!! " !! " #!!! 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