Fillable If all of the answers are No, complete (Illinois State Board of Education)

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If all of the answers are No, complete (Illinois State Board of Education)

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STUDENT NAME:______________________________________________________________________________ DATE OF MEETING: ________________________
ISBE 34-54D (1/22) Illinois State Board of Education, Special Education Department, 100 North First Street, Springfield, Illinois 62777
ELIGIBILITY DETERMINATION
(SPECIFIC LEARNING DISABILITY)
Complete for initial evaluations, reevaluations, or a review of an independent or outside evaluation when a specific learning disability is suspected.
DETERMINANT FACTOR
The determinant factor for the student’s suspected disability is:
☐ Yes ☐ No
Lack of appropriate instruction in reading, including the essential components of reading instruction (evidence provided)
☐ Yes ☐ No
Lack of appropriate instruction in math (evidence provided)
☐ Yes ☐ No
English Learner status (evidence provided)
If any of the above answers is “Yes,” the student is not eligible for services under IDEA, and the team must complete the Eligibility Determination section accordingly.
If all of the answers are “No,” complete the following sections.
EXCLUSIONARY CRITERIA
The team determined that the following factors are the primary basis for the student’s learning difficulties. Document the source of evidence in each area:
☐ Yes ☐ No
A visual, hearing, or motor disability:
☐ Yes ☐ No
Intellectual disability:
☐ Yes ☐ No
Emotional disability:
☐ Yes ☐ No
Cultural factors:
☐ Yes ☐ No
Environmental or economic disadvantage:
If any of the boxes immediately above is checked “Yes,” the student cannot have a specific learning disability and the team must complete the Eligibility Determination
section accordingly.
INCLUSIONARY CRITERIA
Educational Progress (Over Time)
Evidence in the Documentation of Evaluation Results should support the team’s answer to this question.
Is the student progressing at a significantly slower rate than is expected in any areas of concern?
(Select One)
☐No
☐
Yes
The student is progressing at a significantly slower rate than expected.
☐Yes
The student is currently making an acceptable rate of progress, but only because of the intensity of the intervention that is being provided.
If ”Yes,” in which area(s)?
Discrepancy (At One Point in Time)
Evidence in the Documentation of Evaluation Results should support the team’s answer to this question.
Is the student’s performance significantly below performance of peers or expected standards in any areas of concern?
(Select One)
☐
No
☐Yes
The student’s performance is significantly discrepant.
☐Yes
The student’s performance is not currently discrepant, but only because of the intensity of the intervention that is being provided.
If ”Yes,” in which area(s)?
Use your "Mouse" or "Tab" key to move through the fields and check boxes. After completing last field, save document to hard drive to make future updates or click print button.
STUDENT NAME:______________________________________________________________________________ DATE OF MEETING: ________________________
ISBE 34-54E (1/22) Illinois State Board of Education, Special Education Department, 100 North First Street, Springfield, Illinois 62777
ELIGIBILITY DETERMINATION
(SPECIFIC LEARNING DISABILITY)
Instructional Need
Evidence in the Documentation of Intervention/Evaluation Results form should support the team’s answer to this question.
Are this student’s needs in any areas of concern significantly different from the needs of typical peers and of an intensity or type that exceeds general education
resources?
(Select One)
☐ No
☐ Yes T
he student’s instructional needs are significantly different and exceed general education resources.
If yes
, which areas?
If any of the boxes in the Inclusionary Criteria section are marked “No,” the student does not have a specific learning disability and the team must complete the
Eligibility Determination section accordingly.
ELIGIBILITY DETERMINATION
Step 1: Disability Adversely Affecting Educational Performance
☐ Yes ☐ No Based on the answers to the questions in the Determinant Factors, Exclusionary Criteria, and Inclusionary Criteria sections, does the student have a
specific learning disability?
If the answer is “No,” the student is not eligible for special education services under the category of Specific Learning Disability and the team must complete Step 2
below.
If the answer is “Yes,” indicate the area below and complete Step 2.
☐Basic reading skills
☐Mathematical calculation
☐Reading fluency skills
☐Mathematical problem-solving
☐
Reading comprehension
☐
Written expression
Step 2: Special Education and Related Services
☐Specialized instruction is required in order for the student to make progress and reduce discrepancy (eligible)
☐Specialized instruction is not required in order for the student to make progress and reduce discrepancy (not eligible)
Each team member must sign below to certify that the report reflects his/her conclusions for specific learning disability. Any participant who disagrees with the team’s
decision must submit a separate statement presenting her/his conclusions.
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
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Completed 13 April 2022

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