Student Name: Alicia 1

I. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE

Results of initial or most recent evaluation and results of state and district assessments:
Alicia was most recently evaluated through a psycho-educational report called the Woodcock Johnson III Tests of Achievement. It is a “norm-
referenced assessment that evaluates academic skills in the areas of reading, math, and written expression.”
The standard score for each category/cluster is 100, and the standard deviation is 15.
Results:
Cluster Age Equivalent (Year-Month) Percentile (standard deviation=15) Standard Score (Standard=100)

Phonemic Awareness 11-3 43 97

Oral Language Expression 9-8 24 90
Verbal Ability 13-2 67 107
Broad Reading 9-10 22 88
Broad Math 5-6 >1 12
Broad Written Language 8-9 7 78
Description of academic, developmental and/or functional strengths:
Alicia currently attends all subjects except for math and written expression within the general education classroom.
Ms. Kauffman (Alicia’s special education teacher) reports the following academic strengths for Alicia:
Alicia has average skills in reading decoding and average to above average reading comprehension skills, so she does well analyzing multiple choice
and short answer questions related to reading content.
Alicia writes in complete sentences, writes with few grammatical errors, and has excellent spelling skills.

Description of academic, developmental and/or functional needs:

Alicia receives resource support for math and written expression outside of the general education classroom.
Ms. Kauffman (Alicia’s special education teacher) reports the following academic needs for Alicia in written expression:
Alicia has difficulty summarizing what she has read by using her own thoughts and ideas, so she relies heavily on visual aids to support her
comprehension skills.
Alicia struggles in organizing her ideas for writing, so she needs extensive support for the various stages of writing paragraphs and short essays such
as writing topic sentences and pre-writing in order to edit her own work and make corrections.
In short essays and paragraphs, Alicia also has frequent errors in punctuation, subject-verb agreement, and the correct use of point of view that is
appropriate to the task.

Ms. Kauffman (Alicia’s special education teacher) reports the following functional needs for Alicia in math:
Alicia specifically struggles with computation and reasoning and problem solving, which is manifested through her having difficulty in writing number
sentences and choosing operations to use to solve word problems. Alicia’s teacher reports that these difficulties prevent Alicia from applying math to
real world situations. Because of these difficulties, Alicia benefits from one-on-one support in problem solving.
Alicia is reliant on a calculator for all math computation.

Parental concerns regarding their child’s education:

Alicia’s mother speculates that she could possibly have school anxiety because of her reluctance to attend school and answer questions in class,
putting her head down on the desk when she is called on.
Alicia’s mother reports that she has taken her to a doctor in response to frequent complaints of a stomachache and headache, but the doctor
confirmed that there are no significant medical issues.
Impact of the disability on involvement and progress in the general education curriculum (for preschool, how the disability affects participation in appropriate
activities):
Ms. Kauffman (Alicia’s special education teacher) reports that Alicia has been quiet and withdrawn, not wanting to participate in classroom or school
activities.
Alicia’s mother reports that over the last two months, Alicia has been so reluctant to get up and get ready for school that the struggle to get her
transported to school is too great sometimes that she will call Alicia in absent, which has resulted in 12 absences this semester.

Georgia Department of Education

Model Form July 2011