Santa Barbara County
Special Education Local Plan Area …………..A Joint Powers Agency
E l i gi bi l i ty Work sheet f or S p eci f i c L earn i n g Di sab i li ty ( S L D)
Us i n g E i th er Di screp an cy, Resp on se to S ci en ti f i c, Resear ch B ased In terven ti on (RtI )
or Pa tte rn of S tren gth s an d Weak n esses ( PS W) d ata
STUDENT NAME:
DISTRICT:
PARENT/GUARDIAN:
BIRTHDATE:
SCHOOL:
DATE OF IEP TEAM MEETING:
D i r e ct i o ns : T hi s f or m n e e d s t o b e c o mp l et e d b y t h e s c ho o l ps yc h o l o gi st as a pa r t o f t h e
a s s es s me n t p r o c e ss i f S L D i s a n a r e a of s us p e ct e d di sa b i l i t y.
I.
Presence of processing disorder directly related to Specific Learning Disability
Yes
No
Check appropriate area(s):
Attention
Visual Processing
Auditory Processing
Sensory Motor Skills
Cognitive Abilities (including association, conceptualization and expression)
There must be a processing deficit to meet eligibility under SLD – Stop here if the answer is no.
II.
Achievement
Yes
No The student does not achieve adequately for the *student’s age or to meet state-approved standards in one or
more of the following areas, when provided with learning experiences and instruction appropriate for the
student’s age or state-approved grade-level standards:
Oral expression
Basic reading skill
Mathematics calculations
Listening comprehension
Reading fluency skills
Mathematics problem solving
Written expression
Reading comprehension
(*see recommended Academic Achievement Assessment Matrix – recommended functioning at 9th%ile or
below)
III. Indicate below if student meets Specific Learning Disability through severe discrepancy method:
Yes
No The multidisciplinary assessment team finds a severe discrepancy exists between intellectual ability and
achievement based on standardized tests.
Yes
No The multidisciplinary assessment team finds a severe discrepancy based on alternative measures as specified on
the assessment plan.
If student does not meet SLD eligibility using severe discrepancy method, then move on to Part IV
IV. Indicate below if student meets Specific Learning Disability though either RtI (if applicable) or PSW:
A. Response to Scientific, Researched-Based Intervention (RtI):
Yes
N/A
No The student does not make sufficient progress as defined as below the 9th percentile in one or more areas
identified in II. Achievement above when using a process based on the student’s response to scientific, research
based intervention.
Attach Documentation of Response to Intervention (RtI) Fidelity Worksheet (SELPA82), if applicable
NOTE: Worksheet MUST be provided to parent/guardian
Comments:
OR
B. Pattern of Strengths and Weaknesses (PSW):
Yes
No The student exhibits a pattern of strengths (above the 25th percentile) and weaknesses (below the 9th percentile)
in performance, achievement or both, relative to age, state-approved grade-level standards, or intellectual
development that is determined by the IEP team to be relevant to the identification of a specific learning
disability, using appropriate assessments.
Attach Pattern of Strengths and Weaknesses (PSW) Worksheet (SELPA83)
Comments:
SELPA81 7-30-15 (E)
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Santa Barbara County
Special Education Local Plan Area …………..A Joint Powers Agency
V.
Exclusionary factors:
Specific learning disabilities do not include learning problems that are primarily the result of visual, hearing, or motor
disabilities, of intellectual disability, of emotional disturbance, or of environmental, cultural, or economic disability. If any of
the items below (A-H) are checked “Yes”, the student may not be identified as having a specific learning disability.
A. Visual, hearing, or motor disability
Yes
No
B. Intellectual disability
Yes
No
C. Emotional disturbance
Yes
No
D. Cultural factors
Yes
No
E. Environmental or economic disadvantage
Yes
No
F. Limited English proficiency
Yes
No
G. Limited school experience or poor school attendance
Yes
No
H. Lack of appropriate instruction in reading or math
Yes
No
a. The IEP team considered data that demonstrate that prior to, or as a part of, the referral process, the pupil was provided
appropriate instruction in regular education settings, delivered by qualified personnel; and
b. The IEP team considered data-based documentation of repeated assessments of achievement at reasonable intervals,
reflecting formal assessment of student progress during instruction, which was provided to the pupil’s parents.
VI. Student was observed in his/her learning environment?
Yes
No
Yes
No
Yes
No
Relevant behavior related to academic functioning noted during observation:
VII. Summary:


Based upon Section I – VI, student appears to meet eligibility criteria as a student with a specific
learning disability. If yes, indicate process used:
Discrepancy
RtI
PSW
The degree of the student’s impairment appears to require special education services.
NEXT STEPS:


If at the IEP team meeting student is found eligible with a specific learning disability, then complete appropriate specific
learning disability eligibility form in SEIS.
Document in the assessment report the method(s) used to determine eligibility.
SELPA81 7-30-15 (E)
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