<p> Wakulla County School Board Evaluation Report and Written Summary CONFIDENTIAL Name: Male Female DOB: School: Grade: Evaluator’s Name: Referral Date: Evaluation Completion Date:</p><p>Identified area(s) of concern Reading Fluency Reading Comprehension Behavior Developmental Mathematics Social Interaction Written Expression Oral Expression Listening Comprehension Phonological Processing Other</p><p>Parent Conferences (attach documentation of two (2) or Dates: more) Yes No The student’s parent(s) or guardian(s) were notified about the amount and nature of student performance data that would be collected and the general education services that would be provided, including planned intervention(s) for increasing the student’s rate of progress and the expected outcomes of those intervention(s). Yes No N/A An immediate evaluation was requested by parent and/or school personnel. Interventions have been conducted in accordance to the procedures in the district’s Response to Intervention plan concurrently with the evaluation. Documentation is attached. Documentation is available and attached that indicates that at least two interventions have been conducted or that interventions have been conducted in accordance to the procedures in the district’s Response to Intervention plan prior to the evaluation.</p><p>Observations (attach observation form/summary) Date Summary of Behaviors Relevant to Academic Functioning Observation #1 Observation #2</p><p>Relevant Information from Social and Developmental History (attached) and School Records Educationally Relevant Medical Findings: Retention History: Attendance: Academic History:</p><p>Sensory Screening - Sensory screenings to rule out possible sensory deficits that may interfere with the student’s academic and behavioral progress have been conducted. Vision Pass Fail Speech Pass Fail Enrolled N/A Hearing Pass Fail Language Pass Fail Enrolled N/A</p><p>Summary of School-Based Diagnostic Assessment Results (Attach Documentation) Results of Previous and/or Additional Assessment Data Not Applicable Test Date Scores</p><p>Intervention Summary Instruction/Intervention Implementer Duration/Frequency Fidelity/Support RtI Response  ? - e r o C d d d d d d</p><p> e d e t e g r a T e v i s n e t n I</p><p>Analysis of Response to Intervention Data (see attached comparison data) Summary of Student’s Rate of Progress: Performance Discrepancy: The student exhibits the following discrepancy in level of performance: State District Class</p><p>School Grade Peer Group #2:</p><p>Statement of Need: </p><p>Consideration of factors impacting learning. Determine whether level of performance and rate of progress are not primarily the result of any of the following. (No=not a factor) See attached data and rationale Irregular pattern of attendance and/or high mobility rate Age Yes No Yes No</p><p>Yes No Cultural factors Yes No Gender</p><p>Yes No Environmental or economic disadvantage Yes No Other</p><p>Yes No Limited English Proficiency</p><p>Yes No Behavior</p><p>Yes No Intellectual Disability</p><p>Yes No Emotional Behavior Disability Intellectual Ability</p><p>Academic Achievement</p><p>Processing</p><p>Adaptive Behavior</p><p>Emotional/Behavioral Ratings</p><p>Language</p><p>Summary and/or Recommendations</p><p>Person qualified to conduct and interpret individual diagnostic evaluations:</p><p>Signature Title Date</p><p>Signature Title Date </p>