/ Disability Suspected Form

STUDENT: Birthdate: //

Last (legal) First (not nickname) M.I.

Gender: Male Female Grade: Teacher/Service Provider:

Resident District: Building:

Attending District: Building:

Disability is suspected if “yes” is checked for any of the following:

Yes No Are there data to suggest that the child:

·  has a diagnosis of a condition that is specifically listed in IDEA’s disability categories or is clearly included within one of IDEA’s disability categories, and

·  the condition has a discernible adverse effect on educational performance?

(If yes, summarize the data used to conclude that the child meets these criteria)

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6/18/2012

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Yes No Are there data to suggest that the child has received high quality instruction (including universal instruction and, when appropriate, targeted or intensive interventions), and the child’s performance

·  is not meeting standards and is not progressing towards meeting standards; and

·  is unique when compared to peers; and

·  cannot be explained by other, more plausible factors than a suspected disability?

(If yes, summarize the data used to conclude that the child meets these criteria)

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6/18/2012

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Yes No Are there data to suggest that the child has received high quality instruction, and

·  is meeting standards or is progressing toward meeting standards with the provision of targeted or intensive interventions that are matched to the area(s) of concern and implemented with integrity; and

·  may require ongoing and substantial resources?

(If yes, summarize the data used to conclude that the child meets these criteria)

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If disability is not suspected:

If the team has responded “No” to all items above, provide a rationale for the decision not to suspect (e.g., educational performance has changed recently; other, more plausible factors than disability account for the child’s performance; needs can be met through general education interventions, etc.)

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Participants involved in decision:

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Name / Position / Name / Position

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Date of Determination:

Note:

·  Written parental consent for a full and individual initial evaluation must be sought when disability is suspected.

·  Prior Written Notice of a refusal to conduct an evaluation must be provided when parents have requested an evaluation and disability is not suspected.

·  This form must be retained as a part of the student’s record.

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