Reason for Referral/Background Information

/ Austin Public Schools ISD 492
401 3rd Avenue NW
Austin MN 55912-2378
/ EVALUATION REPORT
Student: / StudentSample
School: / Austin Community Learning Center
/ ID: / SAMPLE
Grade:
/ Date:
DOB:

Initial EvaluationReevaluationFunctional Behavioral AssessmentTransition

Reason for Referral/Background Information

Information, Strengths and Concerns Reported by Parent(s)

Educationally Relevant Medical Information

Special Considerations

Student's language, cultural, economic or environmental background does not indicate that special adaptations in assessment procedures need to be made. Student's physical or sensory status does not indicate that special accommodations need to be made in the assessment process.

Existing Data, Current Evaluation Results and Interpretation

-Intellectual

-Academic

In the general education classroom, the following was observed about Student's academic performance:

-Communication

-Motor

-Sensory Status

Student passed the vision and hearing screenings on

-Health/Physical Status

-Social/Emotional/Behavioral

-Functional/Adaptive Behavior

-Observations

Date of Observation #1 / Observer: / Setting:

Results of observation:

Date of Observation #2 / Observer: / Setting:

Results of observaton:

-Secondary Transition

1. Interests and Preferences

a) Child:

b) Parents:

2. Assessment Information (how the disability affects each area)

a) Post Secondary Education and Training:

b) Employment:

c) Independent Living (when appropriate, include recreation & leisure, community participation and

home living):

3. Determination of Needs

a) Need to do:

b) Need to learn:

Summary

Special Education Needs and Adaptations

--Special Education Needs That Derive From The Disability

-Adaptations/Modifications

The IEP Team should consider the following adaptations/modifications to allow the student access to the general education curriculum:

Eligibility Determination

Student meets the following components of the Minnesota criteria for Developmental Cognitive Disability: Mild-Moderate:

A. Student has a composite score at or below the 15% on a nationally normed, technically adequate measure of adaptive behavior which documents needs in the following domains (minimum 4 areas)across multiple environments, supported by systematic observation and parent input as sources to document need and level of support:

Daily living and independent living skills;
Social and interpersonal skills;
Communication skills;
Academic skills;
Recreation and leisure skills;
Community participation skills;
Work and work-related skills.

B. Student has significantly below average general intellectual functioning as measured by an individually administered, nationally normed test of intellectual ability:

an individually administered test of intellectual ability that yields an intelligence quotient 2 Standard Deviations below the mean (+ or - 1 SEM);
verified by two or more systematic observations; and one or more of the following:
supplemental tests of specific abilities:
criterion-referenced tests:
alternative methods of intellectual assessment:
clinical interviews of family members, and/or
observation and analysis of behavior across environments.

According to the ---, Student has a Full Scale IQ of -- (+/- --), which is at the --%ile. This places Student in the - range of ability.

Date / StudentSample
Student Name

To be completed during meeting of qualified professionals and parent(s)

Based on the information included in this report, the student:

Is not eligible for special education because the student did not meet State criteria in the following areas examined:

Autism Spectrum Disorders / Developmental Cognitive Disability / Specific Learning Disability
Deaf & Hard of Hearing / Emotional or Behavior Disorder / Speech or Language Impairment
Deaf-Blind / Other Health Disabilities / Traumatic Brain Injury
Developmental Delay / Physically Impaired / Visual Impaired
Severely Multiply Impaired

Is eligible for special education for the following reason(s):

For initial evaluation, the student meets entrance criteria for the disability(ies) indicated below.
For initial evaluation, the student qualifies through a team override decision.
For re-evaluation, the student continues to have a disability and continues to demonstrate a need for special education and related services.
Primary disability:
Secondary disability(ies):
Autism Spectrum Disorders / Developmental Cognitive Disability / Specific Learning Disability
Deaf & Hard of Hearing / Emotional or Behavior Disorder / Speech or Language Impairment
Deaf-Blind / Other Health Disabilities / Traumatic Brain Injury
Developmental Delay / Physically Impaired / Visual Impaired
Severely Multiply Impaired

Team Member Signatures

SIGNATURE / TITLE
Parent
Regular Education Teacher
Special Education Teacher
School District Representative
Student (by grade nine or age 14)