Barton County Special Services
2535 Lakin
Great Bend, Kansas 67530
(620) 793-1550 ~ Fax (620) 793-1551
Evaluation/Eligibility Team Report
Initial Evaluation
Reevaluation
Student Name:
Meeting Date:
Birth Date:
Parents/Legal Education Decision Maker:
School:
Grade:
CONFIDENTIAL INFORMATION – FOR PROFESSIONAL USE ONLY
This information is to be regarded as strictly confidential and is to be made available to authorized
persons only.
Reason for Referral:
Background Information
Previously identified disabilities/areas (check all exceptionalities that apply and enter initiation and dismissal
dates)
Autism
Emotional Disturbance
Deaf-Blind
Traumatic Brain Injury
Learning Disability
Developmental Delay
Gifted
Hearing Impaired
Present Primary Exceptionality
Present Secondary Exceptionality
Additional Data
Intellectual Disability
Other Health Impairment
Speech/Language
Severe Multiple Disabilities
Physically Impaired/
Orthopedic Impairment
Visually Impaired
Related Services: OT
PT
Evaluation Data Summary
General education intervention or screening results:
Record Review:
Interview:
Observation: (Include relevant behavior noted during the observation and the relationship of the behavior to the student’s academic
functioning.)
Tests:
WISC-IV
WJ-III
Speech/Language
Adapted Behavior Scales
Social/Emotional Rating Scales
Functional Behavioral Assessment
Other:
Present Levels of Educational Performance: Include current, specific, measurable objective
baseline data.
Health/Vision/Hearing
Health can be described as:
excellent
Health conditions that may affect learning:
good
fair
poor
Medications:
Health Plan Needed:
Vision Screening Date
Hearing Screening Date
Pass
Fail
Pass
Fail
Comments:
Evaluation/Eligibility Report, BCSS
Revised August 2011
Page 2
Motor
No gross/fine motor concerns
Gross motor concerns: Describe
Fine motor concerns; Describe
This person participates in Regular PE
This person participates in Regular PE with modifications
This person has completed PE requirements.
Comments:
Behavioral and Social/Emotional Observations and Testing
Short attention span; unable to concentrate; appears restless
Does not complete tasks; careless and disorganized
Seeks excessive attention
Socially isolated; withdrawn: Describe
Difficulty dealing with authority figures
Self-perception: Describe:
Peer Interaction: Describe
Poor anger control; frustrated
Strengths and/or comments:
Impact on education:
Evaluation/Eligibility Report, BCSS
Revised August 2011
Page 3
Behavior Assessment System for Children-2nd Edition: Interpretative Guidelines for T-Scores
Classification
Adaptive Scales
Clinical Scales
Clinically Significant
Very High
At-Risk
High
Average
Average
At-Risk
Low
Clinically Significant
Very Low
T-Score Range
70 and above
60-69
41-59
31-40
30 and below
Self-Report
Clinical Scales
Attitude to School
Attitude to Teachers
Sensation Seeking
School Problems
Atypicality
Locus of Control
Social Stress
Anxiety
Depression
Sense of Inadequacy
Somatization
Internalizing Problems
Attention Problems
Hyperactivity
Inattention/Hyperactivity
Emotional Symptoms Index
Adaptive Scales
Relations with Parents
Interpersonal Relations
Self-Esteem
Self-Reliance
Personal Adjustment
Rater
Summary:
Evaluation/Eligibility Report, BCSS
Revised August 2011
Page 4
Parent/Teacher Report
Clinical Scales
Hyperactivity
Aggression
Conduct Problems
Externalizing Problems
Anxiety
Depression
Somatization
Internalizing Problems
Attention Problems
Learning Problems
School Problems
Atypicality
Withdrawal
Behavioral Symptoms Index
Adaptive Scales
Adaptability
Social Skills
Leadership
Study Skills
Functional Communication
Adaptive Skills
Raters
Summary:
Conner’s Self Report Rating Scales: Interpretative Guidelines for T-Scores
70+
66-70
61-65
45-60
44 to <30
Markedly atypical, indicates significant problem
Moderately atypical, indicates significant problem
Mildly atypical, possible significant problem
Average to slightly atypical, should not raise a concern
Low scores are good, should not raise a concern
A. Family Problems
B. Emotional Problems
C. Conduct Problems
D. Cognitive Problems/Inattention
E. Anger Control Problems
F. Hyperactivity
G. ADHD Index
H. DSM-IV: Inattentive
I. DSM-IV: Hyperactive-Impulsive
J. DSM-IV: Total
Rater
Evaluation/Eligibility Report, BCSS
Revised August 2011
Student
Page 5
Summary:
Conners’ Teacher/Parent Rating Scales: Interpretative Guidelines for T-Scores
70+
66-70
61-65
45-60
44 to <30
Markedly atypical, indicates significant problem
Moderately atypical, indicates significant problem
Mildly atypical, possible significant problem
Average to slightly atypical, should not raise a concern
Low scores are good, should not raise a concern
A. Oppositional
B. Cognitive Problems/
Inattention
C. Hyperactivity
D. Anxious/Shy
E. Perfectionism
F. Social Problems
G. Psychosomatic
(parents only)
H. Conner’s' ADHD Index
I. Conner’s' Global Index
Restless-Impulsive
J. Conner’s' Global Index
Emotional Liability
K. Conners' Global Index:
Total
L. DSM-IV: Inattentive
M. DSM-IV: Hyperactive/
Impulsive
N. DSM-IV: Total
Raters
Summary:
Evaluation/Eligibility Report, BCSS
Revised August 2011
Page 6
Emotional and Behavior Problems Scale-2 (Hawthorne, EBPS-2 S/PV 2001)
Learning
Interpersonal
Relations
Inappropriate
Behavior
Under Normal
Circumstances
Unhappiness/
depression
Physical
Symptoms/
fears
Total Percentile
Score
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
SS=
%
%
%
%
%
%
%
%
Raters
Summary:
In Kansas State Regulations for Special Education “Emotional Disturbance” is defined as follows: “The term
means a condition exhibiting one or more of the following characteristics over a long period of time and to a
marked degree that adversely affects a child’s educational performance: an inability to learn that cannot be
explained by intellectual, sensory, or health factors; an inability to build or maintain satisfactory interpersonal
relationships with peers and teachers; inappropriate types of behavior or feelings under normal circumstances; a
general pervasive mood of unhappiness or depression; and a tendency to develop physical symptoms or fears
associated with personal or school problems. The term does not apply to children who are socially maladjusted,
unless it is determined that they have an emotional disturbance.”
In Best Practices in Assessing and Differentiating ED/SM in Children and Adolescents (MEDS-PDN), a simple
guide to differentiating Emotional Disturbance from Social Maladjustment includes the following criteria:
ED
No
SM
Yes
Was the behavior instrumental in obtaining some secondary gain, particularly to benefit
the child or harm another person?
Explain:
No
Yes
Was the student experiencing subjective distress?
Explain:
Yes
No
Was the behavior purposeful and calculated?
Explain:
Evaluation/Eligibility Report, BCSS
Revised August 2011
Page 7
Recommendations:
No significant behavioral concerns
Responds to school-wide management system
Conduct a Functional Behavioral Assessment
Develop a Behavior Intervention Plan
Provide positive behavioral support
Placement in Special Education for an Emotional Disturbance
Communication
No communication concerns
Comments and/or concerns:
Intellectual
WPPSI-III
Date:
Verbal
Performance
Full Scale
SB-IV
Date:
Verbal
Reas.
Abs./Visual
Reas.
Short Term
Memory
Quant.
Reason.
Composite
SB-V
Date:
Nonverbal
Verbal
Full Scale
WISC-III
Date:
VC
Verbal
PO
Performance
FD
Full Scale
PS
WISC-III
Date:
Verbal
Performance
Full Scale
VC
PO
FD
PS
Date:
VCI
PRI
Full Scale
WMI
PSI
PRI
Full Scale
WMI
PSI
WISC-IV
WISC-IV
Date:
VCI
Results:
Evaluation/Eligibility Report, BCSS
Revised August 2011
Page 8
Testing Observations:
Strengths:
Weaknesses:
Educational Impact:
Additional Comments:
Past test results reflect present functioning
Previous results are suspect; explain:
Academic Achievement
DAR:
Print Awareness
Rhyming Words
Segmenting Words
Hearing Initial Consonant Sounds
Hearing Final Consonant Sounds
Auditory Blending
Naming Capital Letters
Naming Lowercase Letters
Matching Letters
Matching Words
Writing Words
Consonant Sounds
Consonant Blends
Short Vowel Sounds
Rule of Silent E
Vowel Digraphs
Evaluation/Eligibility Report, BCSS
Revised August 2011
Mastered
Mastered
Mastered
Mastered
Mastered
Mastered
Mastered
Mastered
Mastered
Mastered
Mastered
Mastered
Mastered
Mastered
Mastered
Mastered
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Page 9
Diphthongs
Vowels with R
Two-Syllable Words
Polysyllabic Words
Word Recognition
Oral Reading (Accuracy)
Oral Reading (Fluency)
Silent Reading Comprehension
Spelling
Word Meaning
Mastered
Mastered
Mastered
Mastered
DAR Level:
DAR Level:
DAR Level:
DAR Level:
DAR Level:
DAR Level:
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Mastered Yet
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
Not Administered
AREA
SS
Mental Computation &
Estimation
--
Not Administered
Not Administered
Not Administered
Not Administered
Key Math-3:
AREA
SS
AE
Numeration
---
Algebra
---
Geometry
---
Addition & Subtraction
Multiplication &
Division
Measurement
Data Analysis
& Probability
BASIC
CONCEPTS
---
OPERATIONS
AE
AREA
--
Foundations of
Problem Solving
Applied Problem
Solving
--
APPLICATIONS
SS
AE
---
---
TOTAL TEST
COMPOSITE
WJ-III:
AREA
SS
AE
Br. Written Language
AREA
SS
AE
Written Expression
AREA
SS
AE
Basic Writing
Brief Writing
Brigance Diagnostic Comprehensive Inventory of Basic Skills, Revised:
AREA
Quotient AE
Recognizes Colors
Self-Help Skills
Personal Data Response
Identifies Body Parts
Understands Directional and
Positional Concepts
GENERAL KNOWLEDGE
AND LANGUAGE
AREA
Running and Skipping
Gross-Motor Skills
Standing Gross-Motor
Skills
Walking Gross-Motor
Skills
GROSS-MOTOR
SKILLS
Joins Sets
Numeral Comp.
Visual Disc.-Forms, Letters, &
Words
Recites Alphabet
Rote Counting
Understands
Quantitative Concepts
Reads Uppercase Letters
Counts Objects
Reads Lowercase Letters
Reads Numerals
READING
MATH
Evaluation/Eligibility Report, BCSS
Revised August 2011
Quotient AE
AREA
Quotient AE
Draw A Person
Visual Motor Skills Forms
Prints Lowercase Letters
in Sequence
Prints Uppercase Letters
Dictated
Prints Lowercase Letters
Dictated
Prints Uppercase Letters
in Sequence
Prints Personal Data
Writes Numerals in
Sequence
GRAPHOMOTOR AND
WRITING SKILLS
Page 10
WJ III:
AREA
SS
AE
AREA
SS
AE
AREA
Oral Language
Broad Math
Math Calculation
Oral Expression
Broad Written Lang
Math Reasoning
Listening Comp
Basic Reading
Basic Writing
Broad Reading
Reading Comp
Written Expression
SS
AE
SS
AE
SS
AE
WJ III:
AREA
SS
AE
AREA
SS
AE
AREA
Oral Language
Broad Math
Math Calculation
Oral Expression
Broad Written Lang
Math Reasoning
Listening Comp
Basic Reading
Basic Writing
Broad Reading
Reading Comp
Written Expression
MBA:
AREA
SS
AE
AREA
Basic Skills
Basic Reading
Basic Writing
Factual Knowledge
SS
AE
AREA
Basic Math
Testing Observations:
Reading:
Math:
Evaluation/Eligibility Report, BCSS
Revised August 2011
Page 11
Writing:
Social Studies:
Science:
Comments:
Adaptive Behavior
Adaptive behavior consistent with intellectual functioning
Adaptive behavior Not consistent with intellectual functioning
Comments:
Transition/Vocational Skills
Vocational Interests:
Work Habits:
Evaluation/Eligibility Report, BCSS
Revised August 2011
Page 12
Vocational Training
and Experiences:
Comments:
Assistive Technology
Comments:
BASIS for ELIGIBILITY DETERMINATION
YES
Question 1: Does this child exhibit an exceptionality?
NO
Data Sources used to support response:
GEI/Screening
Record Review
Interview
Observation
Testing
Discussion of how the data led you to the response:
YES
Question 2: Does the child need special education?
Data Sources used to support response:
GEI/Screening
Record Review
Interview
Observation
NO
Testing
Discussion of how the data led you to the response:
If child is suspected of having a learning disability, the severe discrepancy is primarily the result of:
Visual, hearing or motor impairment
YES
NO
Mental retardation or emotional disturbance
YES
NO
Environmental, cultural or economic disadvantage
YES
NO
Exclusionary Factors
The determined factor for eligibility is due to:
Evaluation/Eligibility Report, BCSS
Revised August 2011
Page 13
A lack of instruction in reading or mathematics
Explain:
YES
NO
Limited English Proficiency
Explain:
YES
NO
Environmental, cultural or economic disadvantage
Explain:
YES
NO
Any educationally relevant medical findings:
Parent Concerns
Comments:
COMMITTEE RECOMMENDATIONS
It is the judgment of the undersigned members of the evaluation team, including parents, that an
evaluation addressing all areas of concern has been completed and:
The student is eligible for special education because:
The criteria as a child with an exceptionality as determined by the Cooperative’s eligibility
Indicators has been met
and
Special education services are necessary to enable this student to receive educational
benefits in accordance with his/her abilities or capabilities.
Child meets the following criteria for
Check the applicable box(es).
AM
Communication
DB
Vision Loss
DD
Physical
ED
Interpersonal Relationships
GI
Aptitude
HI
Hearing Loss
LD
Oral Expression
Listening Comprehension
Written Expression
Basic Reading Skills
Reading Fluency Skills
Reading Comprehension
Mathematics Calculation
Mathematics Problem Solving
MD
At Least Two Disabilities
Evaluation/Eligibility Report, BCSS
Revised August 2011
Social Interaction
Before age of 3
Hearing Loss
Cognitive
Adaptive
Behavior /Emotions
Achievement
Communication
Social/Emotional
Physical Symptoms/Fears
Educational Impact
Matrix
Educational Impact
Severe Educational Needs
Page 14
ID
Aptitude
Adaptive Behavior
OHI
Chronic or Acute Health Problems
OI
Orthopedic or Health Impairment
SL
Language
TBI
Injury to brain from external source
VI
Vision Loss
Voice
Fluency
Achievement
Educational impact
Educational impact
Articulation/Phonology
Impaired functioning
Educational Impact
The student is not eligible for special education because:
The criteria as a child with an exceptionality as determined by the Cooperative’s eligibility
Indicators has not been met
or
Special education services are not necessary to enable this student to receive
educational benefits in accordance with his/her abilities or capabilities.
Child does not meet criteria for
based on:
.
Team Members:
Position
Signature
Date
Agree
Disagree
Parent
Parent
Admin/Designee
Psychologist
Gen. Ed. Teacher
Sp. Ed. Teacher
*Minority Report: Any member of this team dissenting from the final team recommendations may (and in the case of a student being
considered fro a learning disability, must) present, in writing, his or her recommendations and/or the reason(s) for disagreeing with the
decision.
Evaluation/Eligibility Report, BCSS
Revised August 2011
Page 15
I certify that a comprehensive evaluation has been completed for the student.
_____________________________________
Director of Special Services
Date:___________________________
The school psychologist reviewed the results of the comprehensive evaluation including test scores, summary and
recommendations for my child and I have received a copy of the evaluation.
The school staff has discussed and I have been given information on the process of guardianship and conservatorship
(effective when student turns 18 years of age).
__________________________________
(Psychologist’s Signature)
___________________________________
(Parent’s Signature)
__________________________________
(Date)
___________________________________
(Date)
Evaluation/Eligibility Report, BCSS
Revised August 2011
Page 16