Evaluation/Eligibility Report
Documentation of Eligibility
South Carolina Public Charter School District
Evaluation Report and Documentation of Eligibility
CONFIDENTIAL
Name:
Date of Birth:
Age:
Date Evaluation Completed:
Date of Evaluation Planning Meeting:
Grade:
School:
Date of Eligibility Determination:
This report reflects information that existed at the time of evaluation planning, as well as any new
information gathered during the evaluation process, including any and all information presented by the
parent.
Section I: Review of existing information: Listed below is each evaluation procedure, assessment, record, or
report this team has reviewed and used in determining whether additional information is necessary in order to
conduct the evaluation.
REASON FOR REFERRAL AND EDUCATIONAL BACKGROUND
SUMMARY OF RESEARCH-BASED ACCOMMODATIONS AND/OR INTERVENTIONS
DEMOGRAPHIC, DEVELOPMENTAL, AND MEDICAL/HEALTH HISTORY
ENGLISH LANGUAGE PROFICIENCY
VISION
HEARING
SPEECH / LANGUAGE / COMMUNICATION
COGNITIVE / PROCESSING
ACADEMIC ACHIEVEMENT
ADAPTIVE BEHAVIOR
SOCIAL / EMOTIONAL / BEHAVIORAL
Student name, School name
MOTOR / SENSORY
TRANSITION
Section II: Determination of need for additional information: After reviewing existing information, this team has
determined that:
No additional information is needed in order to conduct an evaluation. Existing information will be used to
complete the evaluation and to determine eligibility and educational needs. Proceed to Section VI. If no additional
information is needed, the parents have the right to request an assessment to determine whether the child continues
to be a child with an disability, and to determine the educational needs of the child (34 CFR § 300.305(d)). The LEA
is not required to conduct the assessment unless requested to do so by the child's parents.
Addition information is needed in order to determine eligibility/continued eligibility and educational needs.
Proceed to Section III.
Section III: Additional Information Needed for Evaluation Plan:
Need
Evaluation Component / Area of Evaluation
School records:
Demographic, health, developmental and education history
Documentation or assessment of English language proficiency:
Medical records:
Existing evaluations:
Observation:
Interview:
Vision screen
Hearing screen
Documentation of academic interventions and results of progress
monitoring:
Functional behavioral assessment (determining what causes or
maintains a behavior)
Behavior log/Anecdotal records:
Documentation of behavioral interventions and results of progress
monitoring:
Comprehensive developmental evaluation (cognition, communication,
motor, activities of daily living, social/emotional maturity)
Cognitive Processing (problem solving and processing)
Adaptive behavior assessment (personal and functional skills
necessary for independence)
Behavior rating scales (social, emotional, behavioral functioning):
Personality measure
Preacademic, academic, or functional academic achievement OR
developmental skills assessment
Areas: ___ Preacademic skills ___Functional academic skills
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Title of Team Member
Responsible for Obtaining
Parent/Caregiver
School Psychologist
School Psychologist
School Psychologist
Student name, School name
___Developmental skills assessment __Oral expression ___Listening
comprehension ___Written expression ___Basic reading skill
___Reading fluency skills ___Reading comprehension
___Mathematics calculation ___Mathematics problem solving
___Other:
Autism rating scale
Written report of audiological evaluation
Medical history documenting chronic middle ear infection
Receptive and expressive communication skills in preferred mode
Written report of visual examination
Functional vision (use of vision in environment)
Literacy media and braille skills
Vision specific skills (developmental visual skills)
Functional communication (communication skills in the school setting)
Oral peripheral examination (structure and function of mouth)
Articulation (production of sounds)
Language (receptive, expressive, social)
Speech fluency (rhythm, rate, fluency)
Voice (pitch, intensity, quality, resonance)
Language pragmatics (language in social situations)
Documentation of physical functioning (for TBI)
Behavior assessment (for TBI)
Assessment of language processing and use, memory, attention,
reasoning, abstract thinking, judgment, problem-solving skills, auditory
perception, visual perception (for TBI)
Visual-motor skills
Fine motor skills (small muscle movements)
Sensory functioning (processing information from the environment
taken in by the senses)
Self-care skills
Gross motor skills (large muscle movements)
Assessment of communication, adaptive, and social skills to determine
need for applied behavior therapy or social behavior therapy
Assessment of child’s need for assistive technology (devices and
services that assist the child in adapting to and/or accessing
educational instruction and settings)
Assessment of child’s need for orientation and mobility training
(services for children with visual impairment that assist them in
navigating the educational environment)
Assessment of child’s interests and preferences regarding
postsecondary outcomes for the purpose of determining transition
needs
Other:
Hearing teacher
Vision teacher
Vision teacher
Vision teacher
Speech therapist
Speech therapist
Speech therapist
Speech therapist
Speech therapist
Speech therapist
Speech therapist
School Psychologist and
Speech therapist
Occupational therapist
Occupational therapist
Occupational therapist
Physical therapist
O&M specialist
Section IV: Evaluation Schedule:
This is an initial evaluation and will be completed within 60 calendar days of receipt of written parental consent to
evaluate.
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Student name, School name
Section V: Review of Additional Data Collected:
Areas
Current Levels of Performance (based on additional data)
Section VI: Eligibility Determination:
Are this student’s difficulties primarily due to:
1. a lack of appropriate instruction in reading, including the essential components of reading
(phonemic awareness, phonics, vocabulary development, reading fluency including oral
reading skills, and reading comprehension strategies?)
Yes
No
2. a lack of appropriate instruction in math?
Yes
No
3. limited English proficiency?
Yes
No
Does the child meet disability-specific eligibility according to South Carolina State Board of Education
regulations 43-243 and 43-243.1?
Yes
No
If Yes, does the child, by reason thereof, need specially designed instruction in order to receive a free
appropriate public education?
Yes
No
If Yes, which disability category/categories:
Specific Learning Disability
Intellectual Disability
Emotional Disability
Developmental Delay
Speech or Language Impairment
Traumatic Brain Injury
Autism
Other Health Impairment
Orthopedic Impairment
Vision Impairment
Deaf and Hard of Hearing
Deafblindness
Multiple Disabilities (Also check above all disabilities for which the child qualifies)
Not Eligible for services under IDEA
Additional Criteria for Initial Determination of a Specific Learning Disability
Not applicable for reevaluation or other disability category
1. Does the child achieve adequately for his or her age or to meet state-approved,
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Yes
No
Student name, School name
grade-level standards in one or more of the following areas, when provided with learning
experiences and instruction appropriate for the child’s age or state-approved gradelevel standards? If no, indicate in which areas the child does not meet standards.
Listening comprehension
Oral expression
Written expression
Basic reading skill
Reading fluency skills
Reading comprehension
Mathematics calculation
Mathematics problem solving.
2. Does the child make sufficient progress to meet age or state-approved, grade-level
Yes
No
standards in one or more of the following areas when using a process based on the child’s
response to scientific, research-based interventions; or, does the child exhibit a pattern of
strengths and weaknesses in performance, achievement, or both, relative to age, state-approved grade-level
standards, or intellectual development, that is determined to be relevant to the identification of a specific learning
disability, using appropriate assessments?
If no, indicate the areas below.
Listening comprehension
Oral expression
Written expression
Basic reading skill
Reading fluency skills
Reading comprehension
Mathematics calculation
Mathematics problem solving.
Indicate which method(s) was used to make this determination:
Response to Intervention
Strengths and weaknesses
3. Are the evaluation findings primarily the result of a visual, hearing, or motor disability; mental retardation;
emotional disturbance; cultural factors; or environmental or economic disadvantage.
Yes
No
Section VII: Educational Needs for all Eligible Students (initial evaluation and reevaluation):
NA if student was not determined to be eligible
Description of Educational Needs (an analysis of the educational relevance of the evaluation results, strengths and
weaknesses, and a description of the adverse educational impact, including how the disability affects involvement
and progress in the general education curriculum (or for preschool children, in appropriate activities)):
Recommended Specially Designed Instruction (recommendations to the IEP team to assist in the development of
the IEP’s present levels of performance and annual goals. Specify the areas in which the child requires specially
designed instruction (i.e. math, gross motor, social skills, etc.)):
Necessary Related Services (specify the related services needed in order for the child to benefit from special
education (i.e. occupational therapy, physical therapy, counseling, audiology services, interpreting services, etc.)):
Other Information Needed to Develop the IEP (determined through the evaluation process and from parental input,
including any recommended supplementary aids and services for the child and program modifications or supports for
school personnel, if needed):
QUANTITATIVE RESULTS
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Student name, School name
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