Multi-Disciplinary Team Report For Determining A Specific Learning Disability Form printable pdf download

SOUTH BEND COMMUNITY SCHOOL CORPORATION

Special Education Department

Multi-disciplinary Team Report for Determining a Specific Learning Disability

Date: ______________

Student: _________________________ SBCSC ID#: __________

STN#: _____________

School: __________________________ Grade: ___________

Teacher: __________________

Relevant behaviors noted during observations: ________________________________________

______________________________________________________________________________

Are there any educationally relevant medical findings? ____ Yes

____ No

If yes, describe: ________________________________________________________________

_____________________________________________________________________________

Are the student’s academic deficits primarily the result of:

Environmental, cultural, economic disadvantage

___ Yes

___ No

•

Any other disability (hearing, visual, or orthopedic

•

impairment or mental or emotional disability)

___ Yes

___ No

Are academic deficits correctable without special education and related services?

___ Yes

____ No

If no, describe the research-based interventions that have been proven to be ineffective with the

student. Attach additional page, if necessary:

Intervention

Length of implementation

Outcome

______________________________________________________________________________

The Multi-disciplinary Team certifies that this student ___ has ___ does not have a specific

learning disability.

The committee believes the student demonstrates a learning disability in the following area(s).

___

Reading Skills

___ Math Reasoning

___

Reading Comprehension

___ Math Calculation

___

Expressive Language

___ Listening Comprehension

___

Written Expression

Basis for proposed determination of a learning disability:

______________________________________________________________________________

Signature/Title of Team Members

Check one

AGREE

DISAGREE

Psychologist ________________________________

_______

General Ed. Teacher __________________________

_______

Special Ed. Teacher ___________________________

_______

Other (specify) _______________________________

_______

* If there is disagreement, that individual’s written statement must be attached

Multi-Disciplinary Team Report For Determining A Specific Learning Disability Form

Related Articles

Related forms

Related Categories