Review of Evaluation DataADE SPED OPTIONAL FORM
AGES 3-21
Student Name: ______DOB:______Date:______
REVIEW OF EVALUATIONDATA
LEA/District: ______
Birthdate: ______Age: ______Grade: ______
(CHECK ONE) INITIAL EVALUATION RE-EVALUATION
Conducted In a Conference Through consultation with required committee members
Previous Eligibility Determinations (can be NA for initial evals) / Date(s) for Eligibility Determination / Evaluation/Reevaluation Report in FileYes No
Yes No
Yes No
Yes No
The IEP team must review existing evaluation data on the child. Each of the following areas of information should be considered as the team reviews pertinent information:
- Review of all EC and cumulative records,
- Summary of previous evaluations/assessments,
- Evaluations and information provided by the parents of the child;
- Current classroom-based, local or state assessments, and classroom based observations;
AND
- Observations by teachers and related service providers.
The purpose of this document is to identify what additional data, if any, are needed to determine:
- Whether the child is a child with a disability or continues to have a disability;
- The present levels of academic achievement and related development needs, and educational needs of the student,
- Whether the child needs special education and related services, or continues to need special education and related services.
- Whether any additions or modifications to the special education and related services are needed to enable the child to meet measurable annual goals set out in the Individualized Education Program of the child and to participate, as appropriate in the general curriculum.
REVIEW OF EXISTING DATA (Completion required for all disabilities.)
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name and Summary of Most Current Evaluation Information: / Need for further data:Social/Developmental History (including:changes in medical/health status, changes in home/school environment, any behavioral changes, changes in school performance, any goals the parent has for the child) / Yes No
Educational/Early Intervention History / Yes No
Hearing Screen / Yes No
Vision Screen / Yes No
*Proceed to the formDisability-Specific Review of Existing Data for each area of disability or suspected disability.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
AUTISM
SCHOOL AGE
Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction that adversely affects a child’s educational performance. Autism is generally evident prior to age 3. Other characteristics often associated with autism are engagement in repetitive activities and stereotypic movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences.
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation.Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:Individual Intelligence/Cognitive Functioning / Yes No
Individual Achievement / Yes No
Adaptive Behavior / Yes No
Communicative Abilities (receptive and expressive language) / Yes No
Observations (done in a variety of settings and includes personal/social behaviors) / Yes No
Medical (physical exam or specialized) / Yes No
Additional Components / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
AUTISM
EARLY CHLDHOOD
Autism means a developmental disability significantly affecting verbal and nonverbal communication and social interaction that adversely affects a child’s educational performance. Autism is generally evident prior to age 3. Other characteristics often associated with autism are engagement in repetitive activities and stereotypic movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences.
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:Cognitive/Intellectual Abilities (assessment should be comprehensive enough to determine functional cognitive/problem-solving skills) / Yes No
Communicative Abilities
Receptive & Expressive Language / Yes No
Social/Emotional (one adaptive behavior) / Yes No
Observation (required in variety of settings and includes personal/social behaviors) / Yes No
Medical (physical exam or specialized) / Yes No
Self-Help (may be included in the cognitive, adaptive behavior and/or programming assessments) / Yes No
Programming (functional curriculum–based) / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
DEAF-BLINDNESS
SCHOOL AGE
Deaf-Blindness means concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational needs that they cannot be accommodated in special education programs solely for children with deafness or children with blindness These impairments adversely affect a child’s educational performance.
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:Individual Intelligence / Yes No
Individual Achievement/Functional Skills Assessment / Yes No
Adaptive Behavior / Yes No
Communicative Abilities (both receptive and expressive language) / Yes No
Orientation and Mobility Assessment / Yes No
Medical / Yes No
Audiological / Yes No
Opthalmological / Yes No
Additional Components / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
DEAF-BLINDNESS
EARLY CHILDHOOD
Deaf-Blindness means concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational needs that they cannot be accommodated in special education programs solely for children with deafness or children with
blindness. These impairments adversely affect a child’s educational performance.
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:Cognitive/Intellectual (may be assessed through a formal evaluation or in the programming assessment) / Yes No
Communicative Abilities
Receptive and Expressive Language / Yes No
Social /Emotional (adaptive behavior ) / Yes No
Motor (if needed) / Yes No
Self-Help (may be included in the cognitive, adaptive behavior and/or programming assessment) / Yes No
Programming (one criterion or curriculum based measure) / Yes No
Orientation and Mobility Assessment / Yes No
Medical / Yes No
Audiological / Yes No
Ophthalmological / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
HEARING IMPAIRMENT
SCHOOL AGE
Deafness means a hearing impairment that adversely affects educational performance and
is so severe that the child is impaired in processing linguistic information through hearing, with or without amplification.
Hearing Impairment means an impairment in hearing, whether permanent or fluctuating, that adversely affects a child’s educational performance but that is not included under the definition of deafness.
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:Individual Intelligence / Yes No
Individual Achievement / Yes No
Adaptive Behavior / Yes No
Communicative Abilities (both expressive and receptive language, phonetic level, auditory-listening ability) / Yes No
Visual Perception / Yes No
Audiological (including audiometric and amplification systems) / Yes No
Additional Components / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
HEARING IMPAIRMENT (INCLUDING DEAFNESS)
EARLY CHILDHOOD
Deafness means a hearing impairment that adversely affects educational performance and is
is so severe that the child is impaired in processing linguistic information through hearing, with or without amplification.
Hearing Impairment means impairment in hearing, whether permanent or fluctuating, that adversely affects a child’s educational performance but that is not included under the definition of deafness.
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:Audiological / Yes No
Hearing Aid Evaluation (required, if applicable) / Yes No
Auditory Comprehension / Yes No
Cognitive/Intellectual(may be assess through a formal evaluation or programming assessment) / Yes No
Communicative Abilities
- Both Receptive and Expressive
- Augmentative/Alternative Communication(when indicated)
- Phonetic Level Evaluation
Social/Emotional (one adaptive behavior) / Yes No
Self-Help (may be included in the cognitive, adaptive behavior and/or programming assessment) / Yes No
Programming (one criterion or curriculum based measure) / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
EMOTIONAL DISTURBANCE
SCHOOL AGE
Emotional Disturbancemeans a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a student’s educational performance:
- An inability to learn that cannot be explained by intellectual, sensory or health factors,
- An inability to build or maintain satisfactory interpersonal relationships with peers or teachers,
- Inappropriate types of behavior or feelings under normal circumstances,
- A general pervasive mood of unhappiness or depression,
- A tendency to develop physical symptoms or fears associated with personal or school problems. The term includes schizophrenia. The term does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance.
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:Individual Intelligence / Yes No
Individual Achievement / Yes No
Adaptive Behavior / Yes No
Communicative Abilities / Yes No
Clinical Diagnosis / Yes No
Behavioral Observation (variety of settings including frequency, duration, and intensity of behavior) / Yes No
Learning Processes / Yes No
Subject Area Assessment (for each area of suspected deficit) / Yes No
Additional Components / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
INTELLECTUAL DISABILITY
SCHOOL AGE ONLY
Intellectual Disabilitymeans significantly sub-average general intellectual functioning, existing concurrently with deficits in adaptive behavior and manifested during the developmental period that adversely affects a child’s educational performance.
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:Individual Intelligence / Yes No
Individual Achievement / Yes No
Adaptive Behavior / Yes No
Communicative Abilities (Expressive and Receptive Language) / Yes No
Programming(specificsubject area, if appropriate and functional skills assessment) / Yes No
Additional Components / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
MULTIPLE DISABILITIES
SCHOOL AGE
Multiple Disabilities means concomitant impairments. The combination of these impairments causes such severe educational needs that they cannot be accommodated in special education programs solely for one of the impairments. The term does not include deaf-blindness.
When formal, standardized assessments can be administered, the requirements for each suspected disability must befollowed.
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:Individual Intelligence/Cognitive Abilities / Yes No
Individual Achievement/Functional Skills Assessment / Yes No
Adaptive Behavior / Yes No
Communicative Abilities (both receptive and expressive language) / Yes No
Learning Processes / Yes No
Medical (physical exam, specialized if indicated) / Yes No
Additional Optional Components (motor development; vocational) / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
MULTIPLE DISABILITIES
EARLY CHILDHOOD
“Multiple Disabilities” means concomitant impairments (combination of cognitive, physical and/or sensory disabilities), the combination of which causes such severe developmental/educational needs that they cannot be accommodated in special education programs solely for one of the impairments. The term does not include children with deaf-blindness.
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:A systematic, in-depth, multi-faceted assessment must be administered in terms ofmedical (including neurological, when indicated), psychological, and developmental needs. When assessments can be administered the requirements for each area of suspected disability will be followed. / Yes No
Observations across multiple natural environments/tasks / Yes No
Cognitive/Intellectual (may be assessed through a formal evaluation or in the programming assessment) / Yes No
Communicative Abilities:
- Receptive and Expressive Language
- Augmentative/Alternative Communication (when indicated)
Social /Emotional (adaptive behavior) / Yes No
Motor (when needed) / Yes No
Self-Help (may be included in the cognitive, adaptive behavior and/or programming assessment) / Yes No
Programming (one criterion or curriculum based measure) / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
NON-CATEGORICAL (DEVELOPMENTAL DELAY)
EARLY CHILDHOOD
“Non-categorical” means a condition of developmental delay which impairs a child’s functioning and which has a high predictability of impairing normal developmental performance. “Impaired functioning” means that a difference exists between the child’s expected level of developmental and his/her current level of functioning. Areas of developmental delay include: Cognition, Communication, Motor, Social or Emotional Development and Self-Help.
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:Cognitive/Intellectual Abilities / Yes No
Communicative Abilities (both receptive and expressive language) / Yes No
Motor (if indicated) / Yes No
Social/Emotional (adaptive behavior)
Additional assessment for children who may demonstrate inappropriate behavior including:
- Behavioral rating scales or checklist
- Systematic observations
Self-Help (May be included in the adaptive behavior, cognitive/intellectual and or programming assessments) / Yes No
Programming (one criterion or curriculum-based measure) / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
ORTHOPEDIC IMPAIRMENT
SCHOOL AGE
Orthopedic Impairment means a severe orthopedic impairment that adversely affects a child’s educational performance. The term includes impairments caused by congenital anomaly, impairments caused by disease, and impairments from other causes.
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:Individual Intelligence / Yes No
Individual Achievement / Yes No
Adaptive Behavior / Yes No
Communicative Abilities (expressive and receptive) / Yes No
Learning Processes / Yes No
Medical (physical or specialized) / Yes No
Additional Components / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.
DISABILITY SPECIFIC REVIEW OF EXISTING DATA
ORTHOPEDIC IMPAIRMENT
EARLY CHILDHOOD
“Orthopedic impairment” means a severe orthopedic impairment that adversely affects a child’s developmental/educational performance. The term includes impairments caused by congenital anomaly (e.g., clubfoot, absence of some member, spina bifida, etc.), impairments caused by disease (e.g., poliomyelitis, bone tuberculosis, etc.), and impairments from other causes (e.g., cerebral palsy, amputations, and fractures or burns that cause contractures).
Summarize the most recent assessment, the date it was administered, and any change(s) since the most recent evaluation/reevaluation. Indicating “yes” or “we discussed this area” is not sufficient.
Assessment Areas: / Date, Name, and Summary of Most Current Evaluation Information: / Need for further data:Medical (written statement from a physician establishing the type of orthopedic impairment) / Yes No
Cognitive/Intellectual Abilities / Yes No
Communicative Abilities
- Both Receptive and Expressive Language
- Articulation (when indicated)
- Augmentative/Alternative communication (when indicated)
Social/Emotional (adaptive behavior required) / Yes No
Self-Help (may be included in the adaptive behavior, cognitive/intellectual and or programming assessments) / Yes No
Motorincluding
gross and fine motor development; neuromuscular development; sensory integration; daily living activities; and/or need for adaptive equipment. / Yes No
Programming (one criterion or curriculum-based measure) / Yes No
*Proceed to the form No Additional Data Needed/Additional Data Needed.