Adverse Effect Worksheet

Optional Form for ARC Eligibility Decision-making

The ARC must determine that a child has a disability under IDEA. In order to qualify for special education services a child’s disability must adversely affect the child’s educational performance.

“Adverse effect” means the progress of the child is impeded by the disability to the extent that the educational performance is significantly and consistently below the level of similar age peers.

The term “educational performance” includes academic areas and non-academic areas. Educational performance in non-academic areas can include reading, math, communication, etc.; progress in meeting goals for the general curriculum; and performance on state-wide and local assessments. Non-academic areas include daily living activities, behavior, mobility, mental health, etc.

The ARC must determine and document that a child’s disability has an adverse affect in one or more areas of educational performance noted above.

The following worksheet was designed to help teams identify and use a variety of adverse effect measures. The ARC must use multiple sources of data to document the child’s performance is significantly and consistently below the level of same age peers. ARCs will complete the sources of data as appropriate for each individual student and the suspected disability area(s).

Using the multiple sources of data in the worksheet will aid the ARC in the comparison of the student to same age peers. Comparison to peers is the difference between the individual’s level of performance and the expected level of performance for individuals of the same age or other established standards.

For Information Purposes Only – July 2010

* Student Information

Name: / Ethnicity:
School: / Birth Date:
Grade: / Primary Language or Mode of Communication:
Date of Meeting to Determine Eligibility:

* Referral

Reason(s) the student was referred for special education:

* Suspected Disability Area(s) Determined by ARC Prior to Evaluation

* Summary of Progress Monitoring (For reevaluation describe the specially designed instruction provided in accordance with the IEP)

Area(s) of Difficulty including academic, non-academic, behavioral and/or ESL concerns: / Type Area of Difficulty Here / Type Area of Difficulty Here / Type Area of Difficulty Here / Type Area of Difficulty Here
Evidence Based Intervention(s) Provided for Area:
Baseline Performance Data, date and performance level for Area:
Results of Intervention, dates and performance levels for Area:
Teacher/Personnel Providing Intervention:

* ARC Intervention Analysis for Area(s) Noted Above

Type Area of Difficulty Here / Type Area of Difficulty Here / Type Area of Difficulty Here / Type Area of Difficulty Here
Appropriate research-based interventions were targeted toward the area(s) of concern noted for the student / Yes No / Yes No / Yes No / Yes No
Appropriate research-based interventions were provided for a sufficient length of time to make reasonable progress in the curriculum / Yes No / Yes No / Yes No / Yes No
Appropriate research-based interventions were adjusted and changed as needed based on progress data / Yes No / Yes No / Yes No / Yes No
The child’s data performance remains atypical from same age peers / Yes No / Yes No / Yes No / Yes No


English Language Learners

Identified as ELL / Date: Listening Speaking Reading Writing
Results from the Program Services Plan are included in the interventions section above / Yes No
Most Recent Access for ELLs results / Date: Status: LEP Redesignated as Fully English Proficient

* Results of State Assessments

Date / Name of State Specific Assessment / Content Area / Individual Performance Level / Performance Level of Peers / Amount of Difference in comparison to peers / Significant difference from expected norms or other established standards when compared to similar aged peers?
Yes No
Yes No
Yes No
Yes No
Yes No


* Results of District Assessments

Date / Name of District Specific Assessment / Content Area / Individual Performance Level / Performance Level of Peers / Amount of Difference in Comparison to Peers / Significant difference from expected norms or other established standards when compared to similar aged peers?
Yes No
Yes No
Yes No
Yes No
Yes No

* Results of District Universal Screening Assessments

Name of Universal Screening Assessment / Content Area / Individual Performance Level / Performance Level of Peers / Comparison -
Difference from Peers / Significant difference from expected norms or other established standards when compared to similar aged peers?
Fall / Winter / Spring / Fall / Winter / Spring / Fall / Winter / Spring
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No


* Most Recent Grades

Content Area: / Grade / Class Rank / Significantly below expected norms or other established standards when content area grades are compared to grades of similar aged peers
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Note: In using grades from homogeneously grouped classes compare to average performing peers at that grade level rather than within the class

Review of Student Work, Language Samples or Portfolio Entries

Date / Type of Student Work Reviewed / Content Area / Individual Performance Level / Performance Level of Peers / Amount of Difference in Comparison to Peers / Significant difference from expected norms or other established standards when compared to similar aged peers?
Yes No
Yes No
Yes No
Yes No
Yes No


Non-Academic Areas

Date / Non-Academic Area / Report Name or Source / Individual Performance Level / Performance Level of Peers / Amount of Difference in comparison to peers / Significant difference from expected norms or other established standards when compared to similar aged peers?
Behavior: / Disciplinary records
Rating scales Specify:
FBAs
Systemic observations in more than 1 setting over a significant period of time. / Yes No
Self-help or Daily Living Skills: / Rating scales Specify:
Systemic observations in more than 1 setting over a significant period of time. / Yes No
Mental Health / Yes No
Health Concerns, illness or disease / Yes No
Ability to sustain attention to task over a period of time / Rating scales Specify:
Systemic observations in more than 1 setting over a significant period of time. / Yes No
Strength to sustain attention to task over a period of time / Rating scales Specify:
Systemic observations in more than 1 setting over a significant period of time. / Yes No
Date / Non-Academic Area / Report Name or Source / Individual Performance Level / Performance Level of Peers / Amount of Difference in comparison to peers / Significant difference from expected norms or other established standards when compared to similar aged peers?
Vitality to sustain attention to task over a period of time / Rating scales Specify:
Systemic observations in more than 1 setting over a significant period of time. / Yes No
Motor, coordination or mobility / Rating scales Specify:
Systemic observations in more than 1 setting over a significant period of time.
Other Assessment Specify: / Yes No
Sound errors, voice quality, or fluency disorders / Rating scales Specify:
Systemic observations in more than 1 setting over a significant period of time.
Other Assessment Specify: / Yes No
Attendance problems, irregular attendance, excessive tardiness, attendance at multiple schools / Yes No
Significant non-academic issues not yet mentioned / Rating scales Specify:
Systemic observations in more than 1 setting over a significant period of time.
Other Assessment Specify: / Yes No

* Adverse Affect Questions

Yes / No / Explain:
Multiple measures indicate the student is significantly and consistently below same age peers
Concerns are by observed by multiple people across different times and in different settings
Concerns are primarily caused by
Limited English Proficiency
Concerns are caused due to lack of appropriate instruction in reading, including the essential components of reading
Concerns are caused by a lack of instruction in math
Ecological factors (e.g., race, ethnicity, culture, language, or life circumstances) are affecting the educational performance in the areas of concern
The student data performance is atypical when compared to peers of similar socioeconomic status and ethnicity
The adverse effect measures establish that the adverse effect has been present for at least 6 months
If not present for at least 6 months, the documentation establishes that the disability is not temporary and that an adverse effect will escalate without immediate intervention
The educational needs of the student require services and support that extend beyond what typical general education resources alone can provide

Looking at the entire picture of the student in comparison to peers the ARC determines the disability has an adverse effect on educational performance. Yes No

If Yes, summarize how the disability adverse affects the student’s educational performance.

For Information Purposes Only – July 2010