Checklist for Learning Disability Eligibility Report

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Revised 10/17/07

Checklist for Learning Disability Eligibility Report: Initial Evaluation

The following elements are

required

for each section of initial LD Eligibility Reports. If information is missing, or questions are unanswered, the team is not ready to make an eligibility determination.

Name:

Birthdate:

Evaluator:

School:

Grade:

Report Date:

Section 1: Background Information

Reason for the referral (state areas of concern and disability/disabilities suspected)

Previous testing

History in special programs (special education, Title I,

ELL)

Parent concerns and perspective, including background of disabilities, especially in areas related to current difficulties

Section 2: Students who qualify for special education as having learning disabilities have very low skills relative to expectations for the student’s age, or relative to the student’s progress toward Oregon achievement.

Source(s)

Cumulative file

Individual Problem Solving Worksheet

Report cards

Developmental history

Source(s)

Review of existing information including teacher collected work samples

List Oregon Assessment of Knowledge & Skills

(OAKS) scores, both current and historical

List all DIBELS subtest scores (both current and

Required in area of concern (K-3)

Reading

DIBELS

Phonics Inventory

WIAT-II: Listening Comprehension historical) o o

Insert DIBELS or IDEL tables (at end of checklist)

Summarize actual growth to expected growth and

Math

CBMs

WIAT-II: Numerical Operations &

 o student scores to average scores

List individual achievement test results in standard scores by subtest

Include standard scores for tests given in the past

Mathematics Reasoning

Writing

Writing and/or Spelling CBMs

WIAT-II: Written Expression or o

For any subtests with SS below 90, describe the

TOWL-III specific skill deficits that contribute to the low score o

List classroom assessment scores and curriculum

Optional in area of concern (K-3)

 based measures (includes pre- and post-tests, math and writing CBMs)

Analyze historical data.

Reading

WIAT-II: Pseudoword Decoding,

Word Reading, Reading

- Have scores always been low?

Comprehension o

If not, a learning disability is unlikely.

Writing

- Are scores relatively low? o

If not, get one more piece of information about the

WIAT-II: Spelling o

Has the student had intensive assistance to maintain skills at that level?

Required in area of concern (4-5)

Reading

achievement tests consistent?

DIBELS

WIAT-II: Reading Comprehension skills in question.

 o

Confirm results with reports from teachers, which must be consistent.

If inconsistent results are reported, decide which is

Math

CBMs

WIAT-II: Numerical Operations &

Revised 10/17/07 valid and justify the decision. o

Consider the demands of each assessment

(content, speed, fluency) o

Lower scores may be considered valid if they reflect performance on a test that is more comprehensive or involves more complex demands than other assessments used.

Finish with a summary statement about the stude nt’s low skills. o

Describe the student’s academic weaknesses. o

Note if the significant skill deficits combine with strengths to form a pattern of achievement that has been demonstrated to be associated with an LD subgroup. Strengths should be informally assessed by reviewing report cards and work samples. If gathered information is inconclusive, conduct curriculum based measures in potential areas of strength.

1) Reading Disability: Word Recognition o

Weaknesses: phonological processing, o spelling

Strengths: math computation, spatial and motor skills

2) Reading Disability: Fluency o

Weaknesses: fluency o

Strengths: word recognition

3) Reading Disability: Comprehension o

Weaknesses: vocabulary, receptive o language, working memory, attention

Strengths: phonological processing

4) Math Disability o

Weaknesses: math computation, attention, working memory, motor and spatial skills o

Strengths: word recognition, spelling, vocabulary

5) Written Expression Disability o

Weaknesses: handwriting, spelling, composition o

Strengths: math computation

Mathematics Reasoning

Writing

Writing and/or Spelling CBMs

WIAT-II: Written Expression or

TOWL-III

Two scored writing samples using

Oregon rubric

Optional in area of concern (4-5)

Reading

WIAT-II: Listening Comprehension

Writing

WIAT-II: Spelling

Required in area of concern (6-12)

Reading

CBMs

WIAT-II: Pseudoword Decoding,

Word Reading, Reading

Comprehension

Math

CBMs

WIAT-II: Numerical Operations &

Mathematics Reasoning

Writing

Writing and/or Spelling CBMs

WIAT-II: Written Expression or

TOWL-III

Two scored writing samples using

Oregon rubric

Optional in area of concern (6-12)

Writing

WIAT-II: Spelling

Cumulative file

Individual Problem Solving Worksheet

Report cards

Work samples

Teacher reports

State/District Assessment Results

Individual Achievement Test Results

Revised 10/17/07

Section 3: Students with learning disabilities have academic skill deficits that are resistant to wellplanned and implemented research based interventions that were designed to increase the child’s rate of learning.

State what the baseline skill level was (a number), and how that relates to the general population.

State what the interventions were and the basis upon

 which they were chosen. Include: o

Specific curriculum/method used o

How much time per day o

Length of intervention o

Group size o

Level and type of reinforcement used o

If needed, additional behavior interventions

Describe the student’s response to the intervention

(progress monitoring data, including the measure and frequency). o

How does this relate to the general population? o

How does this relate to progress of intervention cohort?

Does this progress support a picture of a skill deficit that is resistant to instruction?

Section 4:

The student’s academic performance and behavior were observed in a regular classroom setting.

Observation must occur in area of concern

Note relevant behavior and its relationship to academic functioning

Section 5: The student has been provided the opportunity to learn the skills.

Document the level of instructional stability throughout the student’s educational experience o

Mobility (# of schools attended) o

Attendance (over the years) o

Reason(s) for excessive absences o

Cumulative effect of absences (“Missed 20 days per year for 4 year, equating to one semester missed”)

Describe key characteristics of the

core

instruction the student has received in area of concern o

Research based? Mention specific curricula, if known. o

Has the student received instruction in phonemic awareness, phonics, fluency, comprehension and vocabulary? o

Amount/intensity? o

Training of instructor (certified? IA?) o

Size of group

Source(s)

Progress monitoring data

Student Intervention Profile

Information from interventionist

Source(s)

Observation data

Source(s)

Cumulative file

Individual Problem Solving Worksheet

Student Intervention Profile

Developmental history

Report cards

Teacher interviews

Revised 10/17/07

Section 6:

The student does not have another disability or sensory problem.

Report results of current vision and hearing screenings.

Report historical difficulties with vision and hearing as reported by parent (infections, tubes, surgeries)

Have there ever been suspicions of other disabilities?

Consider: o

Attention-Deficit/Hyperactivity Disorder o

Autism Spectrum Disorder o

Other Health Impairment o

Communication o

Emotional Disturbance o

Mental Retardation

Report results of evaluations done regarding any areas of concern raised at the time of referral or during the evaluation. This is the place to explain, if you decided not to assess those areas, why you didn’t.

This is the section to report results of functional behavior assessments, Conners scales, language assessments, etc.

If an IQ test was given, this is the place to note statistically unusual performance.

Section 7:

The student’s problem is not the result of cultural factors or environmental or economic disadvantage.

Describe the student’s school history starting with preschool.

Describe pertinent information about family literacy

 levels.

Describe pertinent information about the family’s social history that could account for stressors, such as: o

Frequent moves o

Homelessness o

Divorce o

Unemployment o

Extended illnesses or deaths in the family

Section 8:

The student’s problem is not the result of limited English proficiency.

Identify the student’s primary and secondary languages.

Report current levels of: o

Primary Language Oral Proficiency o

Primary Language Writing Proficiency o

Primary Language Reading Proficiency o

English Oral Proficiency o

English Writing Proficiency o

English Reading Proficiency o

Acculturation Screening Results

How many years has the student lived in the US?

And

What is the home language?

And

Source(s)

Cumulative file

Individual Problem Solving Worksheet

Developmental History

Report cards

Teacher interviews

Assessment results

Minutes of Evaluation Planning

Medical Statement

Source(s)

Cumulative file

Individual Problem Solving Worksheet

Developmental History

Source(s)

Cumulative file

Individual Problem Solving Worksheet

Parent Interview

LAS scores

Acculturation Screening

Revised 10/17/07

What is the parents’ literacy proficiency?

And

What is a typical academic profile for a student with this language and family history?

Section 9: Is there sufficient evidence to support the conclusion that this student is eligible for special education as a student with a learning disability?

This is the place that the “basis for determination” is stated clearly. o

Does the student have low skills? o

Has the student made slow progress despite intensive intervention? o

Have all exclusionary factors been ruled out? o

Note if the significant skill deficits combine with strengths to form a pattern of achievement that has been demonstrated to be associated with an LD subgroup.

Source(s)

Every component of the report in sections 1-8.

Discussion of the team.

Oregon Assessment of Knowledge and Skills (OAKS) Table

Reading

Benchmark

Student

Score

3rd

204

4th

211

5th

218

6th

222

7th

227

8th

231

10th

236

Percentile

Math

Benchmark

Student

Score

205 212 218 221 226 230 236

Percentile

Writing

Benchmark 32-39 40-49 40-49

Student

Score

Dynamic Indicators of Basic Early Literacy Skills (DIBELS) Tables

ISF

LNF

PSF

NWF

K-Fall

Score %ile Benchmark

8

8

N/A

N/A

K-Winter

Score %ile Benchmark

25

27

18

13

K-Spring

Score %ile Benchmark

N/A

40

35

25

Revised 10/17/07

LNF

PSF

NWF

ORF

1st-Fall

Score %ile Benchmark

37

35

24

N/A

1st-Winter

Score %ile Benchmark

N/A

35

50

20

1st-Spring

Score %ile Benchmark

N/A

35

50

40

NWF

ORF

2nd-Fall

Score %ile Benchmark

50

44

2nd-Winter

Score %ile Benchmark

N/A

68

2nd-Spring

Score %ile Benchmark

N/A

90

ORF

3rd-Fall

Score %ile Benchmark

77

3rd-Winter

Score %ile Benchmark

92

3rd-Spring

Score %ile Benchmark

110

ORF

4th-Fall

Score %ile Benchmark

93

4th-Winter

Score %ile Benchmark

105

4th-Spring

Score %ile Benchmark

118

ORF

5th-Fall

Score %ile Benchmark

104

5th-Winter

Score %ile Benchmark

115

Indicadores Dinámicos del Éxito en la Lectura (IDEL) Tables

K-Fall

Score %ile Benchmark

K-Winter

Score %ile Benchmark

LNF

(FNL) 6

5th-Spring

Score

25

K-Spring

Score

%ile

%ile

Benchmark

124

Benchmark

40

PSF

(FSF)

NWF

(FPS)

15

N/A

30

20

50

35

Revised 10/17/07

LNF

(FNL)

PSF

(PSF)

NWF

(FPS)

ORF

(FLO)

1st-Fall

Score %ile Benchmark

1st-

Winter

Score

35

50

35

N/A

%ile Benchmark

1st-

Spring

Score

N/A

50

70

20

%ile Benchmark

N/A

50

90

40

NWF

(FPS)

ORF

(FLO)

2nd-

Fall

Score %ile Benchmark

2nd-

Winter

Score

90

35

%ile Benchmark

2nd-

Spring

Score

N/A

50

%ile Benchmark

N/A

65

ORF

(FLO)

3rd-Fall

Score %ile Benchmark

3rd-

Winter

Score

60

%ile Benchmark

3rd-

Spring

Score

70

%ile Benchmark

85

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