Graves County Public Schools
Consideration for Exclusionary Factors
Student: ________________________
Date of Birth: ________________
School: _________________________
Evidence Utilized:
Parent Interview
Multidisciplinary Eval
SIS Data/Information
Referral
Teacher Interview
Outside Eval
Environmental, Cultural, and Economic Factors
Environmental Factors
Absenteeism/tardiness, multiple school
placements, changes in family structure, social
services involvement, community/medical
resources
Cultural Factors
Length of time in the USA, previous opportunities for
language instruction, instruction in previous country,
ESL/ELL opportunities, migrant services
Economic Factors
Family financial problems, parent job loss, family living
arrangements, lack of funds for education enrichment or
mental health services, lack of transportation
Date of ARC: ________________
Attendance Data
Student Interview
Dev/Social History
Factors
Present
Significant
Impact On
Achievement
Yes
Yes
No
No
N/A
N/A
Yes
Yes
No
No
N/A
Yes
N/A
Yes
No
No
N/A
N/A
Yes
Yes
No
No
N/A
Yes
N/A
Yes
No
No
N/A
Yes
N/A
Yes
No
No
N/A
N/A
Yes
No
ESL Information
Other:
Comments
Other Exclusionary Factors
Limited or no participation in Preschool, Head Start or
other early learning opportunities
Limited or no participation in enrichment programs
(intervention services)
Behavior problems not related to suspected disability
Exclusionary Factors Impact Statement
Based on the evidence, this assessment indicates that
exclusionary facts have a substantial impact on this
student’s educational performance.
Comments/Evidence