Name of School
School Address
Area Code/Phone Number
PSYCHOEDUCATIONAL EVALUATION REPORT
Name:
Birth Date:
Gender:
Age:
Parent/Guardian:
Address:
Student ID Number:
Registered School:
Residence School:
Grade:
Male
, New Mexico
87
Phone Number:
Ethnicity:
Home Language:
Primary Language:
Language Proficiency:
Referral Date:
Date of Consent:
Testing Date(s):
Report Date:
EVALUATOR
Licensed Educational Diagnostician
Licensed School Psychologist
ASSESSMENTS
REFERRAL INFORMATION
was referred for an educational evaluation by his parents. Notification of referral information indicates
concern(s) in the area(s) of
.
EDUCATIONAL HISTORY
A review of his school records at
revealed
HEALTH RECORD REVIEW
The school nurse completed a vision and hearing screening on
vision.
passed the hearing screening.
which revealed that
passed
A review of a current health assessment, completed by the school nurse revealed that current health is
Confidential Student Name
.
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PARENT INTERVIEW
were interviewed in person on
.
STUDENT ASSISTANCE TEAM
The student was presented to the Student Assistance Team by his
during Student Assistant Team meeting(s),
. According to information collected
Tier I interventions were provided in the area(s) of
and
did make expected gains. Tier II
interventions were then implemented. Tier II interventions provide targeted, supplemental, individual, research
based support for a student who is performing below expectations and for whom Tier I instruction and
interventions have proven insufficient.
Tier II Interventions Goals:



The following progress monitoring and district assessment information was reported.
Name of Assessment
Skills Assessed
Assessment Date
Score
Review of Factors Which Could Impact Performance
State evaluation guidelines require a review of relevant factors that could impact a student’s progress in the
school setting. Cultural, linguistic, environmental and socio-economic are considered.




Cultural factors include cultural practices which could impact a student’s performance on a test or in
school. Commitment to time, movement, affect, and reliance on the manner in which one communicates
are some of the variables considered during the instruction day and testing.
Linguistic factors include the student’s dominant language, language spoken in the home, and
language(s) of instruction. The student’s first language and exposure to a second language are important
variables to consider. The duration and frequency of a second language other than English is subject to
investigation to determine if a student has acquired language proficiency in English before attempting to
measure academic or intellectual abilities.
Environmental factors include conditions, forces, or external stimuli which impinge upon a student’s
ability to succeed in the school setting or during testing.
Socio-economic factors which could impact health, nutrition, attitude, or exposure toward learning are
also reviewed.
Confidential Student Name
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EVALUATION
DESCRIPTIONS OF TEST SCORES
One or more derived scores are used to report standardized test results. Some of these scores and their
definition are as follows:
 Relative Proficiency Index (RPI) is a criterion reference measure which provides information about the
relative predicted ease or difficulty with which a student will be likely to perform similar grade or age
level work. An RPI of 5/90 means the student is predicted to perform at a 5% success level while the
average peers would perform at a 90% success level.
 Percentile (%ile) A score that gives the rank of a student compared with others of the same age (e.g. a
percentile of 70 means the student’s scores is equal to or greater than 70 out of 100 students of the
same age).
 Age Standard Score (SS) An age standard score is a measure of a student’s standing compared with
others of the same age. Standards scores have a mean of 100 and a standard deviation of 15.
 Age Equivalent (AE) A score that reflects a student’s performance in terms of the age level at which the
score falls. An age equivalent of 3-4 means the student made the same score by the average child who
is 3 years 4 months of age.
 Scaled Score This is a type of standard score with a mean of 10 and a standard deviation of 3,
typically used to report subtests results for intelligence scales.
 Standard Error of Measurement (SEM) A standard error of measurement is an estimate of the amount
of error associated with a student’s obtained score and is directly related to the reliability of a test.
 T-Score A T-Score is a standard score based on a distribution with a mean of 50 and a standard
deviation of 10.
CLASSROOM OBSERVATION
ASSESSMENT OBSERVATIONS
was evaluated in
session(s) at
.
demonstrated
. He did not wear glasses
during the testing. Rapport was easy to establish. The testing environment was adequate for the
administration of all test instruments. Test results appear to be valid estimates of current skill levels.
ASSESSMENTS
EVALUATION SUMMARY
ELIGIBILITY CRITERIA
The Eligibility of Specific Learning Disability is being considered. The Eligibility Determination Team will use
the 2011 New Mexico Technical Evaluations and Assessment Manual (TEAM) guidelines to determine
eligibility(ies).
Determination of eligibility is made by members of an Eligibility Determination Team (EDT) and requires that a
student meet evaluation criteria and demonstrates a need for special education services. An EDT meeting will
be held to review all available information related to the student.
RECOMMENDATIONS
Your Name and Credentials
Licensed Educational Diagnostician
Licensed School Psychologist
An interpretation of the results of this assessment was conducted on
Confidential Student Name
with
.
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