Specific Learning Disabilities Team Report Form Page 2
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27) The student was observed in the learning environment, including the general classroom
Yes
No
setting, to document the student’s academic performance and behavior in the areas of
difficulty. An observation summary/report is attached and describes the relevant behavior
noted during the observation, if any, and the relationship of that behavior to the student’s
academic functioning.
The specific instructional strategies used and the student-centered data collected are
8)
documented and available in the Eligibility Committee Report.
Yes
No
9) Note educationally relevant medical findings, if any (Write N/A if no relevant medical findings apply):
The Eligibility Committee used the above evaluation data analysis and discussion to determine:
The student DOES meet the eligibility criteria for a specific learning disability that adversely
impacts his/her education and is eligible for special education and related services.
The student DOES NOT meet the eligibility criteria for a specific learning disability and is not
eligible for special education and related services as a student with a specific learning disability.
The student’s parents were notified about the following: The State’s policies (i.e., WVBE Policy 2419,
Chapter 4, Section 2.L. including Support for Personalized Learning) regarding the amount and nature of student
performance data that would be collected and the general education services that would be provided; strategies for
increasing the student’s rate of learning; results of repeated assessments of student progress AND, the parent’s
right to request an evaluation at any time throughout the Support for Personalized Learning process.
Date of parent notification: ___________
Eligibility Committee Members
Signature
Position
Agreement with EC Determination
_________________________________________________
Chairperson
Yes
No
_________________________________________________
Evaluator/Specialist
Yes
No
_________________________________________________
Teacher
Yes
No
_________________________________________________
Parent
Yes
No
_________________________________________________
Student
Yes
No
_________________________________________________
Other
Yes
No
NOTE: If this report does not represent an individual team member’s conclusions, that team member must submit a separate
statement presenting the member’s conclusions.
Meeting Notes (if applicable)
West Virginia Department of Education
September 2014
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