North Kingstown School Department

Pupil Personnel Services

50 East Court

North Kingstown, RI 02852

Phone: 401-336-3120 Fax: 401-398-0674

EVALUATION TEAM MEETING DATE: ______/______/______

STUDENT D.O.B. _____/_____/_____

SCHOOL GRADE ______CASEMANAGER______

Assessment(s) completed by the Evaluation Team:

EVALUATION / DATE / EVALUATION / DATE / EVALUATION / DATE
Educational / Social History / Adaptive PE
Psychological / Occupational Therapy / Neuropsychological
Speech /Language / Physical Therapy / Vision
Psychiatric / Vocational / Hearing
Clinical Psychological / Adaptive Functioning / Other

Based on the above evaluation(s) completed/obtained, the Evaluation Team has made the determination

that thechild

DOES NOT HAVEa disability, which adversely impacts school performance and requires special education services.

HASa disability, which adversely impacts school performance and requires special education services in the following area

If the team decides that additional evaluation(s) are required to determine eligibility, they still must complete this

form based on the current information and then reconvene upon the completion of the new evaluative information.

THE CHILD’S DISABILITY CATEGORY:

 / DISABILITY /  / DISABILITY /  / DISABILITY /  / DISABILITY
Autism Spectrum Disorder / Deaf-Blindness / Deafness / Developmental Delay
Emotional Disturbance / Hearing Impairment / Mental Retardation / Multiple Disability
Orthopedic Impairment / Other Health Impaired / *Specific Learning Disability / Speech /Language
Traumatic Brain Injury / Visual Impairment

*Requires additional documentation PPS13A LearningDisability Report

Participants in the decision making process:

SIGNATURE OF PARTICIPANTS / ROLE / Summary Reflects My Opinion
Yes √ No
Parent(s)
Chairperson/District Representative
Psychologist
Special Educator
Regular Educator
Speech/Language Pathologist
Student (where appropriate)
Other:
Other:
DISSENTING OPINION:

STUDENT D.O.B.//

A copy of the Evaluation Team results has been provided to the parent/guardian, OR

A summary of Evaluation Team results are presented below:

Classroom Performance:

Area Affected:
Educational Need:

Summary of behavior(s):

Strengths:
Area Affected:
Educational Need:
Present Level of Performance

Educational/Achievement:

Strengths:
Area Affected:
Educational Need:
Present Level of Performance:

Psychological/Aptitude:

Strengths:
Areas Affected:
Educational Need:
Present Level of Performance:

Assessment:

Strengths:
Areas Affected:
Educational Need:
Present Level of Performance:

Assessment:

Strengths:
Areas Affected:
Educational Need:
Present Level of Performance:

Assessment:

Strengths:
Areas Affected:
Educational Need:
Present Level of Performance:

PPS 12 EVALUATION TEAM SUMMARY: Back to Back YELLOW REV 1/2013

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