MADISONMETROPOLITANSCHOOL DISTRICT

DEPARTMENT OF EDUCATIONAL SERVICES - SPECIAL EDUCATION

Student / Student # / Date of Birth / Gender / Grade / School of Attendance

INDIVIDUALIZED EDUCATION PROGRAM (IEP) EVALUATION REPORT

ADDITIONAL DOCUMENTATION REQUIRED WHEN CHILD IS EVALUATED FOR SPECIFIC

LEARNING DISABILITIES

Date of IEP Team Meeting

For students being evaluated for a specific learning disability, include a statement for each area below:

A. Information demonstrating that the student was provided appropriate instruction in regular education.

B.Information demonstrating that the student received repeated assessments of achievement reflecting student progress.

C.Information demonstrating that the student’s parents were provided information on the above assessments of achievement of their child.

D.Relevant behavior noted during observation of the student in his or her learning environment (including the regular classroom) and the relationship of that behavior to the student’s academic functioning (if using observational data of the student’sacademic performance and behavior done prior to the referral for the evaluation, see the Information from Review of Existing Data).

E.Educationally relevant medical findings. None

F. The student received intensive intervention, which was applied in a manner highly consistent with its design, closely

aligned to pupil need, and culturally appropriate.

G.The student’s achievement relative to his or her age, or to meeting state-approved grade level standards in one or more of the following: oral expression, listening comprehension, written expression, basic reading skill, reading fluency skills, reading comprehension, mathematics calculation and mathematics problem solving.

H.The student’s progress relative to meeting age or state-approved grade level standards in areas listed in F. above when using the student’s strengths and weaknesses in performance, achievement or both relative to age, state-approved grade level standards or intellectual development.

I.The effects of a visual, hearing or physical (motor) disability; cognitive disability, emotional disturbance; cultural factors; environmental or economic disadvantage; or limited English proficiency on the student’s achievement level.

The IEP Team assures that the decision of whether the child has a specific learning disability was based on information from a variety of sources and not on any single measure or assessment as the sole criterion. Each IEP team participant must sign below and indicate whether he/she agrees with the conclusion regarding whether or not the child is a child with a specific learning disability. If this does not reflect his/her conclusion, then that IEP team participant must also attach a statement with his/her conclusions.

Name and title / Signature / Concurrence
YES / NO

Distribution:

IDEA Records Manager Rev. 01/07

School

Parent/ Legal Guardian