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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ETR Evaluation Team Report

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

D. EXCLUSIONARY FACTORS

The evaluation team has determined that its findings are NOT primarily the result of:

A Visual, Hearing, or Motor Disability	Limited English Proficiency
Mental Retardation	Environmental or Economic Disadvantage
Emotional Disturbance	Cultural Factors

E. DOCUMENTATION- UNDERACHIEVEMENT NOT DUE TO A LACK OF APPROPRIATE INSTRUCTION

Regardless of the process used to identify a child as having a specific learning disability, the team must ensure that the child's underachievement is not due to a lack of appropriate instruction in reading or math by considering the following information:

1.Data that demonstrate that prior to, or as part of the referral process, the child was provided appropriate instruction in general education settings, delivered by qualified personnel.

Summarize the data used by the team to document this requirement:

2.Data-based documentation of repeated assessments of achievement at reasonable intervals, reflecting formal assessment of student progress during instruction, that was provided to the child's parent.

Summarize the data-based documentation used by the team to document this requirement:

F.OBSERVATION

Summarize the child's academic performance and behavior in the areas of difficulty as observed in the child's learning environment including the regular classroom setting.

G. MEDICAL FINDINGS

Describe the educationally relevant medical findings, if any:

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ETR Evaluation Team Report

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

4 ELIGIBILITY

ELIGIBILITY DETERMINATION

It is the determination of the team that:

The determining factor for the child's poor performance is not due to a lack of YES NO appropriate instruction in reading or math or the child's limited English proficiency. For

the preschool-age child the determining factor for the child's poor performance is not due to a lack of preschool pre-academics..

BASIS FOR ELIGIBILITY DETERMINATION: (or Continued Eligibility)

Provide a justification for the eligibility determination decision, describing how the student meets or does not meet the eligibility criteria as defined in OAC 3301-51-01 (B)(10) (Definitions) and OAC 3301-51-06 (Evaluations). Include how the disability affects the

child's progress in the general education curriculum.

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ETR Evaluation Team Report

CHILD'S NAME:	ID NUMBER:	DATE OF BIRTH:
5 SIGNATURES		DATES

DATE OF MEETING:

DATE OF LAST ETR:

REFERRAL DATE:

EVALUATION TEAM

The names, titles and signatures below identify the members of the evaluation team and indicate whether or not each team member is in agreement with the conclusions of the report.

NAME	TITLE	SIGNATURE	DATE			STATUS
	Parent					Agree
						Disagree
						Agree
						Disagree
						Agree
						Disagree
						Agree
						Disagree
						Agree
						Disagree
						Agree
						Disagree
						Agree
						Disagree
						Agree
						Disagree
						Agree
						Disagree
						Agree
						Disagree
						Agree
						Disagree

STATEMENT OF DISAGREEMENT

If a team member is not in agreement with the team's determination, the team member shall attach to this report a written statement explaining his or her reason for disagreeing with the team's determination.

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ETR Evaluation Team Report

EVALUATION PLANNING FORM

Preschool Disability Determination

	CHILD'S NAME:								DATE OF PLAN:
	ID NUMBER:
									INITIAL EVALUATION
	DATE OF BIRTH:
									REEVALUATION
	TEAM CHAIRPERSON:
	SUSPECTED DISABILITY:
	TEAM MEMBERS
	NOTE:

1Information must be collected for all the areas in the left-hand-hand column using one of the five methods listed across the top. The * areas must use one of the four assessment methods.

2.In the appropriate box, document each assessment which has already occurred . Indicate the title of the person who conducted the assessment and the date.

3.In the appropriate box, write the title of the person who will conduct the evaluation(s) needed for the MFE.

Preschool Child with a Disability: A child who 1) is at least three years of age and not yet six; 2) has a disability, demonstrated by a documented deficit in one or more areas** of development, which has an adverse effect upon normal development and functioning.

**Areas of deficit include 1) communication skills including form, content, and use of language, but not solely in speech articulation or phonology; 2) hearing abilities, 3) motor abilities, 4) social/emotional/behavioral functioning; or 5) vision abilities, or a combination of deficits which must include cognitive and/or adaptive behavior combined with one or more deficits in areas 1-5 above.

The team has taken into cosideration limited English proficiency in planning this assessment

The team has taken into consideration possible sources of racial/cultural bias in planning the assessments.

SIGNATURES

School District Representative (Name/ Date)		Parent (Name/ Date)
Regular Education Teacher (Name/ Date)		Intervention Specialist (Name/ Date)

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ETR Evaluation Team Report

EVALUATION PLANNING FORM

School Age Disability Determination

CHILD'S NAME:

DATE OF PLAN:

ID NUMBER:

INITIAL EVALUATION

DATE OF BIRTH:

REEVALUATION

TEAM CHAIRPERSON:

SUSPECTED DISABILITY:

TEAM MEMBERS

ASSESSMENT AREAS RELATED TO SUSPECTED

DATA

FURTHER

PERSON RESPONSIBLE FOR ASSESSMENT AND

TESTING

DISABILITY(IES)

AVAILABLE1

REPORT

NEEDED2

Information Provided by Parent

General Intelligence

Academic Skills

Classroom Based Evaluations and

Progress in the General Curriculum

Data from Interventions

Communicative Status

Vision

Hearing

Social Emotional Status

Physical Exam/General Health

Gross Motor

Fine Motor

Vocational/Transition

Background History

Observations

Behavior Assessment

Adapted Behavior

Other: (circle) Braille needs as determined by

VI teacher or appropriately trained/licensed personnel. Audiological needs as determined by certified/ licensed audiologist.

Assistive Technology needs.

Other:

1Sufficient data to determine eligibility

2Additional data required to determine eligibility. Check if further testing is needed

The Team has taken into consideration limited English proficiency to plan this assessment.

The Team has taken into consideration possible sources of racial or cultural bias in planning this assessment

SIGNATURES

School District Representative (Name/ Date)		Parents (Name/ Date)
Regular Education Teacher (Name/ Date)		Intervention Specialist (Name/ Date)

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ETR Evaluation Team Report

EVALUATION PLANNING FORM

Preschool Eligibility Determination

CHILD'S NAME:				DATE OF PLAN:
ID NUMBER:
				INITIAL EVALUATION
DATE OF BIRTH:
				REEVALUATION

TEAM CHAIRPERSON:				TRANSITION FROM PART C
SUSPECTED DISABILITY:
TEAM MEMBERS
NOTE:

1Each domain must be assessed using one of the methods listed.

2The areas related to the suspected disability must be assessed using all the methods listed (data from early intervention only applies if the child is transitioning from "Help Me Grow"**). Refer to the chart on the next page.

3Provide the name of the individual responsible for the required data.

* Observations are in more than one setting and in multiple activities.

The team has taken into consideration limited English proficiency in planning this assessment and determining eligibility as a preschool child with a disability.

The team has taken into consideration possible sources of racial/cultural bias in planning the assessments.

SIGNATURES

School District Representative (Name/ Date)		Parent (Name/ Date)
General Preschool/Regular Education Teacher (Name/ Date)		Preschool Special Education Teacher (Name/ Date)

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ETR Evaluation Team Report

EVALUATION PLANNING FORM

Preschool Eligibility Determination

The following chart can assist the team planning for assessments and determining eligibility.

Suspected Disability:

Autism (AUT)	Cognitive Disability (CD)	Deaf- Blindness (DB)
Deaf	Emotional Disturbance (ED)	Hearing Impairment (HI)
Multiple Disabilities (MD)	Orthopedic Impairment (OH)	Other Health Impairment (OHI)
Speech or Language Impairment (S/L)	Specific Learning Disability (SLD)	Traumatic Brain Injury (TBI)
Visual Impairment (VI)	Developmental Delay (DD)

Based upon the suspected disability, the following areas should be considered in planning the evaluation. The team determines the assessment plan.

ASSESSMENT AREAS	AUT	CD	D/B DEAF ED	HI	MD	OH	OHI SLD	S/L	TBI	VI	DD2
PREVIOUS INTERVENTIONS
COGNITION1
PREACADEMIC SKILLS3
HEARING4
AUDIOLOGICAL
VISION4
ADAPTIVE BEHAVIOR
COMMUNICATION
ORAL EXPRESSION
LISTENING COMPREHENSION
WRITTEN EXPRESSION
GROSS MOTOR SKILLS
FINE MOTOR SKILLS
SOCIAL FUNCTIONING
EMOTIONAL STATUE
BEHAVIORAL STATUS
PHYSICAL/MENTAL/HEALTH

1Intelligence quotient required for a cognitive disability only.

2All possible areas for developmental delay are noted. The team will decide the areas to be assessed for eligibility.

3Preacademic skills are related to content standards and basic functional skills for preschoolers and provide information on current level of performance.

4Vision and hearing screening are part of the basic requirements for entry into program, just like kindergarten, and are part of the Early Learning Program Guidelines,

A preschool child is determined eligible because of a disability that (1) adversely affects the child's performance and ability to participate in developmentally appropriate activities and therefore, (2) the child is in need of special education and relate services.

Eligibility in a disability category other than developmental delay must be determined first. If the child is eligible with a disability category of speech/language impairment, cognitive disability or emotional disturbance, the team may choose to use the term developmental delay without any further assessments. If the child does not meet the criteria for any of these disability categories, the team is to consider developmental delay. Developmental Delay means the child has a disability in one or more of the following areas of development: physical, cognitive, communication, social or emotional, or adaptive. A developmental delay is substantiated by a delay of 2.0 standard deviations below the mean in one area of development or 1.5 standard deviations below the mean in two areas of development. The standard deviation cannot be the sole factor in determining the child has a disability.

A preschool child with a disability is at least age 3 and not of compulsory school age. A child who will be three as of December 1 of the school year can begin earlier than the third birthday. a child who will be age 5 as of December 1 is to have kindergarten (pre-academic skills) considered. Age is determined as of the district entry date; if a child is age 6 as of that date, the child is no longer a preschooler.

Additional data beyond what is necessary for eligibility may be collected and reviewed for programming purposes.

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