CHARLES COUNTY PUBLIC SCHOOLS
DEPARTMENT OF SPECIAL EDUCATION
Specific Learning Disability Eligibility Checklist
Name of Student:
School:
☐Y ☐N
1.
Date of Birth:
Date of Eligibility Determination:
Documentation of a processing disorder that impacts the student in the area(s) of:
☐Oral Expression
☐Listening Comprehension
☐Written Expression
☐Basic Reading Skill
☐Reading Fluency Skills
☐Reading Comprehension
☐Mathematics Calculation
☐Mathematics Problem Solving
Processing deficit:
Evaluation source/date:
☐Y ☐N 2.
AND, There is documentation of an educational evaluation and psychological evaluation that
indicate a severe discrepancy between achievement and cognitive ability (see discrepancy
chart).
☐Cognitive score, certified valid for the purpose and for the student by a certified school
psychologist or licensed psychologist.
Measure(s) used/scores:
☐ Appropriate achievement measures certified valid for the purpose and for the student by
a certificated teacher for each area of suspected deficit.
Measures used/scores:
☐Y ☐N 3.
☐ N/A
☐Y ☐N 4.
OR, If a significant discrepancy is not documented through a standard score comparison, a
significant discrepancy is documented by the IEP Team and sufficient data is present to
demonstrate the presence of a specific learning disability.
Information used to override significant discrepancy criteria:
The student has been provided with learning experiences and instruction appropriate for
his/her age or State-approved grade-level standards and demonstrates inadequate
achievement ,and exhibits a pattern of strengths and weaknesses in performance,
achievement, or both, relative to age, State-approved grade-level standards, or intellectual
development.
Measures used:
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CHARLES COUNTY PUBLIC SCHOOLS
☐Y ☐N 5.
DEPARTMENT OF SPECIAL EDUCATION
The student has not made sufficient progress to meet age or State-approved grade level
standards when using a process based on the student’s response to scientific, researchbased intervention (RtI).
Intervention/Strategy:
If the RtI criteria cannot be met, document reason for overriding this area:
☐Y ☐N 6.
Is lack of achievement a result of any of the following? (If yes, check areas that apply)
☐Visual, Hearing, or Motor Disability ☐ Intellectual Disability ☐Emotional Disability
☐English Language Learner (ELL) ☐ Environmental, Cultural, or Economic Disadvantage
The IEP team used the above interpretation of the evaluation data to determine:
☐ The student has a Specific Learning Disability that adversely impacts his/her developmental
progress and is eligible for specifically designed instruction and related services (IEP).
☐ The student has a Specific Learning Disability but it does not adversely impact his/her
developmental progress; therefore, the student is not eligible for an IEP.
☐ The student does not have a Specific Learning Disability and is not eligible for an IEP.
☐ Evaluation data was insufficient to determine eligibility. Additional assessments and/or data
will be obtained/collected in the area(s) of:
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