Evaluation (Kentucky)

Last Modified on 12/16/2024 9:45 am CST

Tool Search: Special Ed Documents

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 KY Evaluation 2023.1 print format. Formats are selected in Eval Types.

Screenshot of the list of editors in the Evaluation. Editor Home

Editor Home

The Editor Home lists the editors available, their status, and Modification and Completion information.

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, and the editor is read-only. This does not lock the editor from further editing but indicates the user considers the editor 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. The following statuses are only available for certain state-specific documents: ESign indicates that the editor has functionality related to the eSignature process. See the following articles for your state's eSignature information: Nevada Plan eSignature Editors Nebraska Plan eSignature Editors Delaware Plan eSignature Editors South Dakota Plan eSignature Editor Complete Pending eSignature indicates the plan has been entered and sent via the Campus Parent portal to the student's guardian for eSignature.
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 Information

The following table lists the actions available for the editors. When resizing the window, certain buttons are condensed into a single Action button.

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 is usually found within the detail screen or 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 Type 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 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 a listing of all the student's applicable enrollment records. See the Enrollments tool documentation for additional information.
Cancel	Navigates the user to the Editor Home screen or the List Screen for List editors.
Status	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. The user must click In Progress to further edit after an editor is marked Complete. Not Needed indicates the editor does not apply to the student's plan or evaluation. This makes the editor read-only. However, this does not lock the editor from further editing. Click the In Progress button to further edit after an editor is marked Not Needed. In Progress only displays when the editor is in the Complete or Not Needed status and allows additional edits to be made. The following status is only available for the Nevada IEP: Complete Pending eSignature only displays for certain editors. This button marks the editor as complete until the parent/guardian electronically signs those plan sections via the Campus Parent Portal. See the Special Ed eSignature Process articles for additional information.
Print	Prints the entire document.
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 is displayed. 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.

Editor Lock Out and Release Logic

Only one user at a time can actively work on an editor. A person with a padlock icon ( Screenshot of the 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.

To release an editor, the user must:

navigate to the next editor by clicking Save and Next or the Editors button and selecting the next editor from the side panel.
click the Cancel button to return to the Editor Home screen.
log out of the Campus application.
navigate to a different tool in the Campus application.

Editors are automatically released when the in-application timeout limit has been exceeded. This is a back-end process and is usually around 30-60 minutes.

Template Banks

Certain fields within several editors have an Add Template icon that displays next to their name. Clicking this button displays a side panel with the available library of predetermined text for that field. Template Banks are managed in System Administration.

Screenshot of the Add Template icon highlighted and the Template Bank side panel displayed on the right. Template Bank Side PanelClick the plus (+) icons next to the category to view the available template values.

Screenshot of an expanded Template Bank Category on the left and several template values selected on the right. Expanded Category and Values SelectedTemplate Bank Categories display on the left and the selected text displays on the right. Click the Add button to add the template value. This adds the template to the queue of values on the right. The red X removes selected templates while the sequence field can be used to reorder the templates. Another option is to use the up and down arrows next to the sequence field to reorder values.

Click Cancel to go back to the document. The Clear Selected Template(s) button removes all selected template values from the right selection screen.

Once selections are finalized, click the Insert Selected Template(s) button to add the values to the field within the document in the selected order. Template values are separated by carriage returns.

Screenshot of an example field with several template bank selections added. Example Template Bank Selections in the Document

Text Editors

Images should not be inserted into text fields.

Editors

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

Evaluation Header

The Evaluation Header includes the dates associated with evaluation of the student, including the date the student was notified, the date of consent for initial evaluation and the date of consent for services.

Screenshot of the Evaluation header editor. Evaluation Header Editor

Click here to expand...

Field	Description	Validation
ARC Date Required	The date the Admissions and Release Committee met.	N/A
Evaluation Type Required	The type of evaluation. Options include: Initial Evaluation Reevaluation Transferred	These options are hard-coded.
Date of Consent/Denial for Services	The date the parent/guardian gave consent/denial for an evaluation.	N/A
Reason for missing 60 day timeline	The reason the 60 day timeline for evaluation was not met. Options include: Timeline met, but consent not signed at meeting Availability of Evaluation Personnel Personnel Training Issue Excessive Student Absenteeism Transfer Student Parental Factors Issues with District Tracking System Difficulty Obtaining External Evaluation Components	These options are hard-coded.

Field	Description	Database Name/Location (when Refresh is clicked)	Validation
Primary Disability, if currently identified	The student's primary disability.	Enrollment > Primary Disability Enrollment.disability1	This field is read-only and is pulled from the student's Enrollment record upon Refresh. Displays None when a disability is not identified.
Grade	The student's current grade.	Enrollment > Grade enrollment.grade	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
School Name	The student's school of attendance.	Learner Planning > Learning Plans > Enrollments > residentSchool enrollment.residentSchool	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
School Phone	The student's school of attendance phone number.	Learner Planning > Learning Plans > School > Phone v_SchoolCurrent.phone	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
District Information
District Number	The district number associated with the Enrolled school.	System Administration > Resources > District Information > State District Number	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
District Name	The district name associated with the Enrolled school.	System Administration > Resources > District Information > Name	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
District Address	The district address associated with the Enrolled school.	System Administration > Resources > District Information > Address	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
District Phone	The district phone number associated with the Enrolled school.	System Administration > Resources > District Information > Phone	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
District SPED Address	The district special education address associated with the Enrolled school.	System Administration > Resources > District Information > SPED Address	This field is read-only and is pulled from the student's Enrollment record upon Refresh.
District SPED Phone	The district special ed phone number associated with the Enrolled school.	System Administration > Resources > District Information > SPED Phone	This field is read-only and is pulled from the student's Enrollment record upon Refresh.

Field	Description	Database/UI Location (when Refresh is clicked)
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
Gender	The student's gender.	Census > People > Demographics > Gender identity.gender
Birthdate	The student's birthdate.	Census > People > Demographics > Birth Date identity.birthDate
Race, Ethnicity	The student's race/ethnicity.	Census > People > Demographics > Race/Ethnicity identity.raceEthnicity
Primary Mode of Communication of Student	The student's language they speak at home. Values available are found in the locked Attribute Dictionary, LanguageList.	Census > People > Demographics > Home Primary Language identity.homePrimaryLanguage
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
Student Number	The student's identification number.	Census > People > Demographics > Student Number
State ID	The student's state identification number.	Census > People > Demographics > State ID
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 > Case Manager Name
Title	The role of the team member.	Student Information > Special Ed > General > Team Members > Case Manager Title
Phone	The phone number of the team member.	Student Information > Special Ed > General > Team Members > Case Manager Work Phone

Field	Description	Database/UI Location (when Refresh is clicked)	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, parent/guardian(s) with a sequence number print in the order defined. Un-sequenced parent/guardians display at the bottom.
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, a drop down with an option to select which address displays. When there is only one address, the dropdown 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.
E-mail	The primary email address for the parent/guardian.	Census > People > Demographics > Email	This field populates from Census.

Column Name	Description
Padlock Icon	The user currently editing the Multi-Disciplinary Report record.
Report Discipline	The area evaluated.
Report Discipline Summary	This displays the first 100 characters of the Report Discipline Summary.

Field Name	Description	Validation
Current Disability	The student's current disability. Options include: Autism Deaf-Blindness Developmental Delay Emotional-Behavioral Disability Functional Mental Disability Hearing Impairment Mild Mental Disability Multiple Disabilities Orthopedic Impairment Other Health Impairment Specific Learning Disability Speech or Language Impairment Traumatic Brain Injury Visual Impairment	The options available are available in a locked Attribute Dictionary, Enrollment > Primary Disability.
If "Multiple Disabilities" is selected, list categories *Required	The student's disabilities, when applicable. Options include: Autism Deaf-blindness Emotional-Behavioral Disability Functional Mental Disability Hearing Impairment Mild Mental Disability Orthopedic Impairment Other Health Impairment Specific Learning Disability Traumatic Brain Injury Visual Impairment	*This field is available and required when Multiple Disabilities is selected above. Once an option is selected, it no longer displays in the dropdown. The options available are available in a locked Attribute Dictionary, Enrollment > Primary Disability. The Multiple Disability, Developmental Delay, and Speech of Language Impairment options do not display.
List Current Disability Area(s) *Required	The options when Developmental Delay is selected include: Cognition Motor development Self-help/adaptive behavior Communication Social-emotional development The options when Specific Learning Disability is selected include: Oral Expression Written Expression Reading Fluency Skills Mathematics Calculation Listening Comprehension Basic Reading Skills Reading Comprehension Mathematics Reasoning The options when Speech or Language Impairment is selected include: Speech Sound Production and Use Language Fluency Voice	*This field is available and required when Developmental Delay, Specific Learning Disability or Speech or Language Impairment is selected from the Current Disability dropdown. Once an option is selected, it no longer displays in the dropdown. The options available are available in a locked Attribute Dictionary, Enrollment > Developmental Delay/Specific Learning Disability/Speech Language.
Current Related Services	The student's current services. Options include: N/A OT PT Speech O & M Special Transportation Other	Multiple options can be selected.
Specify Other *Required	The student's other services.	*This field is available and required when Other is selected above.
Previous Eligibility Determinations
Previous Eligibility Determinations	A description of the student's previous eligibility determination.	N/A
ARC Dates for Eligibility Determination	The ARC dates of the eligibility determination.	N/A
Evaluation/Reevaluation Report in File	Indicates the Evaluation/Reevaluation Report is included in the files. Options are Yes or No.	N/A

Column Name	Description
Padlock Icon	The user currently editing the Review of Records record.
Expand/Collapse	When expanded, associated date, score, and scaled score display.
Assessment Area	The assessment area.

Field	Description	Validation
Assessment Area Required	The assessment area. Options include: Communication Status Academic Performance Health, Vision, Hearing, Motor Abilities Social and Emotional Status General Intelligence Transition Needs Functional Vision/Learning Media Assessment Functional Hearing, Listening and Communication Assessment	Once a user creates a record for an Assessment Area, that option no longer displays in the dropdown. The options available are located in a locked Attribute Dictionary, Evaluation > Assessment Area.
*<Assessment Area>: <Text>* *The card is limited to 8 rows.*
Date	The date of the assessment.	N/A
Test	The test administered.	N/A
Scale	The scale of the test.	This field is limited to 50 characters.
Standard Score	The score of the test.	This field is limited to 50 characters.
Interpretation of Results	A description of the interpretation of the results of the assessment.	N/A

Column Name	Description
Padlock Icon	The person currently working on the Review of Current Performance record.
Documentation	The assessment area.
Additional Assessments	Indicates additional assessments are needed.

Field	Description	Validation
*RR-Review of Current Performance* Directions: Summarize current information about the student's academic and functional performance levels. At least two observations are required for all evaluations. Include information for applicable items listed and any other relevant information.
Documentation Required	The assessment area. Options include: Communication Status Academic Performance Health, Vision, Hearing, Motor Abilities Social and Emotional Status General Intelligence Transition Needs Functional Vision/Learning Media Assessment Functional Hearing, Listening and Communication Assessment	The options available are located in a locked Attribute Dictionary, Evaluation > Assessment Area.
<Documentation Area> Documentation Method *Required	The options available when Communication Status is selected include: IEP Progress Data for each Goal Assistive Technology Augmentative Communication Devices Primary Mode of Communication Observations Other, Specify The options available when Academic Performance is selected include: IEP Progress Data for each Goal Grades (current and previous year) Attendance State Assessment Results District Assessment Results Work Sample Results Effective Accommodations Basic Skills On-Task Behavior Rate of Learning Work Completion Math Computation Math Reasoning Written Language Reading Decoding Reading Comprehension Universal Screening Data Observations Intervention Data School-Bases Assessment Learning Styles Other, Specify The options available when Health, Vision, Hearing, Motor Abilities is selected include: IEP Progress Data for each Goal Current Health Status Medications and Impact Diagnosis Vision Screening Hearing Screening Vision/Hearing Difficulties Gross/Fine Motor Skills Motor Planning Sensory Issues Injuries Mobility Observations Other, Specify The options available when Social and Emotional Status is selected include: IEP Progress Data for each Goal Adaptive Skills Attention, Hyperactivity, Impulsivity Issues Disciplinary Referrals Suspensions Bus/School Peer Interaction Adult Interaction Aggression Self-Control Functional Behavior Assessments Observations Social/Developmental History Update Other, Specify The options available when General Intelligence is selected include: Aptitude Retention of Information (memory) Application of Knowledge Reasoning Skills Generalizes Knowledge Problem Solving Skills Observations Other, Specify The options available when Transition Needs is selected include: IEP Progress Data for each Goal required Individual Learning Plan (ILP) Transition Assessments Learning Styles Community Based Instruction Careers of Interest Work Experience Collaboration with Others Independent Living Home Responsibilities Multi-Year Course of Study required Observations Other, Specify	*This field is available and required when a documentation area is selected for all areas except Functional Vision/Learning Media Assessment and Functional Hearing, Listening and Communication Assessment. The <Documentation Area> name and options available change based on the Documentation option selected. The options available are located in a locked Attribute Dictionary, EvaluatorAssessment > Communication Status/Academic Performance/Health/Social and Emotional Status/General Intelligence/Transition Needs.
Other, Specify *Required	The other documentation method.	*This field is available and required when Other, Specify is selected.
Functional <Name> Assessment	A description of the additional assessment needed.	This field is available when Functional Vision/Learning Media Assessment or Functional Hearing, Listening, & Communication Assessment is selected in the Documentation dropdown. This field's name changes based on the selection made in the Documentation dropdown; Functional Vision/Learning Media Assessment OR Functional Hearing, Listening, & Communication Assessment.
<Label> Provide information if blind or visually impaired Functional Vision/Learning Media Assessment Functional Hearing, Listening, & Communication Assessment <Label> changes based on what option is selected.
Summary	A summary of the review.	N/A
ARC Determined Additional Assessments Required	Indicates additional assessments are necessary. Options are, Are needed or Are not needed.	N/A

Column Name	Description
Padlock Icon	The person currently working on the Eligibility Form record.
Eligible Disability	The student's disability.
Determination	The determination.
ARC Determination	The ARC determination. This field pulls from the field, The ARC used the interpretation of the evaluation data documented above to determine. This displays as one of the following options: Eligible Not Eligible Not Eligible, no impact Insufficient Data

Field	Description	Validation
Autism Eligibility The ARC determines a student to meet the eligibility criteria for autism and is eligible for specially designed instruction and related services when:
1a. The student has a developmental disability, generally evident before age 3, significantly affecting verbal and nonverbal communication.	Indicates the student has a developmental delay impacting verbal and nonverbal communication. Options include: Yes No Insufficient	N/A
1b. The student has a developmental disability affecting social interaction.	Indicates the student has a developmental disability impacting their social interactions. Options include: Yes No Insufficient	N/A
2. The student's deficits are not primarily the result of an emotional- behavioral disability.	Indicates the student's deficits are not the result of an emotional/behavioral disability. Options include: Yes No Insufficient	N/A
3. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
4. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
5. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's autism eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for autism, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for autism and is not eligible for specially designed instruction and related services. The student has autism, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Field	Description	Validation
Deaf-Blindness Eligibility The ARC determines a student to have a disability of deaf-blindness and is eligible for specially designed instruction and related services when:
1a. Student has a Hearing Impairment. Attached Hearing Impairment Eligibility Form	Indicates the student has a hearing impairment. Options are Yes or No.	N/A
1b. Student has a Visual Impairment. Attached Visual Impairment Eligibility Form	Indicates the student has a visual impairment. Options are Yes or No.	N/A
2. The combination of the two impairments causes such severe communication, developmental and educational needs that the student cannot be accommodated in special education programs designed solely for students with visual impairments or hearing impairments, unless supplementary assistance is provided to address educational needs resulting from the two disabilities.	Indicates the combination of the two impairments impacts the student significantly unless supplementary assistance is provided. Options are Yes or No.	N/A
3. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
4. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
5. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's deaf-blindness eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for deaf-blindness, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for deaf-blindness and is not eligible for specially designed instruction and related services. The student has deaf-blindness, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Field	Description	Validation
Developmental Delay Eligibility The ARC determines a student to have a developmental delay and is eligible for specially designed instruction and related services when:
1. Student is three through eight years of age. Note: Eligibility for DD ends on the student's ninth birthday.	Indicates the student is between 3 and 8 years of age. Options are Yes or No.	N/A
*2. Student has not acquired skills or achieved commensurately with recognized performance expectations for his/her age in one or more* of the developmental areas.**	Indicates the student is behind same-age peers in acquired skills and achievement in one or more developmental areas. Options include: Yes No Insufficient	N/A
Developmental Areas	Indicates the area of development the student requires assistance to match the level of same-age peers. Options include: cognition communication motor development social-emotional development self-help/adaptive behavior	N/A
3a. Performance compared/analyzed by ARC	Indicates the ARC analyzed the student's performance. Options include: Yes No Inconclusive	N/A
Student demonstrates a measurable, verifiable difference between expected performance and current level of performance by	Indicates the student demonstrated a verifiable difference between expected and current level of performance. Options include: scores of two standard deviations or more below the mean in one or more of the five (listed above) developmental areas using norm-referenced instruments and procedures; OR scores of 1.5 standard deviations below the mean in two or more of the five developmental areas (listed above) using norm-referenced instruments and procedures	Users can either select an option from these two checkboxes OR one of the 3b options.
3b. If 3a is marked inconclusive, the professional judgement of the ARC verifies the existence of significant atypical quality or pattern of development.	Indicates the ARC verifies the existence of significant atypical quality or pattern of development. Options include: Yes No NA	N/A
4. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
5. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
6. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's developmental delay eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for developmental delay, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for developmental delay and is not eligible for specially designed instruction and related services. The student has developmental delay, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Field	Description	Validation
Emotional-Behavioral Disability Eligibility The ARC determines a student to have an emotional-behavioral disability and is eligible for specially designed instruction and related services when:
Social-emotional needs have been compared/analyzed by ARC	Indicates the ARC analyzed the student's social-emotional needs. Options include: Yes No Insufficient	N/A
When provided with interventions to meet instructional and social-emotional needs, the student continues to exhibit one or more of the following, when compared to the student's peer and cultural reference groups, across settings, over a long period of time and to a marked degree	Indicates the student continues to display one of the following with intervention. Options include: Severe deficits exist in social competence or appropriate behavior which causes an inability to build or maintain satisfactory interpersonal relationships with adults or peers. Severe deficits exist in academic performance which are not commensurate with the student's ability level and are not solely a result of intellectual, sensory, or other health factors but are related to the student's social-emotional problems. The student exhibits a general pervasive mood of unhappiness or depression. The student exhibits a tendency to develop physical symptoms or fears associated with personal or school problems.	N/A
2. The severe deficit in social competence, appropriate behavior and academic performance is not the result of isolated inappropriate behaviors that are the result of willful, intentional or wanton acts.	Indicates the social/behavior/academic performance is not the result of isolated inappropriate intentional behaviors. Options include: Yes No Insufficient	N/A
3. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
4. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
5. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's emotional-behavioral disability eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for an emotional-behavioral disability, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for an emotional-behavioral disability and is not eligible for specially designed instruction and related services. The student has an emotional-behavioral disability, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Field	Description	Validation
Functional Mental Disability Eligibility The ARC determines a student to have a functional mental disability and is eligible for specially designed instruction and related services when:
1a. Cognitive functioning is at least three standard deviations below the mean.	Indicates the student's cognitive functioning is at least three levels below the mean. Options are Yes or No.	N/A
1b. Adaptive behavior is at least three standard deviations below the mean.	Indicates the student's adaptive behavior is at least three levels below mean. Options are Yes or No.	N/A
1c. A severe deficit exists in overall academic performance including acquisition, retention and application of knowledge.	Indicates a severe deficit exists in the student's overall academic performance. Options include: Yes No Insufficient	N/A
1d. Manifestation is typically during the developmental period.	Indicates the manifestation of the deficit is during the student's developmental period. Options are Yes or No.	N/A
2. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
3. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
4. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's autism eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for a functional mental disability, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for a functional mental disability and is not eligible for specially designed instruction and related services. The student has a functional mental disability, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Field	Description	Validation
Hearing Impairment Eligibility The ARC determines a student to have a hearing impairment and is eligible for specially designed instruction and related services when:
1. The student has a hearing loss that may be mild to profound, unilateral or bilateral, or permanent or fluctuating.	Indicates the ARC analyzed the student's hearing loss information. Options are Yes or No.	N/A
2. The hearing loss results in difficulty in identifying linguistic information through hearing.	Indicates the student's hearing loss results in difficulty in identifying linguistic information through hearing. Options include: Yes No Insufficient	N/A
3. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
4. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
5. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's hearing impairment eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for a hearing impairment, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for a hearing impairment and is not eligible for specially designed instruction and related services. The student has a hearing impairment, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Field	Description	Validation
Mild Mental Disability Eligibility The ARC determines a student to have a mild mental disability and is eligible for specially designed instruction and related services when:
1a. Cognitive functioning is at least two standard deviations, but not more than three standard deviations below the mean.	Indicates the student's cognitive functioning is a least two levels, but no more than three levels below the mean. Options are Yes or No.	N/A
1b. Adaptive behavior is at least two standard deviations below the mean.	Indicates the student's adaptive behavior is a least two levels, but no more than three levels below the mean. Options are Yes or No.	N/A
1c. Severe deficit exists in overall academic performance including acquisition, retention and application of knowledge.	Indicates the student has severe deficits in their overall academic performance. Options are Yes or No.	N/A
1d. Manifestation is typically during the developmental period.	Indicates manifestation of the mild mental disability is typical during the student's developmental period. Options are Yes or No.	N/A
2. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
3. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
4. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's mild mental disability eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for a mild mental disability, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for a mild mental disability and is not eligible for specially designed instruction and related services. The student has a mild mental disability, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Field	Description	Validation
Multiple Disabilities Eligibility The ARC determines a student to have multiple disabilities and is eligible for specially designed instruction and related services when:
1a. Disabilities compared/analyzed by ARC	Indicates the ARC analyzed the student's disabilities data. Options are Yes or No.	N/A
The student has a combination of two or more of the following disabilities	Indicates which of the following combination of disabilities the student experiences. Options include: autism deaf-blindness emotional-behavioral disability functional mental disability hearing impairment mild mental disability orthopedic impairment other health impairment specific learning disability traumatic brain injury visual impairment	N/A
1b. The student's disability is not solely a combination of deafness and blindness.	Indicates the student's disability is not a combination of deaf/blindness. Options are Yes or No.	N/A
1c. The student's disability is not a combination of speech or language impairment and one other disabling condition.	Indicates the student's disability is not a combination of speech/language impairment and one other condition. Options are Yes or No.	N/A
1d. The combination of these disabilities causes such severe educational needs that they cannot be accommodated through special education programs solely for one impairment.	Indicates the combination of disabilities impacts the student severely where accommodation through special education for one impairment does not suffice. Options include: Yes No Insufficient	N/A
2. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
3. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
4. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's multiple disabilities eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for multiple disabilities, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for multiple disabilities and is not eligible for specially designed instruction and related services. The student has multiple disabilities, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Field	Description	Validation
Orthopedic Impairment Eligibility The ARC determines a student to have an orthopedic impairment and is eligible for specially designed instruction and related services when:
1. Orthopedic Impairment existence and causes compared/analyzed by ARC	Indicates the ARC analyzed the student's orthopedic impairment data. Options are Yes or No.	N/A
A severe orthopedic impairment exists and is caused by one or more of the following	Indicates an orthopedic impairment exists and is caused by one or more of the following. Options include: 1a. congenital anomaly such as clubfoot or absence of some member 1b. disease such as poliomyelitis or bone tuberculosis 1c. other causes such as cerebral palsy, amputations, fractures or burns that cause contractures	N/A
2. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
3. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
4. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's autism eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for an orthopedic impairment, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for an orthopedic impairment and is not eligible for specially designed instruction and related services. The student has an orthopedic impairment, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Field	Description	Validation
Other Health Impairment Eligibility The ARC determines a student to have an other health impairment and is eligible for specially designed instruction and related services when:
1a. The existence of a health impairment caused by chronic or acute health problems such as acquired immune deficiency syndrome, asthma, attention deficit disorder, attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, sickle cell anemia, Tourette's syndrome or tuberculosis.	Indicates the ARC determined the student has a health impairment caused by chronic or acute health problems. Options are Yes or No.	N/A
The other health impairment is	A description of the student's medical condition.	N/A
1b. Health problem limitations compared/analyzed by ARC	Indicates the ARC analyzed the health problem limitations. Options are Yes or No.	N/A
Due to the chronic or acute health problem, the student has limited	Based on the student' medical condition, the student is limited in the following areas. Options include: strength vitality alertness (including heightened alertness to environmental stimuli that results in limited alertness with respect to the educational environment)	N/A
2. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
3. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
4. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's other health impairment eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for an other health impairment, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for an other health impairment and is not eligible for specially designed instruction and related services. The student has an other health impairment, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Evaluation (Kentucky)

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Eligibility Form

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Autism Eligibility

Deaf-Blindness Eligibility

Developmental Delay Eligibility

Emotional-Behavioral Disability Eligibility

Functional Mental Disability Eligibility

Hearing Impairment Eligibility

Mild Mental Disability Eligibility

Multiple Disabilities Eligibility

Orthopedic Impairment Eligibility

Other Health Impairment Eligibility

Specific Learning Disability Eligibility

Speech or Language Impairment Eligibility

Traumatic Brain Injury Eligibility

Visual Impairment Eligibility

Eligibility Determination

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Field	Description	Validation
Specific Learning Disability Eligibility The ARC determines a student to have a specific learning disability and is eligible for specially designed instruction and related services when:
1. The student is provided with learning experiences and instruction appropriate for the student's age or state-approved grade level standards.	Indicates the student is provided with learning experiences/instruction appropriate for age and state-approved grade level standards. Options include: Yes No Insufficient	N/A
2. Method A or B compared/analyzed by ARC	Indicates the ARC analyzed method A or B data. Options are Yes or No.	N/A
Methods	The method of data. Options include: Method A: Severe Discrepancy. The student exhibits a pattern of strengths and weaknesses in performance, achievement or both relative to ability level or intellectual development. Note: The ARC must use the SLD Reference Tables when choosing this method. OR Method B: Response to Intervention. The student fails to achieve a rate of learning to make sufficient progress to meet grade level standards aligned with the Kentucky Academic Standards (KAS) in one or more of the areas identified below when assessed using a response to scientific, research-based intervention process.	Only one option can be selected.
3. Student Achievement compared/analyzed by ARC	Indicates the ARC analyzed student achievement data. Options include: Yes No Insufficient	N/A
The student does not achieve adequately, as indicated on multiple data sources, for the student's age or grade level standards aligned with KAS in one or more of the following areas	Indicates the student does not achieve adequately in one or more of the following areas. Options include: oral expression listening comprehension written expression basic reading skills reading fluency skills reading comprehension mathematics calculation mathematics reasoning	N/A
4. The deficits in achievement are not primarily the result of any of the following: visual, hearing, or motor impairment, mental disability, emotional-behavioral disability, cultural factors, environmental or economic disadvantage or limited English proficiency.	Indicates the deficits in achievement are not the result of the listed disabilities. Options include: Yes No Insufficient	N/A
5. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
6. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
7a. The following relevant behavior was noted during the observations of the student	A description of the student noted behavior during observation.	N/A
7b. What is the ARC's interpretation of the relationship of the observed behavior (7a) to the student's educational functioning?	A description of the ARC's interpretation of the relationship between the observed behavior to the student's academic performance.	N/A
8. Educationally relevant medical findings, if any	A description of any applicable medical findings.	N/A
9. Document the instructional strategies implemented and the student-centered data collected based on the student's response to scientific, research-based intervention.	A description of the instructional strategies implemented.	N/A
10a. The student's parents have been notified of the policies regarding	Indicates the student's parent(s)/guardian(s) have been notified of policies. Options include: amount and nature of the student performance data that is collected and the general education services that are provided strategies for increasing the student's rate of learning parent's right to request an evaluation	N/A
10b. Describe how the information above was provided to the parent.	A description of how the parent(s)/guardian(s) were notified.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's specific learning disability eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for a specific learning disability, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for a specific learning disability and is not eligible for specially designed instruction and related services. The student has a specific learning disability, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.
Admission and Release Committee Members All ARC members shall certify with their signature below whether the report reflects each members conclusion. A member who disagrees shall submit a separate statement explaining the member's conclusion. Each differing conclusion must be attached (associated in Infinite Campus) to the Eligibility Determination Form and Written Report.
Name	The name of the ARC member.	N/A
Role	The role of the ARC member	N/A
Conclusion	The ARC member's conclusion. Options are Agree or Disagree.	N/A

Field	Description	Validation
Speech or Language Impairment Eligibility This form documents the student's eligibility for SLI as a disability category only. This form is not required for speech or language as a related service. The ARC determines a student to have a speech or language impairment and is eligible for specially designed instruction and related services when:
Communication disorder areas compared/analyzed by ARC	Indicates the ARC analyzed communication disorder data. Options are Yes or No	N/A
Communication disorder in one or more of the following	The type of communication disorder. Options include: absence of language delayed acquisition of language impaired articulation language impairment stuttering voice impairment	N/A
2. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
3. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
4. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's speech or language impairment eligibility status.	Note: The guidelines in the Kentucky Eligibility Guidelines - Revised for Students with Speech Language Impairment, 2009* may be used as supporting evidence to verify speech language impairment.
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for a speech or language impairment, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for a speech or language impairment and is not eligible for specially designed instruction and related services. The student has a speech or language impairment, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Field	Description	Validation
Traumatic Brain Injury Eligibility The ARC determines a student to have a traumatic brain injury and is eligible for specially designed instruction and related services when:
1a. Evaluation information collected across multiple settings verifies an acquired injury to the brain caused by external physical force, resulting in total or partial functional disability or psychosocial impairment or both. This is not a congenital, degenerative, or brain injury induced by birth trauma.	Indicates the student acquired a severe injury to the brain resulting in a total or partial disability and/or psychosocial impairment. Options are Yes or No.	N/A
Traumatic brain injury is evidenced by information that indicates an open or closed head injury resulted in an impairment in one or more of the following areas	The are in which the impairment impacts. Options include: cognition judgement language problem-solving memory sensory, perceptual and motor abilities attention reasoning psychosocial behavior physical functions abstract thinking information processing speech	N/A
1b. The extent of the brain injury is compared/analyzed by ARC	Indicates the ARC analyzed the extent of the brain injury data. Options are Yes or No.	N/A
The extent of the brain injury is	A description of the extent of the injury.	N/A
2. Evaluation information confirms there is an adverse effect on educational performance.	Indicates there is an adverse impact on the student's educational performance. Options are Yes or No.	N/A
3. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
4. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's traumatic brain injury eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for a traumatic brain injury, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for a traumatic brain injury and is not eligible for specially designed instruction and related services. The student has a traumatic brain injury, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Field	Description	Validation
Visual Impairment Eligibility The ARC determines a student to have a visual impairment and is eligible for specially designed instruction and related services when:
1. There is documentation of a visual impairment/loss and the child demonstrates the characteristics of blindness or visual impairment/loss (which includes both partial sight and blindness).	Indicates the student has a documented visual impairment. Options are Yes or No.	N/A
2. Evaluation information confirms, even with correction, there is an adverse effect on educational performance.	Indicates the evaluation confirms the adverse impact of the visual impairment on the student's educational performance. Options are Yes or No.	N/A
3. Evaluation information confirms lack of instruction in reading and math is not a determinant factor in the eligibility decision.	Indicates a lack of instruction in reading/math is not a determinant factor on the eligibility decision. Options are Yes or No.	N/A
4. Evaluation information confirms limited English proficiency is not a determinant factor in the eligibility decision.	Indicates limited English proficiency is not a determinant factor in the eligibility decision. Options are Yes or No.	N/A
Provide supporting documentation that demonstrates the ARC: Used multiple sources to triangulate the data and substantiate the existence of the disability; and Confirmed progress of the student is impeded by the disability to extend the student's educational performance is significantly and consistently below the level of similar age peers.
Supporting Documentation	A text field used to describe the supporting documentation used to determine the student's visual impairment eligibility status.	N/A
The ARC used the interpretation of the evaluation data documented above to determine *Required	The ARC's determination. Options include: The student meets the eligibility criteria for a visual impairment, which adversely impacts her/her education, and is eligible for specially designed instruction and related services. The student does not meet the eligibility criteria for a visual impairment impairment and is not eligible for specially designed instruction and related services. The student has a visual impairment impairment, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services. Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained in the area(s) of:	*This field is required in order to Complete the editor. Only one option can be selected.
Specify Additional Assessments and Data *Required	A description of the additional assessments and data used to make the determination.	*This field is available and required when Evaluation Data are insufficient...." is selected above.
Date ARC will reconvene to review and determine eligibility *Required	The date the ARC plans to meet again to review and determine the student's eligibility.	*This field is available and required when "Evaluation Data are insufficient...." is selected.

Field	Description	Validation
*Eligibility Determination* Document the ARC decision regarding the determination of the student's eligibility for special education and related services and reasons for the decision on the appropriate Eligibility Determination form(s). (Note: For Multiple Disabilities, complete a separate form for each underlying disability category.)
Date of Eligibility Determination Required	The date of determination.	N/A
Student does not have an educational disability requiring special education and related services	Indicates the student does have a disability that required special ed or related services.	*Users must select this field or a Primary Disability.
Primary Disability *Required	The student's primary disability. Options include: Autism Deaf-Blindness Developmental Delay Emotional-Behavioral Disability Functional Mental Disability Hearing Impairment Mild Mental Disability Multiple Disabilities Orthopedic Impairment Other Health Impairment Specific Learning Disability Speech or Language Impairment Traumatic Brain Injury Visual Impairment	*Users must select either a Primary Disability or the checkbox indicating they do not have a disability. The Primary Disability auto-populates when there is an existing, locked Evaluation upon initial creation of the Evaluation. The options available in the dropdown are located in a locked Attribute Dictionary, Enrollment > Primary Disability.
List Current Disability Area(s) *Required	When Developmental Delay is selected, the options available include: Cognition Motor development Self-help/adaptive behavior Communication Social-emotional development When Specific Learning Disability is selected, the options available include: Oral Expression Written Expression Reading Fluency Skills Mathematics Calculation Listening Comprehension Basic Reading Skills Reading Comprehension Mathematics Reasoning When Speech or Language Impairment is selected, the options available include: Speech Sound Production and Use Language Fluency Voice	*This field is available and required when Developmental Delay, Specific Learning Disability or Speech or Language Impairment are selected as the Primary Disability. The options available are located in a locked Attribute Dictionary, Evaluation > Speech Language/Developmental Delay/Specific Learning Disability.
*For students identified as Multiple Disabilities document the underlying disabilities below:*
Underlying Disability (A) *Required	The first underlying disability. Options include: Autism Deaf-Blindness Emotional-Behavioral Disability Functional Mental Disability Hearing Impairment Mild Mental Disability Orthopedic Impairment Other Health Impairment Specific Learning Disability Traumatic Brain Injury Visual Impairment	*When Multiple Disabilities is selected as Primary Disability, Underlying Disability A and B are required. The options available in the dropdown are located in a locked Attribute Dictionary, Enrollment > Primary Disability (excluding Multiple Disability, Developmental Delay, and Speech or Language Impairment).
Underlying Disability (B) *Required	The second underlying disability. Options include: Autism Deaf-Blindness Emotional-Behavioral Disability Functional Mental Disability Hearing Impairment Mild Mental Disability Orthopedic Impairment Other Health Impairment Specific Learning Disability Traumatic Brain Injury Visual Impairment	*When Multiple Disabilities is selected as Primary Disability, Underlying Disability A and B are required. The options available in the dropdown are located in a locked Attribute Dictionary, Enrollment > Primary Disability (excluding Multiple Disability, Developmental Delay, and Speech or Language Impairment).
Underlying Disability (C)	The third underlying disability. Options include: Autism Deaf-Blindness Emotional-Behavioral Disability Functional Mental Disability Hearing Impairment Mild Mental Disability Orthopedic Impairment Other Health Impairment Specific Learning Disability Traumatic Brain Injury Visual Impairment	The options available in the dropdown are located in a locked Attribute Dictionary, Enrollment > Primary Disability (excluding Multiple Disability, Developmental Delay, and Speech or Language Impairment).
Underlying Disability (D)	The fourth underlying disability. Options include: Autism Deaf-Blindness Emotional-Behavioral Disability Functional Mental Disability Hearing Impairment Mild Mental Disability Orthopedic Impairment Other Health Impairment Specific Learning Disability Traumatic Brain Injury Visual Impairment	The options available in the dropdown are located in a locked Attribute Dictionary, Enrollment > Primary Disability (excluding Multiple Disability, Developmental Delay, and Speech or Language Impairment).