Pasco County Schools Rev. 7/15

Pasco County Schools Rev. 7/15

Team Analysis of Data

A. Meeting Date: / Date of Receipt of Parental Consent:
B. Demographic Information:
Student Name: / DOB:
School: / Grade: / ID #:
Current Eligibilities/Related Services: / Vision Screen: / Hearing Screen:
Previous Ineligibilities and/or Discontinuations: / Retention History:
Parent Contacts: / Subgroups:
Identified Areas of Concern that have been targeted for intervention:
Relevant Medical Findings:
(documented)
Other Relevant Information:
Intervention Summary for the targeted area of concern:
Check if interventions are waived. Interventions cannot be waived for Language Impaired and Specific Learning Disabilities (K-12). Indicate the rationale for waiving interventions under the instructional details of educational need.
Intensive Interventions were not implemented based on the data collected.
FBA/BIP were implemented if behaviors impacted the student in the educational environment.
Start Date and End Date / Instruction/Intervention / Implementer/
Title / Duration/
Frequency
Intensive
Analysis of Response to Intervention Data (See attached, which includes graphs and documentation of parent involvement.
Performance discrepancy (Attach graphed data): District School Class AYP Sub Group Other (e.g., Tier II, III Peer Group)
Rate of Progress (Attach graphed data representingintervention intensity, rate of progress, expected rate of progress)
Is there evidence of fidelity in the implementation of the interventions? SelectYesNoNA
Additional Information(if applicable):
The student’s response to intervention was Selectpositivequestionable poorNA.
Additional Information(if applicable):
Comments:
Formal Assessment and Need:
Standardized Norm-Referenced Instrument(s) Results:
Instructional Details of Educational Need:

Summary of Eligibility Criteria for

Language Impairment Rev. 7/13

Yes / No / Evaluation Included:
The student’s parent(s) or guardian(s) were notified about the amount and nature of student performance data that would be collected and the general education services that would be provided, interventions for increasing the student’s rate of progress, and the parental or guardian right to request an evaluation.
Information gathered from parent(s)/guardian(s), teacher(s), and the student, when appropriate, support the results of the observations and standardized instruments. (If no, attach documentation.)
Yes / No / Is lack of performance and/or rate of progress PRIMARILY THE RESULT OF: / Specify the documentation supporting each factor:
Limited English Proficiency
Environmental or Economic Factors
Ethnicity and/or Cultural Factors
Gender and Age
Summary of Academic Areas of Concern:
Yes / No / Does the student achieve adequately meeting grade-level standards in all of the following areas? If no, check all areas in which student is not meeting expectations.
Reading comprehension / Oral expression / Social interaction
Phonological processing / Listening comprehension / Written expression
Emergent literacy skills
(Pre K only)
Yes / No / All of the following statements should be answered “Yes” to make a determination of “Eligible” in the area of Language Impaired.
Results of the standardized norm-reference instrument reveal significant language deficit.
The language deficits have an adverse effect on the child’s ability to perform and/or function in the typical learning environment as evidenced by the observation(s) conducted by a Speech-Language Pathologist. Two observations are required for pragmatic language deficits that cannot be verified by the use of standardized instruments.
The student received scientific, research-based instruction in the general education setting.
Not applicable (for Pre K students only)
Response to scientific, research-based instruction/intervention is inadequateOR
Intensive interventions are demonstrated to be effective but require sustained and substantial effort.
Not applicable (for Pre K students only)
The student demonstrates evidence of eligibility for Language Impairment.
Yes / N/A / Additional Team Recommendations:
Current eligibilities/related services:
Further action:
Signatures of group determining eligibility. Each of the following individuals certifies their agreement with the determination of eligibility and assures that this determination was made in accordance with subsection (6) of Rule 6A-6.0331. Please sign over your title or write in your position.
ESE Director/Designee / Parent / Parent
General Education Teacher / ESE Teacher / Speech/Language Pathologist
School Psychologist / Other: Name/Position / Other: Name/Position
School Based Administrator / Other: Name/Position / Other: Name/Position
The following team members DISAGREE with the conclusion of the group. Attach a separate statement presenting each member’s conclusion.
Name/Position / Name/Position / Name/Position