Student: Student Name DOB: 00 / 00 / 2000 s1

DEC 3-DD (1 of 2)

SUMMARY OF EVALUATION/ELIGIBILITY WORKSHEET-DEVELOPMENTAL DELAY (Ages 3 through 7)

Student: Student Name DOB: 00 / 00 / 2000 School: School Name Grade: Grade

00 / 00 / 2000 Hearing Screening: Pass Fail Method of Screening: 00 / 00 / 2000 Vision Screening: Pass Fail Method of Screening: 00 / 00 / 2000 Motor Screening: 00 / 00 / 2000 Health Screening: 00 / 00 / 2000 Speech/Language Screening: 00 / 00 / 2000 Academic and Functional Skills Observation across settings: 00 / 00 / 2000 Summary of conference with parent(s) or documentations of attempts to conference with parent(s): 00 / 00 / 2000 Social/Developmental History: 00 / 00 / 2000 Educational Evaluation: 00 / 00 / 2000 Adaptive Behavior Evaluation: 00 / 00 / 2000 Psychological Evaluation (including cognitive and social/emotional measures): 00 / 00 / 2000 Other:

As a result of the required screenings, evaluations, and review of existing information, what do we now know about the student? Strengths:

Needs:

Final 1-08 DEC 3-DD (2 of 2)

Student: Student Name DOB: 00 / 00 / 2000 School: School Name Grade: Grade

Documentation of impairment with A and/or B: A. Delayed/Atypical Development in one or more of the following areas: physical, cognitive, communication, social/emotional, or adaptive: (30% delay in an assessment that yields scores in months or 2 or more standard deviations below the mean on standardized tests in one area; or 25% delay in an assessment that yields scores in months or 1.5 or more standard deviations below the mean on standardized tests in two or more areas.)

B. Delayed/Atypical behavior(s) that is so significantly inadequate or inappropriate that it interferes with the child’s ability to learn and/or cope with normal situational or environmental demands. Must be evidenced that the patterns of behavior occur in more than one setting over an extended period of time. List documentation required by NC Regulations for specific age criteria.

What is the adverse effect on educational performance?

What evidence exists that the student requires specially designed instruction?

AFTER COMPLETING WORKSHEET, IEP TEAM MUST DETERMINE ELIGIBILITY. (See Eligibility Determination Form)

Final 1-08