Adverse Effect Worksheet
Optional Form for ARC Eligibility Decision-making
The ARC must determine that a child has a disability under IDEA. In order to
qualify for special education services a child’s disability must adversely affect the
child’s educational performance.
“Adverse effect” means the progress of the child is impeded by the disability to
the extent that the educational performance is significantly and consistently
below the level of similar age peers.
The term “educational performance” includes academic areas and non-academic
areas. Educational performance in non-academic areas can include reading,
math, communication, etc.; progress in meeting goals for the general curriculum;
and performance on state-wide and local assessments. Non-academic areas
include daily living activities, behavior, mobility, mental health, etc.
The ARC must determine and document that a child’s disability has an adverse
affect in one or more areas of educational performance noted above.
The following worksheet was designed to help teams identify and use a variety of
adverse effect measures. The ARC must use multiple sources of data to
document the child’s performance is significantly and consistently below the level
of same age peers. ARCs will complete the sources of data as appropriate for
each individual student and the suspected disability area(s).
Using the multiple sources of data in the worksheet will aid the ARC in the
comparison of the student to same age peers. Comparison to peers is the
difference between the individual’s level of performance and the expected level
of performance for individuals of the same age or other established standards.
For Information Purposes Only – July 2010
ARC Adverse Effect Worksheet
*denotes required for all disability area(s)
* Student Information
Name:
School:
Grade:
Ethnicity:
Birth Date:
Primary Language or Mode of Communication:
Date of Meeting to Determine Eligibility:
* Referral
Reason(s) the student was referred for special education:
* Suspected Disability Area(s) Determined by ARC Prior to Evaluation
* Summary of Progress Monitoring (For reevaluation describe the specially designed instruction provided in accordance with the IEP)
Area(s) of Difficulty
including academic,
Type Area of Difficulty Type Area of Difficulty Type Area of Difficulty Type Area of Difficulty
non-academic,
Here
Here
Here
Here
behavioral and/or ESL
concerns:
Evidence Based
Intervention(s) Provided
for Area:
Baseline Performance
Data, date and
performance level for
Area:
Results of Intervention,
dates and performance
levels for Area:
Teacher/Personnel
Providing Intervention:
For Information Purposes Only – July 2010
* ARC Intervention Analysis for Area(s) Noted Above
Type Area of Difficulty Type Area of Difficulty
Here
Here
Appropriate researchYes
No
Yes
No
based interventions
were targeted toward
the area(s) of concern
noted for the student
Appropriate researchYes
No
Yes
No
based interventions
were provided for a
sufficient length of
time to make
reasonable progress
in the curriculum
Appropriate researchYes
No
Yes
No
based interventions
were adjusted and
changed as needed
based on progress
data
The child’s data
Yes
No
Yes
No
performance remains
atypical from same
age peers
For Information Purposes Only – July 2010
Type Area of Difficulty
Here
Yes
No
Type Area of Difficulty
Here
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
English Language Learners
Identified as ELL
Results from the Program Services
Plan are included in the interventions
section above
Most Recent Access for ELLs results
Date:
Listening
Speaking
Yes
Date:
Status:
Reading
Writing
No
LEP
Redesignated as Fully
English Proficient
* Results of State Assessments
Date
Name of State Specific
Assessment
Content Area
Individual
Performance
Level
Performance
Level of
Peers
Amount of
Difference in
comparison to
peers
Significant
difference from
expected norms or
other established
standards when
compared to similar
aged peers?
Yes
Yes
Yes
Yes
Yes
For Information Purposes Only – July 2010
No
No
No
No
No
* Results of District Assessments
Date
Name of District
Specific Assessment
Content Area
Individual
Performance
Level
Performance
Level of
Peers
Amount of
Difference in
Comparison to
Peers
Significant
difference from
expected norms or
other established
standards when
compared to similar
aged peers?
Yes
Yes
Yes
Yes
Yes
* Results of District Universal Screening Assessments
Name of Universal
Content Area
Individual
Performance Level
Screening
Performance Level
of Peers
Assessment
Fall
Winter
Spring
Fall
Winter
Spring
Comparison Difference from
Peers
Fall
Winter
Spring
Significant
difference from
expected norms or
other established
standards when
compared to similar
aged peers?
Yes
Yes
Yes
Yes
Yes
Yes
For Information Purposes Only – July 2010
No
No
No
No
No
No
No
No
No
No
No
* Most Recent Grades
Content Area:
Grade
Class
Rank
Significantly below expected norms or other established standards
when content area grades are compared to grades of similar aged
peers
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Note: In using grades from homogeneously grouped classes compare to average
performing peers at that grade level rather than within the class
Review of Student Work, Language Samples or Portfolio Entries
Individual
Date
Type of Student Work
Content Area
Performance
Reviewed
Level
Performance
Level of
Peers
Amount of
Difference in
Comparison to
Peers
Significant
difference from
expected norms or
other established
standards when
compared to similar
aged peers?
Yes
Yes
Yes
Yes
Yes
For Information Purposes Only – July 2010
No
No
No
No
No
Non-Academic Areas
Date
Non-Academic Area
Behavior:
Report Name or Source
Disciplinary records
Rating scales Specify:
Individual
Performance
Level
Performance
Level of
Peers
Amount of
Difference in
comparison to
peers
Significant
difference from
expected norms or
other established
standards when
compared to similar
aged peers?
Yes
No
Yes
No
Mental Health
Yes
No
Health Concerns,
illness or disease
Ability to sustain
attention to task over
a period of time
Yes
No
Yes
No
Yes
No
FBAs
Systemic observations
in more than 1 setting over
a significant period of time.
Self-help or Daily
Living Skills:
Strength to sustain
attention to task over
a period of time
Rating scales Specify:
Systemic observations
in more than 1 setting over
a significant period of time.
Rating scales Specify:
Systemic observations
in more than 1 setting over
a significant period of time.
Rating scales Specify:
Systemic observations
in more than 1 setting over
a significant period of time.
For Information Purposes Only – July 2010
Date
Non-Academic Area
Vitality to sustain
attention to task over
a period of time
Motor, coordination or
mobility
Sound errors, voice
quality, or fluency
disorders
Attendance problems,
irregular attendance,
excessive tardiness,
attendance at multiple
schools
Significant nonacademic issues not
yet mentioned
Report Name or Source
Individual
Performance
Level
Performance
Level of
Peers
Amount of
Difference in
comparison to
peers
Significant
difference from
expected norms or
other established
standards when
compared to similar
aged peers?
Rating scales Specify:
Yes
No
Systemic observations
in more than 1 setting over
a significant period of time.
Rating scales Specify:
Yes
No
Systemic observations
in more than 1 setting over
a significant period of time.
Other Assessment
Specify:
Rating scales Specify:
Yes
No
Yes
No
Yes
No
Systemic observations
in more than 1 setting over
a significant period of time.
Other Assessment
Specify:
Rating scales Specify:
Systemic observations
in more than 1 setting over
a significant period of time.
Other Assessment
Specify:
For Information Purposes Only – July 2010
* Adverse Affect Questions
Yes No Explain:
Multiple measures indicate the student is significantly
and consistently below same age peers
Concerns are by observed by multiple people across
different times and in different settings
Concerns are primarily caused by
Limited English Proficiency
Concerns are caused due to lack of appropriate
instruction in reading, including the essential
components of reading
Concerns are caused by a lack of instruction in math
Ecological factors (e.g., race, ethnicity, culture,
language, or life circumstances) are affecting the
educational performance in the areas of concern
The student data performance is atypical when
compared to peers of similar socioeconomic status
and ethnicity
The adverse effect measures establish that the
adverse effect has been present for at least 6 months
If not present for at least 6 months, the documentation
establishes that the disability is not temporary and that
an adverse effect will escalate without immediate
intervention
The educational needs of the student require services
and support that extend beyond what typical general
education resources alone can provide
For Information Purposes Only – July 2010
Looking at the entire picture of the student in comparison to peers the ARC determines the disability has an adverse effect
on educational performance.
Yes
No
If Yes, summarize how the disability adverse affects the student’s educational performance.
For Information Purposes Only – July 2010