DEC 3-SLD (1 of 2)
Discrepancy/Alt to Discrepancy Model
SUMMARY OF EVALUATION/ELIGIBILITY WORKSHEET-SPECIFIC LEARNING DISABILITY
Student: DOB: / /
School: Grade:
Date / Instrument / Summary of Required Screenings and Evaluations/ / Discrepancy Model:
Hearing Screening: / Pass FaildB (Intensity Level)Hz (Frequencies)
/ / Vision Screening: / Pass FailFarR 20/L 20/
NearR 20/L 20/
/ / Speech/Language Screening:
/ / Two research-based interventions to address academic skill deficiencies and documentation of the results of the interventions, including progress monitoring documentation:
/ / Summary of conference(s) with parent(s) or documentation of attempts to conference:
/ / Review of Existing Data:
/ / Social/Developmental History:
/ / Academic, Functional and Behavioral Observation across settings:
/ / Educational Evaluation:
/ / Psychological Evaluation (to include an intellectual evaluation):
/ / Other:
DEC 3-SLD (2 of 2)
Discrepancy/Alt to Discrepancy Model
Student: DOB: / /
School: Grade:
As a result of the required screenings, evaluations, and review of existing information, what do we now know about the student? Include characteristics of a specific learning disability consistent with the definition.
Strengths:Needs:
Document the impairment in the Discrepancy/Alternative to Discrepancy Method:
Discrepancy:- Inadequate achievement to meet age, or State-approved grade level standards as evidenced by a discrepancy between achievement and measured ability of at least 15 points in one or more of the following areas:
Basic Reading SkillsReading Fluency SkillsReading Comprehension
Mathematics CalculationMathematical Problem Solving
OR
A pattern of strengths and weaknesses in performance, achievement, or both relative to age, State-approved grade-level standards, or intellectual development.
- Insufficient progress to meet age or State-approved grade-level standards in one or more of the areas identified above in (A) of this section when using a process based on the student’s response to scientific, research-based intervention.
A.Documentation that the assessment measures did not accurately reflect the discrepancy between achievement and ability;
- Documentation of the assessment measures used, the assessment results, the criteria applied to judge the importance
of the difference between expected and current achievement.
Attach documentation gathered for (A) and (B) above and used in the determination of the presence of a substantial discrepancy in the student's performance.
For either approach used above, have the following factors been ruled out as the primary cause of the disability: sensory or motor deficits, intellectual or serious emotional disabilities, environmental, cultural, linguistic, or economic influences, or lack of instruction in reading or math? YES NO
If “NO”, describe which factor(s) are the primary contributors to the academic delay.
Note: The child cannot be considered eligible as SLD if the response is ‘NO”.
What is the adverse effect on educational performance? (Include a statement of the relationship of the behavior noted during the observation to the student’s academic functioning. Also, address the effect of any applicable educationally relevant medical findings.)
What evidence exists that the student requires specially designed instruction?
IEP TEAM MUST complete ELIGIBILITY determination.
Final 1-08