Pasco County Schools Rev. 7/15
Pasco County Schools Rev. 7/15
Team Analysis of Data
A. Meeting Date: / Date of Receipt of Parental Consent:B. Demographic Information:
Student Name: / DOB:
School: / Grade: / ID #:
Current Eligibilities/Related Services: / Vision Screen: / Hearing Screen:
Previous Ineligibilities and/or Discontinuations: / Retention History:
Parent Contacts: / Subgroups:
Identified Areas of Concern that have been targeted for intervention: /
Relevant Medical Findings:
(documented)
Other Relevant Information:
Intervention Summary for the targeted area of concern:
Check if interventions are waived. Interventions cannot be waived for Language Impaired and Specific Learning Disabilities (K-12). Indicate the rationale for waiving interventions under the instructional details of educational need.
Intensive Interventions were not implemented based on the data collected.
FBA/BIP were implemented if behaviors impacted the student in the educational environment.
Start Date and End Date / Instruction/Intervention / Implementer/
Title / Duration/
Frequency
Intensive
Analysis of Response to Intervention Data (See attached, which includes graphs and documentation of parent involvement.
Performance discrepancy (Attach graphed data): District School Class AYP Sub Group Other (e.g., Tier II, III Peer Group)
Rate of Progress (Attach graphed data representing intervention intensity, rate of progress, expected rate of progress)
Is there evidence of fidelity in the implementation of the interventions? SelectYesNoNA
Additional Information (if applicable):
The student’s response to intervention was Selectpositivequestionable poorNA.
Additional Information (if applicable):
Comments:
Formal Assessment and Need:
Standardized Norm-Referenced Instrument(s) Results:
Instructional Details of Educational Need:
Summary of Eligibility for Emotional/Behavioral Disability Rev. 9/2013
Yes / No / Evaluation Included:The student’s parent(s) or guardian(s) were notified about the amount and nature of student performance data that would be collected and the general education services that would be provided, interventions for increasing the student’s rate of progress, and the parental or guardian right to request an evaluation.
Functional Behavioral Assessment (FBA) New Reviewed Revised
A well-delivered, scientific, research based Behavior Intervention Plan (BIP) of reasonable intensity and duration that was implemented with fidelity.
A social/developmental history was compiled from a structured interview with the parent (s) or guardian(s).
A psychological evaluation that includes assessment procedures necessary to identify the factors contributing to the development of an emotional/behavioral disability.
Review of educational data that included information on the student’s academic level of performance, and the relationship between the student’s academic performance and emotional/behavioral disability.
A medical evaluation was conducted if needed.
Information gathered from parent(s)/guardian(s), teacher(s), and the student, when appropriate, that support the results of the observations and standardized instruments. (If no, attach documentation.)
Yes / No / Is lack of performance and/or rate of progress PRIMARILY THE RESULT OF: / Specify the documentation or evidence supporting each factor checked:
Lack of appropriate instruction
Limited English Proficiency
Physical factors
Sensory factors
Socio-cultural factors
Developmental factors
Medical factors
(if checked must review a physicians report)
Health factors
(with the exception of mental health)
Temporary reactions to life events or crisis
(less than six months)
Age, culture, gender, ethnicity
Significant improvement following the implementation of evidence-based interventions
Social maladjustment w/o an Emotional/Behavioral Disability
Behaviors exhibited for less than six months and in only one setting
(one setting must include school)
One or more of the following internal or external factors are evidenced by the evaluation data and must impact the student’s ability to maintain adequate performance in the educational setting to make a determination of “Eligible” in the area of Emotional/Behavioral Disabilities.
Internal Factors:
Feelings of sadness, or frequent crying, or restlessness, or loss of interest in friends and/or school work, or
mood swings, or erratic behavior or
Fears, phobias, or excessive worrying and anxiety regarding personal or school problems or
Behaviors that result from thoughts and feelings that are inconsistent with actual events or circumstances, or difficulty maintaining a normal thought process or excessive levels of withdrawal from persons or events
External Factors:
Inability to build or maintain satisfactory interpersonal relationships with peers in the school setting, teachers in the school setting, and other adults in the school setting
Behaviors are chronic, disruptive and manifestations of feelings, symptoms, or behaviors as specified in internalizing factors such as:
Non compliance
Verbal and/or physical aggression
Poorly developed social skills
Yes / No
The student demonstrates a need for special education services over and above what is provided through general education.
Yes / N/A / Additional Team Recommendations:
Current eligibilities/related services:
Further action:
Signatures of group determining eligibility. Each of the following individuals certifies their agreement with the determination of eligibility and assures that this determination was made in accordance with subsection (6) of Rule 6A-6.0331. Please sign over your title or write in your position.
ESE Director or Designee / Parent/Guardian / Parent/Guardian
General Education Teacher / ESE Teacher / Speech/Language Pathologist
School Psychologist / School Social Worker / Other: Name/Position
School Based Administrator / Other: Name/Position / Other: Name/Position
The following team members DISAGREE with the conclusion of the group. Attach a separate statement presenting each member’s conclusion.
Name/Position / Name/Position / Name/Position