Confidential - Custer School District / CSD Homepage
531368010477500 Report Date:Student Name: DOB: Age:Address: Gender: Grade: Parent/Guardian Name: Phone: ? Initial Evaluation? 3-Year Re-evaluation? New Transfer on IEP Categorical areas to be considered: I. BACKGROUND INFORMATIONREASON FOR REFERRAL: (include review of existing data, current parent/teacher concerns and prior evaluations)For students receiving special education services, State and Federal rules require a reassessment every three years to determine eligibility (to determine whether the disability remains present and whether the student remains in need of special education services) and present levels of performance. Evaluation results will also be utilized to develop the individualized education plan (IEP).Reason for Referral: (for re-evaluations, include SpEd history)Teacher and parent information that was shared as part of the review of existing data.Teacher Input: Parent Input: STUDENT RECORD REVIEW: Current grades in classes, attendance data, behavior/discipline referral data, MAP (district) and Smarter Test (state) test data, and relevant medical information were all reviewed and utilized as a basis for this evaluation.Background information provided by: Date: Academic Background (past programs and interventions-include RR, RtI, Title, PBIS, etc.):Current Grades:Smarter Balanced Scores: These assessments are designed to measure a student's academic performance in reading and math skills as compared to other South Dakota students.ELA/Literacy ScoresGrade – YearELA ScoreLevelMin. Score to Meet StdMath ScoresGrade – YearMath ScoreLevelMin. Score to Meet StdAttendance Data (include excused, unexcused, suspensions, tardies):School Year: Total Days of School: Total Days in Attendance: Absences:Quarter 1: Quarter 2: Quarter 3: Quarter 4: Tardies:Quarter 1: Quarter 2: Quarter 3: Quarter 4: School Year: Total Days of School: Total Days in Attendance: Absences: Quarter 1: Quarter 2: Quarter 3: Quarter 4: Tardies:Quarter 1: Quarter 2: Quarter 3: Quarter 4: Discipline Data:Medical HistoryHearing:Vision:Diagnostic:Medication:NWEA (Northwest Evaluation Association) MAP Results:The Northwest Evaluation Association’s (NWEA) computerized Measures of Academic Progress provide an accurate assessment of student progress in mastering the basic skills of reading, math, and language usage. The results of the assessments provide teachers and parents with an accurate assessment of student progress in the mastering the basic skills needed to be successful in high school and beyond.All of the tests developed by NWEA use the RIT (Rasch Unit) scale to measure student achievement and student growth. The RIT score relates directly to the curriculum scale in each subject area. It is an equal-interval score (like feet and inches) so scores can be added together to calculate accurate class or school averages. RIT scores range from about 150 to 300. RIT scores make it possible to follow a student’s educational growth from year to year. (insert MAP chart)DOCUMENTATION OF INTERVENTIONS (initial only):An intervention is a data driven plan or process that is specific, measurable, reasonable and implemented consistently for a minimum of 5-6 weeks in an attempt to remediate the skill deficit affected by the suspected disability.4381513081000II. STANDARDIZED ASSESSMENT RESULTS: EVALUATION PROCEDURES, RESULTS AND INTERPRETATION: Areas to be addressed:? Academic Achievement? Articulation ? Audiological ? Ability ? Language ? Ophthalmological ? Observation? Fluency? Chronic/Acute Health (Diagnosis)?Adaptive Behavior (to include social)? Voice? Current Medical Data/Records? Behavior? Fine Motor ? Autism Specific Instrument ? Transition? Gross Motor? Orientation/Mobility? Developmental (Cognitive, Adaptive, Motor, Communication, Personal/Social) ? Braille? Other: Assessment Measures (include required standardized assessments and skill-based assessments)InstrumentDateEvaluators-53340100330SUMMARY OF PSYCHOLOGICAL EVALUATION:Intellectual FunctioningIntelligence is the capacity people have to act purposefully, to think rationally, and to deal effectively with their environment. An intelligence test is given to estimate learning potential. Test scores reflect a student’s performance on a variety of cognitive activities and make a comparison to age peers. Test results are often used to determine expected levels of achievement. Test:Administered by:Date:Results:-628651295400ACHIEVEMENT ASSESSMENT:Academic Performance Academic achievement refers to a student’s skills in the areas of reading, written language, mathematics, oral expression, and listening comprehension. Academic achievement can be assessed through the use of formal and informal tests, classroom performance, teacher and parent information, and observations. Information from these sources is used to identify a student’s academic strengths and weaknesses, and can be used to develop IEP goals and objectives.Test:Administered by:Date:Results:-571501206500ACHIEVEMENT SKILL BASED ASSESSMENT:Test:Administered by:Date:Results:Test:Administered by:Date:Results:-533401409700BEHAVIORAL ASSESSMENT:Emotional, social, and behavioral functioning is observed and assessed in a variety of ways.? The use of standardized norm referenced questionnaires is one way to determine the severity of the behavior difficulties and to identify the patterns of behavior.? Additional information may be obtained through interviews, checklists, rating scales and observations. School records such as discipline and attendance reports are also considered. When historic data is available, progress and changes in behavior can be determined.? Test:Administered by:Date:Results:-533401257300BEHAVIORAL SKILLS BASED ASSESSMENT:Test:Administered by:Date:Results:-533401377950III. ADDITIONAL ASSESSMENT RESULTSAdditional assessments may include fine/gross/visual motor, adaptive, speech, sensory, etc. -533401447800HEALTH/ MEDICAL ASSESSMENT RESULTS38101320800TRANSITION ASSESSMENT (on or before age 16):For each pupil, the district shall conduct a multidisciplinary assessment of secondary transition needs and plan appropriate services to meet the pupil's transition needs. Areas of assessment and planning must be relevant to the pupil's needs and may include work, recreation and leisure, home living, community participation, and post-secondary training and learning opportunities. To appropriately assess and plan for a pupil's secondary transition, additional IEP team members may be necessary and may include vocational education staff members and other community agency representatives as appropriate.Test:Administered by:Date:Results:Transition strengths and needs based upon skill-based assessment:-53340-190500SUMMARY OF STUDENTS STRENGTHS AND NEEDS/STUDENTS PRESENT LEVELS OF PERFORMANCE: (include current classroom-based assessment such as AIMSweb, teacher recommendations, information from parents)Skill-Based Assessment, formerly known in the State of South Dakota as Functional Assessment, addresses skills a student demonstrates on skill-specific assessments, such as reading, math, language, behavior, and adaptive skills. Skill-based data collected through the evaluation process is essential in determining eligibility, developing educational goals, and developing a program designed to provide educational benefit. Skill areas identified through standardized assessment as areas of disability must be further evaluated through skill-based assessment. Data collected through skill-based assessment are the building blocks of an Individual Educational Program (IEP). The assessment provides a baseline of a student’s strengths and a list of specific needs which aid the IEP team in developing goals. If a student is determined to be eligible to receive special education or special education and related services, the IEP team must identify, based on evaluation results, which skill areas should be addressed in the IEP. Strengths and needs in the identified skill areas should be addressed in the Present Levels of Academic Achievement and Functional Performance (PLAAFP). Each skill area addressed in the PLAAFP must be targeted by a goal based on the student’s needs, unless the team justifies in the PLAAFP why a goal is not needed.READING SKILLS (Basic Reading, Reading Fluency, Reading Comprehension)The student can perform the following skills: No concerns in this area.The student needs to learn the following skills: No concerns in this area.WRITTEN EXPRESSION SKILLSThe student can perform the following skills: No concerns in this area.The student needs to learn the following skills: No concerns in this area.MATH SKILLS (Math Calculation, Math Reasoning)The student can perform the following skills: No concerns in this area.The student needs to learn the following skills: No concerns in this area.LISTENING COMPREHENSION SKILLSThe student can perform the following skills: No concerns in this area.The student needs to learn the following skills: No concerns in this area.ORAL EXPRESSION SKILLSThe student can perform the following skills: No concerns in this area.The student needs to learn the following skills: No concerns in this area.BEHAVIOR SKILLSThe student can perform the following skills: No concerns in this area.The student needs to learn the following skills: No concerns in this area.SPEECH/LANGUAGE SKILLSThe student can perform the following skills: No concerns in this area.The student needs to learn the following skills: No concerns in this area.MOTOR/SENSORY SKILLSThe student can perform the following skills: No concerns in this area.The student needs to learn the following skills: No concerns in this area.ADAPTIVE BEHAVIOR SKILLSThe student can perform the following skills: No concerns in this area.The student needs to learn the following skills: No concerns in this area.POST-SECONDARY TRANSITION SKILLSThe student can perform the following skills:Employment:Recreation & Leisure:Home Living:Community Participation:Post-Secondary Education:The student needs to learn the following skills:Employment:Recreation & Leisure:Home Living:Community Participation:Post-Secondary Education:SUMMARY OF FINDINGS:CATEGORICAL AREAS (NEEDS) AND RELATED SERVICES TO BE CONSIDERED BY THE MULTI-DISCIPLINARY TEAM:This page left blank intentionallySTUDENT NAME: SIMS: PARENT/GUARDIAN NAME: MEETING DATE: SCHOOL DISTRICT: Custer School District 16-1SCHOOL: DOB: AGE: GRADE: ? Initial Determination of Eligibility? Re-determination of Eligibility Basis for making eligibility determination is drawn from a variety of sources, (which may) include aptitude (ability) and achievement, parent input and teacher recommendations, as well as information about the student’s physical condition, social or cultural background, and adaptive behavior.The evaluation team will examine the evaluation results, other factors, the suspected disabilities, the adverse effects of the disability and if the student requires specialized instruction before determining if the student requires special education services.SUMMARY OF EVALUATION REPORTS USED FOR DETERMININATION OF ELIGIBILITYName of Measure or AssessmentDate AdministeredTest Scores/Results(Standard Scores (SS)/ Mean=100) (T-Scores/ Mean =50)(Standard Deviations (SD)/ Mean=0)Ability: WISC-VAchievement: WJ-IVBasic Reading Skills: Reading Comprehension:Reading Fluency:Written Expression:Oral Expression:Math Calculation:Math Reasoning:Listening Comprehension:*An individual achievement score at or below a standard score of is needed to demonstrate ?a significant discrepancy between measured ability and achievement according to South Dakota special education criteria for a specific learning disability.Speech/Language:Social-Emotional:Occupational Therapy:Physical Therapy:Other:Other:(Insert Category Documents here!) Others Factors Considered:Is the underachievement of the student due to the lack of instruction in Reading or Math, or limited English proficiency?? Yes? No – Reading? Yes? No – Math? Yes? No – Limited English ProficiencyEligibility Determination:? Yes ? No - has a diagnosed disability;? Yes ? No - the disability adversely affects the student’s educational performance; andList the adverse effects of the disability on student’s educational performance:? Yes ? No - the student requires specially designed instruction to receive a free appropriate public education.The team determined this student meets eligibility criteria under the following category: (check the category that will be reported on student count)? Deaf-Blindness - 500? Vision Loss - 540? Emotional Disturbance - 505? Deafness – 545 ? Cognitive Disability - 510 ? Speech/Language- 550? Hearing Loss - 515 ? Other Health Impairment – 555? Specific Learning Disability – 525? Autism Spectrum Disorder - 560 ? Multiple Disabilities – 530?Traumatic Brain Injury – 565 ? Orthopedic Impairment – 535? Developmental Delay - 570Related Service(s): Student therapy needs to be determined during IEP program developmentARSD 24:05:27:22 , 24:05:27:23, 24:05:27:24, 24:05:27:25, and 24:05:27:16Criteria for Occupational Therapy ServicesThe student has a disability and requires special education; ? No – Stop Here ? Yes – Proceed to the next question:The student must demonstrate performance on a standardized assessment instrument that falls at least 1.5 standard deviations below the mean in one or more of the following areas: fine motor skills, sensory integration, or visual; and ? No – Stop Here ? Yes – Proceed to the IEP team meeting and team will determine the following:The student needs occupational therapy to benefit from special education.Criteria for Physical Therapy ServicesThe student has a disability and requires special education; ? No – Stop Here ? Yes – Proceed to the next question:The student must demonstrate performance on a standardized assessment instrument that falls at least 1.5 standard deviations below the mean on a standardized motor assessment instrument; and? No – Stop Here ? Yes – Proceed to the IEP team meeting and team will determine the following:The student needs physical therapy to benefit from special education.Speech – Language PathologyThe student has a disability and requires special education; ? No – Stop Here ? Yes – Proceed to the IEP team meeting and team will determine the following:To be provided as a related service, the IEP team must determine that the related service is required in order for the student to benefit from the special education programTransition: For student that are eligible for special education services, transition must be in effect no later than age 16. ARSD 24:05:27:13.02 and 24:05:27:01.03TransitionThe student has a disability and requires special education; ? No – Stop Here? Yes – Proceed to the IEP team meeting and determine if transition services are required. NAMEPOSITIONYESNODATE()()()()()()()()()()()()()()()()()()()()*A dissenting opinion in the form of a written report citing the specific reason(s) for disagreeing with the eligibility and/or placement override decision is required. ................
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