Pro 6 Etr Form – Fill Out and Use This PDF

ETR Evaluation Team Report

INSTRUCTIONS

There are four parts to this form, i.e., Part 1,2,3 and 4. Parts 1,2 and 4 must be completed for all initial evaluations and reevaluations. Part 3 must be completed for initial evaluations if the suspected area of disability is Specific Learning Disability. Part 3 must be completed for reevaluations if the child is currently a child identified as having a specific learning disability or the team is considering a change in the child's disability category to Specific Learning Disability.

In Part 1 each member of the evaluation team will list in the “Areas of Assessment” box the area or areas that they will be assessing, i.e., vision, hearing, fine motor, gross motor, emotional/behavioral or intellectual ability. The evaluator will also provide, in Part 1, the evaluation method and strategies used to conduct the assessment by checking the appropriate boxes. A detailed summary of the results of the assessment or assessments will be provided in the “Summary of Assessment Results” section. The evaluator will sign their assessment page and include his or her position title. The date on this section will be the date the evaluator completed his or her assessment.

Part 2 will be completed by the team chair or district representative by gathering all team members' assessments (Part 1) and summarizing them in the boxes provided in Part 2. The interventions summary is completed for both initial evaluations and reevaluations per the instructions found on the form and in Procedures and Guidance for Ohio Educational Agencies serving Children with Disabilities. The reason(s) for the evaluation is also completed for both initial and reevaluations. The summary of information provided by the parents of the child will include information from the referral form as well as any information provided by the parent through behavioral checklists, interviews or meetings, outside evaluations.

Once all assessment information is gathered and summarized, the team will meet and review all information. The team will then describe the child's educational needs based on the information gathered, and state the implications for instruction and progress monitoring in the appropriate text box.

The team will then consider whether or not the child may have a specific learning disability based on the elements found in Part 3. If no one suspects a disability under this category, the team may skip Part 3 and move into Part 4.

In Part 4 the team determines whether or not the child is eligible for special education and related services by addressing each of the statements found in this section. The final text box in this section is completed with the information that supports the team's eligibility determination. All members of the team sign the report at the conclusion of this section. If any team member disagrees with the team's determination, the team member must attach a written statement of disagreement to the report.

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ETR Evaluation Team Report

CHILD'S NAME:ID NUMBER:DATE OF BIRTH:

1	INDIVIDUAL EVALUATOR'S ASSESSMENT
	Section to be completed by each individual evaluator

EVALUATOR NAME:

POSITION:

AREAS OF ASSESSMENT:

Indicate the area(s) that were assessed by the evaluator in accordance with the evaluation plan.

EVALUATION METHODS AND STRATEGIES

Indicate the types of assessment strategies used to gather information about the child's performance

ASSESSMENT INFORMATION

Provide a summary of the information obtained from the assessment results per the evaluation plan including the child's strengths, areas of need and baseline data

SUMMARY OF ASSESSMENT RESULTS:

DESCRIPTION OF EDUCATIONAL NEEDS:

IMPLICATIONS FOR INSTRUCTION AND PROGRESS MONITORING:

Evaluator's Signature:		Date:

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ETR Evaluation Team Report

CHILD'S NAME:	ID NUMBER:	DATE OF BIRTH:
2 TEAM SUMMARY

Combine all Part 1's Individual Evaluator's Assessment from all evaluators into team summary

INTERVENTIONS SUMMARY

Provide a summary of all interventions done prior to the child's referral for an evaluation or done as part of the initial evaluation. For all reevaluations provide a summary of interventions routinely provided to this child.

REASON(S) FOR EVALUATION:

SUMMARY OF INFORMATION PROVIDED BY PARENTS OF THE CHILD:

SUMMARY OF OBSERVATIONS: (only required for preschool and SLD)

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ETR Evaluation Team Report

CHILD'S NAME:	ID NUMBER:	DATE OF BIRTH:

MEDICAL INFORMATION:

SUMMARY OF ASSESSMENT RESULTS:

DESCRIPTION OF EDUCATIONAL NEEDS:

IMPLICATIONS FOR INSTRUCTION AND PROGRESS MONITORING:

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ETR Evaluation Team Report

CHILD'S NAME:ID NUMBER:DATE OF BIRTH:

3 DOCUMENTATION FOR DETERMINING THE EXISTENCE OF

A SPECIFIC LEARNING DISABILITY

REQUIRED NOTIFICATION

If the child has participated in a process that assesses the child's response to scientific, research based intervention, indicate if the parents were notified about the following prior to the evaluation:

The state's policies regarding the amount and nature of student performance data that	YES	NO
would be collected and the general services that would be provided. (See Procedures

and Guidance for Ohio Educational Agencies serving Children with Disabilities)

Strategies for increasing the child's rate of learning	YES	NO
The parents right to request an evaluation	YES	NO
Section A must be completed
Either Section B or Section C must be completed

A. IDENTIFIED AREAS

Identify one or more of the following areas in which the team has determined that the child is not achieving adequately for the child's age or state-approved grade-level standards when provided with learning experiences and instruction appropriate for the child’s age or state-approved grade level standards.

Oral Expression	Reading Fluency Skills	Written Expression	Mathematics Calculation
Listening Comprehension	Reading Comprehension	Basic Reading Skill	Mathematics Problem solving

B. RESPONSE TO SCIENTIFIC, RESEARCH-BASED INTERVENTION

Assessment information should be summarized in this section if the evaluation team used a process based on a child's response to scientific, research-based interventions to determine whether the child has a specific learning disability in one or more of the areas identified in Section A.

C. PATTERNS OF STRENGTHS AND WEAKNESSES

Assessment information should be summarized in this section, if the evaluation team used alternative research-based procedures to determine if the child exhibited a pattern of strengths and weaknesses in performance, achievement or both, relative to age, state-approved grade-level standards or intellectual development that the team determined to be relevant to the identification of a specific learning disability in one or more of the areas identified in Section A.

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