DEC 3-TBI (1 of 2)

(Revised 2/08)

SUMMARY OF EVALUATION/ELIGIBILITY WORKSHEET-TRAUMATIC BRAIN INJURY

Student: DOB: ____/____/____

School: Grade:

DateInstrumentSummary of Required Screenings and Evaluations

___/___/___ / Hearing Screening / __ Pass __ Fail ___ dB (Intensity Level) ___ Hz (Frequencies)
___/___/___ / Vision Screening / __ Pass __ Fail Far R 20/___ L 20/___ Near R 20/___ L 20/___
___/___/___ / Speech/Language Screening:
___/___/___ / Two research based interventions to address academic and/or behavioral skill deficiencies and documentation of the results of the interventions:
*Note:
Screenings listed above may be waived for students who have been medically diagnosed with traumatic brain injury and who have received medical and/or rehabilitative services in a medical or rehabilitation program or setting within the previous twelve months.
___/___/___ / Review of medical history and records:
___/___/___ / Review of educational history and records:
___/___/___ / Summary of conference with parent(s) or documentations of attempts to conference:
___/___/___ / Social/Developmental History:
___/___/___ / Academic/Functional and Behavior Skills observations across settings:
___/___/___ / Educational Evaluation:
___/___/___ / Psychological Evaluation which is current within one year and is conducted by a qualified professional described in NC Regulations:
___/___/___ / Motor Evaluation:
___/___/___ / Other:

DEC 3-TBI (2 of 2)

Student: DOB: ____/____/____

School: Grade:

As a result of the required screenings, evaluations, and review of existing information, what do we now know about the student?

Strengths:
Needs:

Documentation of impairment in the following areas:

Written verification of traumatic brain injury (e.g., that the child has sustained and injury from which brain injury can be inferred) by a licensed physician or licensed psychologist (appropriately practicing in the specialty of neuropsychology). No time limits exist for written verification.

What is the adverse effect on educational performance?

What evidence exists that the student requires specially designed instruction?

AFTER COMPLETING WORKSHEET, IEP TEAM MUST DETERMINE ELIGIBILITY. (See Eligibility Determination Form)