Date		
	mm/dd/yy	
Student’s Name  					 Birthdate  			

School 	                    	__________________ District____________________________

Date of Initial Eligibility		 ____________Date of Reestablished Eligibility__________________

A. Indicate the primary evaluation model used in determining eligibility for this student [Select only one box to indicate the primary model used, however, districts are not precluded from completing other portions of this form if additional elements are used.]

 The Response to Intervention (RTI) model was the primary model used for this evaluation. 
 The Patterns of Strengths and Weaknesses (PSW) model was the primary model used for this evaluation. 
 The discrepancy model was the primary model used for this evaluation. 

B. The team has completed the following evaluation components (attach evaluation report):

1.	Review of existing information from a variety of sources, including the parents, teacher recommendations (including Oregon state assessments, if available), the student’s cumulative records, previous IEPs or IFSPs, teacher collected work samples, and information about the child’s physical condition, background, and adaptive behavior. Evaluation report includes relevant information from these sources used in the eligibility determination.

  ______________	  ______________	
Report Date	Date Reviewed	

2.	An assessment of the child’s academic achievement toward Oregon grade-level standards. [Add lines as necessary]
	
________________________	  __________________	  _______________	  ______________	
Examiner/Title	Assessment	Date Conducted	Date Reviewed	

3.	An observation of the child’s academic performance and behavior in a regular classroom setting, or in the case of a child less than school age or out of school, an observation in an age-appropriate environment.   (Describe relevant behavior noted during observation, and its relationship to academic functioning in evaluation report.)  

  ________________________	  __________________	  _______________	  ______________	
Observer/Title	Date Conducted	Report Date	Date Reviewed	

4.	Progress monitoring data:    (described in evaluation report)

Data that demonstrate that before or as part of the referral process, the child was provided with appropriate instruction in regular education settings by qualified personnel.
	  _______________
Report Date	  ______________
Date Reviewed
	
Data-based documentation of repeated assessments of achievement at reasonable intervals, reflecting formal assessment of student progress that is directly linked to instruction.
	  _______________
Report Date	  ______________
Date Reviewed

5.	If using a response-to intervention (RTI) model:  list scientifically-based interventions attempted (based on the district’s RTI model) and describe the child’s response in the evaluation report. [Add lines as necessary]

Prior to Consent	________________________	  __________________	  _______________	  ______________	
for evaluation:	Intervention type	Intervention period	Report Date	Date Reviewed	
	________________________	  __________________	  _______________	  ______________	
	Intervention type	Intervention period	Report Date	Date Reviewed	
Post Consent	________________________	  __________________	  _______________	  ______________	
for evaluation:	Intervention type	Intervention period	Report Date	Date Reviewed	
	________________________	  __________________	  _______________	  ______________	
	Intervention type	Intervention period	Report Date	Date Reviewed	

6.	 If using a model based on student’s strengths and weaknesses:  Evaluation of the child’s strengths and weaknesses in performance, achievement, or both, relative to age, state-approved grade level standards, or intellectual development.  Results described in evaluation report.

________________________	  __________________	  _______________	  ______________	
Examiner/Title	Assessment	Date Conducted	Date Reviewed	
________________________	  __________________	  _______________	  ______________	
Examiner/Title	Assessment	Date Conducted	Date Reviewed	

7.	If using a discrepancy model:  Evaluation of a significant discrepancy between a student’s academic achievement, relative to age, (including progress toward state-approved grade level standards), and his or her intellectual development.  Results described in evaluation report. 

________________________	  __________________	  _______________	  ______________	
Examiner/Title	Assessment	Date Conducted	Date Reviewed	
________________________	  __________________	  _______________	  ______________	
Examiner/Title	Assessment	Date Conducted	Date Reviewed	

8.	If deemed necessary by the team:

a.	A developmental history.  Relevant history noted in evaluation report, attached.

  _______________	_______________	  ______________	
Date Conducted	Report Date	Date Reviewed	

b.	Other assessment(s) related to cognition, fine motor skills, perceptual motor skills, communication, social/emotional status, perception or memory.  Results described in evaluation report, attached.

________________________	  __________________	  _______________	  ______________	
Examiner/Title	Assessment	Date Conducted	Date Reviewed	
________________________	  __________________	  _______________	  ______________	
Examiner/Title	Assessment	Date Conducted	Date Reviewed	

c.	A medical statement or health assessment statement indicating whether there are any physical factors that may be affecting the student’s educational performance.  Relevant medical findings are described in evaluation report, attached.

  ______________________________________________	  _______________	  ______________	
Physician, Nurse Practitioner, or Physician’s Assistant	Date Conducted	Date Reviewed	

C.  The Team has determined that:

1.	The student does not achieve adequately for the child’s age or to meet Oregon grade-level standards in one or more of the following areas when provided with learning experiences and instruction appropriate for the child’s age or state-approved grade level standards: 

 Basic reading skills
 Reading fluency skills
 Reading comprehension
		 Mathematics calculation
 Mathematics problem solving	 Written expression
 Oral expression	
 Listening comprehension
	
If one or more boxes are checked, continue.  If no boxes are checked, the child cannot be found eligible.

2.	The child:

   Does not make sufficient progress to meet age or Oregon grade-level standards in one or more of the areas listed in 1 when using a process based on the child’s response to scientific, research-based instruction; and/or

   Exhibits a pattern of strengths and weaknesses in performance, achievement, or both, relative to age, Oregon grade-level standards, or intellectual development, that is determined to be relevant to the identification of a specific learning disability, and/or
   Demonstrates a significant discrepancy between his or her academic achievement, relative to age, (including progress toward state-approved grade level standards), and his or her intellectual development.  Results described in evaluation report.
If one or all boxes are checked, continue.  If no boxes are checked, the child cannot be found eligible.

3.	The student’s lack of achievement is primarily the result of:

yes	
no	a)	A visual, hearing, or motor impairment, mental retardation, emotional disturbance, cultural factors, or environmental or economic disadvantage.

yes	
no	b)	A lack of appropriate instruction in reading, including the essential components of reading instruction (phonemic awareness, phonics, vocabulary development; reading fluency/oral reading skills; and reading comprehension strategies).

yes	
no	c)	A lack of appropriate instruction in math.

yes	
no	d)	Limited English proficiency.
	
If all of the boxes are checked “no”, continue.  If “yes” to any of these the student cannot be found eligible.  

4.	The student has a specific learning disability in one or more of the following areas:

 Basic reading skills
 Reading fluency skills
 Reading comprehension
		 Mathematics calculation
 Mathematics problem solving	 Written expression
 Oral expression	
 Listening comprehension

yes	
no	5.  The student’s disability has an adverse impact on the student’s educational performance when the student is at the age of eligibility for kindergarten through age 21, or has an adverse impact on the child’s developmental progress when the child is age three through kindergarten.	

yes	
no	6.  The student needs special education services as a result of this disability.	

D. The student  does  does not qualify for special education. 

1.	This statement reflects my conclusions (Note: if the report does not reflect a member’s conclusions, the member must submit a separate statement presenting the differing conclusion):

Signatures of Team Members		Title	Agree	Disagree	

	

	

	

	

	

	

			

2. The following have been provided to the child’s parents:

•	A copy of the evaluation report and eligibility statement.
•	If using response to intervention model, a copy of the initial notice, provided to parents in a timely manner, including:
•	ODE and district policies describing the amount and nature of student performance data to be collected and the general education services to be provided as part of the district’s response to intervention model;
•	Strategies for increasing the child’s rate of learning; and
•	The parents’ right to request an evaluation.

	

Signature of person completing eligibility form	
Position	
Date	

	

This form is used to:

•	Document whether the student meets the eligibility criteria for specific learning disability and the basis for that determination in accordance with 20 USC §1414(b)(6) and 34 CFR 300.307 to 300.311.

•	Meet the requirements of OAR 581-015-2170, OAR 581-015-2120, and CFR 300.8 regarding the need to establish eligibility for special education services.

•	Document the date that initial eligibility was established and/or the date that eligibility is re-established; 

•	Provide a place for the team to sign the statement and indicate whether or not each member agrees or disagrees with the eligibility determination; and

•	Document that the parent was given a copy of evaluation report(s) and eligibility statement.

Directions:

	Enter the date the form was completed by the team.

Enter the student’s complete legal name; do not use a nickname.

Enter the student’s school name.

Enter the student’s date of birth.

Enter the date of initial eligibility or the date that eligibility is reestablished. For districts using the RTI process to determine eligibility under the category of Specific Learning Disability, the date of eligibility cannot occur on the same day of consent as additional interventions (following parent consent for evaluation) are a required component of a comprehensive review.

A. Indicate the primary evaluation model used in determining eligibility for this student. 

	Select only one of these three boxes to indicate the primary evaluation model used in the eligibility evaluation for this student. Please note: Selecting only one box as required, does not preclude an evaluator or team from entering information throughout the document or within sections reflecting other evaluation models. 

B.  Document the completion and review of the required evaluation elements.  Attach evaluation report(s) summarizing the relevant information from the evaluation components.

(1)	The team must review existing information, including information from the parent(s), the student’s cumulative records, previous IEPs or IFSPs, teacher collected work samples, state assessment information, and other relevant information.  Document the date of the report summarizing any relevant information from these sources, and the date reviewed by the team.  

(2)	The team must conduct an assessment of the student’s academic achievement toward Oregon grade-level standards.

(3)	The team must conduct an observation (by a qualified professional who is a member of the evaluation team and someone other than the child’s regular teacher) of the child’s academic performance and behavior in a regular classroom setting, or in the case of a child less than school age or out of school, an observation in an age-appropriate environment.  Include in the evaluation report a description of relevant behavior noted during the observation and its relationship to the child’s academic functioning.  

Note:  Information from an observation during routine classroom instruction and monitoring of the child’s performance completed before the child was referred may also be used to satisfy this requirement.
(4)	Progress monitoring data: To ensure that underachievement in a child suspected of having a specific learning disability is not due to a lack of appropriate instruction in reading or math, the group must consider, as part of the evaluation the components below.  

(a)	Data that demonstrate prior to, or as part of, the referral process, the child was provided appropriate instruction in regular education settings, delivered by qualified personnel.

(b)	Data-based documentation provided to the child’s parents of repeated assessments of achievement at reasonable intervals, reflecting formal assessment of student progress during instruction.

Please note: Progress monitoring data must be considered regardless of which of the three models is selected: Response to Intervention, a Pattern of Strengths and Weaknesses or the discrepancy model.  

Please note: If using an RTI model, the team must consider and the evaluation report must describe: progress monitoring data conducted on a schedule that allows comparison of the child’s progress to the performance of peers, that is appropriate to the child’s age and grade placement, that is appropriate to the content monitored, and that allows for interpretation of the effectiveness of the intervention.  

(5)	Document completion of one or both types of assessment:

(a)	If using a response to intervention (RTI) model, the report must document:
•	Date of report
•	Type, intensity and duration (Starting and ending dates or length of each intervention)
•	of scientific, research-based instructional interventions/strategies provided;
•	Data showing the child’s rate of progress during the instructional intervention; 
•	Comparison of the child’s rate of progress to expected rates of progress; and
•	Data showing intervention (by type, period, and date) used prior to date of consent to evaluate and following a parent’s provision of consent to evaluate. 

Note: If using a response to intervention model, the parents must have been notified of the following prior to initiation: ODE and district policies regarding the amount and nature of student performance data to be collected and the general education services to be provided; strategies for increasing the child’s rate of learning; and the parent’s right to request an evaluation.  See end of this ODE sample form for boxes to check that parents were given this notice.  

       (6)     	Document the evaluation of the child’s strengths and weaknesses in performance, achievement, or both, relative to age, Oregon grade-level standards, or intellectual development.  For each test, list the examiner/title, the name of the assessment, the date conducted, and the date reviewed by the team.  

Note:  If the team is using existing data, indicate the assessment information used, and the date the team determines this information to be valid.  Attach documentation of each evaluation.

     (7)     	Document the process used to evaluate the findings of any significant discrepancy between the child’s academic achievement, relative to age, and his or her intellectual development. This process should include documentation of the use of progress-monitoring data toward state-approved grade level standards. For each test, list the examiner/title, the name of the assessment, the date conducted, and the date reviewed by the team.  

(8) The team may conclude that the following additional information is necessary.  

(a)  	Developmental history – to determine whether the student has a disability. Summarize the relevant developmental history in the evaluation report and document the date the developmental history was conducted or obtained, the report date, and the date this information was reviewed by the team.

(b)	Assessments related to cognition, fine motor skills, perceptual motor skills, communication, social/emotional status, perception, or memory.  Describe the relevant information from these assessments in the evaluation report and document the name and title of the examiner, the name of the assessment, the date conducted, and the date reviewed by the team.

(c)	A medical or health assessment statement to rule out or confirm the existence of other physical factors that may be affecting the student’s educational performance.  Describe the relevant findings from this statement in the evaluation report and  document the name and title of the physician, nurse practitioner, or physician’s assistant completing this form, the date the form was completed, and the date reviewed by the team.

C.  Document the team’s conclusions regarding the eligibility criteria:  

(1) If the student is not achieving adequately for the student’s age or to meet Oregon grade-level standards when provided with learning experiences and instruction appropriate for the child’s age or Oregon grade-level standards, check the appropriate boxes in section (1). 

Note: Achievement that is below a child’s ability but not below the child’s age or Oregon grade-level standards will not meet this criterion. Achievement that is below the child’s age or Oregon grade-level standards will not meet this criterion if the student has not been provided with learning experiences and instruction by qualified personnel and appropriate to the child’s age or Oregon grade-level standards.  

Note: If no boxes are checked, the student will not be eligible.  

(2) If a response to intervention model is used and the student has not made sufficient progress in response to scientific, research-based instructional interventions, check the first box.

If the student exhibits a pattern of strengths and weaknesses in performance, achievements, or both, relative to age, Oregon grade-level standards, or intellectual development, that is determined by the team to be relevant to the identification of a specific learning disability, check the second box.

If the evaluation determines that there is a significant discrepancy between the student’s academic achievement, relative to age, and his or her intellectual development and other potential contributing factors are excluded, check the third box. 

Note:  If no boxes are checked, the child cannot be found eligible as having a specific learning disability.  If the team concludes that the child satisfies the criteria for both, then check both boxes.

(3) If the team has checked at least one box from section (1) and one box from section (2), 		determine whether the student’s lack of achievement is due to any of the factors listed below:

a.	A student may not be found eligible as a student with a specific learning disability if the primary reason for the student’s lack of achievement is a vision, hearing or motor impairment, mental retardation, emotional disturbance, cultural factors, or environmental or economic disadvantage;
b.	A child may not be determined to be a child with a specific learning disability if the determinant factor is lack of appropriate instruction in reading, including in the essential components of reading (as defined in section 1208(3) of the Elementary and Secondary Education Act of 1965).  The “Essential Components of Reading Instruction includes explicit and systematic instruction in: Phonemic awareness; Phonics; Vocabulary development; Reading fluency, including oral reading skills; and Reading comprehension strategies 
c.	A child may not be determined to be a child with a specific learning disability if the determinant factor is lack of appropriate instruction in math.
d.	 A child may not be determined to be a child with a specific learning disability if the determinant factor is Limited English proficiency. 

Note:  If any of the boxes in item (3) are checked “yes”, the student will not be eligible as a student with a specific learning disability.

(4)	Indicate whether the student has a specific learning disability in one or more areas by checking the appropriate boxes in section (4) of the eligibility form.

(5)	Indicate whether the student’s disability adversely affects the student’s educational performance (for school-age children) or has an adverse impact on the child’s developmental progress (age 3 through kindergarten).  

Note: If the “no” box is checked, the student will not be eligible as a student with a specific learning disability.

(6)	Indicate whether the student needs special education as a result of the disability.  

Note: If the “no” box is checked, the student will not be eligible as a student with a specific learning disability.

D.  Determine if there is consensus regarding the eligibility determination.

(1)	If the consensus is “yes”, check “yes”.  If the consensus is “no”, check “no”.  If there is not consensus, the district must make a determination regarding the student’s eligibility.

(2) Have each team member (including the parents) sign the form, indicating his/her title, and whether he/she agrees or disagrees with the eligibility determination by checking the appropriate box.

(3) Give a copy of the evaluation report and eligibility statement to the parent(s) and document that you have done so by checking the box. Also indicate if parents were given progress monitoring data for their child collected before or as part of the evaluation process. 

Note:  If using a response to intervention model, document that parents were given notice of: ODE and district policies regarding the amount and nature of student performance data to be collected and the general education services to] be provided; strategies for increasing the child’s rate of learning; and the parent’s right to request an evaluation.  

(Sample)

Parent Notification when using Response to Intervention under the 
Individuals with Disabilities Education Act (IDEA)
---------------------------------------------------------------------------------------------------------------------

Response to Intervention (RTI)

Response to Intervention (RTI) is a way of organizing instruction and assessment that has two purposes:

1. To identify children needing help in reading, math, and writing, and prevent the development of serious learning problems; and
 
2. To identify children who, even when they get extra help, make very limited progress.  Research has shown that these children sometimes have learning disabilities. 

General education services to be provided and strategies for increasing the child’s rate of learning

Each school district using a RTI model must have standard intervention protocols for each level of intervention and the curricula and interventions that will be used for students at each level.  Typically, RTI models provide interventions at universal, targeted, and intensive levels.   

Universal level:  These are research based interventions used with all students at a particular age or grade level.

Targeted level: These are research-based interventions used with students whose progress places them at some risk for not meeting instructional goals and whose deficiencies are easily grouped with other students with similar deficiencies.  

Intensive level:  These are research-based interventions that are used with students whose progress places them at high risk for not meeting instructional goals and whose deficiencies are so unique as to require individualized instructional approaches.  

School districts have decision rules regarding the amount and nature of student performance data that will be collected as part of the district’s RTI model.  Progress monitoring must be conducted on a schedule that:
•	Allows comparison of the child’s progress to the performance of peers, 
•	Is appropriate to the child’s age and grade placement, 
•	Is appropriate to the content monitored, and 
•	Allows for interpretation of the effectiveness of the intervention.  

[Insert a parent directed description of the RTI model used by the district, and the curriculum, interventions and strategies used at each level.  Include: information about the amount and nature of progress monitoring data to be collected as part of the district’s RTI model; and timelines to acquire their (parental) consent for evaluation once a shift occurs from collecting data to ascertain responsiveness to instruction to collecting additional information and data as part of a comprehensive evaluation that addressed all suspected areas of disability.]

When children continue to have difficulty:

The school will tell you whether your child begins to make sufficient progress or if your child has continued difficulty. If you and the school have tried several interventions, and progress is still limited, you will be asked to give your consent for an evaluation. The purpose of such an evaluation is to determine your child’s specific educational needs, and to consider whether a disability may impact his or her learning.

Parent participation:

Parents are essential to children’s success in school. When a child needs supplemental instruction, school staff will describe that instruction to you.  School staff will also ask you to tell them about anything you think might affect your child’s learning. For example, it is important for the school to know if a child has missed a lot of school, experienced a trauma, or is having problems with friends at school. These types of problems may affect a student’s progress, and if we know about them, we can design an intervention more effectively. Parents frequently partner with the school to provide extra practice to develop skills. If you do want to provide extra support at home, you can work with the school to make yourself part of your child’s program.

Parent request for evaluation:

A parent may request an evaluation for special education at any time, including during any stage of the RTI process.  To request a special education evaluation, contact the school principal, a special education teacher or counselor at your child’s school, or the district’s special education director.  

[Insert specific names and contact information]