NOTICE AND ELIGIBILITY DECISION REGARDING

SPECIAL EDUCATION SERVICES

STUDENTS NAME: Carrie Smith
Date this report was given or sent to parent (student @ age 19)
Check One:

Initial Eligibility

Result

Area of Assessment:

of

Reevaluation

Vision Screening
Date 10/18/2014

Page
10/31/2014

Hearing Screening
P-Pass

Dat
e

10/18/2014

Result

P-Pass

Achievement

Date: 10/18/2014
Assessment Woodcock Johnson Tests of Achievement-Third Edition (WJ-III)
:
Standard Scores (Total): 80
Other Scores: Letter-Word Identification-76; Passage Comprehension-99; Word Attack-82; Understanding
Directions-100; Picture Vocabulary-98; Calculation-84; Applied Problems-92; Spelling-84;
Writing Samples-89

Area of Assessment: Intelligence

Assessment:
Wechsler Intelligence Scale for Children-Third Edition (WISC-III)
Full Scale: 96
Standard Scores (Total):
Verbal
Intelligence
Quotient-89; Performance Intelligence Quotient-102;
Other Scores:

Area of Assessment: Grades

Assessment:
Classroom subject grades
n/a
Standard Scores (Total):
Carrie has received the following grades at Sunshine Elementary School for the first 9-week
Other Scores:
progress report card: Reading- 56; ELA-57; Math-66; Social Studies-59; Science-75.

Area of Assessment: Behavioral Observation

Assessment:
Teacher observational notes
n/a
Standard Scores (Total):
According to Carries classroom teacher, Carrie is a fairly confident young lady and pays
Other Scores:

close attention in class. Carrie works well with her peers and enjoys any kind of group work.
Carrie often turns in incomplete and inaccurate work that usually has some kind of
doodling on it. When Carrie becomes frustrated with independent work, she will often
shut down and begin drawing instead.

Final Completion Date of ALL Evaluations: _10/18/2014________

SDE Approved 12/19/2007

STUDENTS NAME: Carrie Smith

Page

of

SLD ONLY SECTION For each option checked below, include documentation of a specific learning
disability in the assessment section of this report.

[ ] Option 1: Response(s) to Intervention.

[ ] Option 2: Pattern of strengths and weaknesses.
[ ] Option 3: Severe Discrepancy (SD) Documentation.
A. If using the predicted achievement model (regression to the mean effective 7/1/98):
IQ score:

96

Predicted Achievement (PA) score:

97

Obtained Achievement (OA) score(s)

determined one of two ways:
One Achievement Test
Total test score

PA

97 - OA

80 = SD

PA

- OA

= SD

17

(SD must be 16 points

or greater for all ages)

80

OR
Two Composites OR Two Subtests
Scores from two different achievement tests that measure the same deficit skill area
(i.e., Composite Reading scores from two different tests; Subtest Calculation scores
from two different tests)
Severe discrepancy (SD) between ability and achievement:

[ x ] YES

[ ] NO

B. If using the simple standard score method (only for students identified before July 1, 1998):
IQ Score ________ - Achievement Score ________ = SD ________
(SD must be 15 or greater to 11 years; must be 23 or greater for 11 years and older)
Complete for all students suspected of SLD, regardless of option(s) chosen above.
1. For educationally relevant behaviors noted during the classroom observation(s) and educationally relevant
medical findings (if any), please refer to page(s)
1
of this report.
2. Student behavior or difficulty that affects his/her academic functioning:
Reading and math deficits.

3. The following factors have been ruled out as the primary cause of the impairment (all must be considered
and checked to qualify for SLD):
SDE Approved 12/19/2007

[ x ] Environmental/Cultural/Economic Concerns
[ x] Mental Retardation [ x ] Emotional Disturbance

[ x ] Visual/Hearing Disabilities
[ x ] Motor Disabilities

STUDENTS NAME: Carrie Smith

Page 3

of

ELIGIBILITY DECISION
ELIGIBLE:
[ x ] YES
[ ] NO
AREA OF DISABILITY: Specific Learning Disabilities
If the selected area of disability is Multiple Disabilities, list at least two disability areas for which the student
is eligible.
__________________________________________
__________________________________________
Explanation (if needed):

Complete for all students:

Was lack of appropriate instruction in math and/or reading, including the essential components of reading instruction
(as defined in section 1208(3) of the Elementary and Secondary Education Act of 1965) or limited English
proficiency the determining factor in the decision?
[ ] YES
[ x ] NO
(See documentation included in this report.)

DESCRIPTION OF OTHER OPTIONS CONSIDERED AND WHY THEY WERE REJECTED

CHECK ONE:

Eligibility Committee [ ]

Position
I AGREE with the
conclusions written in
this report

Parent
Parent
General Education Teacher
Special Education Teacher
LEA Representative
Evaluation Results Interpreter
Student
Other

I DO NOT AGREE
with the conclusions
written in this report.
The attached statement
represents my
conclusions in this area.

Position

IEP Team

[x ]

Signature

Date

Signature

Date

SDE Approved 12/19/2007

My signature below verifies that if you require notice and an explanation of your rights in your native language, the
LEA/agency has accommodated you to ensure your understanding. You are fully protected under the rights addressed
in your copy of the Special Education Rights document. You may access another copy of your rights at
www.alsde.edu. Once in the Web site, select Sections/Special Education/Forms. If you cannot access the Web site and
want another copy of your rights, have any questions, or wish to arrange a conference, please contact:
Name:

Finn Agency

Telephone:

(205) 456-7890

Signature of Education Agency Official

SDE Approved 12/19/2007