Document date: Eligibility Report – Learning Disability Page of _
Student’s Name: / District ID: / State ID: / Grade: / Sex:
Native Lang: / Ethnicity: / Birth Date: / Age:
District: / School:

Traditional Discrepancy Model: This form is to be completed in addition to the Eligibility Report (Form 380 a-c).

1. Not Achieving Adequately: Summarize relevant documentation, pertaining to the characteristics of learning disabilities, and gathered during the pre-referral and/or evaluation process. This documentation should indicate a pattern of strengths and needs in performance, achievement, or both, relative to age, Idaho Content Standards, or intellectual development.

2. Comparing ability and achievement:

Intellectual Ability / Academic Achievement Test / Discrepancy
Regressed Full-Scale Score / Broad Area / Broad Area Score / Regressed full-scale score minus broad area score.
Reading
Math
Written Language

3. Other considerations:

a. Is this discrepancy primarily the result of a visual, hearing, or motor disability; cognitive impairment; or emotional disturbance? [] Yes [] No

b. What effects on performance, if any, are from environmental, cultural, or economic disadvantages?

4. Observation of behavior and academic functioning: Attach documentation of the relevant behavior noted during regular classroom observation in the area(s) of concern based on the referral and the relationship of that behavior to the student’s academic functioning. (In the case of a student less than school age or out of school, the student must be observed in an environment appropriate for the student’s age.)

Name of Observer: / Title:
Site: / Date of observation: / Duration of observation:

5. List educationally relevant medical findings, if any:

6. Severe discrepancy:

There is a severe discrepancy between achievement and ability that cannot be corrected without special education and related services? [] Yes [] No

January 2007 Form 400a

Copy to the confidential folder, each service provider, and the parent or adult student.