ELIGIBILITY DETERMINATION
(ALL DISABILITIES OTHER THAN SPECIFIC LEARNING DISABILITY)
DETERMINANT FACTORS
The determinant factor for the student’s suspected disability is:
Yes
No
Lack of appropriate instruction in reading, including the essential components of reading instruction
(Evidence Provided)_______________________________________________________________________
Yes
No
Lack of appropriate instruction in math (Evidence Provided)________________________________________
Yes
No
Limited English Proficiency (Evidence Provided):________________________________________________
If any of the above answers is “yes,” the student is not eligible for services under IDEA and the team must complete Step 1 and 4 below. If all of the answers are “no,” complete Steps 1-4.
COMPLETE FOR STUDENTS SUSPECTED OF HAVING A DISABILITY UNDER IDEA.
STEP 1 - DISABILITY
No Disability Identified (Complete Step 4 and write “Not Eligible for Special Education Services” in the Disability section of the Conference Summary Report page.)
Disability Identified
Based on the team’s analysis, identify the disability(s):
PrimarySecondary
□ Autism (O)□
□ Cognitive Disability (A)□
□ Deaf/Blindness (H)□
□ Deafness (G)□
□ Developmental Delay (3-9) (N)□
□ Emotional Disability (K)□
□ Hearing Impairment (F)□
Primary Secondary
□ Multiple Disabilities (M)□
□ Orthopedic Impairment (C)□
□ Other Health Impairment (L)□
□ Speech or Language Impairment (I)□
□ Traumatic Brain Injury (P)□
□ Visual Impairment including Blindness (E)□