Revised 11/24/15
Child Study Assessment Profile Secondary 9-12
Date:
Student:
Grade:
Assessment case manager:
Initial Evaluation
Re-Evaluation
SLD
OHD
D.O.B
EBD
Other
Teacher:
Describe other options or factors/options that were
considered relevant to this evaluation such as behavior,
blindness or visual impairment, deafness or hard of
hearing, assistive technology, race, culture, or language:
Interventions, if any that preceded this evaluation:
Following is a statement of adaptations needed to conduct
this evaluation:
A description of any other options that the district considered
and the reasons why those options were rejected:
_________________________________________________
Intellectual Functioning: Evaluated bySchool Psychologist: ________________________________
Differential Ability Scales - Second Edition (DAS-II)
Comprehensive Test of Non-verbal Intelligence – Second Edition (CTONI-2)
Kaufman Assessment Battery for Children - Second Edition (K-ABC II)
Review of Records
Wechsler Intelligence Scale for Children - Fifth Edition (WISC-V)
Woodcock Johnson: Tests of Cognitive Abilities
_______________________________
_______________________________
Academic Performance: Evaluated by Special EducationTeacher:____________________________
Classroom Observation
Cognitive Processing Inventory (CPI)
Information Processing Questionnaire, Parent and Teacher
Wechsler Individual Achievement Test- Third Edition (WIAT-IV) PreK-12
Wide Range of Achievement Test -4 (WRAT)
Woodcock Johnson IV – Tests of Achievement (WJ-IV)
________________________________
________________________________
Communication: Evaluated by Speech/Language Clinician: ________________________________
Clinical Evaluation of Language Fundamentals-4th Edition (CELF-5) (ages 9-12 yrs)/(ages 13-21 yrs)
Comprehensive Assessment of Spoken Language (CASL) (3- to 21-11)
Expressive Vocabulary Test (2-6 to 90 years)
Language Sample(s)
Oral and Written Language Scales 3-21
Peabody Picture Vocabulary Test (2.6-90)
Social Language Development Test - Adolescent
Templin-Darley Articulation Test
Test of Language Competence – Expanded Edition
The Adolescent Test of Problem Solving (6-11)
________________________________
________________________________
Social, Emotional, Behavioral: Evaluated by:________________________________
Achenbach Child Behavior Checklist (parent/teacher)
Behavior Assessment System for Children - Third Edition (BASC-3) (parent/teacher/self)
Children’s Depression Inventory-Second Edition
Conner’s Teacher and Parent Rating Scale III–Third Edition
Diagnostic Predictive Scale
Functional Behavior Assessment (observations, parent and teacher interview)
Multidimensional Anxiety Scale for Children
Observations (home/classroom) Staff person(s) doing observations
Piers Harris Children’s Self Concept Scale
Student Interview
________________________________
________________________________
Social Emotional Disorders: Evaluated by: ________________________________
ADOS (Autism Diagnostic Observation Schedule)
Autism Spectrum Rating Scale (ASRS)
Dyssimia Rating Scale
Developmental History
Educational Autism Criteria
Observation in Two Settings
Parent Interview
Social Responsiveness Scale (SRS-2)
Stress Survey Schedule
Student Interview
________________________________
________________________________
Motor Ability: Evaluated by Occupational Therapist: ________________________________
Adolescent/Adult Sensory Profile-Self Questionnaire
Beery Test of Visual-Motor Integration 6th Edition
Bruininks-Osteretsky Test of Motor Proficiency, Revised Edition
Child Sensory Profile 2
Clinical Observations
Pediatric Evaluation of Disability Inventory (PEDI)
Review of Handwriting Samples
School Companion Sensory Profile 2 Teacher Interview
Test of Visual Motor Skills 3rd Edition
Test of Visual Perceptual Skills 3rd Edition
________________________________
________________________________
Adaptive Skills: Evaluated By School Psychologist: ________________________________
Adaptive Behavior Assessment System-Third Edition (ABAS-3)
Normative Adaptive Behavior Checklist-Revised
Vineland Adaptive Behavior Scales II
Woodcock Johnson: Scales of Independent Behavior-Revised
________________________________
________________________________
Functional OHD Assessment: Evaluated by Special Education Teacher: _____________________
Conner’s Rating Scale III–Third Edition (Parent/Teacher/Student)
Organizational/Work Skills Checklist
Parent Interview conducted by a licensed special education teacher
Review of Records
Systematic Observation (at least one conducted by a licensed special education teacher)
Teacher Interview conducted by a licensed special education teacher
________________________________
________________________________
Physical Education Status: Evaluated by Adaptive Phys. Ed. Teacher:_________________________
Checklist for Adapted Physical Education Students with POHI/TBI
Curriculum Based Assessment for DAPE Level 3 DCD
General Physical Education Assessment for Developmental Adapted Physical Educ.
Physical Education Classroom Observation
Physical Education Skills Based Inventory
Physical Fitness Testing
Test of Gross Motor Development-2 Short Form
________________________________
________________________________
Sensory: Evaluated by Licensed School Nurse: ________________________________
Current Vision and Hearing Status
Review of Records
________________________________
________________________________
Physical/Health: Evaluated by Licensed School Nurse/School Psychologist/Special Education Teacher
__________________________________________________
Health Assessment
Parent/Student Interview
Review of Records
Verification of Medical Diagnosis
________________________________
________________________________
Transition: Evaluated by Special Education Teacher: ______________________________
Enderle-SeversonTransition Rating Scale
Informal Transition Checklist
Counseling Career Planner
________________________________
________________________________
Other: Evaluated by School Psychologist or Special Education Teacher: ______________________
Cognitive Processing Inventory (CPI)
___________________________________
Home/Family Questionnaire
Review of Records
________________________________
________________________________