BISMARCK PUBLIC SCHOOLSSPECIAL EDUCATION DEPARTMENT
INTELLECTUAL DISABILITY WORKSHEET
Determination of Disability: (Student’s name) meets special education eligibility under the category of Intellectual Disability due to significantly sub average general intellectual functioning and significantly impaired adaptive behavior that adversely affects (Student’s name) educational performance.
Qualifying Criteria
A student is eligible for special education in the area of Intellectual Disability when (ALL must be evident):
[ ]Significantly impaired intellectual functioning, which is defined in most cases as two or more standard deviations below the mean, with consideration given to the standard error of measurement for the test, on an appropriate individually administered, standardized measure of intelligence; AND
[ ] Significantly impaired adaptive behavior* in the home and/or community determined by a composite score on an individual standardized instrument to be completed with or by the child’s primary caretaker which measures two or more standard deviations below the mean, with consideration given to the standard error of measurement for the test; AND
*Adaptive Behavior Skills to Consider:
[ ] Conceptual: language/communication, reading, writing, math, knowledge, and memory
[ ] Social: interpersonal skills, social responsibility, following rules, social problem solving
[ ] Practical: activities of daily living, safety, work tasks, schedules/routines, organizing;
[ ] Significantly impaired adaptive behavior* in the school, daycare center, residence, or program determined by a composite score on an individual standardized instrument to be completed with or by the child’s teacher which measures two or more standard deviations below the mean, with consideration given to the standard error of measurement for the test; AND
*Adaptive Behavior Skills to Consider:
[ ] Conceptual: language/communication, reading, writing, math, knowledge, and memory
[ ] Social: interpersonal skills, social responsibility, following rules, social problem solving
[ ] Practical: activities of daily living, safety, work tasks, schedules/routines, organizing
[ ] Developmental history that indicates the delays in intellectual and adaptive behavior functioning were manifested during the developmental period.
[ ] As part of the specific eligibility criteria, the Team must consider general determinant (exclusionary) factors: lack of appropriate reading and math instruction, language proficiency, culture, socio-economic status, attendance, frequent moves, incarceration, substance abuse, etc. must be discussed and determined to not be primary factors for the student’s lack of performance.
Adverse Impact on Educational Performance:
[ ] The team must also consider the adverse effect of the disability on educational performance and the need for specially designed instruction.
Data for determining eligibility was gathered from (List multiple resources; Not all may apply):
[ ] Cumulative file review
[ ] Review of previous interventions
[ ] Interview/Developmental History Information (Teacher, Parent, Student)
[ ] Age-Appropriate Systematic Observation(s) – Adaptive Behavior
[ ] Age-Appropriate Adaptive Behavior Characteristics Checklist
[ ] Tests (Intelligence Tests (required), Adaptive Behavior Rating Scales (required), NDSA, MAP, CBMs, etc.)
[ ] Assessment Instrument Selection Form for Intellectual Disability (intended for use prior to assessment planning)
[ ] Other: ______
Note:Untestable situations:
[ ] History of extremely low adaptive behavior and poor functioning
[ ] At least 2 years delayed in academic growth
[ ] Very slow rate of growth (significantly below grade-level expectations)
[ ] Has been requiring specialized instruction to learn even at that slower pace
[ ] Documentation of history of attempts to administer formal cognitive measures and description oflimitations preventing testing
LAST REVISED 3/18/16