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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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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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 / Position6/18/2012
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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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