CHARLES COUNTY PUBLIC SCHOOLSDEPARTMENT OF SPECIAL EDUCATION
Specific Learning Disability Eligibility Checklist
Name of Student: / Date of Birth:School: / Date of Eligibility Determination:
☐Y☐N / 1. / Documentation of a processing disorder that impacts the student in the area(s) of:
☐Oral Expression ☐Listening Comprehension ☐Written Expression
☐Basic Reading Skill ☐Reading Fluency Skills ☐Reading Comprehension
☐Mathematics Calculation ☐Mathematics Problem Solving
Processing deficit:
Evaluation source/date:
☐Y ☐N / 2. / AND,There is documentation of an educational evaluation and psychological evaluation that indicate a severe discrepancy between achievement and cognitive ability (see discrepancy chart).
☐Cognitive score, certified valid for the purpose and for the student by a certified school psychologist or licensed psychologist.
Measure(s) used/scores:
☐Appropriate achievement measures certified valid for the purpose and for the student by a certificated teacher for each area of suspected deficit.
Measures used/scores:
☐Y ☐N
☐ N/A / 3. / OR,If a significant discrepancy is not documented through a standard score comparison, a significant discrepancy is documented by the IEP Team and sufficient data is present to demonstrate the presence of a specific learning disability.
Information used to override significant discrepancy criteria:
☐Y ☐N / 4. / The student has been provided with learning experiences and instruction appropriate for his/her age or State-approved grade-level standards and demonstrates inadequate achievement ,and exhibits a pattern of strengths and weaknesses in performance, achievement, or both, relative to age, State-approved grade-level standards, or intellectual development.
Measures used:
☐Y ☐N / 5. / The student has not made sufficient progress to meet age or State-approved grade level standards when using a process based on the student’s response to scientific, research-based intervention (RtI).
Intervention/Strategy:
If the RtI criteria cannot be met, document reason for overriding this area:
☐Y ☐N / 6. / Is lack of achievement a result of any of the following? (If yes, check areas that apply)
☐Visual, Hearing, or Motor Disability ☐ Intellectual Disability ☐Emotional Disability
☐English Language Learner (ELL) ☐ Environmental, Cultural, or Economic Disadvantage
The IEP team used the above interpretation of the evaluation data to determine:
☐ The student has aSpecific Learning Disabilitythat adversely impacts his/her developmental progress and is eligible for specifically designed instruction and related services (IEP).
☐ The student hasaSpecific Learning Disability but it does not adversely impact his/her developmental progress; therefore, the student is not eligible for an IEP.
☐ The student does not have aSpecific Learning Disability and is not eligible for an IEP.
☐ Evaluation data was insufficient to determine eligibility. Additional assessments and/or data will be obtained/collected in the area(s) of:
SE 07/13