Fillable Eligibility Committee Report Form printable pdf download

ELIGIBILITY COMMITTEE REPORT

Hancock County Schools

Student Full Name __________________________________________

Date ______________________________

School ___________________________________________________

Date of Birth_______________________

Parent(s)/Guardian(s) _______________________________________

Grade_____________________________

Address ___________________________________________________

WVEIS#___________________________

City/State _________________________________________________

Telephone_________________________

Initial

Re-Evaluation

Other __________________________________

The Eligibility Committee (EC) considered the following multi-disciplinary reports and other relevant information.

Academic Information

Developmental Skills

Social Skills

Achievement

Health__________

Transition Assessments

Classroom Performance

Hearing

Functional Vocational Evaluation

Teacher Report

Information from the Parents

Vocational Aptitudes

Adaptive Skills

Intellectual Ability

Interests/Preferences

Assistive Technology

Motor Skills

Vision

Behavioral Performance

Observation(s)

Orientation and Mobility

Perceptual-Motor

Other _____________________________

Functional Behavioral Assessment

Communication

__________________________________

____________________________________________________________________________________________________________________________________________________________________

A student cannot be identified as a student in need of special education services if the primary reason for the

decision is due to any of the following:



A lack of appropriate instruction in the essential components of English/language arts (reading); or



A lack of instruction in mathematics; or



Limited English proficiency

For initial evaluation or reevaluation, the student meets the three-prong test of eligibility:

Meets the eligibility requirements for one of the specific exceptionalities; and

Experiences an adverse effect on educational performance; and

Needs special education.

For reevaluation only:

If a student no longer meets the eligibility criteria in one of the designated exceptionalities, the EC must

provide the justification for continued eligibility. ______________________________________________

_________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________

The Eligibility Committee has determined the student’s primary area of exceptionality is (only one):

Autism (AU)

Exceptional Gifted (EG)

Developmental Delay (PS)

Emotional/Behavioral Disorders (BD)

Gifted (GF)

Specific Learning Disability (LD)

Blindness and Low Vision (VI)

Intellectual Disability (

Speech/Language Impairment (CD)

Designate

WVEIS Code __MM __MD __MS)