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Contact Information:
If you have questions about this document or would like additional information, please contact:
the Special Education Monitoring Team
Form #2 - Special Education Evaluation Plan and Report
Cover Page
Local Education Agency: _____________________________________________
Student Name: ____________________________________________________
Child Count ID #: ____________________________________________________
Grade: Date of Birth: _____________
Current Educational Program: _________________________________________________________
Town of Residence: ___________________________________________________________________
Name of Parent/Guardian/Ed Surrogate_________________________________________________
Reason for Referral: ___________________________________________________________________
Date of Referral: _________________________________________________________________
Date of Planning Meeting: __________________________________________________________
Date Consent was Received: __________________________________________________________
Date of EPT Meeting in Which Eligibility Decision was Made: ______________________________
Date the Report was Completed: _______________________________________________________
Date the Report was Issued to Parent/Guardian/Ed Surrogate:______________________________
Was the Eligibility Decision Issued within 60 days of date of consent? ☐ Yes ☐ No
If the eligibility decision was not issued within 60 days of the date of consent, was the
Parent/Guardian/Ed Surrogate informed of a delay within 60 days of consent in writing?
☐ Yes ☐ No
The Evaluation Plan was delivered through (check all that apply):
☐ Postal Mail ☐ Secure Email ☐ In-Person
The Evaluation Plan was developed through (Check all that apply):
☐ Conversation ☐ Correspondence ☐ Formal Meeting
Special Education Evaluation Plan Report
(Revised: February 22, 2023)
Page 2 of 11
Evaluation and Planning Team (EPT) Members (table below):
Name
Role
Involved
Plan
in
Agreed with
Decision
Parent / Guardian
(circle one)
/ Ed. Surrogate
☐
☐
Yes
No
☐ Agree
☐ Disagree
Initial: ______
Adult Student
☐
☐
Yes
No
☐ Agree
☐ Disagree
Initial: ______
Student (when appropriate)
☐
☐
Yes
No
☐ Agree
☐ Disagree
Initial: ______
Local Education Agency Representative
☐
☐
Yes
No
☐ Agree
☐ Disagree
Initial: ______
Special Education
Provider
Teacher or Service
☐
☐
Yes
No
☐ Agree
☐ Disagree
Initial: ______
General Education Teacher
☐
☐
Yes
No
☐ Agree
☐ Disagree
Initial: ______
Individual who can interpret
instructional implications
☐
☐
Yes
No
☐ Agree
☐ Disagree
Initial: ______
Individual who can conduct diagnostic
examinations (SLD requirement)
☐
☐
Yes
No
☐ Agree
☐ Disagree
Initial: ______
Other (describe):
☐
☐
Yes
No
☐ Agree
☐ Disagree
Initial: ______
Other (describe):
☐
☐
Yes
No
☐ Agree
☐ Disagree
Initial: ______
Other (describe):
☐
☐
Yes
No
☐ Agree
☐ Disagree
Initial: ______
Special Education Evaluation Plan Report
(Revised: February 22, 2023)
Page 3 of 11
Disability Determination - Section One
A. The EPT is developing this plan (or developed this plan) to assess the following suspected
disability area(s), please check all that apply:
☐ Autism Spectrum Disorder ☐ Intellectual Disability
☐ Specific Learning Disability ☐ Deaf-Blindness
☐ Multiple Disabilities ☐ Speech or Language Impairment
☐ Developmental Delay ☐ Orthopedic Impairment
☐ Traumatic Brain Injury ☐ Emotional Disturbance
☐ Other Health Impairment ☐ Visual Impairment
☐ Hearing Loss
B. What concerns or areas to evaluate were or will be included in the disability determination?
In each section below, specify the tests and/or assessment procedures used:
Concern or area: _____________________________________________
Assessment Area: _____________________________________________
Assessment(s)/Evaluation(s): _______________________________________
Name of assessor / evaluator: ____________________________________________________
Role of Professional (i.e., School Psychologist, Physical Therapist, etc.): _____________
Concern or area: _____________________________________________
Assessment Area: _____________________________________________
Assessment(s)/Evaluation(s): _______________________________________
Name of assessor / evaluator: ____________________________________________________
Role of Professional (i.e., School Psychologist, Physical Therapist, etc.): _____________
Concern or area: _____________________________________________
Assessment Area: _____________________________________________
Assessment(s)/Evaluation(s): _______________________________________
Name of assessor / evaluator: ____________________________________________________
Role of Professional (i.e., School Psychologist, Physical Therapist, etc.): _____________
Special Education Evaluation Plan Report
(Revised: February 22, 2023)
Page 4 of 11
Evaluations and information provided by the parent of the student (or documentation of LEA’s
attempts to obtain parental input): ______________________________________________________
_____________________________________________________________________________________
Observations/Recommendations by Teachers and by related services providers, when
appropriate: _________________________________________________________________________
_____________________________________________________________________________________
If an assessment is not conducted under standard conditions, describe the extent to which it
varied from standard conditions, including if the assessment was given in the student’s native
language, or other mode of communication: _____________________________________________
_____________________________________________________________________________________
Summary of findings/interpretation of evaluation results, including consideration of all
available evaluation data, and the team’s analyses of the student’s functioning levels: _________
_____________________________________________________________________________________
Present levels of academic achievement - Describe the student’s present levels, strengths, and
the resulting academic needs, when appropriate. Include communicative status, motor abilities,
and transition needs as appropriate. For students with limited English proficiency (LEP),
include current level(s) of English language proficiency in reading, writing, speaking, and
understanding/listening: ______________________________________________________________
_____________________________________________________________________________________
Present levels of functional performance - Describe the student’s present levels, strengths, and
the resulting functional and developmental needs, when appropriate: _______________________
_____________________________________________________________________________________
Behavioral information – Include social and emotional status and behavioral strengths and
needs, when appropriate: ______________________________________________________________
_____________________________________________________________________________________
Eligibility Verification: A student must not be found to be eligible for special education and
related services if the determining factor for the student’s suspected disability is any of those
listed below. Respond Yes or No to, and provide evidence for, each determining factor below:
Special Education Evaluation Plan Report
(Revised: February 22, 2023)
Page 5 of 11
☐ Yes ☐ No Lack of appropriate instruction in reading, including the essential components
of reading instruction. Provide evidence:
_____________________________________________________________________________________
_____________________________________________________________________________________
☐ Yes ☐ No Lack of appropriate instruction in math. Provide evidence:
_____________________________________________________________________________________
_____________________________________________________________________________________
☐ Yes ☐ No Limited English proficiency. Provide evidence:
_____________________________________________________________________________________
_____________________________________________________________________________________
Does the Evaluation and Planning Team conclude that the student met the disability
determination in the area of ______________________________? ☐ Yes ☐ No
Special Education Evaluation Plan Report
(Revised: February 22, 2023)
Page 6 of 11
Adverse Effect - Section Two
Adverse effect on educational and functional performance is determined by a review of school
performance measures by the EPT in light of the student’s disability. The documentation
requirement for this section is the one basic skill and a minimum of multiple school
performance measures. However, if the student has additional educational or functional needs,
they MUST also be addressed here or in the Needs section of this Evaluation Report. Once a
student has been found eligible in one adverse effect basic skill category, their additional special
education services may be offered based upon the needs of the student or the appropriateness
of other standard supports available within their school. In addition, if a student is found not to
have an adverse effect in any one of the basic skills assessed, it would be necessary to document
each additional basic skill area of concern to prove ineligibility.
Basic Skill Area(s) of concern (check all that apply):
☐ Basic Reading Skills ☐ Reading Comprehension
☐ Reading Fluency (SLD only) ☐ Motor Skills
☐ Mathematics Calculation ☐ Mathematics Reasoning
☐ Written Expression ☐ Listening Comprehension
☐ Oral Expression ☐ Functional Performance/Skills
Measures of School Performance: Questions for the EPT to Consider Determining if the
Disability Adversely Effects Educational and Functional Performance
Questions within this document serve as a guide on data and information sources which may
support EPT decision-making in determining adverse effect. EPT Teams are not required to
complete every category if not appropriate given a student’s unique circumstance. This is not an
exhaustive list of questions and EPT Teams can populate the Other category with descriptions
of additional information that was collected and reviewed as part of the eligibility
determination process. The key is to examine to the extent the disability identified adversely
effects educational and functional performance.
1. Do standard or percentile scores on nationally-normed individually-administered
achievement test(s), or for children ages 3 to 5, appropriate multi-domain nationally-normed
test(s) or rating scale(s), demonstrate adverse effect?
Verification: _________________________________________________________________________
Is there evidence of Adverse Effect? ☐ Yes ☐ No ☐ N/A
Special Education Evaluation Plan Report
(Revised: February 22, 2023)
Page 7 of 11
2. Do standard or percentile scores on nationally-normed group-administered achievement
test(s), including nationally-normed, curriculum-based measures, demonstrate adverse
effect?
Verification: _________________________________________________________________________
Is there evidence of Adverse Effect? ☐ Yes ☐ No ☐ N/A
3. Do any reports prepared by the SU/SD or presented by the parent/guardian reflect adverse
effect in any of the basic skill areas? (Grades or other measures of academic proficiency)
Verification: _________________________________________________________________________
Is there evidence of Adverse Effect? ☐ Yes ☐ No ☐ N/A
4. Does the child’s performance on comprehensive assessments based on a system of learning
results, or the Common Core as of 2014, or measurements of indicators within the Early
Childhood Learning Guidelines, demonstrate adverse effect?
Verification: _________________________________________________________________________
Is there evidence of Adverse Effect? ☐ Yes ☐ No ☐ N/A
5. Do criterion-referenced assessments demonstrate adverse effect in any of the basic skill
areas?
Verification: _________________________________________________________________________
Is there evidence of Adverse Effect? ☐ Yes ☐ No ☐ N/A
6. Do child’s work products, language samples, or portfolios demonstrate adverse effect?
Verification: _________________________________________________________________________
Is there evidence of Adverse Effect? ☐ Yes ☐ No ☐ N/A
7. Does disciplinary evidence, or rating scales based on systemic observations in more than
one setting (whenever possible) by professionals or parents/guardians, demonstrate adverse
effect in any of the basic skill areas?
Verification: _________________________________________________________________________
Is there evidence of Adverse Effect? ☐ Yes ☐ No ☐ N/A
Special Education Evaluation Plan Report
(Revised: February 22, 2023)
Page 8 of 11
8. Do the child’s attendance patterns demonstrate adverse effect?
Verification: _________________________________________________________________________
Is there evidence of Adverse Effect? ☐ Yes ☐ No ☐ N/A
9. Do the child’s social, behavioral, or emotional deficits (if any), as observed by professionals
or parents/guardians in multiple settings (whenever possible), on clinical rating scales or in
clinical interviews, demonstrate adverse effect in any of the basic skill areas?
Verification: _________________________________________________________________________
Is there evidence of Adverse Effect? ☐ Yes ☐ No ☐ N/A
10. Other (add any other data sources)
Verification: _________________________________________________________________________
Is there evidence of Adverse Effect? ☐ Yes ☐ No ☐ N/A
EPT Rationale for Using Only One School Performance Measure
If only one measure of school performance was used to determine adverse effect, document the
EPT’s rationalization for this single measure determination:
Has the EPT determined that the information gathered on the child meets the district’s
definition of adverse effect? ☐ Yes ☐ No
Basic Skill Area that met Adverse Effect: ______________________________ (Choose a category)
Special Education Evaluation Plan Report
(Revised: February 22, 2023)
Page 9 of 11
Need for Special Education Services - Section Three
This section seeks to provide justification that the student/child:
a. requires specially designed instruction that cannot be provided through the
educational support system or through the school’s standard instructional
conditions; or
b. for Early Childhood Special Education, a justification that a delay is at a level that
would affect future success in the home, school, or community without intervention
prior to enrollment in elementary school.
For Early Special Education Services, if it is found that the child needs special education
services, the statement should include justification that a delay is at such a level that
without intervention prior to enrollment in elementary LEA, it would affect his/her
future success in the home, school, or community.
1. Questions and answers necessary for the EPT to determine whether the disability and
adverse effect combine to result in a need for special education services:
A. What accommodations and modifications, if any, are necessary for the student to
demonstrate progress within the general education (including early childhood)
curriculum? ______
________________
B. In what areas does the student require specially designed instruction that cannot be
provided through the educational support system, or through the standard instructional
conditions, supplementary aids and services within the school? ______________________
C. If the student is experiencing educational difficulty in a basic skill area, but does not
qualify for special education under adverse effect or need, what additional information
needs to be provided as part of the referral to the Section 504 Team or Educational
Support Team? ________________________________________________________________
2. Identify additional educational and functional performance needs of the student not
documented in the Adverse Effect section that were assessed and may need to be addressed
either by the IEP Team, the Section 504 Team or the school’s multi-tiered system of support
or other standard supports available to students through the school.
Additional area(s) requiring consideration:
☐ Basic reading skills ☐ Reading Comprehension
☐ Reading Fluency (SLD only) ☐ Motor Skills
☐ Mathematics calculation ☐ Mathematics reasoning
Special Education Evaluation Plan Report
(Revised: February 22, 2023)
Page 10 of 11
☐ Written expression ☐ Functional Performance/Skills
☐ Listening comprehension ☐ Oral Expression
☐ Social/Emotional/Behavioral
For Early Childhood Special Education:
☐ Adaptive Development ☐ Cognitive Skills
☐ Speech and Language Development ☐ Social or Emotional Development
☐ Physical Development (fine or gross motor skills)
☐ Medical condition(s) (please describe)
3. Summarize the Evaluation and Planning Team’s decision regarding the need for special
education services:_________________________________________________________________
4. Does the team conclude that the student has a need for special education services?
☐ Yes ☐ No
Decision of the Evaluation and Planning Team Regarding Eligibility - Final Page
Based upon the results of this Evaluation Plan and Report, the Evaluation and Planning Team
has determined that __________________________________________:
☐ Meets or continues to meet the special education eligibility requirements under the disability
category/categories: __________________________________________________________________
☐ Did not meet or did not continue to meet the special education eligibility requirements. The
reason(s) for determining this ineligibility is/are: _________________________________________
Enclosures:
Once the evaluation is completed, if you agree with the eligibility decision, please initial in the
last column where your name is listed on (pages 1 & 2 of this document).
If you disagree, please complete the next page, where information about parental rights and
disagreement are located.
Special Education Evaluation Plan Report
(Revised: February 22, 2023)
Page 11 of 11
Report of Disagreement
If a child/student has a documented disability but does not demonstrate either an adverse effect
or a need for special education services, they must be referred to their building principal who
then ensures that the Section 504 Team reviews the student/child’s eligibility and supports.
If you do not agree with the evaluations used to make this decision, you may request an
independent educational evaluation. The criteria for selecting an evaluator for an independent
evaluation, including the location and qualification of the evaluator, must meet the same
standard as used by the school district. If you cannot find an evaluator, ask the school district to
provide you with information about where you can get such an evaluation. The independent
evaluation must be done at public expense, unless the school district asks for a due process
hearing to prove their evaluation was appropriate. If the hearing officer agrees with the school
district, the independent evaluation would be completed at your own expense.
Both the state and federal laws concerning special education of children with disabilities
include many parental rights. Receiving notices about the proposed actions or decisions the
school wishes to take regarding your child and your being a part of the educational planning
team for your child with a disability are examples of rights given to you by these laws. These
laws also require that the school follow certain procedures to make sure you know your rights
and are afforded the opportunity to exercise those rights. You received a copy of these rights
when your child was referred.
Name: __________________________________________________________
Role: ________________ Date: _____________
Reasons for Disagreement: _______________________________________
Conclusion: ____________________________________________________
Signature: ____________________________________________________
You should read them carefully and, if you have any questions regarding your rights, please
contact:
School Staff: __________ __________Phone: ___________________
Written Address for Mail: _______________________________________
