XXXX (Name of School/District)
Main Address of School/District
City/State/Zip
EARLY CHILDHOOD MULTIDISCIPLINARY EVALUATION TEAM REPORT
Student Name:
Date of Birth:
Age:
Educational
Setting:
Parent/Guardian:
Date of Report:
~ Information contained in this report is CONFIDENTIAL and intended for school programming and
planning ~
Reason for Evaluation
Following extensive interventions in the area(s) of XXX, XXX continued to experience a lack of consistent
developmental achievement. On XXX, a referral for a special education evaluation was made by XXXX
to address delays in XXXXX. Parent consent for the evaluation was obtained on XXX.
OR
On XXX, a referral for a special education evaluation was made by the parent to address concerns in
XXX. Parent consent for the evaluation was obtained on XXX.
OR
Michigan requires that students with a disability who enroll from out-of-state are evaluated to determine if
the student meets Michigan criteria as a student with a disability. A review of XXXX’s records indicate that on
XXXX, XXXX was determined to have a XXXX disability in the state of XXXX. An evaluation review plan was
created and parent consent to evaluate was obtained on XXXX.
Relevant Developmental History Related to Area of Disability
Relevant Medical History Related to Area of Disability
Vision, Hearing
Educational History
Additional Information Needed
The Evaluation Review Plan identified existing information available to the evaluation team. It also
identified additional information necessary for a comprehensive evaluation. The methods used by this
evaluation team to obtain the additional information identified by the Evaluation Review Plan include the
following:
Methods Used to Collect Evaluation Data
Xxxxx – Page 2
XXX, Title
XXX, Title
Xxxxx – Page 3
PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Teacher Interview
Observations of Child in the Learning Environment
Learning and Problem-Solving Development
History of Instruction/Intervention
Present Level of Learning and Problem-Solving
Educational Implications
Communication
History of Instruction/Intervention
Present Level of Receptive Language/Listening Comprehension
Present Level of Expressive Language/Oral Expression
Adapted Communication
Present Level of Articulation
Present Level of Fluency
Present Level of Voice
Educational Implications
Social-Emotional
History of Instruction/Intervention
Present Level of Sense of Self
Present Level of Responsibility for Self and Others
Xxxxx – Page 4
Present Level of Play Skills
Observable Behavior
Educational Implications
Physical Development
History of Instruction/Intervention
Present Level of Perceptual/Fine Motor
Present Level of Gross Motor and Mobility Skills
Present Level of Sensory Processing
Present Level of Organization
Educational Implications
Adaptive Behavior and Functional Living Skills
History of Instruction/Intervention
Present level of adaptive behavior and functional living skills within the school environment
Present Level of Self-Care Skills
Educational Implications
The Findings are not Primarily the Result of Certain Factors Other than the Suspected Disability
[Provide evidence to support “rule-out” factors of MET face sheet] For example:
XXX and his parents’ native language is English. A review of the vision and hearing screenings in the
CA-60 as well as teacher and parent input revealed no concerns with these modalities. XXX has
developed positive peer relationships both in the classroom and outside of school where he participates
in a variety of activities. XXX’s teacher noted that XXX demonstrates good sportsmanship and gross
motor skills are appropriate for his age. Cognitive skills fall within the average range. XXX received
regularly scheduled interventions, and XXX’s parents did not provide any information that would suggest
cultural, environmental, or economic factors as primary explanations for XXX’s difficulties that he is
presenting with in the classroom.
Summary Statement
Xxxxx – Page 5
In assessing for whether XXX has a XXX and is in need of special education, the evaluation process
determined:

RECOMMENDATION TO BE CONSIDERED BASED UPON EDUCATIONAL NEEDS

The result of this comprehensive evaluation indicates that XXXX meets the criteria under Rule
340.xxxx as a student with a xxxxxx impairment in the area(s) of XXX.

The result of this comprehensive evaluation indicates that XXXX does not meet the criteria under
Rule 340.xxxx as a student with a xxxxxx impairment.
Katie Powers
School Psychologist
Nina Wagar
Early Childhood Special Education Teacher
Kelli Fenlon
School Social Worker/ECSE Service Coordinator
Amy Richards
Speech and Language Therapist
Susan Stackhouse
Speech and Language Therapist
Tracy Tunison
Speech and Language Therapist
Rebecca Villemure
Speech and Language Therapist
Sarah Crouse
Registered Occupational Therapist
Mary Johnson
Registered Occupational Therapist
Eric Dunlap
Physical Therapist
Christy Dunne
Teacher Consultant of the Hearing Impaired
Kim Seaney
Visual Impaired and Orientation and Mobility Specialist
Xxxxx – Page 6
TEST SCORE ADDENDUM
Average standard scores fall within a range of 85 to 115 and are more
reliable to report student performance than grade equivalents.
(Name of Assessment):
List Composite/Domain/Quotient/Index)
Subtest(s)
List Composite/Domain/Quotient/Index)
Subtest(s)
(Name of Assessment):
List Composite/Domain/Quotient/Index)
Subtest(s)
List Composite/Domain/Quotient/Index)
Subtest(s)
Standard
Score
%ile
Grade
Equivalency
Standard
Score
%ile
Grade
Equivalency