Enter District Name Here

Specific Learning Disability (SLD)

Eligibility Determination Form and Written Report

Attachment to Admissions and Release Committee (ARC) Conference Summary/Action Form

Initial Determination of Eligibility for this Category of Disability / Re-Determination of Eligibility for this Category of Disability
Student’s Full Name: / SSID:
Date of Birth: / Date of Eligibility Determination:
School:

The ARC determines a student to have a Specific Learning Disability and is eligible for specially designed instruction and related services when:

Complete
During
ARC / The ARC compared and analyzed evaluation data and documents the following interpretation:
Y N
Insufficient / 1. / The student is provided with learning experiences and instruction appropriate for the student’s age or state-approved grade level standards;
Y N
Insufficient / 2. / The student does not achieve adequately, as indicated on multiple data sources, for the student’s age or grade level standards aligned with the Kentucky Program of Studies 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:
Oral Expression Listening Comprehension
Written Expression Basic Reading Skills
Reading Fluency Skills Reading Comprehension
Mathematics Calculation Mathematics Reasoning
Y N
Insufficient / 3. / The student fails to achieve a rate of learning to make sufficient progress to meet grade level standards aligned with the Kentucky Program of Studies in one or more of the areas identified above when assessed using a response to scientific, research-based intervention process;
OR
The student exhibits a pattern of strengths and weaknesses in performance, achievement, or both relative to ability level or intellectual development.
Y N
Insufficient / 4. / The deficits in achievement are not primarily the result of vision, hearing, or motor impairments; mental disability; emotional behavioral disability; cultural factors, environmental or economic disadvantage, or limited English proficiency.
Y N
Insufficient / 5. / Evaluation information confirms there is an adverse effect on educational performance (must be present for eligibility).
Y N
Insufficient / 6. / Evaluation information confirms that lack of instruction in reading and/or math was not a determinant factor in the eligibility decision
Y N
Insufficient / 7. / Evaluation information confirms that limited English proficiency was not a determinant factor in the eligibility decision.


Specific Learning Disability

Eligibility Determination Form and Written Report

Student’s Full Name: / SSID:
Y N
Insufficient / 8. / Evaluation information confirms there is an adverse effect on educational performance.
9a. / The following relevant behavior was noted during the observation of the child:
9b. / Relationship of the observed behavior (9a.) to the child’s academic functioning:
10. / Educationally relevant medical findings, if any:
11. / The instructional strategies used and the student-centered data collected in response to scientific, research-based intervention performance:
Y N
Insufficient / 12. / Documentation of the instructional strategies, educational services, and data collected on student performance is given to the parent.

On the following page provide Supporting Documentation that demonstrates the ARC:

·  Used multiple data sources that substantiate the existence of the disability (triangulation of data);

·  Confirmed the progress of the child is impeded by the disability to the extent that the child’s educational performance is significantly and consistently below the level of similar age peers.


Specific Learning Disability

Eligibility Determination Form and Written Report

Student’s Full Name: / SSID:
Supporting Evidence:

The ARC used the above interpretation of the evaluation data to determine:

The student has a specific learning disability that adversely impacts his/her education and is eligible for specially designed instruction and related services.

The student does not have a specific learning disability and is not eligible for specially designed instruction and related services.

The student has a specific learning disability, but it does not adversely impact his/her education; therefore, the student is not eligible for specially designed instruction and related services.

Evaluation data was insufficient to determine eligibility. Additional assessments and/or data in will be obtained/collected the area(s) of:

The ARC will reconvene by to review and determine eligibility.


Specific Learning Disability

Eligibility Determination Form and Written Report

Student’s Full Name: / SSID:

Admission and Release Committee Members

Parent/Guardian signature below confirms receipt of documentation concerning the district’s policies regarding:
o  The amount and nature of the student performance data that is collected and the general education services that are provided
o  Strategies for increasing the child’s rate of learning; and
o  The parent’s right to request an evaluation

Printed Names with

Titles of ARC Members

/

Signatures

/

Agree

/

Disagree

Parent/Guardian
District Representative
Regular Education Teacher
Special Education Teacher
School Psychologist/Evaluator
Speech/Language Clinician
Student
Other, Specify:
Other, Specify:
Other, Specify:
Other, Specify:

Page | 1 Specific Learning Disability Eligibility Determination and Written Report Form

Revised 03/15/2011