DEC 3-SLD (1 of 3)

Method of eligibility: Discrepancy Rt

SUMMARY OF EVALUATION/ELIGIBILITY WORKSHEET-SPECIFIC LEARNING DISABILITY
Student: Student N!e DOB: "" / "" / #"""
S$%&&': S$%&&' N!e G(de: G(de
Dte Re)u*(ed S$(een*n+,
nd E-'ut*&n,
Dt S&u($e/Su!!(. &/ Re,u't,
!! " !! " #!!! $earing Screening: %ass &ail d' (ntensity Le(el) $) (&re*+encies)
!! " !! " #!!! ,ision Screening: %ass &ail F( R #!" L #!"
Ne( R #!" L #!"
!! " !! " #!!! Speech"Lang+age
Screening:

!! " !! " #!!! Re(ie- of E.isting
Data:

!! " !! " #!!! S+//ary of
conference(s) -ith
parent(s):

!! " !! " #!!! Research-based
inter(entions to address
acade/ic s0ill
deficiencies (progress
/onitoring data):

!! " !! " #!!! Social"De(elop/ental
$istory:

!! " !! " #!!! 1cade/ic2 &+nctional
and 'eha(ioral
3bser(ation(s):

!! " !! " #!!! 4Ed+cational E(al+ation
!! " !! " #!!! 4%sychological
E(al+ation (ncl+ding
ntellect+al E(al+ation)

!! " !! " #!!! 3ther:
4Re*+ired -hen +sing the discrepancy /ethod to deter/ine eligibility5
A, (e,u't &/ t%e (e)u*(ed ,$(een*n+,0 e-'ut*&n,0 1(&+(e,, !&n*t&(*n+ dt0 nd (e-*e2 &/ e3*,t*n+ *n/&(!t*&n0
2%t d& 2e n&2 4n&2 5&ut t%e ,tudent6 In$'ude $%($te(*,t*$, &/ ,1e$*/*$ 'e(n*n+ d*,5*'*t. $&n,*,tent 2*t%
t%e de/*n*t*&n7
Strengths:
6eeds:
&inal #-11
DEC 3-SLD (# of 3)
Student: Student N!e DOB: "" / "" / #"""
S$%&&': S$%&&' N!e G(de: G(de
B,ed &n *n/&(!t*&n /(&! !u't*1'e ,&u($e,0 1(&-*de d&$u!entt*&n &/ ,*+n*/*$nt de'., *n t%e /&''&2*n+:
7he child does not achie(e ade*+ately for the child8s age2 intellect+al de(elop/ent or to /eet State-appro(ed grade-le(el standards
in one or /ore of the follo-ing areas -hen pro(ided -ith learning e.periences and instr+ction appropriate for the child8s age or
State-appro(ed grade le(el-standards:
Listening Co/prehension 3ral E.pression 9ritten E.pression
'asic Reading S0ills Reading &l+ency S0ills Reading Co/prehension S0ills
Mathe/atics Calc+lation Mathe/atical %roble/ Sol(ing 6one (not eligible)
Select &ne of the follo-ing:
7he child does not /a0e s+fficient progress to /eet age or State-appro(ed grade-le(el standards in one or /ore of the areas
identified abo(e -hen +sing a progress based on the child8s response to scientific2 research-based instr+ction5 :i(e specific
e.a/ples to sho- e(idence of ins+fficient progress5

OR
7he child e.hibits a pattern of strengths and -ea0nesses in perfor/ance2 achie(e/ent2 or both2 relati(e to age2 State-appro(ed
grade-le(el standards or intellect+al de(elop/ent2 that is deter/ined by the gro+p to be rele(ant to the identification of a
specific learning disability2 +sing appropriate assess/ents5 Describe the pattern5 Sho- e(idence of progress /onitoring data2 a
1;-point discrepancy2 or an alternati(e to the discrepancy analysis5

OR
6ot 1pplicable (not eligible)
&inal #-11
DEC 3-SLD (3 of 3)
Student: Student N!e DOB: "" / "" / #"""
S$%&&': S$%&&' N!e G(de: G(de
Select &ne of the follo-ing:
7he follo-ing factors ha(e been r+led o+t a the pri/ary ca+se of the disability: sensory or /otor deficits2 intellect+al or serio+s
e/otional disabilities2 Li/ited English proficiency2 en(iron/ental2 c+lt+ral2 or econo/ic infl+ences2 or lac0 of appropriate
instr+ction in reading or /ath5

OR
Describe -hich factor(s) listed abo(e ca+se the acade/ic delay5 7he child cannot be eligible in the category of SLD5


W%t *, t%e d-e(,e e//e$t0 */ n.0 &n edu$t*&n' 1e(/&(!n$e6 In$'ude ,tte!ent &/ t%e (e't*&n,%*1 &/ t%e
5e%-*&( n&ted du(*n+ t%e &5,e(-t*&n t& t%e ,tudent8, $de!*$ /un$t*&n*n+7 A',&0 dd(e,, t%e e//&(t &/ n.
11'*$5'e edu$t*&n''. (e'e-nt !ed*$' /*nd*n+,7

W%t e-*den$e e3*,t, t%t t%e ,tudent (e)u*(e, ,1e$*''. de,*+ned *n,t(u$t*&n6

IEP TEAM MUST COMPLETE ELIGIBILITY DETERMINATION7
&inal #-11