Specific Learning Disabilities Team Report Form
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1
2Specific Learning Disabilities Team Report
Hancock County
Student’s Full Name ______________________________
Date ________________________
School ________________________________________
Date of Birth __________________
Parent(s)/Guardian(s) ____________________________
Grade _______________________
Address ________________________________________
WVEIS# _____________________
City/State _______________________________________
Telephone ____________________
Initial
Re-Evaluation
Other
When considering whether or not a student may be eligible for special education and related services as a student
with a Specific Learning Disability, the Eligibility Committee must respond to each item below. The EC must
answer “yes” to each yes/no statement to appropriately conclude a student is a student with a specific learning
disability.
1) The student’s multidisciplinary evaluation was sufficiently comprehensive to identify the
Yes
No
student’s special education and related services needs and administered in accordance with
evaluation procedures specified in Policy 2419, Chapter 3, Section 4.
Based on multiple and convergent sources of data, the student’s level of learning reflects
2)
low academic performance compared to same-age peers when provided with learning
Yes
No
experiences and instruction appropriate for the student’s age or State-approved grade-level
standards (NxGCSOs) in one or more of the following areas (Check all areas that apply):
Oral Expression
Reading Comprehension
Listening Comprehension
Reading Fluency Skills
Written Expression
Mathematics Calculation
Basic Reading Skill
Mathematics Problem Solving
3) Identify the method used to determine Eligibility:
Yes
No
The student fails to achieve a rate of learning to make sufficient progress to meet State-
approved grade-level standards (NxGCSOs) in one or more of the areas identified above
when assessed using the SPL process.
OR
The student exhibits a pattern of strengths and weaknesses in performance, achievement
or both, relative to age, State-approved grade-level standards (NxGCSOs) or intellectual
development that is determined by the group to be relevant to the identification of a
specific learning disability.
4) The student’s achievement deficits are NOT primarily the result of vision, hearing or motor
Yes
No
impairments; intellectual disability; emotional/behavioral disorder; cultural factors,
environmental or economic disadvantage or limited English proficiency.
5) Evaluation information and documentation confirm that lack of appropriate instruction in
Yes
No
reading or mathematics was NOT the determinant factor in the eligibility decision.
6) Evaluation information confirms there is an adverse effect on the student’s educational
Yes
No
performance.
West Virginia Department of Education
September 2014
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