______SCHOOL DISTRICT
Exceptional Children Services
CONFIDENTIAL
MULTIDISCIPLINARY EVALUATION TEAM REPORT – Initial/3 year
DP # ______
STUDENT ______BIRTHDATE ______AGE _____ GRADE______SEX ______
PARENT/GUARDIAN ______ADDRESS ______ZIP ______
TELEPHONE ______CURRENT PLACEMENT ______HAC ______
Evaluations/Assessment Used (Check all items considered an attach reports):
_____ / Student Achievement / _____ / Medical/Social / _____ / Attention_____ / Classroom Performance / _____ / Psychological / _____ / Emotional Measures
_____ / Classroom Observation Report / _____ / Speech/Language / _____ / Other ______
Assessment Summary
Domain
/Assessment
/Standard Scores
/Domain
/Assessment
/Standard Scores
Oral Expression
/______
/______
/Adaptive Behavior
/______
/ ______Listening Comprehension
/______
/______
/Vision
/______
/ ______Written Expression
/______
/______
/Hearing
/______
/ ______Basic Reading
/______
/______
/Intellectual
/______
/ ______Reading Comprehension
/______
/______
/-Verbal
/______
/ ______Math Calculation
/______
/______
/- Performance
/______
/ ______Math Reasoning
/______
/______
/- Full Scale
/______
/ ______Other: ______
/______
/______
/- Discrepancy –1.5 sd
/______
/ ______Other: ______
/______
/______
/Other: ______
/______
/ ______Parent Input: ______
______
Reports received by: ______Date received: ______
Primary Disability (Check the condition which results in a need for special education)
The disability may not be based upon a lack of instruction in reading or math or limited English proficiency.
____ / Autism / ____ / Mental retardation / ____ / Serous emotional disorder____ / Deaf-blindness / ____ / Multiple disabilities * / ____ / Specific learning disabled
(do SE 98-11b)
____ / Deafness / ____ / Orthopedic impairment / ____ / Speech impairment
____ / Developmental delay (3-5only) / ____ / Other health impairment / ____ / Traumatic brain injury
____ / Hearing impairment / à / Health condition ______/ ____ / Visual impairment
____ / Language impairment / ____ / Prolonged assistance (0-2 only) / ____ / None
If you have identified a disability, but the student was eligible in other(s), please list: ______
* For multiple disabilities, asterisk all disabilities identified.
IEP Committee Chairperson ______Date ______
Members of IEP Team: (If this report reflects your personal conclusions, sign and circle “Y”. If it does not, sign and circle “N”.
Team Member / Title / Team Member / Title______/ ______/ Y / N / ______/ ______/ Y / N
______/ ______/ Y / N / ______/ ______/ Y / N
______/ ______/ Y / N / ______/ ______/ Y / N
______/ ______/ Y / N / ______/ ______/ Y / N
This information is confidential and shall not be duplicated, copied or released without Informed Parental Consent. (FERPA 99.33)
White: Cum File Yellow: Exceptional Children Service Pink: Parent/Guardian Gold: Special Education Teacher