Evaluation (South Dakota)

Tool Search: Special Ed Documents

Evaluations document the student's educational needs and determine eligibility for special education. This document describes each editor, each field on the editor, 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. The school district gives a copy of the evaluation summary report, including the documentation of eligibility, to the student’s parents.

This document's current format is the SD ESR 2024. Evaluation formats are selected in the Special Ed Eval Types tool.

Screenshot of the Editor Home Screen.Editor Home Screen

Editor Home

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

HeaderDescription
NameThe 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:

Modified ByThe date and the user by whom the editor was last edited.
Completed ByThe 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. 

ButtonDescription
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.

CancelNavigates 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.

EditorsOpens 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.
PreviousNavigates the user to the previous editor.
NextNavigates 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. 

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Editors

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

Evaluation Information

The Evaluation Information editor defines the Evaluation type and corresponding dates.

This editor must be saved before entering data into other editors.

Screenshot of the Evaluation Information Editor.Evaluation Information Editor
Field Description
Evaluation Type
Required
The type of evaluation. Options include:
  • Initial
  • Reevaluation
Evaluation Date
Required
The day of the evaluation meeting.
Consent Date
Required
The day the school received consent from the student's parent/guardian(s) to evaluate their student.

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Student Information

The Student Information editor pulls demographic information regarding the student. This is a read-only editor.

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

Screenshot of the Student Information Editor.Student Information Editor

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Field Name

Description Database and UI Location (when Refreshed is clicked)

Last Name

The student's last name.

 Demographics > Last Name


identity.lastName

First Name The student's first name. Demographics > First Name

identity.firstName
Middle Name The student's middle name. Demographics > Middle Name

identity.middleName
Suffix The student's suffix.  Demographics > Suffix Name

identity.suffix
Birthdate The student's birthdate. Demographics > Birth Date

identity.birthDate
Address The student's address. Households > Address Info

address.number; address.street; address.tag; address.prefix; address.dir; address.apt; address.city; address.state; address.zip
SIMS ID The student's ID number. Enrollment > Student State ID

identity.studentNumber
Case Manager Information
Name The first and last name of the team member. Student Information > Special Ed Team Members
Title The role of the team member. Student Information > Special Ed Team Members
Phone The phone number of the team member. Student Information > Special Ed Team Members

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Enrollment Information

The Enrollment Information editor is a read-only editor that pulls in district and school information where the student is enrolled. 

Screenshot of the Enrollment Information Editor.Enrollment Information Editor

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Field Description Validation
School of Attendance The school where the student attends. Upon Refresh, this field is pulled from the Enrollment tool and cannot be modified.
Grade The student's grade.

Upon Refresh, this field is pulled from the Enrollment tool and cannot be modified.


Database Location: enrollment.grade

District Information
District Number The district number associated with the Enrolled school. District Information > State District Number
District Name The district name associated with the Enrolled school. District Information > Name
District Address The district address associated with the Enrolled school. District Information > Address
District Phone The district phone number associated with the Enrolled school. District Information > Phone
District SPED Address The district special education address associated with the Enrolled school. District Information > SPED Address
District SPED Phone The district special ed phone number associated with the Enrolled school. District Information > SPED Phone

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Parent/Guardian Information

The Parent/Guardian Information editor populates based on the guardian checkbox on the student's Relationships tool. It includes Demographic 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.

Screenshot of the Parent/Guardian Information Editor.Parent/Guardian Information Editor

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Field Description
Print Sequence The order in which the parent/guardian displays.
Name The name of the parent/guardian.
Address The address of the parent/guardian.
Home Phone The parent/guardian's home phone.
Work Phone The parent/guardian's work phone.
Cell Phone The parent/guardian's cell phone.
Email The parent/guardian's email.
Home Primary Language The language the parent/guardian speaks at home.

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Background Information

The Background Information editor documents any background information pertinent to the student and their evaluation. The only field on this editor is Background Information. This field is limited to 8000 characters.

Screenshot of the Background Information Editor.Background Information Editor

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Review of Existing Data

The Review of Existing Data editor documents existing data pertaining to the student's disability before this evaluation was conducted. The only field on this editor is the Data Review field. This field is required and limited to 8000 characters.

Screenshot of the review of existing data editor.Review of Existing Data Editor

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Review of Existing Data, Current Assessments Results

The Review of Existing Data, Current Assessment Results editor documents the areas in which the student was assessed during the evaluation process and the results of those assessments.

Screenshot of the Review of Existing Data, Current Assessments Results List Screen.Review of Existing Data, Current Assessments Results List Screen

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Review of Existing Data, Current Assessments Results List Screen

Column Name Description
Padlock Icon The user currently editing the record.
Area Assessed The area assessed.
Assessments Results The first 100 characters of the results of the assessment description.

Review of Existing Data, Current Assessments Results Detail Screen

Select an existing record or click New to open the detail screen.

Screenshot of the Review of Existing Data, Current Assessments Results Detail Screen.Review of Existing Data, Current Assessments Results Detail Screen
Field Name Description Validation
Area Assessed
Required
The area assessed. Click the Click to expand link to view available options.
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  • Ability
  • Academic Achievement
  • Observation
  • Adaptive Behavior
  • Language
  • Articulation
  • Fluency
  • Social Communication
  • Behavior
  • Functional Behavior Assessment
  • Social/Emotional
  • Autism Specific Instrument
  • Fine Motor
  • Sensory
  • Gross Motor
  • Visual Motor
  • Developmental Delay Areas
  • Chronic/Acute Health (diagnosis)
  • Audiological (hearing)
  • Ophthalmological (Vision)
  • Medical Data for Orthopedic Impairment
  • Transition
  • Other

N/A
Date Assessment Given
Required
The day the assessment was administered.N/A
Specify Other
*Required
The other area assessed.This field is available and required when Other is selected as the Area Assessed.
Name of Area Assessed
Required
A description of the results of the assessment. The name of this field changes to the value selected in the Area Assessed dropdown.

The Template Bank associated with this field is SD Eval Assessment Areas.

This field is limited to 8000 characters.

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Interpretation and Summary of Results

The Interpretive and Summary of Results editor documents the team's interpretation of the evaluation and the assessment results. The only field on this editor is "List adverse effects of the disability on the student's educational performance." This field is required and limited to 8000 characters. The Template Bank associated with this field is SD Eval Interpretation.

Screenshot of the Interpretation and Summary of Results Editor.Interpretation and Summary of Results Editor

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Assessment Information

The Assessment Information editor documents the student's suspected disabilities, and the data sources used to make the determination.

Screenshot of the Determination of Eligibility/Continued Eligibility Editor.Determination of Eligibility/Continued Eligibility Editor

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FieldDescription
Type of Eligibility DeterminationThe type of eligibility determination. Options include:
  • Initial Determination of Eligibility
  • Re-determination of Eligibility
Summary of Evaluation Reports Used for Determination of Eligibility

Columns in this table include:

  • Data Source
  • Date Administered
  • Test Scores/Results
  • Evaluator

See the Evaluations Administered Side Panel section for information about entering data into this table.

Suspected DisabilitiesThe student's suspected disabilities. Multiple options may be selected. Options include:
  • 500 - Deaf Blindness
  • 505 - Emotional Disability
  • 510 - Cognitive Disability
  • 515 - Hearing Loss
  • 525 - Specific Learning Disability
  • Multiple Disabilities
  • 535 - Orthopedic Impairment
  • 540 - Vision Loss
  • 545 - Deafness
  • 550 - Speech/Language Impairment
  • 555 - Other Heath Impaired
  • 560 - Autism Spectrum Disorder
  • 565 - Traumatic Brain Injury
  • 570 - Developmental Delay
Other Factors Considered
Is the underachievement of the student due to lack of instruction in Reading or Math or limited English Proficiency?
Reading Indicates the underachievement of the student is due to a lack of instruction in reading. Options are Yes or No.
Math Indicates the underachievement of the student is due to a lack of instruction in math. Options are Yes or No.
Limited English Proficiency Indicates the underachievement of the student is due to a lack of instruction in limited English Profieciency. Options are Yes or No.
Eligibility Determination
Student has a diagnosed disability Indicates the student has a diagnosed disability. Options are Yes or No.
The disability adversely affects the student's educational performance Indicates the student's disability impacts their educational performance. Options are Yes or No.
List the adverse effects of the disability on the student's educational performance
*Required
A description of the adverse effects of the student's disability on their education.

*This field is available and required when Yes is selected from the "The disability adversely affects the student's educational performance" field.

This field is limited to 8000 characters.
The student required specially designed instruction to receive a free appropriate public education Indicates the student requires specially designed instruction for their education. Options are Yes or No.
The team determined this student meets eligibility criteria under the following category The disability the student has determined by the team. Options include:
  • 500 - Deaf Blindness
  • 505 - Emotional Disability
  • 510 - Cognitive Disability
  • 515 - Hearing Loss
  • 525 - Specific Learning Disability
  • 535 - Orthopedic Impairment
  • 540 - Vision Loss
  • 545 - Deafness
  • 550 - Speech/Language Impairment
  • 555 - Other Heath Impaired
  • 560 - Autism Spectrum Disorder
  • 565 - Traumatic Brain Injury
  • 570 - Developmental Delay
Multiple Disabilities - 530
Category 1 The first disability the student has when they have multiple disabilities. Options include:
  • 500 - Deaf Blindness
  • 505 - Emotional Disability
  • 510 - Cognitive Disability
  • 515 - Hearing Loss
  • 525 - Specific Learning Disability
  • 535 - Orthopedic Impairment
  • 540 - Vision Loss
  • 545 - Deafness
  • 550 - Speech/Language Impairment
  • 555 - Other Heath Impaired
  • 560 - Autism Spectrum Disorder
  • 565 - Traumatic Brain Injury
  • 570 - Developmental Delay
Category 2 The second disability the student has when they have multiple disabilities. Options include:
  • 500 - Deaf Blindness
  • 505 - Emotional Disability
  • 510 - Cognitive Disability
  • 515 - Hearing Loss
  • 525 - Specific Learning Disability
  • 535 - Orthopedic Impairment
  • 540 - Vision Loss
  • 545 - Deafness
  • 550 - Speech/Language Impairment
  • 555 - Other Heath Impaired
  • 560 - Autism Spectrum Disorder
  • 565 - Traumatic Brain Injury
  • 570 - Developmental Delay
Category 3 The third disability the student has when they have multiple disabilities. Options include:
  • 500 - Deaf Blindness
  • 505 - Emotional Disability
  • 510 - Cognitive Disability
  • 515 - Hearing Loss
  • 525 - Specific Learning Disability
  • 535 - Orthopedic Impairment
  • 540 - Vision Loss
  • 545 - Deafness
  • 550 - Speech/Language Impairment
  • 555 - Other Heath Impaired
  • 560 - Autism Spectrum Disorder
  • 565 - Traumatic Brain Injury
  • 570 - Developmental Delay
Related Service(s): Student therapy needs to be determined during IEP program development ARSD 24:05:27:22, 24:05:27:23, 24:05:27:24, 24:05:27:25, and 24:05:27:16
Criteria for Occupational Therapy Services
1. The student has a disability and requires special education Indicates the student requires special education for occupational therapy services. Options are Yes or No.
2. The student must demonstrate performance on a standardized assessment instrument that falls at least 1.5 standard deviations below the mean in one or more of the following areas: fine motor, sensory integration or visual Indicates the student's performance falls at least 1.5 standard deviations below the mean for occupational skills. Options are Yes or No.
Criteria for Physical Therapy Services
1. The student has a disability and requires special education Indicates the student requires special education for physical therapy services. Options are Yes or No.
2. The student must demonstrate performance on a standardized assessment instrument that falls at least 1.5 standard deviations below the mean on a standardized motor assessment instrument Indicates the student's performance falls at least 1.5 standard deviations below the mean for physical skills. Options are Yes or No.
Speech-Language Pathology
1. The student has a disability and requires special education Indicates the student requires special education for speech-language pathology services. Options are Yes or No.
Transition: For student that are eligible for special education services, transition must be in effect no later than age 16 ARSD 24:05:27:13.02 and 24:05:27:01.03
1. The student has a disability and requires special education Indicates the student requires transition services. Options are Yes or No.

Evaluations Administered Side Panel

Select an existing record or click New to open the Evaluations Administered side panel. The editor must be saved before records can be entered into this table.

Field Description Image
Click to enlarge
Data Source
Required
The source of data.

This field is limited to 300 characters.
Evaluations Administered Side Panel
Date Administered
Required
The day the data source was captured.
Test Scores/Results
Required
The results or score of the assessment.

This field is limited to 300 characters.
Evaluator
*Required
The person/agency who administered the data source.

This field pulls in evaluators entered using the Special Ed Evaluator Setup tool.

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Eligibility Determination

The Eligibility Determination editor documents the team's decision about whether the student meets the criteria for their suspected disabilities. Depending on which disability is selected, the editor's fields change. 

Screenshot of the Eligibility Determination List Screen.Eligibility Determination List Screen

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Eligibility Determination List Screen

Column NameDescription
Padlock IconThe user currently editing the record.
Date CompletedThe day the checklist was determined.
ChecklistThe disability.
Meets CriteriaAn indication that the student meets the criteria for the disability.

Eligibility Determination Detail Screen

Select an existing record or click New to open the detail screen. The Detail Screen changes depending on the disability selected in the Eligibility Checklist field. 

Screenshot of the Eligibility Determination Detail Screen.Eligibility Determination Detail Screen
FieldDescriptionValidation
Eligibility Checklist
Required

The student's disability. Options include:

Once a record is created with one of the listed disabilities, that option is removed from the dropdown.
The Eligibility team determined that the student meets criteria under the category of "Disability Selected"Options are Yes or No.N/A
Date Completed
Required
The day the determination was made.N/A

Autism Spectrum Disorder

FieldDescription
2a. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all three of the following, currently or by history
Deficits in social-emotional reciprocityOptions are Yes or No.
Deficits in non-verbal communicative behaviors used for social interactionOptions are Yes or No.
Deficits in developing, maintaining and understanding relationshipsOptions are Yes or No.
Social Communication Severity

Options include:

  • Level 3 - Requiring very substantial support
  • Level 2 - Requiring substantial support
  • Level 1 - Requiring Support
2b. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history

Stereotyped or repetitive motor movements, use of objects, or speech

Options are Yes or No.
Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behaviorOptions are Yes or No.
Highly restricted, fixated interests that are abnormal in intensity or focusOptions are Yes or No.
Hyper-or hypoactivity to sensory input or unusual interest in sensory aspects of the environmentOptions are Yes or No.
Restricted, Repetitive Behavior SeverityOptions include:
  • Level 3 - Requiring very substantial support
  • Level 2 - Requiring substantial support
  • Level 1 - Requiring Support
2c. And all of the characteristics below
Symptoms must be present in the early developmental period but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life; andOptions are Yes or No.
Symptoms cause clinically significant impairment in social, occupational or other important areas of current functioning; andOptions are Yes or No.
Symptoms are not primarily caused by a cognitive disability or developmental delay, and in order to make dual diagnoses of autism spectrum disorder and cognitive disability, social communication must be below that expected for the general developmental levelOptions are Yes or No.

Cognitive Disability

Students must meet both criteria below to qualify for cognitive disability.

FieldDescription
General intellectual functioning 2 standard deviations or more below the mean as determined by the full-scale score on an individual cognitive evaluation, plus or minus standard error or measurementOptions are Yes or No.
Exhibits deficits in adaptive behavior and functioning and academic or preacademic skills as determined by an individual evaluation and manifested before age 18Options are Yes or No.

Deafness

The only field in the Deafness section is a Yes or No dropdown called "An unaided hearing loss in excess of 70 decibels and precludes understanding of speech through the auditory mechanism, even with amplification, and demonstrates an inability in processing linguistic information through hearing even with amplification."

Deaf-Blindness

Students must meet both criteria below to qualify for deaf-blindness.

FieldDescription
Causes such severe communication andOptions are Yes or No.
Other developmental and educational needs that they cannot be accommodated in special education programs solely for children with deafness or children with blindnessOptions are Yes or No.

Developmental Delay

FieldDescriptionValidation
A student with a severe delay in development functions at a developmental levelOptions include:
  • two or more standard deviations below the mean in any one area of development specified in this section
  • 1.5 standard deviations below the mean in two or more areas of development
Only one option can be selected.
Check the areas of development
Adaptive DevelopmentOptions are Yes or No.N/A
Adaptive Development InformationAny adaptive development comments.This field is limited to 100 characters.
Cognitive DevelopmentOptions are Yes or No.N/A
Cognitive Development InformationAny cognitive development comments.This field is limited to 100 characters.
Communication DevelopmentOptions are Yes or No.N/A
Communication AreaOptions are:
  • Receptive Language
  • Expressive Language
Multiple options can be selected.
Communication Development InformationAny communication development comments.This field is limited to 100 characters.
Social or Emotional DevelopmentOptions are Yes or No.N/A
Social or Emotional Development InformationAny social or emotional development comments.This field is limited to 100 characters.
Physical DevelopmentOptions are Yes or No.N/A
Physical Development AreaOptions are:
  • Gross Motor
  • Fine Motor
Multiple options can be selected.
Physical Development InformationAny physical development comments.This field is limited to 100 characters.

Emotional Disability

FieldDescription

1. Emotional disability is a condition that exhibits one or more of the following characteristics to a marked degree over a long period of time

Student must exhibit one or more characteristics to meet criteria

An inability to learn which cannot be explained by intellectual, sensory or health factorsOptions are Yes or No.
An inability to build or maintain satisfactory interpersonal relationships with peers and teachersOptions are Yes or No.
Inappropriate types of behavior or feelings under normal circumstancesOptions are Yes or No.
A general pervasive mood of unhappiness or depressionOptions are Yes or No.
A tendency to develop physical symptoms or fears associated with personal or school problemsOptions are Yes or No.

2. A student may be identified as emotional disability if the following requirements are met

Must meet all criteria

The student demonstrates serious behavior problems over a long period of time, generally at least six months, with documentation from more than one source of the frequency and severity of the targeted behaviorsOptions are Yes or No.
The student's symptoms cause significant impairment in social, emotional, behavioral, occupational, or other areasOptions are Yes or No.
An adverse effect on educational performance is verified through the full and individual evaluation procedures as provided in § 24:05:25:04Options are Yes or No.

Hearing Loss

The only field in the Hearing Loss section is a Yes or No dropdown called "A student may be identified as having a hearing loss if an unaided hearing loss of 35 to 69 decibels is present that makes the acquisition of receptive and expressive language skills difficult with or without the help of amplification."

Orthopedic Impairment

FieldDescription

1. There must be evidence of the following

Must meet all criteria

Severely impaired motor functioning that adversely affects educational performance; andOptions are Yes or No.
Deficits in muscular or neuromuscular functioning that significantly limits the student's ability to move about, sit, or manipulate materials required for learning; andOptions are Yes or No.
Student's bone, joint, or muscle problems affect ambulation, posture, or gross and fine motor skills; andOptions are Yes or No.
Medical data by a qualified medical evaluator describes and confirms an orthopedic impairmentOptions are Yes or No.

Other Health Impaired

The only field on the Other Health Impaired section is a Yes or No dropdown called "1. Other health impaired means having limited strength, vitality or alertness, including heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment is due to chronic or acute health problems such as a heart condition, tuberculosis, rheumatic fever, nephritis, asthma, attention deficit disorder or attention deficit hyperactivity disorder, sickle cell anemia, hemophilia, epilepsy, lead poisoning, leukemia, Tourette syndrome, or diabetes."

Specific Learning Disability

FieldDescriptionValidation
1. Does the student achieve adequately for the student's age or to meet state-approved grade-level standards in one or more of the following areas, when provided with learning experiences and instruction appropriate for the student's age or state-approved grade-level standards
Oral ExpressionOptions are Does or Does Not.N/A
Listening ComprehensionOptions are Does or Does Not.N/A
Written ExpressionOptions are Does or Does Not.N/A
Basic Reading SkillsOptions are Does or Does Not.N/A
Reading Fluency SkillsOptions are Does or Does Not.N/A
Reading ComprehensionOptions are Does or Does Not.N/A
Mathematics CalculationOptions are Does or Does Not.N/A
Mathematics ReasoningOptions are Does or Does Not.N/A
2. Please indicate which method the team will be using to determine SLD eligibilityOptions include:
  • Method A - Discrepancy
  • Method B - Response to Intervention
N/A
The Following Sections (3-8) Required only for Initial Eligibility Determination
3. Document data that demonstrates that prior to, or as part of, the referral process, the student was provided appropriate instruction in regular education settings by qualified personnelA description of how the student was provided appropriate instruction in a regular education setting.This field is limited to 8000 characters.
4. Method A - Discrepancy
Qualified Personnel
Teacher
*Required
The name of the qualified personnel.*This field is available and required when Method B - Response to Intervention is selected from the "Please indicate which method the team will be using to determine SLD eligibility" field. 

This field is limited to 150 characters. 

This field is repeated four times.
Certified
*Required
Options are Yes or No.*This field is available and required when Method B - Response to Intervention is selected from the "Please indicate which method the team will be using to determine SLD eligibility" field.

This field is repeated four times.
Level of CertificationOptions include:
  • Tier I
  • Tier II
  • Tier III
*This field is available and required when Yes is selected from the Certified field. 

This field is repeated four times.
5. Data-based documentation of repeated assessments of achievement at reasonable intervals, reflecting formal assessment of student progress during instruction, which was provided to the student's parentsA description of the documentation of assessments of the student's achievement provided to their parent/guardian.This field is limited to 8000 characters.
6. Method A - Discrepancy
Nothing Needed


Method B - Response to Intervention

Intervention Data

*Attached information if needed


The following columns display in the table. Click Add to add a record to the table in-line.
  • Week #
  • Date
  • Score
7. Attendance Record
School YearThe school year.This field is limited to 9 characters. There are two instances of this field.
Total Days of SchoolThe number of school days.This field is limited to 6 characters. There are two instances of this field.
Totals Days in AttendanceThe number of days the student attended.This field is limited to 6 characters. There are two instances of this field.
Days Absent Quarter 1The number of days the student was absent in quarter 1.This field is limited to 6 characters. There are two instances of this field.
Days Absent Quarter 2The number of days the student was absent in quarter 2.This field is limited to 6 characters. There are two instances of this field.
Days Absent Quarter 3The number of days the student was absent in quarter 3.This field is limited to 6 characters. There are two instances of this field.
Days Absent Quarter 4The number of days the student was absent in quarter 4.This field is limited to 6 characters. There are two instances of this field.

8. A student may not be determined to be a student with a disability if the determinant factor is a lack of appropriate instruction


Is the underachievement of the student due to lack of instruction in

ReadingOptions are Yes or No.N/A
MathOptions are Yes or No.N/A
The Following Sections Required for All Eligibility Determination
9. Indicate which method the team will be using to determine SLD eligibilityOptions include:
  • Method A - Discrepancy
  • Method B - Response to Intervention
N/A
ObserverThe name of the observer.This field is limited to 150 characters.
Observation DateThe day of observation.N/A
Observation NotesAny comments related to the observation.This field is limited to 8000 characters.
10. Document educationally relevant medical findingsAny medical findings.This field is limited to 8000 characters.
11. The evaluation team determines that the student's achievement level problem is/is not primarily the result of
Visual, hearing or motor disabilitiesOptions include:
  • Is
  • Is Not
N/A

Cognitive Disability

Options include:
  • Is
  • Is Not
N/A
Emotional DisabilityOptions include:
  • Is
  • Is Not
N/A
Cultural factorsOptions include:
  • Is
  • Is Not
N/A
Environmental or economic disadvantageOptions include:
  • Is
  • Is Not
N/A
Limited English proficiencyOptions include:
  • Is
  • Is Not
N/A
This Section should only be completed if using a state-approved Response to Intervention model AND RtI criteria will be used to determine eligibility


12. Method B Response to Intervention


If the student has participated in a process that assesses the student's response to scientific, research-based intervention document the following


Questions in this section are available when Method B - Response to Intervention is selected from the "Please indicate which method the team will be using to determine SLD eligibility" field.

The instructional strategies used in the RTI process that assesses the student's response to scientific, research-based interventionThe instructional strategies of the RTI process.This field is limited to 8000 characters.
Number of weeks the student has participated in Tier 3 interventionsThe number of weeks the student participated in a tier 3 intervention.This field is limited to 5 characters.
Number of minutes of core reading instructionThe number of minutes the student spent in core reading instruction.This field is limited to 5 characters.
Number of minutes of intensive, individualized interventionThe number of minutes the student had intensive, individualized intervention.This field is limited to 5 characters.
Frequency of the interventionThe frequency of the intervention.N/A

Research-based intervention strategies


Please list by type, not name


The following columns display. Click the Add button to add a record in-line.
  • Name of Research-Based Intervention Strategy
  • Duration of the Intervention
Fall Universal Screening ScoreThe student's universal screening score for the fall.N/A
Winter Universal Screening ScoreThe student's universal screening score for the winter.N/A
Actual rate of progress compared to benchmark standardThe student's actual rate of progress.This field is limited to 150 characters.
Grade level benchmark standard for end of school yearThe benchmark standard for the end of the school year.This field is limited to 150 characters.
Desired Rate of ProgressThe desired rate of progress.This field is limited to 150 characters.
Predicted Rate of ProgressThe predicted rate of progress.This field is limited to 150 characters.
Is the Predicted Rate of Progress significantly below grade level expectationsOptions are Yes or No.N/A
Team Conclusions
First Name
Required
The team member's first name.N/A
Last Name
Required
The team member's last name.N/A
RoleThe team member's role.N/A
Agree 
or
Disagree
Indicates the team member agrees or disagrees with the evaluation.N/A

Speech/Language Impairments

FieldDescription
Articulation Disorders
Performance on a standardized articulation test falls two standard deviations below the mean and intelligibility is affected in conversationOptions are Yes or No.
Test performance is less than two standard deviations below the mean, but the student is judged unintelligible by the speech and language clinician and one other adultOptions are Yes or No.
Performance on a phonological assessment falls in the profound or severe range and intelligibility is affected in conversationOptions are Yes or No.
Performance on a phonological assessment falls in the moderate range, intelligibility is affected in conversation and during a tracking period of between three and six months there was a lack of improvement in the number and type of errorsOptions are Yes or No.
An error persists six months to one year beyond the chronological age when 90 percent of students have typically acquired the sound based on developmental articulation normsOptions are Yes or No.
Fluency Disorder
The student consistently exhibits one or more of the following symptomatic behaviors of dysfluencyOptions are Yes or No.
Dysfluent Behaviors
*Required
Options include:
  • Sound, syllable, or word repetition
  • Prolongations of sounds, syllables, or words
  • Blockages
  • Hesitations

*This field is available and required when Yes is selected from the "The student consistently exhibits one or more of the following symptomatic behaviors of dysfluency" field.

There is a significant discrepancy from the norm a measured by speech sampling in a variety of contexts

A significant discrepancy from the norm is five dysfluencies a minute

Options are Yes or No.
OR
The disruption occurs to the degree that the individual or persons who listen to the individual react to the manner of speech and the disruptions in a way that impedes communication
Options are Yes or No.
Voice Disorder
Consistent deviations exist in one or more of the parameters of voice: pitch, quality, or volumeOptions are Yes or No.
The voice is discrepant from the norm for age, gender, or culture and is distracting to the listenerOptions are Yes or No.
The disorder is not the result of a temporary problem, such as normal voice changes, allergies, colds, or similar conditionsOptions are Yes or No.
Language Disorder
Through age eight, performance falls 1.5 standard deviations below the mean on standardized evaluation instruments; beginning at age nine, a difference is present on 1.5 standard deviations between performance on an individually administered standardized language assessment instrument and measured expected potential as measured by an individually administered intelligence testOptions are Yes or No.

The student's pragmatic skills, as measured by checklists, language samples, or observation, adversely affect the student's academic and social interactions

Options are Yes or No.

Traumatic Brain Injury

The only field on the Traumatic Brain Injury section is a Yes or No dropdown called "Such as cognition; language; memory; attention; reasoning; abstract thinking; judgement; problem solving; sensory; perceptual; and motor abilities; psychosocial behavior; physical functions; information processing; and speech. The term does not apply to brain injuries that are congenital or degenerative, or brain injuries induced by birth trauma."

Vision Loss

FieldDescription
1. Partial sight is one or more deficiencies in visual acuity, as followsOptions are Yes or No.
Deficiencies in visual acuityOptions are:
  • Visual acuity of not better than 20/70 in the better eye after correction
  • Restricted visual field
  • Limited ability to move about safely in the environment due to a visual disability
2. Blindness - Visual acuity of 20/200 or less in the better eye with correcting lenses or a limited field of vision such that the widest diameter subtends an angular distance of no greater than 20 degrees or has a medically indicated expectation of visual deteriorationOptions are Yes or No.

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