NC 3

STUDENT DATA REVIEW

Student ______School______Grade______

Date ______DOB______

Review the student’s assessment needs:

Possible Evaluation(s) / Addressed by Evaluation / Evaluation Needed?
(Note YES or NO)
Cognitive/Intellectual Ability / May include psychological testing to determine cognitive (ability) of student.
Academic Achievement / Circle areas which need to be evaluated.
Listening comprehension, written language, reading fluency, basic reading, reading comprehension, math calculation, and math reasoning.
Communication / May include speech (production of speech-sounds, voice and/or fluency) and/or language (oral/expressive and receptive).
Behavioral/Social / May include behavioral assessments (ability to relate to others and/or conduct oneself appropriately)
Adaptive Behavior / May include assessments to evaluate daily living skills
Developmental
(for Preschool use only) / Circle areas which need to be evaluated.
Cognitive, language, adaptive, and personal social, fine motor, and/or gross motor.
Motor Skills / May include evaluation of large muscle skills and/or perceptual motor and small muscle skills.
Health/Physical Status / May include relevant health issues, including vision and/or hearing screening – for diagnostic purposes only.
Transition / Required at age 16 and up
Autism
Classroom Observation

Revised 06/10

NC 3

Other:

NC 3

NC 3

Reminder: If a previous evaluation is going to be used to determine eligibility, then that information should also be noted on the prior notice/consent form; for example, “As discussed in our phone conversation, Joe’s ability score has been in the average range on the past two evaluations. For that reason, we will not be reevaluating those skills. His ability score from January 2003 will be used to determine eligibility for special education services.”

**For District Use Only:
Person(s) who reviewed the file ______
Teacher Information: ______
______
______
Review of student record ((i.e. attach current grades, attendance record, enrollment gaps, various school enrollments, retention information, State and District-wide Assessment data, etc.): ______
______
Parent Contacted: (Date) ______
Parent information:______
______
Based upon a review of all referral information, potential areas of disability to evaluate are:
___500 Deaf-Blind ___525 Specific Learning Disability ___550 Speech/Language Impairment
___505 Emotional Disturbance ___530 Multiple Disabilities ___555 Other Health Impaired
___510 Cognitive Disability ___535 Orthopedic Impairments ___560 Autism
___515 Hearing Loss ___540 Vision Loss/Blindness ___565 Traumatic Brain Injury
___ 570 Developmental Delay (3-5 years old only) ___545 Deafness
Refer to the South Dakota Eligibility Guide for testing areas required to determine eligibility

As a result of our review, parental consent is needed for the evaluations noted above (complete prior notice/consent form to evaluate).