination, either using the 1.25 standard deviation (SD) requirement or other empirical evidence used.	N/A
Additional Notes	Any additional comments regarding the determination and/or documentation.	N/A
3. Exclusionary Factors as a Primary Reason DO NOT Apply
Check "Yes" if none of the exclusionary factors are the primary reason for the student's inadequate achievement or insufficient progress. Check "No" if the student's inadequate achievement or insufficient progress are primarily due to one or more exclusionary factor, and check the factor(s) below.	Indicates if none of the exclusionary factors are the primary reason for the student’s inadequate achievement or insufficient progress. Options are Yes or No.	The values available in this dropdown are hard coded.
The student does not meet general education expectations primarily because of	The reason the student does not meet general education expectations. Options include: Environmental, cultural, or economic factors Limited English proficiency Lack of appropriate instruction in the identified area(s) of concern: oral expression, listening comprehension, written expression, basic reading skill, reading fluency skills, reading comprehension, mathematics calculation, or mathematics problem solving Other impairment	Mark all that apply.
Specify Other *Required	Any other reason the student does not meet general education expectations not listed above.	*This field becomes available and required when the associated Other is selected.
Additional Considerations the IEP Team Considered	Any additional considerations made by the IEP team. Options include: Data demonstrating, prior to or as part of the evaluation, the student was or was not provided appropriate instruction. Evidence the student received repeated assessments of achievement reflecting student progress. The student's parent(s) were informed of such assessments.	This needs to be completed whether or not an exclusionary factor applies.
Additional Notes	Any additional comments regarding the determination and/or documentation.	N/A
ADDITIONAL DOCUMENTATION REQUIRED WHEN STUDENT IS EVALUATED FOR SLD
Relevant behavior noted during observation of the student in their learning environment including the regular education classroom and during intensive intervention, and the relationship of that behavior to the student's academic functioning.	A description of the noted behavior of the student during observation.	N/A
Educationally relevant medical findings.	Indicates there are relevant medical findings pertinent to the student's education. Options include Yes or No.	The values available in this dropdown are hard coded.
If yes, specific relevant medical findings *Required	A description of the medical findings, when applicable.	*This field is available and required when the associated dropdown is Yes.
SUMMARY of ELIGIBILITY CRITERIA CONSIDERATION List the area(s) of concern in the box below (e.g., reading fluency, math calculation, and reading comprehension). For each area of concern listed, check “Yes” or “No” to indicate: Inadequate classroom achievement, Insufficient progress, and Exclusionary factors DO NOT apply. If all three are selected "Yes" for at least one area of concern, then the student meets eligibility criteria for SLD.
Area of Concern	The area of concern.	N/A
Insufficient Progress	Indicates the student has made insufficient progress in the area of concern. Options are Yes or No.	The values available in this dropdown are hard coded.
Inadequate Classroom Achievement	Indicates the student has inadequate classroom achievement in the area of concern. Options are Yes or No.	The values available in this dropdown are hard coded.
Exclusionary Factors DO NOT Apply	Indicates exclusionary factors do not apply to the area of concern. Options are Yes or No.	The values available in this dropdown are hard coded.
The IEP team decision of whether the child 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.	Indicates the IEP team's decision was based on information from a variety of sources and not a single measure/assessment.	N/A
DISABILITY CATEGORY CRITERIA DETERMINATION
The documentation of the criteria above demonstrates the student meets the disability category criteria for Specific Learning Disability. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education.	Indicates the student meets the criteria for the disability category of Specific Learning Disability. Options are Yes or No.	The values available in this dropdown are hard coded.
Additional Notes	Any additional comments regarding the determination and/or documentation.	N/A
Team Participant The Team Member names listed in this editor as read-only are listed as Team Members for that student. The name is pulled from the person's District Assignment and cannot be modified. Each IEP team participant must sign below and indicate whether they agree with the conclusions regarding whether or not the child is a child with a specific learning disability. If this does not reflect their conclusions, then that IEP team participant must also attach a statement with their conclusions.
First Name Required	The team member's first name.	The Team Member names are pulled from the Team Member tool and are read-only. Names can be modified when the Add button is used to add a person to the record.
Last Name Required	The team member's last name.	The Team Member names are pulled from the Team Member tool and are read-only. Names can be modified when the Add button is used to add a person to the record.
Role	The role of the team member.	The Team Member role is pulled from the Team Member tool and is read-only.
Agree	Indicates this team member agrees with the conclusions whether or not the student has a Specific Learning Disability. Options are Yes or No.	The values available in this dropdown are hard coded.

Specific Learning Disability - Re-Evaluation

Field	Description	Validation
The student was previously found eligible as having the impairment of SLD. If "No", the IEP team should consider whether the student meets initial SLD criteria.	Indicates the student was previously found eligible as having the impairment of Specific Learning Disability (SLD). Options are Yes or No.	The values available in this dropdown are hard coded.
The student does not perform to generally accepted expectations in the general education classroom without specially designed instruction.	Indicates the student does not perform to generally accepted expectations in the general education classroom without specially designed instruction. Options are Yes or No.	The values available in this dropdown are hard coded.
The student continues to need special education to address needs resulting from the impairment of SLD.	Indicates the student continues to need special education services to address needs from the Specific Learning Disability (SLD). Options are Yes or No.	The values available in this dropdown are hard coded.
Reason for Determination including Data Used	A description of the evidence for the above determination.	N/A
CONSIDERATION OF EXCLUSIONARY FACTORS
Exclusionary Factors as a primary reason DO NOT apply. Answer "Yes" if none of the exclusionary factors apply and complete the section Consideration of Exit Criteria and Continuing Need for Special Education. Answer "NO" if one or more exclusionary factors apply and check the factor(s) below.	Indicates Exclusionary Factors as a primary reason do not apply. Options are Yes or No.	The values available in this dropdown are hard coded.
The student does not meet general education expectations primarily because of	The area in which the student does not meet general education expectations. Options include: Environmental, cultural, or economic factors Limited English proficiency Lack of appropriate instruction in the identified area(s) of concern: oral expression, listening comprehension, written expression, basic reading skill, reading fluency skills, reading comprehension, mathematics calculation, or mathematics problem solving Other impairment	Mark all that apply.
Specify Other *Required	Any other reason the student does not meet general education expectations not listed above.	*This field is available and required when the associated Other is selected.
Additional Notes	Any additional comments regarding the determination and/or documentation.	N/A
ADDITIONAL DOCUMENTATION REQUIRED WHEN STUDENT IS EVALUATED FOR SLD
Relevant behavior noted during observation of the student in their learning environment, including the regular classroom, and the relationship of that behavior to the student's academic functioning.	A description of the noted behavior of the student during observation.	N/A
Educationally relevant medical findings	Indicates there are relevant medical findings pertinent to the student's education. Options include Yes or No.	The values available in this dropdown are hard coded.
If yes, specific relevant medical findings *Required	A description of the medical findings, when applicable.	*This field is available and required when the associated dropdown is Yes.
The IEP team assures that the decision of whether the child 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.	Indicates the IEP team's decision was based on information from a variety of sources and not a single measure/assessment.	N/A
DISABILITY CATEGORY CRITERIA DETERMINATION
The student was previously found eligible as meeting the disability category criteria for Specific Learning Disability and continues to have a disability that adversely affects the student’s educational performance. A student who previously met criteria under the disability category of Specific Learning Disability is not required to meet initial identification criteria upon reevaluation.	Indicates the student has previously met the criteria for the disability category of Specific Learning Disability and continues to have a disability that adversely affects the student’s educational performance. Options are Yes or No.	The values available in this dropdown are hard coded.
Additional Notes	Any additional comments regarding the determination and/or documentation.	N/A
Team Participant The Team Member names listed in this editor as read-only are listed as Team Members for that student. The name is pulled from the person's District Assignment and cannot be modified. Each IEP team participant must sign below and indicate whether they agree with the conclusions regarding whether or not the child is a child with a specific learning disability. If this does not reflect their conclusions, then that IEP team participant must also attach a statement with their conclusions.
First Name Required	The team member's first name.	The Team Member names are pulled from the Team Member tool and are read-only. Names can be modified when the Add button is used to add a person to the record.
Last Name Required	The team member's last name.	The Team Member names are pulled from the Team Member tool and are read-only. Names can be modified when the Add button is used to add a person to the record.
Role	The role of the team member.	The Team Member role is pulled from the Team Member tool and is read-only.
Agree	Indicates this team member agrees with the conclusions whether or not the student has a Specific Learning Disability. Options are Yes or No.	The values available in this dropdown are hard coded.

Specific Learning Disability - Initial Evaluation Using Significant Discrepancy

Field	Description	Validation
The student has made insufficient progress based on Significant Discrepancy.	Indicates the student has made insufficient progress based on Significant Discrepancy. Options are Yes or No.	The values available in this dropdown are hard coded.
If Yes, the student has a significant discrepancy between ability and achievement in one or more of the following areas	The area in which the student the student has a significant discrepancy between ability and achievement. Options include: Oral Expression Basic Reading Skill Mathematics Calculation Listening Comprehension Reading Comprehension Mathematics Problem Solving Written Expression Reading Fluency Skills	N/A
Data Used to Support Determination	A description of the evidence for the above determination.	N/A
If the regression formula was not used to make this determination, the reasons why it was not appropriate to use the regression procedure and documentation that a significant discrepancy exists, including documentation of a variable pattern of achievement or ability, in at least one of the eight areas of potential specific learning disabilities using other empirical evidence.	A description of how this determination was made, including reasons for using the regression formula or not.	N/A
Additional Notes	Any additional comments regarding the determination and/or documentation.	N/A
2. Inadequate Classroom Achievement
The student does not achieve adequately for his/her age/grade-level after interventions occurring beyond core instruction.	Indicates the student does not achieve adequately for their grade/age level after interventions occurring beyond core instruction. Options are Yes or No.	The values available in this dropdown are hard coded.
If Yes, achievement is inadequate in the following area(s)	The area in which the student's achievement is inadequate. Options include: Oral Expression Basic Reading Skill Mathematics Calculation Listening Comprehension Reading Comprehension Mathematics Problem Solving Written Expression Reading Fluency Skills	Mark all that apply.
Data Used to Support Determination	A description of the evidence for the above determination.	N/A
Additional Notes	Any additional comments regarding the determination and/or documentation.	N/A
3. Exclusionary Factors DO NOT Apply
Mark "Yes" if none of the exclusionary factors are the primary reason for the student’s inadequate achievement or insufficient progress. Mark "NO" if the student’s inadequate achievement or insufficient progress are primarily due to one or more exclusionary factor, and check the factor(s) below.	Indicates if none of the exclusionary factors are the primary reason for the student’s inadequate achievement or insufficient progress. Options are Yes or No.	The values available in this dropdown are hard coded.
The student does not meet general education expectations primarily because of	The reason the student does not meet general education expectations. Options include: Environmental, cultural, or economic factors Limited English proficiency Lack of appropriate instruction in the identified area(s) of concern: oral expression, listening comprehension, written expression, basic reading skill, reading fluency skills, reading comprehension, mathematics calculation, or mathematics problem solving Other impairment	Mark all that apply.
Specify Other *Required	Any other reason the student does not meet general education expectations not listed above.	*This field becomes available and required when the associated Other is selected.
Additional Considerations the IEP Team Considered	Any additional considerations made by the IEP team. Options include: Data demonstrating, prior to or as part of the evaluation, the student was or was not provided appropriate instruction. Evidence the student received repeated assessments of achievement reflecting student progress. The student’s parent(s)/guardian(s) were informed of such assessments.	This needs to be completed whether or not an exclusionary factor applies.
Additional Notes	Any additional comments regarding the determination and/or documentation.	N/A
ADDITIONAL DOCUMENTATION REQUIRED WHEN STUDENT IS EVALUATED FOR SLD
Relevant behavior noted during observation of the student, in his or her learning environment, and the relationship of that behavior to the student's academic functioning.	A description of the noted behavior of the student during observation.	N/A
Educationally relevant medical findings	Indicates there are relevant medical findings pertinent to the student's education. Options include Yes or No.	The values available in this dropdown are hard coded.
If yes, specific relevant medical findings *Required	A description of the medical findings, when applicable.	*This field is available and required when the associated dropdown is Yes.
SUMMARY of ELIGIBILITY CRITERIA CONSIDERATION List the area(s) of concern in the box below (e.g., reading fluency, math calculation, and reading comprehension). For each area of concern listed, check “Yes” or “No” to indicate: Inadequate classroom achievement, Insufficient progress, and Exclusionary factors DO NOT apply. If all three are selected "Yes" for at least one area of concern, then the student meets eligibility criteria for SLD.
Area of Concern	The area of concern.	N/A
Insufficient Progress	Indicates the student has made insufficient progress in the area of concern. Options are Yes or No.	The values available in this dropdown are hard coded.
Inadequate Classroom Achievement	Indicates the student has inadequate classroom achievement in the area of concern. Options are Yes or No.	N/A
Exclusionary Factors DO NOT Apply	Indicates exclusionary factors do not apply to the area of concern. Options are Yes or No.	N/A
The IEP team decision of whether the child 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.	Indicates the IEP team's decision was based on information from a variety of sources and not a single measure/assessment.	N/A
DISABILITY CATEGORY CRITERIA DETERMINATION
The documentation of the criteria above demonstrates the student meets the disability category criteria for Specific Learning Disability. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education.	Indicates the student meets the criteria for the disability category of Specific Learning Disability. Options are Yes or No.	The values available in this dropdown are hard coded.
Additional Notes	Any additional comments regarding the determination and/or documentation.	N/A
Team Participant The Team Member names listed in this editor as read-only are listed as Team Members for that student. The name is pulled from the person's District Assignment and cannot be modified. Each IEP team participant must sign below and indicate whether they agree with the conclusions regarding whether or not the child is a child with a specific learning disability. If this does not reflect their conclusions, then that IEP team participant must also attach a statement with their conclusions.
First Name Required	The team member's first name.	The Team Member names are pulled from the Team Member tool and are read-only. Names can be modified when the Add button is used to add a person to the record.
Last Name Required	The team member's last name.	The Team Member names are pulled from the Team Member tool and are read-only. Names can be modified when the Add button is used to add a person to the record.
Role	The role of the team member.	The Team Member role is pulled from the Team Member tool and is read-only.
Agree	Indicates this team member agrees with the conclusions whether or not the student has a Specific Learning Disability. Options are Yes or No.	.The values available in this dropdown are hard coded.

Speech or Language Impairment

Field	Description	Validation
Not Applicable. No concerns with this area of communication.	Indicates there are no concerns with this area of communication.	When this is marked, the fields below become unavailable.
Following consideration of the student's age, culture, language background and dialect, the student demonstrates a language impairment in the area of language form, content, or use. *Required	Indicates the student demonstrates a language impairment in the area of language form, content, or use.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
As evidenced through an observation in a natural environment (must be checked).	N/A	This checkbox must be marked.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is marked.
At least two of the following measurements were used	The type of measures used to make the determination. Options include: Language sample. Dynamic assessment. Criterion-referenced assessment, such as developmental scales. Norm-references assessment** of comprehensive language.	N/A
Explain or reference data or evidence for all measurement boxes checked above. If a norm-referenced assessment was used, explain whether the student demonstrated a significant discrepancy *Required	A description of the evidence of the measures selected above.	*This field is available and required when any of the checkboxes above are marked.
There is a delay in communication that adversely impacts the student's educational performance or social, emotional or vocational development. *Required	Indicates the delay in communication skills impacts the student's educational performance or social, emotional or vocational development. Options include Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
SECTION II. SPEECH SOUND PRODUCTION-ARTICULATION (All four yes/no boxes must be answered Yes)
Not Applicable. No concerns with this area of communication.	Indicates there are no concerns with this area of communication.	When this is marked, the fields below become unavailable.
Following consideration of the student's age, culture, language background and dialect, the student's speech sound production (i.e. articulation) is documented to be delayed. *Required	Indicates the student's sound production is delayed. Options include Yes or No.	This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
As evidenced through an observation in a natural environment (must be checked).	N/A	This checkbox must be marked.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is marked.
At least one of the following measurements were used	The type of measures used to make the determination. Options include: Criterion-references assessment, such as a developmental scale or phonetic inventory. Norm-referenced assessment**	N/A
Explain or reference data or evidence for all measurement boxes checked above. If a norm-referenced assessment was used, explain whether the student demonstrated a significant discrepancy *Required	A description of the evidence of the measures selected above.	*This field is available and required when any of the checkboxes above are marked.
The student's intelligibility is below the expected range for their age. Intelligibility ratings as documented by school staff or caregivers indicate an impact across environments. *Required	Indicates the student's intelligibility is below the expected age range. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This field is required when Initial Evaluation is selected.
The student is less than 30% stimulable for speech sounds found in error. *Required	Indicates the student is less than 30% capable of being stimulated for speech sounds found in error. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
There is a delay in communication that adversely impacts the student's educational performance or social, emotional or vocational development. *Required	Indicates there is a communication delay that impacts the student's educational performance or social, emotional or vocational development. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
SECTION III. SPEECH SOUND PRODUCTION-PHONOLOGY (All three yes/no boxes must be answered Yes)
Not Applicable. No concerns with this area of communication.	Indicates there are no concerns with this area of communication.	When this is marked, the fields below become unavailable.
Following consideration of the student's age, culture, language background and dialect, the student's phonological process use is documented to be non-developmental or outside of the expected developmental range. *Required	Indicates the phonological process use is non-developmental or outside the expected developmental range. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
As evidenced through an observation in a natural environment (must be checked).	N/A	This checkbox must be marked.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is selected.
At least one of the following measurements were used	The type of measures used to make the determination. Options include: Presence of one or more disordered phonological processes occurring at least 40%. Norm-referenced assessment** of phonology	The values available in this dropdown are hard coded.
Explain or reference data or evidence for all measurement boxes checked above. If a norm-referenced assessment was used, explain whether the student demonstrated a significant discrepancy *Required	A description of the evidence of the measures selected above.	*This field is available and required when the associated checkbox is marked.
The student's intelligibility is below the expected range for their age and not due to influences of home languages or dialect. Intelligibility ratings as documented by school staff or caregivers indicate an impact across environments.	Indicates the student's intelligibility is below the expected range for their age and not due to influences of home languages or dialect. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
There is a delay in communication that adversely impacts the student's educational performance or social, emotional or vocational development. *Required	Indicates there is a communication delay that impacts the student's educational performance or social, emotional or vocational development. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
SECTION IV. VOICE (All three yes/no boxes must be answered Yes)
There is documentation of a vocal impairment not due to temporary physical factors (such as allergies, short-term vocal abuse, or puberty) and not due to an acute respiratory virus or infection. *Required	Indicates the student's vocal impairment is not due to a temporary factor or an acute respiratory virus or infection. Options include: Yes No Not Applicable. No Concerns with this area of communication.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
As evidenced through an observation in a natural environment (must be checked).	N/A	This checkbox must be marked.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is marked.
Following consideration of the student's age, culture, language background, or dialect, the student demonstrates characteristics on impairment, which include any of the following *Required	Indicates the student demonstrates characteristics of an impairment. Options include: Yes No The student's vocal volume, including loudness. The student's vocal pitch, including range, inflection, or appropriateness. The student's vocal quality, including breathiness, hoarseness, or harshness. The student's vocal resonance, including hypernasality.	*This dropdown field is required when Initial Evaluation is selected. At least one option must be marked. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkboxes are marked.
This impairment in communication adversely impacts the student's educational performance or social, emotional or vocational development. *Required	Indicates there is a communication delay that impacts the student's educational performance or social, emotional or vocational development. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
SECTION V. FLUENCY (Both yes/no boxes must be answered Yes)
Not Applicable. No concerns with this area of communication.	Indicates there are no concerns with this area of communication.	When this is marked, the fields below become unavailable.
Following consideration of the student's age, language background, culture, and dialect, the student has speaking behaviors characteristic of a fluency disorder.	Indicates the student has speaking behaviors characteristic of a fluency disorder. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
At least one of the following measurements were used	The type of measures used to make the determination. Options include: Observation in a natural environment Case history Norm-referenced assessment** Disfluency analysis	N/A
Explain or reference data or evidence for all measurement boxes checked above. If a norm-referenced assessment was used, explain whether the student demonstrated a significant discrepancy *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is marked.
The presence of one or more of the following characteristics indicates a fluency disorder (check all that apply):
Speech disfluencies associated with stuttering or atypical disfluency, which include repetitions of phrases, words, syllables, and sounds of dysrhythmic phonations such as prolongations of sounds or blockages of airflow typically in excess of 2% of total syllables, one second of duration, and two or more iterations in a repetition. Non-verbal physical movements, such as eye blinking or head jerking, may accompany the stuttering. Negative feelings about oral communication may be significant enough to result in avoidance behaviors in an attempt to hide or diminish stuttering.	N/A	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is marked.
A speech rate that is documented to be rapid, irregular, or both and may be accompanied by sound or syllable omissions, sequencing errors, or a high number of non-stuttering speech disfluencies such as interjections, phrase and whole word repetitions, and revisions. The resulting speech fluency pattern is considered to be significantly disruptive to efficient communication. Negative feelings and attitudes about oral communication may or may not be present under this disfluency profile.	N/A	N/A
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is available and required when the associated checkbox is marked.
This impairment in communication adversely impacts the student's educational performance or social, emotional or vocational development. *Required	Indicates there is a communication delay that impacts the student's educational performance or social, emotional or vocational development. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
SECTION VI. AUGMENTATIVE AND ALTERNATIVE COMMUNICATION (AAC)
The IEP team evaluated the student's language by assessing the student's augmentative and alternative communication skills, when appropriate to determine the student's needs. *Required	Indicates the IEP team assessed the student's augmentative and alternative communication skill to determine the student's needs. Options are Yes or N/A.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
SECTION VII. EXCLUSIONARY FACTORS
There are exclusionary factors *Required	Indicates there are exclusionary factors. Options are Yes or N/A.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
If yes, list exclusionary factors present *Required	A description of the exclusionary factors.	*This field is required when Initial Evaluation is selected.
SECTION VIII. DOCUMENTATION OF REQUIRED IEP TEAM MEMBERS
A speech-language pathologist was an IEP team participant and attended IEP meetings when the team discussed eligibility for a speech or language impairment or identified the student's speech or language needs (or both). *Required	Indicates a speech-language pathologist was an IEP team participant and attended IEP meetings. Options are Yes or No.	*This field is required when Initial Evaluation and Reevaluation is selected. The values available in this dropdown are hard coded.
An educator with foundational knowledge in first and second language instruction and second language acquisition if the student is identified as an English Learner under 20 USC 7801(20) was an IEP team participant and attended IEP meetings when the team discussed eligibility for a speech or language impairment or the need for speech and language services (or both). *Required	Indicates an educator with foundational knowledge in first and second language instruction and second language acquisition if the student is identified as an English Learner was an IEP team participant and attended IEP meetings. Options include: Yes No N/A	*This field is required when Initial Evaluation and Reevaluation is selected. The values available in this dropdown are hard coded.
SECTION IX. DISABILITY CATEGORY CRITERIA DETERMINATION
Initial Evaluation: The student must meet criteria in one of the sections (I-V) above and no exclusionary factors exist. The documentation of the criteria above demonstrates an impairment of speech or sound production, voice, fluency, or language that adversely affects educational performance or social, emotional or vocational development. The student meets the disability category criteria under Speech or Language Impairment. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education. *Required	Indicates the student meets the disability category of Speech or Language Impairment. Options are Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Reevaluation: The student was previously found eligible as meeting the disability category under Speech or Language Impairment and continues to have a disability that adversely affects the student's educational performance or social, emotional, or vocational development. A student whose disability has an adverse effect on educational performance or social, emotional or vocational development must be found to require specially designed instruction in order to continue to be eligible for special education. *Required	Indicates the student previously met the disability category of Speech or Language Impairment and the impairment continues. Options are Yes or No.	*This field is required when Reevaluation is selected. The values available in this dropdown are hard coded.
Explain or reference data or evidence that indicates the student continues to have a disability that adversely affects the student's educational performance or social, emotional, or vocational development *Required	A description of the evidence for the above determination.	*This field is required when "Reevaluation" is selected.

Traumatic Brain Injury

Field	Description	Validation
Does the student have an acquired injury to the brain that occurred following a period of normal development? *Required	Indicates the student has brain injury. Options include Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
If medical information from a licensed physician is available, it was considered by the IEP team. (if available, the IEP team must consider it.)	A description of the medical information considered by the IEP team.	N/A
Describe the Nature of the Acquired Injury and Source(s) of Evidence *Required	A description of the nature of the injury and sources of evidence.	*This field is required when Initial Evaluation is selected.
Was the student's acquired brain injury caused by an external physical force from a strike or blow to the head or from movement of the brain within the skull? e.g., 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	Indicates the brain injury was caused by an external physical force. Options include Yes or No.	This field is required when "Initial Evaluation" is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	*This field is required when Initial Evaluation is selected.
SECTION II. EDUCATIONAL PERFORMANCE (Must be answered yes)
Is the student's educational performance adversely affected due to total or partial functional disability or psychosocial impairment, or both, in one or more of the following areas? In other words, is the student's educational performance in one or more of the areas below partially or totally affected by the acquired brain injury? *Required	Indicates the student's educational performance is impacted by the injury. Options include Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
If yes, check ALL that apply *Required	The areas impacted by the injury. Options include: Cognition Memory Reasoning Communication Problem Solving Physical Functions Speech & Language Attention Abstract Thinking Judgement Sensory, Perceptual and Motor Abilities Information Processing Psychosocial Behavior (psychological or social functioning) Executive Functions (e.g., organizing, evaluating, and goal-directed activities)	*This is available and required if the associated dropdown is Yes.
Explain or Reference Data or Evidence *Required	A description of the evidence for the above determination.	This field is required when Initial Evaluation is selected.
SECTION III. EXCLUSIONARY FACTORS
The student does not have a brain injury that is congenital or degenerative, or a brain injury induces by birth trauma (answer to indicate agreement).	A statement of agreement that the student's injury is not congenital or degenerative or from birth trauma.	N/A
SECTION IV. DISABILITY CATEGORY CRITERIA DETERMINATION
Initial Evaluation: The documentation of the criteria above demonstrates 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 the student’s educational performance. The student meets the eligibility criteria under the disability category of Traumatic Brain Injury. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to be eligible for special education. *Required	Indicates the student meets the eligibility criteria under the disability category of Traumatic Brain Injury. Options include Yes or No.	*This field is required when Initial Evaluation is selected. The values available in this dropdown are hard coded.
Reevaluation: The student was previously found eligible as meeting the disability category criteria under Traumatic Brain Injury and continues to have a disability that adversely affects the student’s educational performance. A student whose disability has an adverse effect on educational performance must be found to require specially designed instruction in order to continue to be eligible for special education. *Required	Indicates the student meets the eligibility criteria under the disability category of Traumatic Brain Injury. and continues to a have a disability that adversely affects the student’s educational performance. Options include Yes or No.	*This field is required when Re-evaluation is selected. The values available in this dropdown are hard coded.
Explain or Reference Data or Evidence	A description of the evidence for the above determination.	This field is required when "Re-evaluation" is selected.

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(ER-1) Need for Specially Designed Instruction

The Need for Specially Designed Instruction editor lists the determination of the student's disability, the evidence for that decision and whether the student requires special education services as a result.

Need for Specially Designed Instruction Editor

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Field	Description	Validation
A. DETERMINATION OF DISABILITY CATEGORY
1. When considering whether the student meets the criteria for one or more disability categories, the IEP team may not find the student eligible if the determining factor is due to a lack of appropriate instruction in reading or math, or due to limited English proficiency. If one of these reasons applies, describe	A description of the determining factor.	N/A
Not Applicable	N/A	When marked, the text area above becomes unavailable.
2. The district must take steps to address the lack of appropriate instruction or the student's limited English proficiency. Recommendations	A recommendation for addressing the student's needed for their limited English proficiency.	N/A
Not Applicable	N/A	When marked, the text area above becomes unavailable.
3. This student meets the criteria for one or more of the following disability categories This information is determined by the checklists entered in the (ER-1) Eligibility Determination editor and those marked as Eligible.	The student's disability category.	This auto-populate with either the impairments marked as Eligible from the Eligibility Determination checklists OR when there are none, it reads: NONE Found (complete A.3.b and A.4 below).
a. For each disability category identified, attach the Criteria for Disability Category form.	A description of the disability criteria.	N/A
b. Were disability categories considered and rejected? attach Criteria for Disability Category form, if used	Indicates the disability categories were considered and rejected. Options include Yes or No.	The values available in this dropdown are hard coded.
If yes, document which disability categories were rejected and how the student did not meet the criteria	A description of how the student does not meet the criteria.	N/A
4. If no disability categories are identified under A. 3., the student is not eligible for Special Education. The IEP team does not need to complete Section B. NEED FOR SPECIALLY DESIGNED INSTRUCTION. Include recommendations other than Special Education, if any	A description of recommendations other than special education for the student when they do not meet the disability categories and are not eligible for special education services.	N/A
B. NEED FOR SPECIALLY DESIGNED INSTRUCTION In order to be eligible for an IEP, the IEP team must determine that the identified disability(ies) adversely affects educational performance and the student needs specially designed instruction as a result. Specially designed instruction means adapting, as appropriate, the content, methodology, or delivery of instruction to address the unique needs of the student that result from the student's disability; and ensure access of the student to the general curriculum, so the student can meet the educational standards of the public agency that apply to all students.
1. Describe how the student's disability affects their access, engagement and progress in the grade-level general education curriculum, including how the disability affects academic or functional skills. e.g., achievement in content areas including early literacy/reading, cognitive learning, communication, independence and self-determination, physical and health, social and emotional learning.	A description of how the student's disability impacts their access, engagement, progress, and academic and functional skills.	N/A
2. Based on a root cause analysis of the effects of the student's disability, describe the student's academic and/or functional disability-related needs. What skills and/or behaviors does the student need to develop and/or improve so the student can meet age/grade level standards and expectations. e.g., decoding, identifying the main idea, basic math calculations, and word problems? (The student needs to develop/improve...)	A description of the student's academic and functional needs.	N/A
3. Can the student's disability-related needs be addressed without specially designed instruction?	Indicates the student's needs can be addressed without specially designed instruction. Options include Yes or No.	The values available in this dropdown are hard coded.
If Yes, the student does not need specially designed instruction. Describe other supports the student may need, such as accommodations through a Section 504 Plan or supports through the general education program, if any	A description of the supports the student needs.	N/A
If No, explain why the student requires specially designed instruction and the adaptations to content, methodology or delivery of instruction needed to address the student's disability-related needs. Check "Yes" in #4 below.	A description of why the student requires specially designed instruction.	N/A
4. By reason of the identified disability category(ies) that adversely affects the student's education performance, does the student need specially designed instruction or in the case of a reevaluation, continue to need specially designed instruction?	Indicates the student needs specially designed instruction or continue specially designed instruction. Options include Yes or No.	The values available in this dropdown are hard coded.

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(ER-3) Braille Needs

The Braille Needs editor describes whether the student requires learning assistance through Braille as a result of a visual impairment.

Braille Needs Editor

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Field	Description	Validation
Evaluation of the child's reading and writing skills, needs, and appropriate reading and writing media.	A description of the students reading and writing skills and needs.	N/A
Does the child demonstrate a current need for instruction in Braille or the use of Braille?	Indicates the student demonstrates a need for instruction in Braille. Options include Yes or No.	The values available in this dropdown are hard coded.
If no, why not? *Required	A description of why the student does not require Braille instruction.	*This field becomes available and is required when No is selected from the above dropdown.
Does the child demonstrate a future need for instruction in Braille or the use of Braille?	Indicates the student demonstrates a need for instruction in Braille in the future. Options include Yes, No, or Cannot be determined at this time.	The values available in this dropdown are hard coded.
If cannot be determined, explain. *Required	A description of why the determination cannot be made concerning the student's future Braille needs.	*This field becomes available and is required when Cannot be determined at this time is selected from the above dropdown.
If no, why not? *Required	A description of why the student does not require future Braille instruction.	*This field becomes available and is required when No is selected from the above dropdown.

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(ER-4) No Disability

The No Disability editor is used to document that the student was determined to not have a disability and does not need special education services.

No Disability Editor

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Field	Description	Validation
Date	The date the team met.	N/A
Initial Evaluation: your child does not have a disability (impairment and need for special education).	Indicates the student does not have disability.	Either this or the Reevaluation checkbox can be marked.
Reevaluation: your child no longer has a disability (impairment and need for special education).	Indicates the student no longer has a disability.	Either this or the Initial Evaluation checkbox can be marked.
As a result, special education and related services will no longer be provided to your child as of *Required	Indicates special education and related services will no longer be provided to the student.	*This field is available and required when the Reevaluation checkbox is marked..
Other options, if any, related to the above proposal which were considered and the reason(s) they were rejected, including a description of any other factors relevant to the proposed action include	The other considerations that led to the proposal.	N/A
None	Indicates no other considerations were documented related to the proposal.	When marked, the text area above becomes unavailable.
Contact Name	The name of the special education contact.	This auto-populates from System Administration > Resources > District Information > District > SPED Contact First Name and SPED Contact Last Name, but can be modified.
Contact Phone	The phone number of the special education contact.	This auto-populates from System Administration > Resources > District Information > District > SPED Phone , but can be modified.
Title	The title of the special education contact.	N/A
Alternate Contact Name	The name of the alternate special education contact.	This auto-populates from System Administration > Resources > District Information > District > Alternate SPED Contact First Name and Alternate SPED Contact Last Name, but can be modified.
Alternate Contact Phone	The phone number of the alternate special education contact.	This auto-populates from System Administration > Resources > District Information > District > Alternate SPED Phone, but can be modified.

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(RE-3) Waiver

The Waiver editor is used to document the agreement the IEP team has made to not have a three-year reevaluation for the student.

Waiver Editor

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Field	Description	Validation
Date	The date the team met.	N/A
We agree a reevaluation to determine whether your child continues to be a child with a disability (impairment and a need for special education) and your child's educational needs is not necessary at this time. We base this on the following reason(s)	The reasons the student does not need to be reevaluated.	N/A
Other options, if any, related to the above action which were considered and the reason(s) they were rejected, including a description of any other relevant factors include	The other considerations that led to the decision.	N/A
None	Indicates no other considerations were documented related to the decision.	When marked, the text area above becomes unavailable.
Date Agreed	The date the waiver was agreed upon.	N/A
Agreed Method	The agreed upon method. Options include: Meeting Spoke on the Phone Exchanged Emails Exchanged Text Messages	The values available in this dropdown are hard coded.
Contact Name	The name of the special education contact.	This auto-populates from System Administration > Resources > District Information > District > SPED Contact First Name and SPED Contact Last Name, but can be modified.
Contact Phone	The phone number of the special education contact.	This auto-populates from System Administration > Resources > District Information > District > SPED Phone , but can be modified.
Title	The title of the special education contact.	N/A
Alternate Contact Name	The name of the alternate special education contact.	This auto-populates from System Administration > Resources > District Information > District > Alternate SPED Contact First Name and Alternate SPED Contact Last Name, but can be modified.
Alternate Contact Phone	The phone number of the alternate special education contact.	This auto-populates from System Administration > Resources > District Information > District > Alternate SPED Phone, but can be modified.

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Classic View

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The Eligibility Report is used to document the student's educational needs and the student's determination of eligibility for special education made by the Individual Education Plan (IEP) or Evaluation team.

The current format of this document is the WI Eligibility Report 2022. Evaluation formats are selected in Eval Types.

WI Eligibility Report Editors An evaluation must be created whether or not the student is determined to have a disability. A copy of the evaluation team report, including the documentation of eligibility, is given to the student's parents by the school district.

Eligibility Report Editors

The following table lists the editors available on the student's Eligibility Report, the section(s) of the print format that include the entered information, a description of what the editor is used for and any special considerations and instructions for using the editor.

Editor Name	Printed Document Section	Description	Special Considerations and Instructions
Evaluation Header	Header	The Evaluation Header editor lists general information about the Evaluation.	This editor must be saved before continuing to other parts of the evaluation. Field definitions may vary by district.
Enrollment Information	Enrollment Information	The Enrollment Information editor includes student data entered on the student's Enrollments tool.	Clicking Get Info from Enrollment synchronizes the information in the editor with the student's Enrollments record. Users can select which Enrollment to link the Enrollment Status editor to using the Enrollment dropdown. Disabilities do not display in this editor. However, disabilities print based on the disabilities determined in the Eligibility Determination editor.
Student Demographics	Student Information	The Student Demographics editor includes student data entered in the Demographics tool.	Clicking Refresh Student Information will synchronize the information in the editor with the current information entered on the Demographics, Households, School and Enrollments tools.
Parent/Guardian Demographics	Guardian Information	The Parent/Guardian Demographics editor populates based on established student/guardian relationships created on the student's Relationships tool or indicated by the guardian checkbox on the Households tool. The editor includes Demographics information for the student's guardian.	Clicking Refresh Guardian Information synchronizes information in the editor with the most recent information from the student's guardian's Demographics, Households, and Team Members tool. If the Start Date for the Educational Surrogate Parent on the Team Members tool falls anytime before or on the Eval Start date, the data will pull into the Parent/Guardian Demographics editor. If the Start Date for the Educational Surrogate Parent falls anytime after the Eval Start Date, the data will NOT pull in to the Parent/Guardian Demographics editor.
(I-3) Team Meeting Cover Page	N/A	The Team Meeting Cover Page indicates the reason the evaluation meeting was held, including if the meeting was a result of the student's performance on assessments.	Template Banks are established in System Administration and available by clicking the white paper icon next to the header of the appropriate sections.
(ER-1) Info from Existing Data	Evaluation Report Including: Determination of Eligibility and Need for Special Education	The Info from Existing Data editor reviews existing data from various sources regarding the student academic achievement in reading and other subjects.	If the Waiver option is selected as the Evaluation Type in the Evaluation Header editor, this editor becomes unavailable. This editor does not print in this instance. Template Banks are available by clicking the white paper icon next to the header of the appropriate sections.
(ER-1) Previous Interventions	Information from Review of Existing Data	The Previous Interventions editor records the previous interventions taken for the student and the effect of the intervention on the student's literacy and other areas.	If the Waiver option is selected as the Evaluation Type in the Evaluation Header editor, this editor becomes unavailable. This editor does not print in this instance.
(ER-1) Additional Assessments	Information from Additional Assessments and Other Evaluation Materials	The Additional Assessments editor records the results from additional assessments and other sources relating to the student's academic achievement and functional performance.	If the Waiver option is selected as the Evaluation Type in the Evaluation Header editor, this editor becomes unavailable. This editor does not print in this instance.
(ER-1) Eligibility Determination	Eligibility Checklist	The Eligibility Determination editor provides a collection of checklists for each disability the student is determined to have. Checklists include the considerations and questions to be addressed for each disability.	If the Waiver option is selected as the Evaluation Type in the Evaluation Header editor, this editor becomes unavailable. This editor does not print in this instance.
(ER-1) Need for Specially Designed Instruction	Determination of Eligibility	The Need for Specially Designed Instruction editor lists the determination of the student's disability, the evidence for that decision and whether the student requires special education services as a result.	If the Waiver option is selected as the Evaluation Type in the Evaluation Header editor, this editor becomes unavailable. This editor does not print in this instance. Template Banks are available by clicking the white paper icon next to the header of the appropriate sections.
(ER-3) Braille Needs	Documentation for Determining Braille Needs for Child with a Visual Impairment (ER-3)	The Braille Needs editor describes whether the student requires learning assistance through Braille as a result of a visual impairment.	If the Waiver option is selected as the Evaluation Type in the Evaluation Header editor, this editor becomes unavailable. This editor does not print in this instance. Template Banks are available by clicking the white paper icon next to the header of the appropriate sections.
(ER-4) No Disability	Notice Of IEP Team Findings that Child is not a Child with a Disability	The No Disability editor is used to document that the student was determined to not have a disability and does not need special education services.	This editor does not print if no information is entered. This editor becomes unavailable if the Yes option under Need for Sped Question #4 is selected or if the Waiver option is selected as the Evaluation Type.
(RE-3) Waiver	Notice of Agreement that a Three-Year Reevaluation Not Needed	The Waiver editor is used to document the agreement the IEP team has made to not have a three-year reevaluation for the student.	This editor does not print if no information is entered. This editor only displays when the Waiver option is selected as the Evaluation Type.

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Eligibility Report (Wisconsin) [.2251 - .2303]

Editor Home

General Evaluation Information

Editor Types

Padlock Icon

Template Banks

Editors

Eligibility Report Header

Enrollment Information

Student Information

Parent/Guardian Information

(I-3) Team Meeting Cover Page

Team Meeting List Screen

Team Meeting Detail Screen

(ER-1) Info from Existing Data

(ER-1) Previous Interventions

Previous Interventions List Screen

Previous Interventions Detail Screen

(ER-1) Additional Assessments

(ER-1) Eligibility Determination

Eligibility Determination List Screen

Eligibility Determination Detail Screen

Autism

Blind and Visually Impaired

Deaf and Hard of Hearing

Deafblind

Emotional Behavioral Disability

Intellectual Disability

Orthopedic Impairment

Other Health Impairment

Significant Developmental Delay

Specific Learning Disability - Initial Evaluation

Specific Learning Disability - Re-Evaluation

Specific Learning Disability - Initial Evaluation Using Significant Discrepancy

Speech or Language Impairment

Traumatic Brain Injury

(ER-1) Need for Specially Designed Instruction

(ER-3) Braille Needs

(ER-4) No Disability

(RE-3) Waiver

Classic View

Eligibility Report Editors

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