Document date: 10/23/15 Eligibility

Report Cover, all categories

Page

of

[X] Initial Assessment [ ] Reassessment

Students Name: Andrew Jackson
District ID: 55014
Native Lang: English
Ethnicity: white
District: Jefferson School District 251

[ ] 3-Year Reevaluation
State ID: ID
Grade: 1
Sex: M
Birth Date: March 31,
Age: 6
2009
School: Jefferson Elementary School

Parent/Guardian Name: Sherrie Jackson

Address: 3995 E 170 N Rigby, ID 83442
Native Language: English

Home Phone: 702 810 2191

Parent/Guardian Name:
Address:
Native Language:

Home Phone:

Daytime Phone:

Daytime Phone:

1. EVALUATION TEAM INFORMATION

Names of All Evaluation Team
Members Invited to Attend

Position or Title

Kendra Durfee

Interventionist

Ciara Argyle

Interventionist

Agreement with Report

[X] Yes [ ] No
[X] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No
[ ] Yes [ ] No

Note: In the case of a learning disability determination, each member must indicate whether the report reflects that
members conclusion. Any evaluation team member who disagrees with the conclusions of this team report must attach a
January 2007

Form 380a
Copy to the confidential folder, each service provider, and the parent or adult student.

separate written statement of his or her conclusions.

January 2007

Form 380a
Copy to the confidential folder, each service provider, and the parent or adult student.