EVALUATION REPORT INCLUDING: Page ____ of ____

DETERMINATION OF ELIGIBILITY AND

NEED FOR SPECIAL EDUCATION
Form ER-1 (Rev. 10/2016)

___________________________________________ SCHOOL DISTRICT

Name of Student__________Sammy________________ WISEid_______________ LEA’s Student ID __________

Type of Evaluation: ☐ Initial ☐ Reevaluation

DATE ON WHICH ELIGIBILITY DETERMINATION WAS MADE _____________03/04/2017________

(month/day/year)

In determining whether the student is a student with a disability, (has an impairment and need for special education) document
and carefully consider information from a variety of sources, including aptitude and achievement tests, parent input, teacher
recommendations, information about the student’s physical condition, social or cultural background, and adaptive behavior.

I. INFORMATION FROM REVIEW OF EXISTING DATA

A. ACADEMIC ACHIEVEMENT
Achievement in reading. For preschool children, information about the child’s acquisition and use of knowledge
and skills (including early language/communication and early literacy).
Achievement in other areas (e.g., mathematics, written language, communication, science, social studies, etc.).
For preschool children, information about other pre-academic skills.
1. Information provided by parent(s)/family
Reading:
Sammy’s mother reported that he had difficulties with the beginning reading process
during first grade.

Other:
His mother states that he is still in need of academic assistance.

2. Summary of previous evaluations

Reading:
At the age of 16, Sammy was assessed in the areas of reading recognition and
comprehension. Per the results of the Peabody Individual Achievement test, Sammy’s
reading recognition scored 64 and reading comprehension was 84. The total reading
score measured 74 with a grade equivalent of 5.1. This is well below grade level
achievement.

Other:
At the age of 16, Sammy was assessed in the areas of verbal comprehension, perceptual reasoning, working
memory, processing speed, overall intelligence, receptive language, decoding, spelling, and arithmetic.
The Wide Range Achievement Test- Revised measured Sammy’s ability to decode at 65
(grade equivalent end of grade 3), spelling measured at 59 (grade equivalent less than
grade 3), and arithmetic at 62 (grade equivalent end of grade 4).
The Wechsler Intelligence Scale for Children -IV had a full scale measurement of 81 (Low-average), a verbal
comprehension of 82, perceptual reasoning of 87, working memory was 80, and processing speed of 78.
Scores on the Peabody Picture Vocabulary Test-Revised indicated that his receptive language skills compared
to his intellectual ability. He received an 84, indicating moderately-low performance.

Formal evaluations over the last 8 years have found that Sammy is functioning intellectually in the low-
average range.

3. Classroom-based, district-wide, or state assessment results

Reading:
 Form ER-1 Name of Student ______________________________________ Page ____ of ____

Upon being placed in the self-contained classroom (classified as a third grader),

Sammy was reading at an average second grade level as indicated by his teacher.
When Sammy was 11, he was reading at a lower third-grade level per classroom
teacher assessment.

Other:
At age 11 Sammy was academically passing 4th grade science. Sufficient progress
academically prompted Sammy’s teachers to return him to a regular fourth grade class
at the end of that year.

4. Observations by teachers, related service providers and others, including classroom-based observations
Reading:
The recent evaluator’s conclusion states that Sammy’s reading recognition is severely
deficient.

Other:
The recent evaluation showed that Sammy was also deficient in spelling and
arithmetic.

5. Information from other sources (e.g., postsecondary transition, medical, etc.)

Reading:
There was no postsecondary transition or additional medical information provided.

Other:
There was no postsecondary transition or additional medical information provided.

B. FUNCTIONAL PERFORMANCE
Functional performance includes activities and nonacademic skills needed for independence and performance at
school, in the home, in the community, for leisure time, and for post-secondary and lifelong learning. Some
examples include: activities of everyday living, school/work/play habits, and social-emotional behavior.
For preschool children: positive social-emotional skills (including social relationships) and use of appropriate
behaviors to meet their needs.

1. Information provided by parent(s)/family:

Sammy’s mother has been very involved with his education, assisting when possible in
the problem-solving process for Sammy. In ninth grade, at age 15, Sammy’s mother
asked if Sammy could be placed in the alternative program for out-of-school youth after
Sammy was involved in numerous fights and became suspended. She is very frustrated
with Sammy’s behavior, and states he is still having emotional outbursts at home. She
knows Sammy needs help emotionally. Sammy’s mother sought the help of outside
personnel to have Sammy re-evaluated.

2. Summary of previous functional performance assessments and evaluations:

Sammy’s recent psychoeducational testing report stated that Sammy appears to have
poor listening skills with stronger visual processing. Sammy’s behavior throughout the
testing was exemplary, indicating that he is capable of controlling his emotions.

3. Observations by teachers, related service providers and others, including classroom-based observations:
 Form ER-1 Name of Student ______________________________________ Page ____ of ____

In elementary school it was observed that Sammy was frequently off task and easily distracted. He also
exhibited problems with impulse control. He would engage in fighting during recess, often if he was being
teased.
At age 10, Sammy participated on the Odyssey of the Mind team. His ability to logically problem solve
helped the team win second in regional competition.
He has demonstrated difficulty setting work goals, accepting restrictions placed on him, and controlling his
impulses.

4. Information from other sources (e.g., postsecondary transition, medical, etc.):

There is no additional information available from medical or other sources.

C. PREVIOUS INTERVENTIONS AND THE EFFECTS OF THOSE INTERVENTIONS ☐ Not Applicable

Effect of the intervention on reading
Previous intervention
achievement/early literacy and other areas
(including data, if applicable)
Showed behavior and work habit
Behavior Contract improvement.

Sammy’s teacher began seeing some

Transferred to a self-contained classroom progress in reading when he was provided
proper support and resource assistance.
Deficiencies in mathematics remained.

Sammy continued to engage in problematic

Alternative school setting behaviors and fighting which ultimately
expelled him from the alternative program.
 Form ER-1 Name of Student ______________________________________ Page ____ of ____

II. INFORMATION FROM ADDITIONAL ASSESSMENTS AND OTHER SOURCES (may include aptitude test
results, teacher recommendations, information about the student’s physical condition, social or cultural background,
adaptive behavior, etc.)

Information from additional assessments or other sources was gathered ☐ Yes ☐ No

(If yes, summarize in A. and B. below or attach report(s).)

A. ACADEMIC ACHIEVEMENT
Achievement in reading. For preschool children, information about the child’s acquisition and use of
knowledge and skills (including early language/communication and early literacy).
Achievement in other areas (e.g., mathematics, written language, communication, science, social studies, etc.).
For preschool children, information about other pre-academic skills.

Reading:

There is no other information provided in the area of reading.

Other:

There is no other academic information provided at this time.

B. FUNCTIONAL PERFORMANCE:
Functional performance includes activities and nonacademic skills needed for independence and performance
at school, in the home, in the community, for leisure time, and for post-secondary and lifelong learning. Some
examples include: activities of everyday living, school/work/play habits, and social-emotional behavior. For
preschool children: positive social-emotional skills (including social relationships) and use of appropriate
behaviors to meet their needs.

Sammy’s parents have been very proactive when it comes to Sammy’s education. Early in his
education, his mother felt an integrated school would provide a better education for Sammy. Sammy
is of African American heritage. His family, including mother, father, and one younger brother, live in a
small rural town.

High school has proven to be challenging for Sammy. According to his mother, he has been suspended on
multiple occasions and expelled from the alternative setting due to fighting and misbehaviors. Sammy has
been placed under the jurisdiction of the juvenile justice system. Sammy is currently receiving counseling
at the community mental health clinic.
 Form ER-1 Name of Student ______________________________________ Page ____ of ____

III. DETERMINATION OF ELIGIBILITY AND NEED FOR SPECIAL EDUCATION

The IEP team must determine whether or not the student is a “child with a disability” and the educational needs of the student. A
student is identified as having a disability if the IEP team determines he or she has an impairment that adversely affects the
student’s educational performance, and as a result, needs special education and related services. Use the eligibility criteria
checklists to assist in documentation of required elements for each impairment area. Additional documentation is required for
specific learning disabilities and visual impairment (see below).

A. DETERMINATION OF ELIGIBILITY

1. When considering whether the student meets the criteria for one or more impairments, the IEP team may not find the
student eligible if the determining factor is due to a lack of appropriate instruction in reading or math, or due to limited
English proficiency.
If one of these reasons applies, describe:

Not Applicable

2. The district must take steps to address the lack of appropriate instruction or the student’s limited English proficiency.
Recommendations:

 Not Applicable

3. This student meets the criteria for one or more of the following impairments (check all that apply):

☐ Autism ☐ Significant Developmental Delay

(first consider other areas of impairment)

☐ Emotional Behavioral Disability ☐ Specific Learning Disability

(complete ER-2A, 2B, or 2C)

☐ Hearing Impairment ☐ Speech or Language Impairment

☐ Intellectual Disability ☐ Traumatic Brain Injury

☐ Orthopedically Impaired ☐ Visual Impairment

(complete ER-3, “Determining Braille Needs”)

☐ Other Health Impairment ☐ None found (complete A.3.b. and A.4.

below)

a. For each impairment identified, document how the student meets the criteria
(attach eligibility checklist worksheet, if used):
Sammy was previously diagnosed with a Specific Learning Disability since grade 2. During his most recent
evaluation, it was recommended by the evaluator that he to qualify for Specific Learning Disability and receive
services accordingly. Based on interviews with his mother and teacher, Sammy displays severe, chronic and
frequent inappropriate behaviors at home and the school setting. He demonstrates aggressiveness, impulse control
issues, and inattentiveness as observed by his teacher. The attached checklist for Emotional Behavioral Disability
provides a comprehensive look at Sammy’s qualifications for EBD.

b. Were impairments considered and rejected? ☐ Yes ☐ No

If yes, document which impairments were rejected and how the student did not meet the criteria:

4. If no impairments are identified under 3., there is no need for special education. Include
recommendations other than special education, if any.

Sammy qualifies for special education.

 Form ER-1 Name of Student ______________________________________ Page ____ of ____

B. NEED FOR SPECIAL EDUCATION

In order for the IEP team to determine the student needs special education, the IEP team must answer “yes” to Question 1 and
identify the needs that cannot be met in regular education, as well as the additions, modifications, or accommodations needed. If the
student only requires modifications that can be made in the regular education program, then the student does not need special
education.

1. By reason of the identified impairment(s) that adversely affects the student’s education performance, does the student
need special education (specially designed instruction)?
Specially designed instruction means adapting, as appropriate to the needs of an eligible student, the
content, methodology, or delivery of instruction to address the unique needs of the student that result
from the student’s disability; and ensure access of the student to the general curriculum, so the
student can meet the educational standards of the public agency that apply to all students.

☐ Yes ☐ No
If yes, complete items 2. and 3. below, as appropriate.
If no, there is no need for special education. Include recommendations other than special education, if any.

2. Does the impairment(s) adversely affect progress toward meeting grade-level reading standards? For preschoolers,
does the impairment adversely affect progress toward the Wisconsin Model Early Learning Standards (WMELS) for
language development, communication and/or early literacy?

☐ Yes ☐ No

3. If the student needs special education, identify the following:

a. The student’s needs that cannot be met through the regular education program as structured:
The needs identified here should be reflected on the IEP: Linking Form under Effects of the Disability.

Sammy is in need of additional assistance in the areas of reading recognition, spelling and arithmetic as evidenced
by assessment scores on the Peabody Picture Vocabulary Test-Revised and the Wide Range Achievement Test-
Revised. He would also benefit from a behavior modification program to help alleviate issues in impulse control,
emotional outbursts, and combative behaviors. Additional behavior assessments will be necessary to conduct in
order to determine exactly which areas are of the most importance.

b. Modifications or accommodations (i.e. supplementary aids and services), if any, that can be made in the regular
education program that will allow the student to access the general education curriculum and meet the educational
standards that apply to all students:

Sammy should be provided seating near strong peers and the classroom teacher. A clear
schedule of what is to be expected during the class, extra time and modifications for
assignments and assessments will also be necessary. In addition Sammy shall be allowed
breaks as needed, be given clarity for directions, and be allowed to use assistive
technology (such as a computer or tablet) that can convert text to voice and vice versa.
Classroom and special education teachers alike should conduct frequent checks for
understanding. The student shall have a behavior plan and behavior contract.

c. Additions or modifications, if any, that the student needs which will be provided through the special education
program (i.e. specially designed instruction and related services):

Sammy would benefit from small group, team taught, or 1:1 instruction in the special
education or alternate learning environment. He would also benefit from aide support for
any academic scaffolding and behavior modeling.