SCHOOL DISTRICT



___________________________ SCHOOL DISTRICT

Exceptional Children Services

CONFIDENTIAL

EDUCATIONAL ASSESSMENT REPORT

STUDENT __________________________________________ BIRTHDATE _______________________ AGE _______________

PARENT/GUARDIAN _________________________________ ADDRESS _____________________________________________

TELEPHONE _________________ GRADE______ SEX ____ CURRENT ATTENDANCE CENTER _________________________

REASON FOR REFERRAL ____________________________________________________________________________________

EXAMINER _________________________________________ DATE OF REPORT_______________________________________

INITIAL & 3 YEAR SCORES/OBSERVATIONS DATE

EVALUATION ASSESSMENTS ADMINISTERED

Standard Score Percentile

KAUFMAN TEST OF EDUCATIONAL ACHIEVEMENT By Age By Age

Reading Decoding

Reading Comprehension

READING COMPOSITE

Mathematics Computation

Mathematics Application

MATHEMATICS COMPOSITE

Spelling

BATTERY COMPOSITE

Normalized Standard

Score Converted From Percentile

TOWL-3 TEST OF WRITTEN LANGUAGE – Third Edition Percentile Rank By Age

Vocabulary

Spelling

Style

Logical Sentences

Sentence Combining

Contextual Conventions

Contextual Language

Story Construction

SPONTANEOUS WRITING QUOTIENT

This information is confidential and shall not be duplicated, copied or released without informed Parental Consent.

Student/Parent Data Fill out completely to avoid possible confusion of student names.

Reason for Referral Obtain the reason for referral from the Consent from (SE 98-2). Indicate if this is a 3-year reevaluation.

Examiner/Evaluator The person completing the evaluation/assessment report should be identified by name and title.

Date of Report List the day the evaluation was completed and the scores were recorded.

Date Administered/ Identify the date(s) during which the test(s) was administered. Multiple testing sessions might have been

Date of Evaluation used.

Assessments Conducted/ List names of all assessments administered or reviewed in developing the report. If reviewing a test which

Reviewed falls outside the evaluation timeline, indicated in the report that it is a review. List test results and dates

administered; in addition to listing total test scores, subtest scores and results shall be indicated.

Scores/Observations/ Identify all scores as standard scores by age. Use conversion chart found in assessment section of the

Behaviors Observed Special Education Handbook if need to convert percentiles to standard scores. Specific observations made

during testing should be noted. Identify characteristics which may affect educational planning.

Recommendations Based upon test results, describe student performance and educational implications. Do Not include

statements which identify a handicapping condition or recommend a specific placement, services, further evaluations, etc.

Discussion/Summary Info. Describe test behavior as it affects student performance. Include information needed to assist the reader in

interpreting test scores. A well-written summary will indicate information appropriate for present levels of performance statements in IEP development.

Student Strengths List relevant strengths, including any information which might be helpful in developing the student’s program

in the least restrictive environment. Include positive information about the student to be shared with parents and staff.

Student Weaknesses List relevant weaknesses. Any area that represents a learning deficit should be noted here. When interpreting diagnostic information, student needs will be discussed. Do Not include statements which identify a handicapping condition or recommend a specific placement, services, further evaluations, etc. These are placement committee prerogatives.

Signature/Title/Date The person completing the evaluation/assessment report should be identified by name and title. List the date that the evaluations were conducted and scores were recorded.

Diagnosis/Physician The professional completing the evaluation must refer to the medical doctor for the diagnosis if there is one. List the M.D. by name.

Routing Route as indicated on the bottom of the form.

STATE RULES

Nondiscriminatory Practices. Testing and evaluation materials and procedures used for the purpose of evaluation and placement of children with disabilities must be selected and administered so as not to be racially or culturally discriminatory.

Evaluation Procedures. School districts shall ensure, at a minimum, that evaluation procedures include the following:

1) Tests and other evaluation materials are provided as follows:

a) Are provided and administered in the child’s native language or by another mode of communication that the child understands, unless it is clearly not feasible to do so;

b) Have been validated for the specific purpose for which they are used; and

c) Are administered by trained personnel in conformance with the instructions provided by the producer;

2) Tests and other evaluation materials include those tailored to assess specific areas of educational need and not merely those which are designed to provide a single general intelligence quotient;

3) Tests are selected and administered so as best to ensure that a test administered to a child with impaired sensory, manual, or speaking skills accurately reflects the child’s aptitude or achievement level or whatever other factors the test purports to measure, rather than the child’s impaired sensory, manual, or speaking skills except where those skills are the factors which the test purports to measure;

4) No single procedure is used as the sole criterion for determining an appropriate educational program for a child;

5) The evaluation is made by a multidisciplinary team or group of persons, including at least one teacher or other specialist with knowledge in the area of suspected disability; and

6) The child is assessed in all areas related to the suspected disability, including, where appropriate, health, vision, hearing, social & emotional status, general intelligence, academic performance, communicative status, and motor abilities.

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