EVALUATION REPORT Students Name:

EVALUATION REPORT (ER)

Student Name: Peyton Manning 1/10/2014 Date Report Pro ided to Parent/!uardian/Surrogate: &ge: $ !rade: 2
nd

School Age

Date of Report (mm/dd/yy): Student "irt# Date: 'o(a) *du(ation &gen(y ('*&): S(#oo) Student is &ttending: ,urrent *du(ationa) Program: ,ounty of Residen(e:

1/11/2014

04/1$/200%

+est ,#ester &rea S(#oo) Distri(t *ast !os#en *)ementary P#one (-ome): P#one (+or2): (.10) /420%%11

,#ester ,ounty

Name and &ddress of Parent/!uardian/Surrogate: Ms3 Mi))y Manning 124 Main Street5 6nit % +est ,#ester5 P&3 1$410

7t#er 8nformation:

None

Complete Sections 1 through !or "ll stu#ents$ I! #etermining eligi%ilit& !or Speci!ic Le"rning 'is"%ilit& (SL')( the SL' component ne"r the en# o! this #ocument must %e complete# "n# use# to complete Sections ) "n# $ 1$ REASON(S) *OR RE*ERRAL+ ;#e 8*P team #as re ie9ed e a)uation data (on(erning your (#i)d and made t#e re(ommendation t#at t#ere is a need for more information a:out your (#i)d3 &dditiona) information in()udes: present )e e)s of a(ademi( performan(e5 ision assessment5 s2i))s re)ated to spee(#5 and adapti e p#ysi(a) edu(ationa) s2i))s3 ,$ SOURCES O* EVALUATION 'ATA - 8n interpreting e a)uation data5 t#e s(#oo) must dra9 upon a ariety of data sour(es5 in()uding t#ose )isted :e)o95 and (arefu))y (onsider t#e information o:tained3 Do(ument t#e information o:tained from t#e sour(es :e)o93 &3 * a)uations and information pro ided :y t#e parent of t#e student (or do(umentation of '*&s attempts to o:tain parenta) input):

Page 1 of 10

July 2008 Revisions

EVALUATION REPORT Students Name: Ms3 Manning (omp)eted t#e +est ,#ester &rea S(#oo) Distri(t Parent 8nput form in Mar(# 20143 ;#e fo))o9ing is a summary from #er input: Peyton )i es 9it# #is mot#er and un()e in +est ,#ester5 P&3 *ng)is# is t#e primary )anguage spo2en at #ome3 -is :io)ogi(a) mot#er passed a9ay 9#en #e 9as t9o= s#e 9as in >ai) and on a met#adone mainten(e program 9#en Peyton 9as :orn3 -is mot#er adopted #im3 Peyton #as a )arge e?tended fami)y of aunts5 un()es5 grandparents5 and (ousins3 Att"chment+ Ms3 Manning reported t#at Peyton 9as @o er)y (ontentA as a :a:y and t#at #e 9as a)9ays affe(tionate and responsi e3 Speech.L"ngu"ge 'e/elopment+ -is mot#er reported t#at Peyton 9as a)9ays a year or more :e#ind norma) e?pe(tations in spee(#3 -o9e er5 #e 9as a:)e to master a s2i)) 9#en #e 9as ready and a:)e3 0ross 1otor 'e/elopment+ -is mot#er reported t#at #e 9a)2ed 9#en #e 9as si?teen mont#s o)d3 S#e furt#er indi(ated t#at a)) gross motor s2i))s 9ere de)ayed and #e needed t#erapy to strengt#en #is (ore3 *ine 1otor 'e/elopment+ -is mot#er des(ri:ed #is fine motor de e)opment as ery de)ayed3 S#e furt#er stated t#at #e is fina))y en>oying t#ings )i2e art and 9riting no9 t#at #e (an do it more easi)y3 A#"pti/e S2ills+ S#e reported t#at Peyton 9as in an intensi e feeding t#erapy program for one year from age 2 to 43 -e #ad an a ersion to foods and diffi(u)ty 9it# t#e )atera) t#rust mo ement of #is tongue3 -e 9as not fu))y toi)et trained unti) 20123 Strengths+ So(ia) and f)e?i:)e5 9ants to p)ease5 #appy5 easy going nature5 tries #ard5 (apa:)e and ery smart5 (an #o)d a (on ersation 9it# you a:out anyt#ing3 Nee#s+ ,an :e @rigidA 9it# t#ings )i2e not parti(ipating5 (ontro))ing a:out #is food5 needs en(ouragement5 (ontinue to de e)op friends#ips3 "3 7:ser ations < 8n()ude tea(#er o:ser ations and o:ser ations :y re)ated ser i(es pro iders5 9#en appropriate: Speci"l E#uc"tion Te"cher (Input !rom 3en 'oughert&)+ Peyton #as :een doing 9e)) in 9riting5 reading3 So(ia) s2i))s group is more diffi(u)t for #im due to t#e amount of students in t#e group3 -o9e er5 #e #as :een parti(ipating a )ot more3 Regul"r E#uc"tion Te"cher (Input !rom Alici" Smith)+ 7 era))5 Peyton #as ad>usted 9e)) to t#e dai)y routines of se(ond grade and is a #appy (#i)d3 &t times5 #e 9i)) de e)op :e#a iors (ounter0produ(ti e to )earning or proper so(ia) intera(tion3 ;#ese :e#a iors seem to in(rease for a s#ort time and t#en de(rease 9it# t#e use of adu)t redire(tion5 :e#a ior (#arts5 B re9ards and (onseCuen(es3 Speech L"ngu"ge Ther"pist (Input !rom S"r" Pin)+ +it#in in spee(# t#erapy setting5 Peyton (omp)etes a)) tas2s as2ed of #im5 parti(ipates 9i))ing)y and intera(ts 9it# t#e t#erapist and peers in t#e room3 Occup"tion"l Ther"p& (Input !rom Trici" O4Neill)+ Peyton #as made ni(e gains in impro ed #and and isua) motor (ontro) 9it# 9riting and (raft tas2s3 -e is moti ated and appears to en>oy 9or2ing 9it# #is #ands to ma2e #is 9or2 neat3 Vision (Input !rom 5"te 1orris)+ Peyton #as :een ma2ing progress on #is ision goa)s during #is ision support sessions3 8t is re(ommended t#at #e (ontinue to 9or2 on a(#ie ing #is goa)3 A#"pti/e PE (Input !rom 1r$ A)+ Peyton #as :een ma2ing progress to9ards #is adapted p#ysi(a) edu(ation goa)s3 Durt#er assessment of #is )o(o motor and o:>e(t (ontro) s2i))s is needed3

Page 2 of 10

July 2008 Revisions

EVALUATION REPORT Students Name: ,3 Re(ommendations :y tea(#ers: ;#e spe(ia) edu(ation and regu)ar edu(ation tea(#er #a e :ot# re(ommended t#e fo))o9ing strategies t#at #a e :een :enefi(ia) for Peyton: repeat dire(tions5 er:a)/ isua) prompts5 mode)ing5 moti ating a(ti ities/re9ards3 D3 ;#e students p#ysi(a) (ondition (in()ude #ea)t#5 ision5 #earing)= so(ia) or (u)tura) :a(2ground= and adapti e :e#a ior re)e ant to t#e students suspe(ted disa:i)ity and potentia) need for spe(ia) edu(ation: Peyton Manning is a $0year0o)d student at *ast !os#en *)ementary S(#oo) in t#e +est ,#ester &rea S(#oo) Distri(t3 -e is (urrent)y identified as a student 9it# a primary edu(ation disa:i)ity of &utism and a se(ondary disa:i)ity of Spee(# and 'anguage impairment3 ,urrent)y5 Peyton re(ei es t#e ma>ority of #is a(ademi( instru(tion in t#e genera) edu(ation setting 9it# an aid t#at assists #im t#roug#out t#e day3 ;#e e a)uation 9i)) assess Peytons (urrent )e e) of a(ademi( and emotiona)/:e#a iora) fun(tioning5 in order to determine an appropriate edu(ationa) program for #im3 Soci"l histor&+ Peyton )i es 9it# #is mot#er and un()e in +est ,#ester5 P&3 *ng)is# is t#e primary )anguage spo2en at #ome3 -is :io)ogi(a) mot#er passed a9ay 9#en #e 9as t9o= s#e 9as in >ai) and on a met#adone mainten(e program 9#en Peyton 9as :orn3 -is mot#er adopted #im3 Peyton #as a )arge e?tended fami)y of aunts5 un()es5 grandparents5 and (ousins3 1e#ic"l histor&+ Peyton 9as :orn premature5 9eig#ing one pound5 due to drug e?posure 9#i)e in t#e 9om:3 -e spent t#e first t#ree mont#s in t#e #ospita) due to )o9 :irt# 9eig#t and prematurity (omp)i(ations3 +#en Peyton 9as one5 #e 9as #ospita)iEed again :e(ause #is )ungs (o))apsed3 -e a)so 9ent under surgery to (orre(t #is eye mus()e position and 9ea2ness3 Peyton #as freCuent ear infe(tions3 -e is (urrent)y not ta2ing any medi(ations on a regu)ar :asis3

*3 &ssessments < 8n()ude5 9#en appropriate5 (urrent ()assroom :ased assessments= aptitude and a(#ie ement tests= )o(a) and/or state assessments= :e#a iora) assessments= o(ationa) te(#ni(a) edu(ation assessment resu)ts= interests5 preferen(es5 aptitudes (for se(ondary transition)= et(3: Peyton is (urrent)y on target for meeting :en(#mar2 t#is year3 D8""'*S: ,omposite S(ore: .2 (;#is is (ategoriEed as intensi e5 t#e goa) 9as 140)3 Pro>e(t Read < $%F a erage +ord Study < 100F Di::)es < 11F Reading &((ura(y < 1%F

6$ I* AN ASSESS1ENT IS NOT CON'UCTE' UN'ER STAN'AR' CON'ITIONS( 'ESCRI7E T8E E9TENT TO :8IC8 IT VARIE' *RO1 STAN'AR' CON'ITIONS (in()uding if t#e assessment 9as gi en in t#e students nati e )anguage or ot#er mode of (ommuni(ation):

Page 3 of 10

July 2008 Revisions

EVALUATION REPORT Students Name: ;$ 'ETER1ININ0 *ACTORS < & student must not :e found to :e e)igi:)e for spe(ia) edu(ation and re)ated ser i(es if t#e determining fa(tor for t#e students disa:i)ity is any of t#ose )isted :e)o93 Respond Ges or No to5 and pro ide e iden(e for5 ea(# determining fa(tor :e)o93 Ges No 'a(2 of appropriate instru(tion in reading5 in()uding t#e essentia) (omponents of reading instru(tion3 Pro ide e iden(e: ;#e +,&SDs reading instru(tion and (ore (urri(u)um addresses a)) fi e (riti(a) areas of reading (p#onemi( a9areness5 p#oni(s5 f)uen(y5 o(a:u)ary5 and (ompre#ension)3 ;#e staff #as :een trained in t#e programs3 'a(2 of appropriate instru(tion in mat#3 Pro ide e iden(e: ;#e +,&SDs mat# (urri(u)um is :ased upon P& mat# standards3 8t is a :a)an(ed approa(# to menta) mat#5 fa(t f)uen(y5 pro:)em so) ing5 (on(eptua) understanding5 and mat# (a)(u)ation3 ;#e staff #a e :een trained in t#e programs3 'imited *ng)is# profi(ien(y3 Pro ide e iden(e: *ng)is# is t#e primary )anguage spo2en at #ome3

Ges

No

Ges

No

N7;*: 8D D*;*RM8N8N! *'8!8"8'8;G D7R SP*,8D8, '*&RN8N! D8S&"8'8;G5 ,7MP'*;* ;-* DETERMINATION OF SPE IFI !EARNIN" DISA#I!IT$ ,7MP7N*N; &; ;-* *ND 7D ;-8S D7,6M*N; "*D7R* ,7MP'*;8N! S*,;87NS % and .3

Complete Sections ) "n#

!or "ll stu#ents$

)$ SU11AR< O* *IN'IN0S.INTERPRETATION O* EVALUATION RESULTS - ,onsidering a)) a ai)a:)e e a)uation data5 re(ord t#e teams ana)yses of t#e students fun(tioning )e e)s3 &3 PR*S*N; '*H*'S 7D &,&D*M8, &,-8*H*M*N; < Des(ri:e t#e students present )e e)s5 strengt#s5 and t#e resu)ting a(ademi( needs5 9#en appropriate3 8n()ude (ommuni(ati e status5 motor a:i)ities5 and transition needs as appropriate3 Dor students 9it# )imited *ng)is# profi(ien(y ('*P)5 in()ude (urrent )e e)(s) of *ng)is# )anguage profi(ien(y in reading5 9riting5 spea2ing and understanding/)istening:

Page % of 10

July 2008 Revisions

= Le/els o! "c"#emic "chie/ement+

Current 0r"#es+ EVALUATION Peyton REPORT is (urrent)y on target for meeting :en(#mar2 t#is year3 Students Name: Input !rom speci"l e#uc"tion te"cher (3en 'oughert&)+ :riting - Peyton (omes up 9it# good 9riting topi(s3 Re(ent)y5 #e (#ose to 9rite to #is friend "o::y for a friend)y )etter or (#ose to 9rite a:out ,#ristmas for an informationa) pie(e3 +it# t#e guidan(e of a grap#i( organiEer5 #e is a:)e to get good ideas do9n on paper and trans)ate t#em into a 9riting pie(e3 Dor 9riting5 Peyton is a))o9ed to (#oose #is o9n topi(s t#at #e is interested in 9#i(# resu)ts in good 9riting3 Peyton strugg)es 9#en it (omes to 9ords t#at #e does not 2no9 #o9 to spe))3 -e a)so #as diffi(u)ty spa(ing #is 9ords and 9riting on one )ine3 -is senten(e 9i)) often go do9n t9o or t#ree )ines3 -e a)so tends to fi?ate on t#ings )i2e o(a:u)ary 9ords in #is regu)ar edu(ation ()assroom or t#e date5 9#i(# a))o9s #im to )ose fo(us3 &not#er strugg)e of Peytons is t#at #is #and9riting is )egi:)e :ut s#ou)d :e neater :y no93 Re"#ing - Peyton is (urrent)y re(ei ing support for sma)) group reading at a )e e) I3 Peytons reading s2i))s regarding understanding is #ig#3 -e is a:)e to ans9er @+-A (ompre#ension Cuestions5 during and after reading3 Peytons reading f)uen(y is on t#e s)o9 side5 #o9e er #is a((ura(y during progress monitoring is #ig# ($.F5 $2F)3 Peyton uses #is magnifying :ar to read :etter3 -e a)so does 9e)) 9#en it (omes to un2no9n 9ords5 #e 9i)) try to sound it out or as2 me to de(ode t#e 9ord for #im on a 9#ite :oard3 8t is diffi(u)t for Peyton 9#en #e (omes a(ross 9ords t#at #e is unfami)iar 9it#5 #o9e er if 9e ma2e it one of our o(a:u)ary 9ords5 #e memoriEes it3 Soci"l S2ills - During so(ia) s2i))s5 9#en Peyton de(ides to parti(ipate5 #e is (apa:)e of ans9ering Cuestions and getting in o) ed in t#e group3 -o9e er5 t#e fa(t of :eing around #is ()assmates tends to :ring out t#e negati e :e#a ior in #im3 Peyton 9i)) sometimes )aug# at ()assmates5 mimi( t#em5 or not pay attention at a))3 +#en Peyton :e#a es )i2e t#is5 (onseCuen(es are ta2en :e(ause it usua))y ends up t#at #e is disrupting #is ()assmates as 9e)) as my so(ia) s2i))s )esson3 Input !rom regul"r e#uc"tion te"cher (Alici" Smith)+ L"ngu"ge Arts - Peyton parti(ipates in t#e regu)ar edu(ation ()assroom for parts of )anguage arts (9ord study and guided reading)3 +it# assistan(e5 Peyton is a:)e to identify and sort for t#e different (ategories of 9ords in 9ord study ea(# 9ee23 -is test s(ores in 9ord study range from 110 $/ for units 22024 in Pro>e(t Read3 8n guided reading5 Peyton (an read independent)y at )e e) I= #o9e er5 f)uen(y is diffi(u)t for #im5 e en 9it# t#e :ar magnifier3 JJ 9i)) often stop mid senten(e to te)) a:out a 9ord pattern or somet#ing e)se #e noti(ed 9#i)e reading5 9#i(# a)so in#i:its reading f)uen(y3 +#en gi en a set of (ompre#ension Cuestions5 Peyton ans9ers (orre(t)y most of t#e time3 During :oo2 dis(ussions 9it# a sma)) group5 #e 9i)) parti(ipate if prompted3 -e (an ans9er some )itera) Cuestions if dire(ted to t#e te?t5 as 9e)) as inferentia) t#in2ing and Cuestions t#at reCuire #im to synt#esiEe information from different p)a(es in t#e te?t3 1"th = Peyton parti(ipates in t#e regu)ar edu(ation ()assroom for mat#3 +it# support5 #e is a:)e to add and su:tra(t one and t9o digit num:ers 9it# and 9it#out regrouping a((urate)y using strategies taug#t in ()ass3 Peyton sti)) needs some support 9it# ot#er (on(epts and mat# termino)ogy3 Dor e?amp)e5 de(omposing 4D s#apes in geometry or understanding termino)ogy su(# as 'ange and (o)e in data (o))e(tion3 Dor t#e 2nd mar2ing period5 Peytons addition :en(#mar2 s(ore 9as 20/%0 (orre(t in 23% minutes= in su:tra(tion5 #is s(ore 9as 21/%0 in 23% minutes3 ;#e end0of0year :en(#mar2 is 4$0%0 9ritten (orre(t)y in 23% minutes3 Peyton is sti)) 9or2ing on (ounting (oins to K1300 and te))ing time to fi e0 minute inter a)s3 7 era))5 Peyton #as ad>usted 9e)) to t#e dai)y routines of se(ond grade and is a #appy (#i)d3 &t times5 #e 9i)) de e)op :e#a iors (ounter0produ(ti e to )earning or proper so(ia) intera(tion3 ;#ese :e#a iors seem to in(rease for a s#ort time and t#en de(rease 9it# t#e use of adu)t redire(tion5 :e#a ior (#arts5 B re9ards and (onseCuen(es3 Ac"#emic "ssessments+ Pro>e(t Read < $%F a erage +ord Study < 100F Di::)es < 11F Reading &((ura(y < 1%F Speech ther"p&+ *+e',al In-u. f'o( Sa'a Pin* Peyton #as a spee(# and )anguage impairment3 -e s#o9s de)ays in #is a:i)ity to er:a))y use (orre(t )anguage3 Digurati e spee(# is ery diffi(u)t for Peyton to understand5 as 9e)) as indire(t reCuests and sar(asm3 -e a)so does not #a e t#e a:i)ity to produ(e t#e Page & of 10 July 2008 Revisions appropriate spee(# sounds5 @s#5A @(#5A @s5A and @EA 9#i(# effe(ts t#e a:i)ity to (ommuni(ate in t#e edu(ationa) setting3 Peyton a)so freCuent)y drops #is @rsA 9#i)e spea2ing5 t#erefore a)so interfering 9it# #is o9n )earning as 9e)) as #is peers3

EVALUATION REPORT Students Name: "3 PR*S*N; '*H*'S 7D D6N,;87N&' P*RD7RM&N,* < Des(ri:e t#e students present )e e)s5 strengt#s5 and t#e resu)ting fun(tiona) and de e)opmenta) needs5 9#en appropriate: *unction"l per!orm"nce+ Peyton is easi)y distra(ted and often off tas25 ta)2ing a:out unre)ated topi(s5 un)ess redire(ted se era) times :y an adu)t/tea(#er/P,&3 -e #as a P,& t#at is 9it# #im t#roug#out t#e s(#oo) days 9#o a)so (o))e(ts data :ased on #is :e#a ior3 Peytons negati e :e#a ior is defiant to9ard aut#ority figures as 9e)) as ()assmates3 Dor e?amp)e5 Peyton 9i)) mimi( #is friends during re(ess3 -is peers freCuent)y te)) t#em t#at t#ey dont )i2e it and Peyton does not stop3 Peyton is a)so defiant to9ard tea(#ers3 During reading and ot#er a(ademi( areas5 Peyton 9i)) use an @a((entA on purpose5 to get attention3 -e 2no9s 9#at #e is doing is not a)oud3 8t ta2es se era) (orre(ting and (onseCuen(ing to get Peyton to read (orre(t)y5 at )east for t#at period of time3 &not#er form of defian(e from Peyton is a noise t#at #e ma2es using #is t#roat5 a)so 2no9n as @:eat :o?ing3A ;#is is anot#er freCuent diso:edient :e#a ior t#at Peyton 9i)) do 9#ene er #e fee)s5 as 9e)) as t#e a((ent3 -e 9i)) @:eat :o?A at any time and it is e?treme)y distra(ting to #is ()assmates5 9#i(# signifi(ant)y interferes 9it# )earning3 ;#ese :e#a iors are not a((epta:)e at s(#oo) and sometimes (onseCuen(es are not enoug# for Peyton3 Peytons a(tions are :eing done so)ey for t#e purpose to annoy t#ose around #im as 9e)) as get attention3 Peyton a)so tends to ignore aut#ority figures 9#i)e :eing redire(ted or as2ed to stop using an a((ent or @:eat :o?ing3A ,3 "*-&H87R&' 8ND7RM&;87N - 8n()ude so(ia) and emotiona) status and :e#a iora) strengt#s and needs5 9#en appropriate: Strengths - Peyton (an :e a great student 9#en #is :e#a ior issues do not interfere3 +#en #e is doing 9e))5 Peyton is a @ro(2 starA and #e )o es t#e attention3 -e (an :e ery po)ite and a #ard 9or2er3 Peyton is a good t#in2er and ans9ers Cuestions (riti(a))y3 Peyton is an a9esome student to #a e in t#e ()assroom5 9#en a(ting appropriate)y3 Peyton a)so e?(e)s at retaining information and pro iding tips 9#en #e (omes into t#e ()assroom3 -e a)so e?(e)s in spe(ifi( topi(s t#at #e is interested in3 Ac"#emic nee#s (rel"te# to #is"%ilit&) - Due to Peytons disa:i)ity5 #e (omes to t#e &utisti( Support ()assroom t#ree times a day for sma)) group reading5 9riting5 and so(ia) s2i))s3 ;#is instru(tion is more one0on0one :ased to meet #is area of needs3 During instru(tion5 #e needs to understand to as2 for a :rea2 :efore getting frustrated due to not understanding3 'e/elopment"l nee#s (rel"te# to #is"%ilit&) - Peyton does not a))o9 anyone to sing or dan(e around #im3 -o9e er5 #e does )i2e musi( ()ass3 Peyton needs to gi e more respe(t to aut#ority figures and de e)op friends#ips :ot# in and out of s(#oo)3 Peyton does not understand t#e (on(ept of figurati e )anguage and some >o2es #e (annot (ompre#end3 Do))o9ing :asi( dire(tions is a)so in need for impro ement as 9e)) as )istening to ot#ers3 &(ademi(a))y5 reading f)uen(y needs impro ing3 *unction"l nee#s (rel"te# to #is"%ilit&) - Peyton #as diffi(u)ty in pragmati(s and spee(# as 9e)) as figurati e )anguage3 -e 9i)) a)so (ontinue to attend so(ia) s2i))s group to de e)op (on ersationa) s2i))s and de e)op friends#ips3 Peyton a)so #as diffi(u)ty fo))o9ing dire(tions and )istening to adu)ts (9#en #e (#ooses not to)3 -e a)so needs to understand t#e (on(ept t#at a tea(#er is an aut#ority figure and must :e respe(ted3

$ CONCLUSIONS < Determination of *)igi:i)ity and *du(ationa) Needs ,omp)ete & or " or ,3 &3 7R "3 ;#e student #as a disa:i)ity :ut does not need spe(ia))y designed instru(tion5 and t#erefore is N7; *'8!8"'* for spe(ia) edu(ation3 ;#e student does not #a e a disa:i)ity and t#erefore is N7; *'8!8"'* for spe(ia) edu(ation3

Page / of 10

July 2008 Revisions

EVALUATION REPORT Students Name: 7R ,3 ;#e student #as a disa:i)ity &ND is in need of spe(ia))y designed instru(tion5 and t#erefore 8S *'8!8"'* for spe(ia) edu(ation3 13 Disa:i)ity ,ategory Primary disa:i)ity (ategory: &utism Se(ondary disa:i)ity (ategory(s)5 if any: 23 Re(ommendations for (onsideration :y t#e 8*P team to ena:)e t#e student to parti(ipate as appropriate in t#e genera) edu(ation (urri(u)um (in()uding spe(ia) (onsiderations t#e 8*P team must (onsider :efore de e)oping t#e 8*P5 measura:)e annua) goa)s5 spe(ia))y designed instru(tion5 and supp)ementary aids and ser i(es): Strengths+ So(ia) and f)e?i:)e5 9ants to p)ease5 #appy5 easy going nature5 tries #ard5 (apa:)e and ery smart5 (an #o)d a (on ersation 9it# you a:out anyt#ing5 mat#3 Nee#s+ ,an :e @rigidA 9it# t#ings )i2e not parti(ipating5 (ontro))ing a:out #is food5 needs en(ouragement5 (ontinue to de e)op friends#ips5 so(ia) s2i))s5 fo))o9ing dire(tions5 figurati e )anguage5 reading f)uen(y3

* a)uation ;eam Parti(ipation

* a)uation ;eam Parti(ipantsL ;it)e
Mot#er Spe(ia) *du(ation ;ea(#er Regu)ar *du(ation ;ea(#er '*& Representati e Spee(# ;#erapist 7((upationa) ;#erapist Hision Support &dapti e P*

&greement and Disagreement reCuired 7N'G 9#en e a)uating students for spe(ifi( )earning disa:i)ity3

&gree

DisagreeLL

Milly Manning
Jen Dougherty

Alicia Smith
Dennis Blue

Sara Pin
Tricia ONeill
Kate Morris
James A

L & (ertified s(#oo) psy(#o)ogist is reCuired for e a)uation of t#e fo))o9ing disa:i)ity (ategories: &utism5 *motiona) Distur:an(e5 Menta) Retardation5 Mu)tip)e Disa:i)ities5 7t#er -ea)t# 8mpairments5 Spe(ifi( 'earning Disa:i)ity or ;raumati( "rain 8n>ury3 & (ertified s(#oo) psy(#o)ogist is not reCuired for Deaf0:)indness5 Deaf and -ard of -earing5 Spee(#/'anguage 8mpairment5 Hisua) 8mpairment5 and 7rt#opedi( 8mpairment3 LL Dor spe(ifi( )earning disa:i)ity on)y5 if a team mem:er disagrees 9it# t#e teams (on()usion re)ated to t#e identifi(ation of t#e student as #a ing a spe(ifi( )earning disa:i)ity5 t#e mem:er must su:mit a separate
Page 0 of 10 July 2008 Revisions

EVALUATION REPORT Students Name: statement presenting t#e mem:ers dissent to t#e '*&3 ;#is information must :e atta(#ed to t#e Evalua.ion Re-o'.3 P)ease su:mit t#is statement to: Dennis ")ue '*& Representati e Name "ro9nM+,&SD3net *mai) &ddress & (opy of t#e P'o1e)u'al Safegua')s No.i1e is a ai)a:)e upon reCuest from your (#i)ds s(#oo)3 ;#is do(ument e?p)ains your rig#ts5 and in()udes state and )o(a) ad o(a(y organiEations t#at are a ai)a:)e to #e)p you understand your rig#ts and #o9 t#e spe(ia) edu(ation pro(ess 9or2s3 Dor #e)p in understanding t#is form5 an annotated Evalua.ion Re-o'. is a ai)a:)e on t#e Pa;;&N 9e:site at 9993pattan3net ;ype @&nnotated DormsA in t#e Sear(# feature on t#e 9e:site3 8f you do not #a e a((ess to t#e 8nternet5 you (an reCuest t#e annotated form :y (a))ing Pa;;&N at 10004410421%3 (%%%) 244204444 P#one Num:er

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July 2008 Revisions

D*;*RM8N&;87N 7D SP*,8D8, '*&RN8N! D8S&"8'8;G

NOTE+ This component must %e complete# >hen #etermining eligi%ilit& !or Speci!ic Le"rning 'is"%ilit&$ The in!orm"tion must %e "tt"che# to "n#.or incorpor"te# into Sections ) "n# o! the complete# Evaluation Report. Pro/i#e #ocument"tion !or items 1=1?$ 13 ;#e student does not a(#ie e adeCuate)y for t#e students age or does not meet State0appro ed grade0 )e e) standards in one or more of t#e fo))o9ing areas 9#en pro ided 9it# )earning e?perien(es and s(ientifi(a))y :ased instru(tion appropriate for t#e students age or State0appro ed grade )e e) standards and )e e) of *ng)is# )anguage profi(ien(y: ora) e?pression5 )istening (ompre#ension5 9ritten e?pression5 :asi( reading s2i))5 reading f)uen(y s2i))s5 reading (ompre#ension5 mat#emati(s (a)(u)ation5 and mat#emati(s pro:)em0so) ing3

23 ,#e(2 :e)o9 to identify t#e pro(ess(es) used to determine e)igi:i)ity3 Response to S(ientifi( Resear(#0"ased 8nter ention (Rt8)3 Do(ument t#e (riteria :e)o93 ;#e student does not ma2e suffi(ient progress to meet age or State0appro ed grade0)e e) standards in one or more of t#ese areas: ora) e?pression5 )istening (ompre#ension5 9ritten e?pression5 :asi( reading s2i))5 reading f)uen(y s2i))s5 reading (ompre#ension5 mat#emati(s (a)(u)ation5 and mat#emati(s pro:)em0so) ing:

Se ere Dis(repan(y :et9een 8nte))e(tua) &:i)ity and &(#ie ement3 Do(ument t#e (riteria :e)o93 ;#e student e?#i:its a pattern of strengt#s and 9ea2nesses in performan(e5 a(#ie ement or :ot# re)ati e to age5 standards or inte))e(tua) de e)opment:

43 ;#e instru(tiona) strategies used and t#e student0(entered data (o))e(ted:

43 ;#e edu(ationa))y re)e ant medi(a) findings5 if any:

%3 ;#e effe(ts of t#e students en ironment5 (u)ture5 or e(onomi( :a(2ground:

.3 Data demonstrating t#at prior to referra) or as part of t#e referra) pro(ess for a spe(ifi( )earning disa:i)ity5 t#e students regu)ar edu(ation instru(tion 9as de)i ered :y Cua)ified personne)5 in()uding t#e *ng)is# as a Se(ond 'anguage (*S') program5 if app)i(a:)e:

/3 Data :ased do(umentation of repeated assessments of a(#ie ement at reasona:)e inter a)s5 ref)e(ting progress during instru(tion5 9#i(# 9as pro ided to t#e parents:

13 &n o:ser ation in t#e students )earning en ironment (in()uding t#e regu)ar ()assroom setting) to do(ument t#e students a(ademi( performan(e and :e#a ior in t#e areas of diffi(u)ty3 Note t#e re)ations#ip of t#at :e#a ior to t#e students a(ademi( fun(tioning:

$3 7t#er data5 if needed5 as determined :y t#e e a)uation team:

103 8n()ude a statement for ea(# item :e)o9 to support t#e (on()usions of t#e e a)uation team t#at t#e findings are not primari)y a resu)t of Hisua)5 #earing5 motor disa:i)ity:

Menta) retardation:

*motiona) distur:an(e:

,u)tura) fa(tors:

*n ironmenta) or e(onomi( disad antage:

'imited *ng)is# profi(ien(y:

Upon completion o! the SL' Component( "tt"ch "n#.or incorpor"te this in!orm"tion into Sections ) "n# o! the complete# Evaluation Report$