Worthington District 518 EVALUATION

1117 Marine Ave REPORT

Worthington, MN 56187 SAMPLE!
(507) 372-1233

Initial Evaluation Student Name: Jane Doe D.O.B.: 10/10/1996

Reevaluation School: Prairie Elementary Grade: 5th
Report Date: 11/12/1996
Consent Date: 9/14/1996
This Evaluation report must include:
* information reported by parents
* summary of all Evaluation results including tests and scores
* present level of performance statement(s) including educational needs that derive from the disability
* interpretation of Evaluation results and determination of eligibility by addressing criteria components verifying the
child with a disability and is in need of (or continues to need) special education and related services
* SLD written report components (for a child suspected of having a specific learning disability)

I. BACKGROUND INFORMATION
REASON FOR REFERRAL:
Be specific. Give adequate information so that the referral concern is well defined.
Jane is being referred for assessment because of concerns regarding her reading ability. Many interventions have been tried
including Reading Recovery, individualized reading instruction, extra practice with phonics, and neurological impress. Jane
continues to struggle in spite of the interventions.
Jane is due for evaluation because it has been three years since her initial evaluation was conducted. The team will gather
new data to determine continued eligibility for special education services and to plan an appropriate program for Jane.
Jane is being referred for assessment because of social/emotional/behavioral concerns. She struggles with on-task behavior,
explosive episodes, controlling behavior and oppositional behavior. She has worked with the family advocate in a social
skills group for 6 weeks without noticeable improvement. Parents have been contacted on numerous occasions. Jane has a
task card in the classroom and has a quiet place to complete work. In spite of the intensive interventions, Jane continues to
struggle with her behavior.
PARENT INFORMATION:
Jane is the youngest of three children. Her two older siblings have no significant behavioral difficulties. Jane was born 6
weeks prematurely, but breathed well on her own at birth and went home from the hospital when she was a week old. She
had some early feeding difficulties and had many ear infections. Jane had bilateral PE tubes placed when she was 11
months old and again at 3 years of age. She was a fussy baby who did not sleep well. George and Claire shared that it has
been a challenge to parent Jane. They have tried time-out, removing privileges, spanking and talking to Jane. Jane is often
oppositional and defiant with them. They are unable to take her to stores or restaurants because of her unpredictable
behavior. They haven't been able to leave her with a babysitter for the past year. Neither set of grandparents feels equipped
to deal with Jane's behavior. The Doe's are willing to assist in the evaluation process in any way. They desperately want
assistance for their daughter.
SCHOOL INFORMATION:
Jane is a first grader who has struggled with behavior since entering school. She has difficulty relating to her peers and is
often bossy and controlling. She is oppositional with all adults except her classroom teacher. She has a rather positive
relationship with her teacher, Ms. Hampton, but is still unable to control her behavior in the classroom. She is not openly
defiant with her teacher but may explode at other children or when she doesn't want to complete assigned work. Jane has
had to be removed from the classroom on numerous occasions because of her disruptive behavior. She has great difficulty
regaining control once she is upset. The interventions that have been tried have had very little impact on her behavior.
II. REVIEW OF EXISTING DATA, CURRENT ASSESSMENT RESULTS
Intellectual
REVIEW OF EXISTING DATA:
You don't need to list test scores, but give a general statement or two regarding past tests.
Jane was initially assessed when she was a second grader. Test results attained at that time using the Wechsler Intelligence
Scale for Children-Fourth Edition indicated average intellectual ability.

CURRENT ASSESSMENT RESULTS:

Test scores

PRESENT LEVEL OF PERFORMANCE:

This should be a summary of the student's strengths and weaknesses with more emphasis on the child than the test scores. It
should include data gathered through observations or teacher interview, not just interpretation.

EDUCATIONAL NEEDS:
This should be a brief statement regarding special education needs.

Academic

REVIEW OF EXISTING DATA:

You don't need to list test scores, but give a general statement or two regarding past tests.

Jane was assessed in the 2nd grade and demonstrated average math scores on the Woodcock-Johnson-Third Edition. She
demonstrated weaknesses in reading and written expression. Her achievement scores in those two areas were far below her
ability level.

CURRENT ASSESSMENT DATA:

TEST SCORES:

PRESENT LEVEL OF PERFORMANCE:

This should be a summary of the student's strengths and weaknesses with more emphasis on the child than the test scores. It
should include data gathered through observations or teacher interview, not just interpretation.

EDUCATIONAL NEEDS:
This should be a brief statement regarding special education needs.

Communication
REVIEW OF EXISTING DATA:
You don't need to list test scores, but give a general statement or two regarding past tests.

CURRENT ASSESSMENT DATA:

TEST SCORES:

PRESENT LEVEL OF PERFORMANCE:

This should be a summary of the student's strengths and weaknesses with more emphasis on the child than the test scores. It
should include data gathered through observations or teacher interview, not just interpretation.

EDUCATIONAL NEEDS:

Motor
REVIEW OF EXISTING DATA:
You don't need to list test scores, but give a general statement or two regarding past tests.

Jane was assessed in the 2nd grade and demonstrated good gross motor skills. She demonstrated slightly weaker fine motor
skills. She had many sensory issues related to touch and sound.

CURRENT ASSESSMENT DATA:

TEST SCORES:

PRESENT LEVEL OF PERFORMANCE:

This should be a summary of the student's strengths and weaknesses with more emphasis on the child than the test scores. It
should include data gathered through observations or teacher interview, not just interpretation.

EDUCATIONAL NEEDS:
This should be a brief statement regarding special education needs.

Functional

REVIEW OF EXISTING DATA:

You don't need to list test scores, but give a general statement or two regarding past tests. Jane was assessed in 2nd grade.
Areas of concern included functional academics, daily living skills, communication skills, social skills, social skills and
recreation and leisure skills.
CURRENT ASSESSMENT DATA:
TEST SCORES:
PRESENT LEVEL OF PERFORMANCE:
This should be a summary of the student's strengths and weaknesses with more emphasis on the child than the test scores. It
should include data gathered through observations or teacher interview, not just interpretation.
EDUCATIONAL NEEDS:
This should be a brief statement regarding special education needs.
Sensory/Health/Physical Status
REVIEW OF EXISTING DATA:
Even if the child has not been assessed previously, this section should include medical history from the file or from
parental interviews.
CURRENT ASSESSMENT DATA:
Include current data regarding hearing and vision. Include current health concerns.
EDUCATIONAL NEEDS:
This should be a brief statement regarding special education needs.
Emotional/Social/Behavioral Development
This section will follow the same format as the other sections with the exception of including the FBA. When observations
are done as part of an FBA they should be included under Current Assessment Results rather than in the observation
section.
Transition
Follow the same format as the other areas regarding existing data, if any, and current data as well as needs.
III. CLASSROOM OBSERVATIONS
Include classroom observations for most situations here (exception FBA).
MAKE SURE THAT OBSERVATIONS RELATE TO THE REFERRAL CONCERN.
If the child is referred because of concerns in reading, dont observe them in math. Observations are a vital part of the
assessment, not just a formality to complete in order to comply with regulations. Information gathered from observations
may be more helpful in programming than formal test scores.
Make sure that in LD cases you are looking for processing difficulties during the observation.
DCD observations should focus on how well the child is able to function independently and participate academically.
OHD observations should specifically address how the health condition is impacting education.
IV. INTERPRETATION AND SUMMARY OF RESULTS
Jane meets criteria for placement in special education under the category of .
Address each section of the criteria, numbering the criteria as it is on the criterion sheet. Use the same language that is used
on those sheets. We will be getting templates that will make this process easier.
LEARNER-BASED NEEDS:
This will address overall needs and may be a summary of the need statements in each section.

Jane continues to meet eligibility for special education services under the category of Autism Spectrum Disorder:
A. 1. Jane displays a qualitative impairment of reciprocal social interactions as evidenced by:
- gross impairment in ability to make friends
- misinterprets others' behaviors and social cues
- significant vulnerability and safety issues due to social naivet
- difficulty relating to peers
2. Jane displays a qualitative impairment in communication as evidenced by:
- early delay of spoken language
- odd production of speech (intonation, rhythm, rate)
- repetitive, idiosyncratic language
- literal interpretation of language ("You're pulling my leg", "I not got ahold of your foot")
3. Jane displays restricted, repetitive, stereotyped patterns of behavior, interests, activities:
- intense, focused preoccupation with a limited range of play, interests, or conversational topics (jungle animals, zoo
keeper, camping)
- some repetitive hand mannerisms (flapping)
- some rigid, rule-bound thinking
B. There is ample verification that ASD adversely affects Jane's present level of performance:
1. There are educational needs in all three core features.
2. Observations in two different settings on two different days verify needs.
3. There is historical summary of developmental history and behavior patterns typical of autism

The Team has determined Jane continues to have a need for direct speech and language therapy. Emphasis should continue
on social language skill development, improving sentence structure, intonation and rhythm of her speech, responding to
"WH" questions, attending consistently to longer sentences to respond appropriately, and remaining on the topic when
talking with peers and adults.