BISMARCK PUBLIC SCHOOLS
SPECIAL EDUCATION DEPARTMENT
PRESCHOOL LANGUAGE IMPAIRMENT WORKSHEET
DETERMINATION OF DISABILITY: (Student’s name) meets/does not meet special education eligibility under the
category of Speech-Language Impairment. Based on the team’s assessment, (Student’s name) is in need of special
education services due to the level, condition, and educational impact of the impairment.
Qualifying Criteria:
The team shall determine that a student is eligible for special education services in the area of Language Impairment
when a student’s total score on the ND Guidelines Language Severity Rating Scale indicates a Moderate (13-16 points) or
Severe (17-20 points) level impairment. Contributing factors to the scale’s total scores include: a formal comprehensive
language assessment, a second formal measure, informal/ non-standardized assessment information, and educational
impact.
Formal/Standardized Comprehensive Language Assessment:
[ ] 86-100 (50%ile, SD 0-.99 below the mean) – (0 pts.)
[ ] 78-85 (16%ile, SD 1.0-1.49 below the mean) – (2 pts.)
[ ] 70-77 (7%ile, SD 1.5-1.99 below the mean) – (3 pts.)
[ ] <70 (2%ile, SD 2.0> below the mean) – (4 pts.)
Second Formal Measure:
[ ] 86-100 (50%ile, SD 0-.99 below the mean) – (0 pts.)
[ ] 78-85 (16%ile, SD 1.0-1.49 below the mean) – (2 pts.)
[ ] 70-77 (7%ile, SD 1.5-1.99 below the mean) – (3 pts.)
[ ] <70 (2%ile, SD 2.0> below the mean) – (4 pts.)
Informal/Non-Standardized Assessment:
[ ] Language skills are developmentally appropriate and do not interfere with communication – (0 pts.)
[ ] Language skills consist of some errors, and do not interfere with communication – (2 pts.)
[ ] Language skills are below the average range; errors are noticeable and interfere with communication – (3 pts.)
[ ] Language skills are significantly below average; errors are prevalent and greatly interfere with communication – (4 pts.)
Educational Impact (including Social/Emotional):
[ ] Language skills are adequate for the student’s participation in varied environments – (0 pts.)
[ ] Language skills are developing and can be addressed in varied environments – (4 pts.)
[ ] Language skills have an effect on the student’s ability to participate in varied environments – (6 pts.)
[ ] Language skills have a significant impact on the student’s ability to participate in varied environments – (8 pts.)
Total Points:
Data For Determining Eligibility was gathered from (List multiple resources):
[ ] Language sample
[ ] Contextual probe
[ ] Structured observation
[ ] Classroom work
[ ] Other curriculum/academic results
[ ] Standardized test(s)
[ ] Teacher/Child/Parent reports, interviews, or checklists
NOTE: Teacher, child, and parent reports, interviews, or checklists are not sufficient evidence by themselves and must be
supported with additional data.
LAST REVISED 1/6/16