Evaluation (Hawaii) [.2211 - .2231]

Last Modified on 10/22/2022 10:51 am CDT

Classic View: Student Information > Special Ed > General > Documents

Search Terms: Special Ed Documents

The Evaluation in Campus is used to document the student's educational needs and the student's determination of eligibility for special education. This document describes each editor, the section(s) of the print format that include the entered information, a description of each field on the editor, and any special considerations and instructions for using the editor and fields.

An evaluation must be created whether or not the student is determined to have a disability. A copy of the evaluation summary report, including the documentation of eligibility, is given to the student’s parents by the school district.

The current format of this document is the HI Eval 2022. Evaluation formats are selected in the Eval Types tool.

Editor Home

The Editor Home lists the editors available on the student's Evaluation and the Modification and Completion information.

Editor Home

Header	Description
Name	The name of the editor.
Status	The state of the editor. Statuses can be: In Progress: indicates a user has entered and saved data in that editor. Not Started: is the default status for all editors. Complete: indicates a user has clicked the Complete button on the editor. This does not lock the editor from further editing, but indicates the user considers the editor to be finished. Not Needed: indicates a user has clicked the Not Needed button on the editor. This is usually done for editors that do not apply to the student.
Modified By	The date and the user by whom the editor was last edited.
Completed By	The date and the user who clicked the Complete button for that editor.

General Evaluation Information

The following table lists the buttons available for the editors:

Button	Description
Save	Different editors have different save options. Click the arrow next to the Save & Stay button to view all saving options for any given editor. Save captures progress and navigates the user to the Editor Home or to the Master Screen for List editors. See the Editor Types section for additional information. Save & Stay captures progress and keeps the user on the current editor. This save button is the default save option and usually found within the detail screen of List editors, such as Goals and Objectives. Save & Next captures progress and navigates the user to the next editor. Save & New captures progress and creates a new record. This save button is usually found within the detail screen of a list editor, such as Goals and Objectives. See the Editor Types section for additional information.
Refresh	Retrieves a new copy of data from the student's record. This includes enrollment, student, parent/guardian, and team member information. This also returns any accidentally deleted people records. Manually entered fields will not change when the refresh button is clicked. The user must Save after clicking Refresh to capture changes. A side panel displays listing all applicable Enrollment records for the student. See the Enrollments tool documentation for additional information.
Cancel	Navigates the user to the Editor Home screen or to the Master Screen for List editors.
Status i.e. Complete, Not Needed, etc.	Changes the status of the editor. Complete indicates the editor is finished. This makes the editor read-only. However, this does not lock the editor from further editing. To further edit after an editor is marked Complete, the user will have to click In Progress. Not Needed indicates the editor does not apply to the student's evaluation. This makes the editor read only. However, this does not lock the editor from further editing. To further edit after an editor is marked Not Needed, click the In Progress button. In Progress only displays when the editor is in the Complete or Not Needed status and allows additional edits to be made.
Print	Prints the entire evaluation.
Editors	Opens a side panel listing all the available editors and their status. Select an editor from this list to navigate to that editor or click Close to collapse the side panel.
Previous	Navigates the user to the previous editor.
Next	Navigates the user to the next editor.

Editor Types

There are two types of editors available: List or Basic editors. When navigating to a Basic editor, the list of fields within the editor display. List editors display a master list of all records within that editor. Clicking an existing record or the New button will open the detail view for an individual record. An example list editor is the Individual Conference Announcement editor.

Padlock Icon

Only one user at a time can actively work on an editor. A person with a padlock icon displays in the Editors side pane, Editor Home, and Master Screen of list editors indicating which editors currently have users working on them. Hovering over the icon displays the name of the user who has checked out the editor, including the current user (you).

Editors that are currently being edited are read only for all other users. The name of the person working on the editor displays in the header. Once the editing user navigates away from an editor, that editor becomes available to work on.

Template Banks

Certain fields within several editors have a paper icon next to their name. When the icon is clicked, a side panel displays with the available library of predetermined text for that field. Template Banks are managed in System Administration.

Editors

The following section lists each editor and describes each field on the editor. Available editors include:

Evaluation Status

The Evaluation Status editor includes general information about the evaluation, including relevant dates, the type of evaluation, and basic student information.

This editor must be saved before continuing to other parts of the evaluation.

Evaluation Status Editor

Fields	Description	Ad hoc	Validation
Date Required	The date this document was created.	Learner Planning > Evaluations > evalDate	When this editor is Completed, the Evaluation Date must match either the Evaluation Meeting Date or the Eligibility Determination Date, with the Eligibility Determination Date taking priority. This date displays on the Documents tool.
Type of Evaluation Required	The type of eligibility documented; Initial Evaluation, Reevaluation, or Triennial Agreement.	Learner Planning > Evaluations > type	The values available in this dropdown are hard coded.
Assessment Needed Required	Indicates if an assessment is needed.	N/A	This field is grayed out when Triennial Agreement is selected as the Type of Evaluation. Yes or No
Evaluation Meeting Date *Required	The date the student is evaluated to determine if they are eligible to receive special education services.	N/A	This field is blank upon entering the editor and read-only. This field auto-populates with the date entered under Conference Actual > Actual Conference Date when the Evaluation Process checkbox is marked. If multiple Conference Actual records exist that meet the criteria, the date will be updated to the most recent date. *This field is required to Complete the editor when No is selected for the Assessment Needed field OR when Triennial Agreement is selected as the Type of Evaluation.
Days until Timeline Due Date	The difference between today's date and the Timeline Due Date.	N/A	This is a read-only field. This field auto calculates. Negative values are supported, as needed. This field is grayed out when Triennial Agreement is selected as the Type of Evaluation. Once an Eligibility Meeting Date is entered, this field no longer calculates.
Consent Sent Date *Required	The date the parent/guardian of the student was sent a request for consent to evaluate the student.	N/A	This field is grayed out when No is selected in the Assessment Needed field. This field is grayed out when Triennial Agreement is selected as the Type of Evaluation. *This field is required when available.
Consent Received Date *Required	The date the parent/guardian of the student returned consent for their student to be evaluated.	Learner Planning > Evaluations > consentDate	This field is grayed out when No is selected in the Assessment Needed field. This field is grayed out when Triennial Agreement is selected as the Type of Evaluation. *This field is required in order to Complete the editor when available.
Timeline Due Date	The date the Evaluation is due. This value is 60 calendar days from the Evaluation Meeting Date if the Assessment Needed field is No OR 60 calendar days from the Consent received Date if the Assessment Needed field is Yes.	N/A	This is a read-only field. This field is grayed out when Triennial Agreement is selected as the Type of Evaluation. When No is selected in the Assessment Needed field, this date automatically calculates to a date 60 calendar days from the Evaluation Meeting Date. When Yes is selected in the Assessment Needed field, this field automatically calculates to a date 60 calendar days from the Consent Received Date.
Eligibility Determination Date *Required	The date the student was determined to be either eligible or ineligible to receive Special Education services.	N/A	*This is a required field upon completion of the Evaluation. This field is blank upon entering the editor and read only. This field is grayed out when Triennial Agreement is selected as the Type of Evaluation. This field automatically populates with the Actual Conference Date entered on the Conference Actual editor when the IDEA Eligibility checkbox is marked. If multiple Conference Actual records exist that meet the criteria, the date will be updated to the most recent date.
Evaluation Delay This section is grayed out when Triennial Agreement is selected as the Type of Evaluation.
Delay Date	The date the Evaluation Meeting will take place after a delay in the process.	N/A	N/A
Primary Delay Reason *Required	The reason for the delay in timeline. Options available can be found in the Attribute Dictionary and are hard coded.	N/A	This field is required if the Delay Date field is populated.
Comments	Any additional information related to the delay.	N/A	N/A
Evaluation Withdrawn This section is grayed out when Triennial Agreement is selected as the Type of Evaluation.
Withdrawn Date	The date the student withdrew from Special Education services.	N/A	N/A
Withdrawn Reason *Required	The reason the student withdrew from Special Education services.	N/A	*This field is required if the Withdrawn Date field is populated.

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Enrollment Information

The Enrollment Information editor reports Special Education information from the student's Enrollment record. This editor is read only.

The Refresh button retrieves a fresh copy of data from the student's record. See the General Evaluation Information section for additional information.

Enrollment Information Editor

Field	Description	Ad hoc	Validation
District	The student's district of residence.	Learner Planning > Learning Plans > subDistrict	This field is pulled from the Enrollment record, then System Administration > Resources > School > State Data Elements > Sub-District.
Complex Area	The location of the building.	Learner Planning > Learning Plans > complexDistrict	This field is pulled from the Enrollment record, then System Administration > Resources > School > State Data Elements > Complex Area.
Grade	The student's current grade.	Enrollment > Grade enrollment.grade	This field is pulled from the Enrollment record.
School Name	The name of the school associated with the student's Enrollment record.	Learner Planning > Learning Plans > Enrollments > residentSchool enrollment.residentSchool	This field is pulled from the Enrollment record.
School Phone	The phone number of the school associated with the student's Enrollment record.	Learner Planning > Learning Plans > School > Phone v_SchoolCurrent.phone	This field is pulled from the Enrollment record, then System Administration > Resources > School.
School Year	The school year associated with the student's Enrollment record.	N/A	This field is pulled from the Enrollment record.

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Student Information

The Student Information editor displays basic information about the student such as demographic information. This is a read-only editor.

The Refresh button retrieves a fresh copy of data from the student's record. See the General Evaluation Information section for additional information.

Student Information Editor

Field Name	Description	Ad Hoc
Last Name	The student's last name.	Census > People > Demographics > Last Name identity.lastName
First Name	The student's first name.	Census > People > Demographics > First Name identity.firstName
Middle Name	The student's middle name.	Census > People > Demographics > Middle Name identity.middleName
Suffix	The student's suffix.	Census > People > Demographics > Suffix Name identity.suffix
Age	The age of the student.	Census > People > Demographics > Age
Birthdate	The student's birthdate.	Census > People > Demographics > Birth Date identity.birthDate
Gender	The student's gender.	Census > People > Demographics > Gender identity.gender
Language at Home	The student's home primary language.	Census > People > Demographics > Language At Home identity.homePrimaryLanguage
First Language	The student's first spoken language.	Census > People > Demographics > First Language identity.languageAlt
Most Used Language	The language the student uses the most.	Census > People > Demographics > Language Most Used identity.languageAlt2
Address	The student's address. This field becomes a dropdown if more than one address exists for the student. The primary household displays by default.	Census > Households > Address Info address.number; address.street; address.tag; address.prefix; address.dir; address.apt; address.city; address.state; address.zip
Student Number	The student's identification number.	Census > People > Demographics > Student Number
State ID	The student's state identification number.	Census > People > Demographics > State ID
Case Manager
Name	The name of the student's Case Manager.	Student Information > Special Ed > General > Team Members > Name
Title	The title of the staff member.	Student Information > Special Ed > General > Team Members > Caseload Role
Phone	The staff member's phone number.	Student Information > Special Ed > General > Team Members > Other Phone

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Parent/Guardian Information

The Parent/Guardian Information editor populates based on the guardian checkbox on the student's Relationships tool. The editor includes Demographics information for the student's guardian.

The Delete button next to each parent/guardian can be used to remove a parent/guardian from the Evaluation.

The Refresh button retrieves a new copy of parent/guardians' data. This will also return any accidentally deleted people. Manually entered fields will not change when the refresh button is clicked. The user must Save after clicking Refresh to capture changes.

Parent/Guardian Information Editor

Field Name	Description	Ad Hoc	Validation
Relationship	The relation of the parent/guardian to the student.	Census > People > Relationships	This field populates from Census. This is part of the header for the parent/guardian.
Last Name	The last name of the parent/guardian.	Census > People > Demographics > Last Name identity.lastName	This field populates from Census. This is part of the header for the parent/guardian.
First Name	The first name of the parent/guardian.	Census > People > Demographics > First Name identity.firstName	This field populates from Census. This is part of the header for the parent/guardian.
Middle Name	The middle name of the parent/guardian.	Census > People > Demographics > Middle Name identity.middleName	This field populates from Census. This is part of the header for the parent/guardian.
Suffix	The suffix of the parent/guardian.	Census > People > Demographics > Suffix Name identity.suffix	This field populates from Census. This is part of the header for the parent/guardian.
Print Sequence	The print order of the parent/guardian(s) on the IEP.	N/A	If no Sequence is selected, parent/guardian(s) print in the order displayed in the UI. If any Sequences are selected, only parent/guardian(s) with a sequence number will print in the order defined.
Address	The parent/guardians' address.	Census > Households > Address Info address.number; address.street; address.tag; address.prefix; address.dir; address.apt; address.city; address.state; address.zip	This field populates from Census. If there are multiple addresses for a person, they will have a drop down with an option to select which address. If there is only one address, the drop down will only hold one option. The populated address will be the one marked "Primary."
Home Phone	The home phone number of the parent/guardian.	Census > People > Demographics > Household Phone	This field populates from Census.
Work Phone	The work phone of the parent/guardian.	Census > People > Demographics > Work Phone	This field populates from Census.
Cell Phone	The cell phone of the parent/guardian.	Census > People > Demographics > Cell Phone	This field populates from Census.
Email	The primary email address for the parent/guardian.	Census > People > Demographics > Email	This field populates from Census.
Interpreter Required	Indicates an interpreter is needed to communicate with the parent/guardian.	N/A	N/A

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Conference Announcement

The Conference Announcement editor is used to document planned meetings of the Evaluation team.

This editor is not optional and must be completed.

Conference Announcement List Screen

Column Name	Description
Padlock Icon	The user currently working on the record.
Meeting Date	The date of the meeting.
Meeting Location	The location of the meeting.
Print in Evaluation	Indicates this meeting information will print on the Evaluation.

Conference Announcement Detail Screen

Field	Description	Validation
Print in Evaluation	Indicates this meeting information will print on the Evaluation.	This defaults to unmarked.
Scheduled Conference Date Required	The meeting date.	N/A
Scheduled Conference Time Required	The meeting time.	N/A
Announcement Date	The date a notification was sent notifying the team members of the meeting.	N/A
Scheduled Conference Location Required	The location of the meeting. Options include: Virtual, Phone, or In-Person.	N/A
Conference Location (specify)	The location of the meeting, if clarification or details are needed.	N/A
Evaluation Process	Indicates the type of evaluation processes needed for the student. Options include: Describe the Student's Educational Concern (Impacts Learning). Review Current Data. Determine what additional data, if any, is needed to define the needs of your child. Determine if an IDEA initial evaluations or reevaluations is warranted.	If the user selects one of these options, they will not be able to select IDEA Eligibility.
IDEA Eligibility	Indicates the student needs an IDEA Evaluation. Options include: Discuss the results of an IDEA initial evaluation or reevaluation. Determine eligibility or continued eligibility for IDEA services.	If the user selects this value they will not be able to select Evaluation Process.
Attendance
First Name	The first name of the team member.	This field is required for saving this editor. This field displays information from the Special Education Team Member tool. Any Team Member with an active status will display here as read-only. The user can also enter an additional entry for this field and when they do, an open text field displays and the user will be required to enter a value.
Last Name	The last name of the team member.	This field is required for saving this editor. This field displays information from the Special Education Team Member tool. Any Team Member with an active status will display here as read-only. The user can also enter an additional entry for this field and when they do, an open text field displays and the user will be required to enter a value.
Role	The role of the team member.	This field is required for saving this editor. Values available in this dropdown include locked attributes: General Education Teacher Related Service Provider Special Education Teacher Specialized Support Instructional Personnel Principal Vice Principal Unlocked Attribute values include: determined by district
Invited	Indicates this team member has been invited to the meeting.	N/A
Excused	Indicates this team member is excused from the meeting.	This field only displays when the Role for that person is one of the following: General Education Teacher Related Service Provider Special Education Teacher Specialized Support Instructional Personnel Principal Vice Principal
Designee for Admin	Indicates this team member has been designated as an administrator for the meeting.	When Role is Principal or Vice Principal, this check box is grayed out.
Admin/Designee Statement This section becomes available when the Designee for Admin checkbox is selected.
Admin Designee Statement:	Indicates why an admin is being used in the meeting.	This is required for saving the editor when available.

Conference Notification

The Conference Notification editor is used to document when notifications were sent out informing the team of meetings.

Conference Notification List Screen

Column Name	Description
Padlock Icon	The user currently working on the record.
Scheduled Meeting	The date of the planned meeting.
Mutually Agreed	Indicates if the parent/guardian consented to the meeting date.

Conference Notification Detail Screen

Conference Notification Detail

Field	Description	Validation
Conference Notification
Scheduled Meeting Date	The date of the scheduled meeting.	This field is required for saving the editor. The options in this field are determined from the Conference Announcement entries.
Mutually Agreed Upon:	Indicates if the parent/guardian consents to the meeting date. Options include: Yes, parent agrees to date and time of meeting and knows the purpose(s) of the meeting. No (unable to move forward until three attempts)	These options are hard coded.
Notified Date:	The date the parent/guardian was notified of the planned meeting date.	There is space for a 1st, 2nd, and 3rd notification fields.
Notified By:	Indicates who sent the notification to the parent/guardian.	N/A
Notify Method:	The manner in which the parent/guardian was notified. Options include: Phone Personal Contact Regular Mail Return Receipt Required Personally Delivered Email Fax	These options are hard coded.
Notified Outcome:	The outcome of the notification.	N/A
Outside Agency Parent Consent Tracking
Agency	Indicates which outside agency is involved, if applicable. Options include: Department of Health - Early Intervention Department of Health - Developmental Disabilities Division Department of Health - Child/Adolescents Mental Health Division Department of Human Services - Division of Vocational Rehabilitation Other (specify)	When Other (specify) is marked, the user will be able to manually enter their own value.
Consent to Invite Needed	Indicates that an Outside Agency should be invited and the Consent to Invite document is needed.	N/A
Consent to Invite Received	Indicates a signed Consent to Invite document was returned to the district.	N/A
Consent Received Date	The date the signed Consent to Invite document was returned to the district.	This field becomes available and required when the Consent to Invite Received check box is selected.
Team Member Notification Tracking This table is read only and displays the following columns: Team Member Name Date Method Notified By Outcome > All of these read only values come from the user selecting the Add Notification button and entering information on a side panel recording when notifications were made to certain team members.
Notification Tracking (side panel) This displays when the user clicks Add Notification or on the ">" from a previous entry in the table.
Team Member Name:	The name of the team member.	The options in this field are determined from the marked entries from Conference Announcement > Invited checkbox. This displays as First Name Last Name, Role.
Date:	The date the team member was notified.	N/A
Method:	The manner in which the team member was notified. Options include: Phone Personal Contact Regular Mail Return Receipt Required Personally Delivered Email Fax	These options are hard coded. Multiple options may be selected.
Notified By:	The person who reached out to the team member.	N/A
Outcome:	The response or end result of the notification.	N/A

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Conference Actual

The Conference Actual editor is used to document meetings that took place.

Conference Actual List Screen

Conference Actual List

Column Name	Description
Padlock Icon	The user currently working on the record.
Scheduled Meeting	The date of the planned meeting.
Actual Meeting	The date the meeting took place.
Actual Location	The location of the meeting.

Conference Actual Detail Screen

Conference Actual Detail

Field	Description	Validation
Actual Conference Notification: <date of actual conference> The "<date of actual conference>" will populate based on the Actual Conference Date entered.
Scheduled Meeting Date Required	The date of the planned meeting.	The options in this field are determined from the Conference Announcement > Scheduled Conference Date entries.
Scheduled Conference Time	The time of the planned meeting.	The options in this field are determined from the Conference Announcement entries. This field is read-only.
Scheduled Conference Location	The planned conference location.	The options in this field are determined from the Conference Announcement entries. This field is read-only.
Scheduled Conference Location (specify)	The location of the meeting, if clarification or details are needed.	The options in this field are determined from the Conference Announcement entries. This field is read-only.
Actual Conference Date	The date the meeting took place.	This is required for saving the editor.
Actual Conference Time	The time the meeting took place.	This is required for saving the editor.
Actual Conference Location	The location of the meeting. Options include: Phone Virtual In-Person	This is a required element for saving the editor. The values available are hard-coded.
Actual Conference Location (specify)	The location of the meeting, if clarification or details are needed.	N/A
Evaluation Process:	Indicates the type of evaluation processes needed for the student. Displays two rows of checkboxes, Scheduled and Actual. Options include: Describe the Student's Educational Concern (Impacts Learning). Review Current Data. Determine what additional data, if any, is needed to define the needs of your child. Determine if an IDEA initial evaluations or reevaluations is warranted.	The Scheduled column is read only and is determined based on the Scheduled Meeting Date selected. The Actual column can be edited. If the user selects one of these options, they will not be able to select IDEA Eligibility.
IDEA Eligibility	Indicates the student needs an IDEA Evaluation. Displays two rows of checkboxes, Scheduled and Actual. Options include: Discuss the results of an IDEA initial evaluation or reevaluation. Determine eligibility or continued eligibility for IDEA services.	The Scheduled column is read only and is determined based on the Scheduled Meeting Date selected. The Actual column can be edited. If the user selects this value they will not be able to select Evaluation Process.
Attendance
Team Member Name	The name of the team member.	This field is read-only and auto populates based on Team Members entered within the Conference Announcement editor who have the Invited checkbox marked. The First Name, Last Name, and Role fields display.
Attended	Indicates the team member attended the meeting.	N/A
Admin/Designee	Indicates if the team member is an admin designee for the meeting.	This field is read-only and auto selected if it was selected within the Conference Announcement editor.
Excused	Indicated the team member was excused from the meeting.	This field is read-only and auto selected if it was selected within the Conference Announcement editor.
Reason for Excusal	The reason the team member was excused from the meeting.	This field is blank upon entering the editor and will require the user to enter a value if the corresponding Excused checkbox is marked.

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Consent for Assessment

The Consent for Assessment editor is used to document the consent gathered to assess the student.

This editor is not available if Triennial Agreement is selected as the Evaluation Type. This editor is also not available if No is selected in the Assessment Needed field on the Evaluation Status editor.

Consent for Assessment Editor

Field	Description	Validation
Consent for Assessment
Consent for Assessment Type	Indicates the type of assessment needing consent. Options include: 102a - Part of an Initial 102c - Part of a Reevaluation	This is a read-only field. This field will auto populate based on the Type of Evaluation selected within the Evaluation Header editor: When Initial Evaluation is selected, "102a - Part of an Initial" displays. When Reevaluation is selected, "102c - Part of a Reevaluation" displays.
Provided to Parent Date Required	The date the Consent for Assessment form was provided to the parent.	N/A
Contact Efforts This table is read-only and displays the following columns: +/- Contact Efforts > All of these read-only values come from the user selecting the Add* button and entering information on a side panel recording what Contact Efforts were made.*
Contacted Efforts (side panel)
Contacted Date	The date the parent/guardian was contacted.	N/A
Contacted By	The person who attempted to contact the parent/guardian.	N/A
Contacted Method	The manner in which the parent/guardian was contacted. Options include: Telephone Personal Contact Regular Mail Return Receipt Requested Personally Delivered E-mail Fax	The values available are hard-coded.
Contacted Name	The person contacted.	N/A
Relationship to Student	The manner of relationship the person being contacted has to the student.	N/A
Outcome	The result of the contact.	N/A
New	Selecting this New button copies the top 6 fields for another entry of Contact Efforts.	N/A
Contact Results
Consent Given	Indicates if consent was given by the parent/guardian.	Yes or No. This is a required field on complete of the editor.
Consent Form Signed Date	The date consent was given.	This is a required field on complete of the editor.
School Received Consent Form Date	The date consent was received.	This is a required field on complete of the editor.
Name of Person Signing Consent Form	The name of the person who signed the consent form.	This is a required field on complete of the editor.
Revocation	Indicates consent has been revoked.	Additional fields become required when marked.
Revocation Form Signed Date	The date the person signed the revocation form.	Only available when Revocation is marked. This field is required on completion of this editor when available.
Name of Person Signing Revocation Form	The name of the person who revoked consent.	Only available when Revocation is marked. This field is required on completion of this editor when available.
School Received Revocation Form Date	The date revocation was received.	Only available when Revocation is marked. This field is required on completion of this editor when available.
Consent Revocation Reason	The reason for revoking consent.	Only available when Revocation is marked. This field is required on completion of this editor when available.

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Assessment Report

The Assessment Report editor is used to document how data has been gathered concerning the student.

Note: Information from this editor displays at the end of the Evaluation document when printed.

Assessment Report List Screen

Field	Description
Padlock Icon	The user currently working on the record.
Sequence	The order in which the record will print.
Assessment	The Assessment type.
Print in Evaluation	Indicates this record will print on the Evaluation.

Assessment Report Detail Screen

Assessment Report Detail Screen (Academic Assessment Example)

Field	Description	Validation
Assessment Required	The assessment type. Options include: Academic Emotional Behavioral Cognitive Multi-Disciplinary Observation Occupational Therapy Physical Therapy Speech and Language	The value selected in the Assessment field changes the rest of the editor (documented below).
Print in Evaluation	Indicates this record will print on the Evaluation.	N/A
Sequence	The order in which the record will print.	N/A
Examiner(s) Required	The person(s) responsible for assessing the student.	N/A
Date of Assessment Required	The day the assessment took or will take place.	N/A
I verify the information in this report is accurate. Required	A checkbox indicating the information in the report is accurate.	N/A
Staff Member Signing Assessment Report	The person who verified the accuracy of the information contained within the report (the person who marked the checkbox above).	This field is read-only and auto-populates with the person's name who is logged in to Camps when the checkbox above was selected.
Licensed Supervisor Signature Required	A checkbox indication a licensed supervisor signature is required on the report.	This field displays when any Assessment Report other than "Academic" or "Observation" is selected.
I verify the information in this report is accurate. Required	A checkbox indicating the information in the report is accurate.	N/A
Licensed Supervisor Signing Assessment Report	The signature of the licensed supervisor if the above checkbox is marked.	This field is read-only and auto-populates with the person's name who is logged in to Camps when the checkbox above was selected.

Academic

Field	Description	Validation
The student was referred by: Required	The person who referred the student for the academic assessment.	N/A
Referred due to the following concerns: Required	The reason for referral. Options include: Speaking Spelling Math Calculation Word Recognition (phonology, letter naming, phonics, word attack) Written Composition (grammar, sentence writing, composition of story or essay, organization) Reading (Language) Comprehension (summarizing, retelling, answering questions, completing cloze [maze] passages) Listening (understanding) Handwriting Math Reasoning Oral Reading Fluency (graded oral reading passages, words correct per minute [WCPM]) Vocabulary (recognition of word meanings, multiple-choice response, production of definitions, use of words in context)	N/A
Background Information
Relevant information regarding: Required	Any pertinent information regarding the student's background.	N/A
Parent Information: Required	Any pertinent information regarding the student's parent/guardian.	N/A
Pre-referral Interventions:	Any pre-referral interventions. Options include: Not Applicable Attended Early Intervention Program Received Private Occupational Therapy Services Received School-Based Interventions Received Teacher Interventions No Interventions Provided Other	N/A
Specify: *Required	Additional information if "Other" is selected above.	*This field is required if "Other" is selected above.
Outcomes:	The outcome of the interventions.	N/A
Environmental, Cultural and/or Dialectal Considerations
Language(s) spoken in the home: Required	The student's spoken language at home.	The values available in this field are pulled from Student Information > Census > Language Spoken in the Home.
Dialect/Cultural Considerations: Required	The student's language they primarily speak. Options include: Standard American English Local Hawaiian Creole (i.e., pidgin English) A mixture of English and Home Language(s) Other	N/A
Specify: *Required	Additional information if "Other" is selected above.	*This field is required if "Other" is selected above.
Assessment Procedures and Results
All domains pertaining to the area(s) of concern were assessed and test results are valid.	A checkbox indicating all area(s) of concern were assessed.	N/A
A variety of assessment procedures were used to gather information.	A checkbox indicating a a variety of assessment methods were used to gather data.	N/A
Tests Administered:	The tests administered to the student.	N/A
Informal/Non-Standardized Measures/Methods Used:	Any other assessment methods used. Options include: Records Review Interview Observation	N/A
Behavioral Observations
Behavior in:	Indicates how the student's behavior was assessed. Options include: One-to-One Setting Group Setting	N/A
Behavior with:	Indicates who assessed the student's behavior. Options include: Familiar Adult Unfamiliar Adult Peers	N/A
Behavior:	The student's behavior assessment. Options include: Interacted with or responded Used repetitive or perseverative behaviors Difficulty switching tasks Followed directions Responded to questions after lengthy pauses Did not interact/respond to communication partner	N/A
Academic Assessment Findings
Analysis of Findings	A text field used to describe the findings.	N/A
Implications for Learning and Educational Impact
Student has challenges with skill area(s) that prevent participation in educational activities.	Indicates the student has challenges pertaining to their academic progress.	N/A
Identify activities and impact on participation:	The activities that impact the student's participation.	This field becomes available when the corresponding check box is selected.
There is no adverse impact on the student's ability to participate in educational activities.	Indicates the student does not have challenges pertaining to their academic progress.	N/A
Summary and Recommendations
Explain:	A summary of the evaluation team's recommendations.	N/A

Cognitive

Field	Description	Validation
Reason for Referral
Explain:	The reason for referral.	N/A
Background Information
Explain:	Any pertinent information regarding the student's background.	N/A
Environmental, Cultural and or Dialectal Considerations
Explain:	Any pertinent information regarding the student's environment, culture, and dialect.	N/A
Functional Performance
Explain:	Any pertinent information regarding the student's functional performance.	N/A
Assessment Procedures and Results
Test(s) Administered:	The tests administered to the student.	N/A
Date(s) of Assessment(s):	When the tests were administered.	N/A
All tests administered were validated for the purposes in the assessment. (Cognitive, Social/Emotional, Academic, etc.)	A checkbox indicating all area(s) of concern were assessed.	N/A
Testing Observation:	Any results observed during testing.	N/A
Assessment Results:	The results of the test.	N/A
Interpretation of Assessment Results:	The interpretation of the test results.	N/A
Implications for Learning and Educational Impact
Explain:	The implications for the student's learning based on the assessments.	N/A
Summary and Recommendations
Explain:	A summary of the team's recommendations for action.	N/A

Emotional Behavioral

Field	Description	Validation
Why does the student require an EBA:	The reason why the student requires an Emotional Behavioral Assessment.	N/A
Background Information
Include relevant information regarding the following (format of provided information to be determined by the assessor):	Any pertinent information regarding the student's background.	N/A
Environmental, Cultural and/or Dialectal Considerations.
Language(s) spoken in the home: Required	The student's spoken language at home.	The values in this field are pulled from Student Information > Census > Language Spoken in the Home.
Dialect/Cultural Considerations: *Required	The student's language they primarily speak. Options include: Standard American English Local Hawaiian Creole (i.e., pidgin English) A mixture of English and Home Language(s) Other	N/A
Specify:	Additional information if "Other" is selected above.	This field appears when "Other" is selected from the field prior.
Cultural or Transcultural Considerations:	Any cultural considerations.	N/A
Any other student or environmental characteristics that affects assessment selection or interpretation:	Any other informational that may impact the student's assessment or interpretation of the assessment.	N/A
Assessment Procedures
Sources of information and assessment tools:	The methods of assessment.	N/A
Additional Assessment Information Data:	Any other assessment methods used.	N/A
Results and Functional Performance
Assessment Results:	The results of the functional performance assessment.	N/A
Implications for Learning and Educational Impact
How the identified characteristics would be expected to impact the student's functioning in the classroom/school setting. Include both positive impact and negative impact.	The implications for the student's learning based on the assessments.	N/A
Formulation
Formulations/Conclusions (integrative description) and diagnostic impressions (if any)	Any conclusions, if any.	N/A
Summary and Recommendations
Summarize:	A summary of the evaluation team's recommendations.	N/A
Strengths-Based Recommendations:	Any recommendations based on the student's strengths.	N/A

Multi-Disciplinary

Field	Description	Validation
Reason for Referral
Explain:	The reason for referral.	N/A
Background Information
Explain:	Any pertinent information regarding the student's background.	N/A
Environmental, Cultural and or Dialectal Considerations
Explain:	Any pertinent information regarding the student's environment, culture, and dialect.	N/A
Functional Performance
Explain:	Any pertinent information regarding the student's functional performance.	N/A
Assessment Procedures and Results
Test(s) Administered:	The tests administered to the student.	N/A
Date(s) of Assessment(s):	When the tests were administered.	N/A
All tests administered were validated for the purposes in the assessment. (Cognitive, Social/Emotional, Academic, etc.)	A checkbox indicating all area(s) of concern were assessed.	N/A
Testing Observation:	Any results observed during testing.	N/A
Assessment Results:	The results of the test.	N/A
Interpretation of Assessment Results:	The interpretation of the test results.	N/A
Implications for Learning and Educational Impact
Explain:	The implications for the student's learning based on the assessments.	N/A
Summary and Recommendations
Explain:	A summary of the team's recommendations for action.	N/A

Observation

Field	Description	Validation
Reason for Referral
The student was referred by: Required	The person who referred the student for the assessment.	N/A
Academic:	The academic area. Options include: Reading Writing Math Other	N/A
Specify:	Additional information if "Other" is selected above.	This field becomes available when "Other" is selected from the corresponding field.
Behavior:	The behavior area. Options include: Unstructured Periods Structured Activities Other	N/A
Specify:	Additional information if "Other" is selected above.	This field becomes available when "Other" is selected from the corresponding field.
Background Information
Relevant information regarding:	Any pertinent information regarding the student's background.	N/A
Parent Information:	Any pertinent information regarding the student's parent/guardian.	N/A
Pre-referral Interventions:	Any pre-referral interventions. Options include: Not Applicable Attended Early Intervention Program Received Private Occupational Therapy Services Received School-Based Interventions Received Teacher Interventions No Interventions Provided Other	N/A
Specify:	Additional information if "Other" is selected above.	This field appears when "Other" is selected from the field prior.
Outcomes:	The outcome of the interventions.	N/A
Environmental, Cultural and/or Dialectal Considerations
Language(s) spoken in the home: Required	The student's spoken language at home.	The values in this field are pulled from Student Information > Census > Language Spoken in the Home.
Dialect/Cultural Considerations: Required	The student's language they primarily speak. Options include: Standard American English Local Hawaiian Creole (i.e., pidgin English) A mixture of English and Home Language(s) Other	N/A
Specify:	Additional information if "Other" is selected above.	This field becomes available when "Other" is selected from the corresponding field.
Assessment Procedures and Results
Observation in the domain of:	A checkbox for the domain.	N/A
Domain: Required	The domain area.	This field becomes available when the corresponding field is selected.
A variety of assessment procedures were used to gather information.	A checkbox indicating a a variety of assessment methods were used to gather data.	N/A
Tests Administered:	The tests administered to the student.	N/A
Informal/Non-Standardized Measures/Methods Used:	Any other assessment methods used. Options include: Records Review Interview Observation	N/A
Writing:	The results of the writing assessment.	N/A
Reading:	The results of the reading assessment.	N/A
Mathematics:	The results of the mathematics assessment.	N/A
Behavior:	The results of the behavior assessment.	N/A
Date of Observation:	When the test was administered.	N/A
Start Time of Observation:	The start time of the test.	N/A
End Time of Observation:	The end time of the test.	N/A
Setting of Observation:	The test setting.	N/A
#of Students in Setting:	The number of students present during the test.	N/A
#of Adults in Setting:	The number of adults present during the test.	N/A
Name and Title of Person Completing Observation:	The person observing.	N/A
Student was observed during:	When the student was observed. Options include: Lecture Discussion Independent seatwork Small group work	N/A
Student's level of engagement and participation:	A description of the student's level of participation during the test.	N/A
Special supports conditions observed:	Any additional observations.	N/A
Instructional strategies and/or behavior supports used during the instruction:	The supports provided to the student during the test. Options include: Wait Time Repetition Visual Supports Graphic Organizers Rephrasing Rate of Instruction Manipulatives Positive Reinforcement Re-direction Teacher Proximity Environmental Factors (lesson organization, no visual supports) External versus Internal (within student factors) Other	N/A
Specify:	Additional information if "Other" is selected above.	This field becomes available when "Other" in the corresponding field is selected.
Student's reaction to instructional strategy(ies) and/or behavior supports provided:	The student's response to the supports provided.	N/A
Student's behavior during the observation session and how the behavior compares to that of other students in the class at the same time:	A comparison between the student's behavior and their peers during the same session.	N/A
Student's academic performance during the observation session and how the performance compares to that of other students in the class at the same time:	A comparison between the student's academic performance and their peers during the same session.	N/A
Implications for Learning and Educational Impact
Student has challenges with skill area(s) that prevent participation in educational activities	Indicates the student has challenges impeding their participation in educational activities.	N/A
Identify activities and impact on participation:	A description of activities and their impact on the student's education.	This field becomes available when the corresponding value is selected.
There is no adverse impact on the student's ability to participate in educational activities	Indicates the student does not have challenges impeding their participation in educational activities.	N/A
Summary and Recommendations
Explain:	A summary of the evaluation team's recommendations.	N/A

Occupational Therapy

Field	Description	Validation
Reason for Referral
The student was referred by: Required	The person who referred the student for the assessment.	N/A
Referred due to the following concerns:	The reason for referral. Options include: School Related Activities of Daily Living Environmental Factors (maintaining and changing positions, orientation and travel on campus, or recreational movement) Student Roles (following class routines, safety awareness, respecting the space/time/materials of others, staying seated, requesting help, making needs known, social awareness, building/maintaining relationships) Access to Learning (participating in class activities, following demonstrations, understanding cause and effect, carrying out verbal directions, attending to instruction, using classroom tools, managing materials, completing assignments, or transition between activities) Play/Recreation (exploring/using objectives/environments/ideas, interacting with peers, modeling, imagining, or creating play schemes)	N/A
Background Information
Relevant information regarding:	Any pertinent information regarding the student's background.	N/A
Parent Information:	Any pertinent information regarding the student's parent/guardian.	N/A
Pre-referral Interventions:	Any pre-referral interventions. Options include: Not Applicable Attended Early Intervention Program Received Private Occupational Therapy Services Received School-Based Interventions Received Teacher Interventions No Interventions Provided Other	N/A
Specify:	Additional information if "Other" is selected above.	This field appears when "Other" is selected from the field prior.
Outcomes:	The outcome of the interventions.	N/A
Environmental, Cultural and/or Dialectal Considerations
Language(s) spoken in the home: Required	The student's spoken language at home.	The values in this field are pulled from Student Information > Census > Language Spoken in the Home.
Dialect/Cultural Considerations: Required	The student's language they primarily speak. Options include: Standard American English Local Hawaiian Creole (i.e., pidgin English) A mixture of English and Home Language(s) Other	N/A
Specify:	Additional information if "Other" is selected above.	This field appears when "Other" is selected from the field prior.
Assessment Procedures and Results
All domains pertaining to the area(s) of concern were assessed and test results are valid.	A checkbox indicating all area(s) of concern were assessed.	N/A
A variety of assessment procedures were used to gather information.	A checkbox indicating a a variety of assessment methods were used to gather data.	N/A
Tests Administered:	The tests administered to the student.	N/A
Informal/Non-Standardized Measures/Methods Used:	Any other assessment methods used. Options include: Records Review Interview Observation	N/A
Context/Environment This section has multiple sections describing the different contexts or environments and the level of impact on the student. For each of the sections listed below, the level of impact and a description should be documented: Physical Layout Organization of Materials/Supplies Availability/Clarity of Performance Expectations Noise Level Visual Stimuli Lighting Number of Individuals Present Temperature Other
Level of Impact:	The level of impact pertaining to the particular environmental condition. Options include: No Impact Minimal Impact Significant Impact	N/A
Description of factor and how it impacts participation and performance in activities:	A description of the environmental condition and specifically how it impacts the student's participation and performance.	N/A
Functional Performance This section has multiple sections describing the functional areas and the student's strengths and challenges in that area. For each of the sections listed below, the student's performance, strengths, challenges, and additional factors should be documented: Self-Care Environmental Factors Student Role/Interaction Skills Learning/Academics Play/Recreation
Student Performance:	The student's performance in the particular area.	N/A
Strengths:	The student's strengths with these activities.	N/A
Challenges:	The student's challenges with these activities.	N/A
Factors Affecting Student Participation:	Additional factors impacting the student's participation in these activities.	N/A
Standardized Assessment Results
Explain:	A summary of the assessment results.	N/A
Implications for Learning and Educational Impact
Student has challenges with skill area(s) that prevent participation in educational activities.	Indicates the student has challenges pertaining to their academic progress.	N/A
Identify activities and impact on participation:	The activities that impact the student's participation	This field becomes available when the corresponding checkbox is marked.
There is no adverse impact on the student's ability to participate in educational activities.	Indicates the student does not have challenges pertaining to their academic progress.	N/A
Level of Support Needed	The level of support the student needs in the particular area. Options include: Functional (little or no support needed) Moderate Level of Support Needed High Level of Support Needed	The Levels of Support Needed, Responsiveness to Assistance, and Comments fields also applies to the following sections: Self-Care Environmental Factors Student Role/Interaction Skills Learning/Academics Play/Recreation
Responsiveness to Assistance	The student's response to assistance in the particular area. Options include: Responsive Somewhat Responsive Not Responsive	N/A
Comments:	Any additional information regarding the particular area.	N/A
Summary and Recommendations
Explain:	A summary of the evaluation team's recommendations.	N/A

Physical Therapy

Field

Description

Validation

Reason for Referral

The student was referred by:
Required

The person who referred the student for the assessment.

N/A

Referred due to the following Mobility concerns within:

The Mobility concerns of the student that led to the referral. Options include:

Classroom
Campus (navigating between buildings, stairs, cafeteria, library, etc.)
Outdoor Recess Play Area
Other

N/A

Specify:

Additional information if "Other" is selected above.

This field appears when "Other" is selected from the field prior.

Background Information

Relevant information regarding medical history:

Any pertinent information regarding the student's background.

N/A

Pre-referral Interventions:

Any pertinent information regarding the student's parent/guardian. Options include:

Not Applicable
Attended Early Intervention Program
Received Private Occupational Therapy Services
Received School-Based Interventions
Received Teacher Interventions
No Interventions Provided
Other

N/A

Specify:

Additional information if "Other" is selected above.

This field appears when "Other" is selected from the field prior.

Outcomes:

The outcome of the interventions.

N/A

Environmental, Cultural and/or Dialectal Considerations

Language(s) spoken in the home:
Required

The student's spoken language at home.

The values in this field are pulled from Student Information > Census > Language Spoken in the Home.

Dialect/Cultural Considerations:
Required

The student's language they primarily speak. Options include:

Standard American English
Local Hawaiian Creole (i.e., pidgin English)
A mixture of English and Home Language(s)
Other

N/A

Specify:

Additional information if "Other" is selected above

This field appears when "Other" is selected from the field prior.

Assessment Procedures and Results

All domains pertaining to the area(s) of concern were assessed and test results are valid.

A checkbox indicating all area(s) of concern were assessed.

N/A

A variety of assessment procedures were used to gather information.

A checkbox indicating a a variety of assessment methods were used to gather data.

N/A

Tests Administered:

The tests administered to the student.

N/A

Informal/Non-Standardized Measures/Methods Used:

Any other assessment methods used. Options include:

Records Review
Interview
Observation

N/A

Context/Environment
This section has multiple sections describing the different contexts or environments and the level of impact on the student. For each of the sections listed below, the level of impact and a description should be documented:

School Mobility
Classroom Activities
Bussing, Arrival, Dismissal
Mealtime
Toileting
Playground/Recess
Physical Education Performance and Participation
Equipment Needs
Other

Level of Impact:

The level of impact pertaining to the particular environmental condition. Options include:

No Impact
Minimal Impact
Significant Impact

N/A

Description of factor and how it impacts participation and performance in activities:

A description of the environmental condition and specifically how it impacts the student's participation and performance.

N/A

Functional Performance
This section has multiple sections describing the functional areas and the student's strengths and challenges in that area. For each of the sections listed below, the student's performance, strengths, challenges, and additional factors should be documented:

Self-Care
Environmental Factors
Student Role/Interaction Skills
Learning/Academics
Play/Recreation

Student Performance:

The student's performance in the particular area.

N/A

Strengths:

The student's strengths with these activities.

N/A

Challenges:

The student's challenges with these activities.

N/A

Factors Affecting Student Participation:

Additional factors impacting the student's participation in these activities.

N/A

Standardized Assessment Results

Explain:

A summary of the assessment results.

N/A

Implications for Learning and Educational Impact

Student has challenges with skill area(s) that prevent participation in educational activities.

Indicates the student has challenges pertaining to their academic progress.

N/A

Identify activities and impact on participation:

The activities that impact the student's participation

This field appears when "Other" is selected from the field prior.

There is no adverse impact on the student's ability to participate in educational activities.

Indicates the student does not have challenges pertaining to their academic progress.

N/A

Level of Support Needed:

The level of support the student needs in the particular area. Options include:

Functional (little or no support needed)
Moderate Level of Support Needed
High Level of Support Needed

The Levels of Support Needed, Responsiveness to Assistance, and Comments fields also applies to the following sections:

Self-Care
Environmental Factors
Student Role/Interaction Skills
Learning/Academics
Play/Recreation

Responsiveness to Assistance:

The student's response to assistance in the particular area. Options include:

Responsive
Somewhat Responsive
Not Responsive

N/A

Comments:

Any additional information regarding the particular area.

N/A

Summary and Recommendations

Explain:

A summary of the evaluation team's recommendations.

N/A

Speech and Language

Field	Description	Validation
Reason for Referral
The student was referred by:	The person who referred the student for the assessment. Options include: Teacher Parent	N/A
Speech	Indicates if the student was referred due to speech concerns.	N/A
Briefly describe concerns:	A description of the speech concern.	This field appears when "Speech" is selected from the corresponding field.
Language	Indicates if the student was referred due to language concerns.	N/A
Briefly describe concerns:	A description of the language concern.	This field appears when "Language" is selected from the corresponding field.
Background Information
Relevant information regarding speech and language development:	Any pertinent information regarding the student's background.	N/A
Pre-referral Interventions:	Any pertinent information regarding the student's parent/guardian. Options include: Not Applicable Attended Early Intervention Program Received Private Occupational Therapy Services Received School-Based Interventions Received Teacher Interventions No Interventions Provided Other	N/A
Specify:	Additional information if "Other" is selected above.	This field appears when "Other" is selected from the corresponding field.
Outcomes:	The outcome of the interventions.	N/A
Parent Information:	Any pertinent information regarding the student's parent/guardian.	N/A
Environmental, Cultural and/or Dialectal Considerations
Language(s) spoken in the home: Required	The student's spoken language at home.	The options in this field come from Census > Language at Home.
Dialect/Cultural Considerations: Required	The student's language they primarily speak. Options include: Standard American English Local Hawaiian Creole (i.e., pidgin English) A mixture of English and Home Language(s) Other	N/A
Specify:	Additional information if "Other" is selected above.	This field appears when "Other" is selected from the corresponding field.
Assessment Procedures and Results
Speech and language skills were comprehensively assessed, and results are valid.	Indicates the student's speech and language skills were adequately assessed.	N/A
A variety of assessment procedures were used to gather information.	A checkbox indicating a a variety of assessment methods were used to gather data.	N/A
Test Administered:	The tests administered to the student.	N/A
Informal/non-standardized measures/methods used:	Any informal methods used for assessment.	N/A
Behavioral Observations
Behavior In:	Indicates how the student's behavior was assessed. Options include: One-to-One Setting Group Setting	N/A
Behavior With:	Indicates who assessed the student's behavior. Options include: Familiar Adult Unfamiliar Adult Peers	N/A
Behavior:	The student's behavior assessment. Options include: Interacted with or responded Used repetitive or perseverative behaviors Difficulty switching tasks Followed directions Responded to questions after lengthy pauses Did not interact/respond to communication partner	N/A
Communication In:	Indicates how the student's communication skills was assessed. Options include: One-to-One Setting Group Setting	N/A
Communication With:	Indicates who assessed the student's communication skills. Options include: Familiar Adult Unfamiliar Adult Peers	N/A
Communication:	The student's communication assessment. Options include: Initiated novel messages Imitated adult Did not initiate but responded to questions Did not initiate or respond to questions	N/A
Comments:	Any additional information.	N/A
Speech/Language/Communication Findings
Tests Administered:	The tests administered to assess the student's speech/language/communication skills.	N/A
Informal/non-standardized measures/methods used:	Any informal methods used for assessment.	N/A
Hearing and Oral Structures
Hearing Screening:	The results of the student's hearing assessment. Options include: Pass Did Not Pass Unable to Complete	N/A
Comments:	Any comments related to the hearing assessment.	N/A
Oral Structures and Functioning:	The results of the student's oral assessment. Options include: Adequate for Speech Production Motoric Difficulties Interfere with Speech Production Structural Abnormalities Interfere with Speech Production Motoric & Structural Abnormalities Interfere with Speech Production	N/A
Comments:	Any comments related to the oral assessment.	N/A
Speech (Speaking) Skills
Voice:	The results of the student's voice assessment. Options include: Voice Quality and Loudness Levels Appropriate Vocal Quality Interferes with Communication Inappropriate Loudness Levels	N/A
Fluency:	The level of speech fluency for the student. Options include: Rhythm and Rate of Speech Appropriate Hesitations and Repetitions Noted when Speaking	N/A
Comments:	Any comments related to the student's voice/fluency.	N/A
Assessment Given:	The assessment given to test the student's speech sound production.	N/A
Score:	The results of the assessment.	N/A
Description and Summary of Speech Sound Production:	A description of the speech sound production assessment.	N/A
Single Words:	A description of the student's use of single words.	N/A
Connected Speech:	A description of the student's use of connected speech.	N/A
Understood by a parent or familiar listener	Indicates the student was able to be understood by familiar listeners.	N/A
Frequency	How often the student was understood by familiar listeners. Options include: Often Sometimes Rarely Never	N/A
Percentage Rating	The percentage of how often the student was understood by familiar listeners.	N/A
Understood by unfamiliar listener	Indicates the student was understood by unfamiliar listeners.	N/A
Frequency	How often the student was understood by unfamiliar listeners. Options include: Often Sometimes Rarely Never	N/A
Percentage Rating	The percentage of how often the student was understood by unfamiliar listeners.	N/A
Comments:	Any additional information regarding the student's speech sound production.	N/A
Language Skills
Management of a Conversation:	An assessment of the student's functional communication skills to manage a conversation. Options include: Initiated a conversation Maintained topic of conversation Provided clarification when the conversational partner requested Did not socially engage with conversational partner Took turns when conversing Monitors language production & makes corrections Speech is socially directed to listener	N/A
Comments:	Any comments related to the student's management of a conversation.	N/A
Telling a Personal Story (describing an event that happened):	An assessment of the student's skills concerning telling a personal story. Options include: Story focused on a specific topic Explained familiar events and sequences Unable to talk about events or explain "what happened" Statements were related to topic Used words to connect ideas/actions	N/A
Comments:	Any comments related to the student's ability to tell a personal story.	N/A
Interact with others while playing	Indicates the student interacts with others while playing.	N/A
Use of language while communicating with peers:	An assessment of the student's use of language while communication with peers. Options include: Did not acknowledge or pay attention to other children during play activities Played near other children but did not interact or acknowledge others Played near other children and attempted to engage and communicate with peers Interacted with adult not peers Took turns and played with other children	N/A
Activities engaged in while playing	Indicates the student engages in activities while playing.	N/A
Use of language while communicating with peers:	An assessment of how the student communication with their peers. Options include: Played imaginatively, talked about events using toys and props Did not use toys and props to act out events or play imaginatively Played imaginatively with toys and props - minimal talking while playing	N/A
Comments:	Any comments related to the student's use of language.	N/A
Strength:	The student's speech strengths.	N/A
Challenge:	The student's speech challenges.	N/A
Level of support needed to acquire skill:	The amount of assistance the student will need to aid them in gaining speech skills. Options include: High level of support needed Moderate level of support needed Minimal level or no support needed	N/A
Student's response to support provided:	The student's reponse to the assistance provided. Options include: Student responsive and motivated Student responsive but needs encouragement Student not responsive	N/A
Words and Communication
Assessment(s) Administered and Score(s):	The assessment given to the student to determine their understanding and use of words.	N/A
Language Sample:	The language sample used in the assessment. Options include: Conversational Personal Story Story Retell	N/A
Mean Length of Utterance	Indicates a mean length of utterance has been calculated.	N/A
Score:	The student's score for length of utterance.	N/A
Mean:	The student's mean length of utterance.	N/A
Standard Deviation:	The student's standard deviation.	N/A
Total Number of Words	Indicates the total number of words has been calculated.	N/A
Score:	The student's score for total number of words.	N/A
Mean:	The student's mean total number of words.	N/A
Standard Deviation:	The student's standard deviation.	N/A
Total Number of Different Words	Indicates the total number of different words has been calculated.	N/A
Score:	The student's score for different words used.	N/A
Mean:	The student's mean for different words used.	N/A
Standard Deviation:	The student's standard deviation.	N/A
Word Knowledge (used the following type of words):	The students word knowledge for the following word types. Options include: Nouns Pronouns Verbs/action words Descriptive words	N/A
Examples:	An example of the student's word knowledge.	N/A
Answered the following question words accurately:	Indicates the student the following question words. Options include: What Where When Who Difficulty Understanding	N/A
Comments:	Any comments regarding the student's question word proficiency.	N/A
Followed One Step Directions:	Indicates the student was able to follow a one step direction. Options include: No Component One Component Two Components Difficulty Understanding	N/A
Followed Two Step Directions:	Indicates the student was able to follow two step directions. Options include: No Component One Component Two Components Difficulty Understanding	N/A
Comments:	Any comments related to the student's ability to follow directions.	N/A
Assessment(s) Administered and Score(s):	The assessment administered to examine the student's syntax and grammar skills.	N/A
Assessment(s) Administered and Score(s):	The results of the assessment. Options include: Single Compound Complex	N/A
Examples:	Examples of the student's syntax and grammar skills.	N/A
Grammatical Form Used:	The type of grammatical form the student used. Options include: Regular past tense Plural Possessive Irregular past tense Present progressive	N/A
Examples:	Examples of the student's grammatical form skills.	N/A
Comments:	Any comments related to the student's grammatical form skills.	N/A
Phonological Awareness	Indicates the student's language and literacy skills. Options include: Discriminated between sounds Aware of/participated in rhyming games, nursey rhymes/songs Segmented Syllables (e.g., counted, tapped, or clapped out) Spontaneously uses alliteration (e.g., "bee-bo-by")	N/A
Comments:	Any comments related to the student's language and literacy skills.	N/A
Print Knowledge Skills	Indicates the student's print knowledge skills. Options include: Book and print organization Left to right directionality Top to bottom directionality Concept of word Print function	N/A
Comments:	Any comments related to the student's print knowledge skills.	N/A
Alphabetic Knowledge:	Indicates the student's alphabet knowledge. Options include: Upper case letter identification Lower case letter identification Sound/letter correspondence	N/A
Comments:	Any comments related to the student's alphabet knowledge.	N/A
Narratives: Retell of a Familiar Story	An assessment of how the student tells a family story. Options include: Named Character(s) Identified time or setting Identified the problem Explained sequences of events Connected sequences of events Explained attempts to resolve problem Ended the story	N/A
Story Retell Abilities:	The skills demonstrated by the student's retelling of a family story. Options include: Age appropriate skills Lacked organization Limited information Numerous stalls and stops Unable to retell a story from memory	N/A
Comments:	Any comments related to the student's retelling of a family story.	N/A
Implications for Learning
Identify the gap between performance and what is expected.	A description of the gap between the student's performance and the expected results.	N/A
Recommendations
Recommendations should align with the implications for learning to address what speech and/or language skills is needed to advance in general education.	A description of the team's recommendations for intervention.	N/A
Summary
A comprehensive speech and language assessment was conducted due to the following speech and language concerns:	An overview of the speech and language concerns that led to this evaluation.	N/A
The following is a summary of the student's performance.	An overview of the student's performance with the evaluation.	N/A
Student's Vocabulary and Knowledge of Different Words was:	The overall result of the student's vocabulary and knowledge of different words. Options include: Age Appropriate Characterized by the ability to <identify strength in this area> however language growth is impacted	N/A
Language growth is impacted because:	The reasoning for this conclusion. Options include: A limited knowledge and use of a variety of words Difficulty recalling and using newly taught words	N/A
Level of support needed to acquire skill:	The level of assistance the student requires to acquire these skills. Options include: High level of support needed Moderate level of support needed Minimal level or no support needed	N/A
Student's response to support provided:	The student's response to the assistance provided. Options include: Student responsive and motivated Student responsive but needs encouragement Student not responsive	N/A

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Reason for Referral

The Reason for Referral editor is used to document the reason the student was referred to be evaluated.

Reason for Referral

Field	Description	Validation
Area(s) related to the suspected disabilities:	The area related to the student's suspected disability. Options include: Academics Reading Comprehension Reading Fluency Math Calculation Math Problem Solving Written Expression Speaking Listening Adaptive Behavior Cognition Behavior Acquisition of Developmental Milestones Hearing Fine Motor Gross Motor Vision Social-Emotional Other	N/A
Specify: Required when available	A text field used to clarify when Other is selected above.	This field displays when the Other checkbox is marked.
The following existing information was reviewed:	The existing documentation or information used in the review process. Options include: Evaluations and information provided by parents of the student Current classroom-based or State assessments Current classroom-based observations Preschool Age: Current observations in the natural environment Observations by teachers and related service providers outside of the classroom	N/A
Summary of information related to concerns:	A text field used to document any information related to concerns.	N/A
There are educationally relevant medical and/or physical issues directly related to the student's learning and access to education.	Indicates is there are relevant medical and/or physical issues related to the student's learning and access to education.	Yes or No
Documentation:	A field used to provide clarity about the above medical issues.	Displays when Yes is selected.
There are educationally relevant physical issues directly related to the student's learning and access to education.	Indicates is there are relevant physical issues related to the student's learning and access to education.	Yes of No
Documentation:	A field used to provide clarity about the above physical issues.	Displays when Yes is selected.
All assessments, materials and/or strategies used, considered racial or cultural bias and linguistic differences.	The assessments used for determination.	N/A
Interventions Summary This table is read only and displays the following columns: +/- Intervention > All of these read only values come from the user selecting the "Add Intervention" button and entering information on a side panel recording what interventions were used.
Intervention Summary (side panel)
Area of Need Required	The student's area of need.	N/A
Instructional Strategies Used	The instructional strategies used for the intervention.	N/A
Length of Time Interventions Provided	The amount of time the intervention will be provided. (# of weeks or months)	N/A
How often and how long interventions were provided	The frequency and length of time the intervention will be provided.	N/A
Student Performance results of interventions	The results of the intervention.	N/A

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Summary and Interpretation of Evaluation Data

Integrate and interpret evaluation data by describing relevant key findings across areas reviewed and assessed related to the area(s) of concern. All data summarized (test results, observations, interviews, etc.) MUST be relevant and related to the referral and suspicion of a disability. Performance must be described. Do NOT just re-state/list every assessment/observation completed. Limit the use of jargon. State findings in language that is understandable to all team members, including the parent.

Summary and Interpretation of Evaluation Data Editor

Field	Description
Findings obtained from a variety of sources were carefully considered and are documented below. This table is read only and displays the following columns: Area of Concern Strengths Limitations All of these read only values come from the user selecting the "New" button and entering information on a side panel recording what summary of findings were.
Summary of Findings in area(s) of Concern (side panel)
Area of Concern: Required	The area of concern.
Strengths:	The student's strengths.
Limitations:	The student's limitations.

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Exclusionary Factors

The Exclusionary Factors editor is used to document any factors excluding the student from regular education.

Exclusionary Factors Editor

Field	Description	Validation
Lack of appropriate instruction in reading	Indicates a lack of appropriate instruction in reading.	Yes or No This is a required field for saving the editor.
Lack of appropriate instruction in math	Indicates a lack of appropriate instruction in math.	Yes or No This is a required field for saving the editor.
Environmental or Economic Factors	Indicates there are environment or economic factors excluding the student from regular education.	Yes or No This is a required field for saving the editor.
Cultural Factors	Indicates there are cultural factors excluding the student from regular education.	Yes or No This is a required field for saving the editor.
Limited English Proficiency	Indicates there is a limitation in English proficiency excluding the student from regular education.	Yes or No This is a required field for saving the editor.

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Eligibility Criteria Checklist

The Eligibility Criteria Checklist is used to document if the student meets the criteria for difference disabilities.

Eligibility Criteria List Screen

Column Name	Description
Padlock Icon	The user currently working on the record.
Sequence	The order in which the record will print.
Eligibility Category	The area assessed.
Eligible	Indicates if the student is eligible to receive special ed services in that area.
Print in Evaluation	Indicates this record will print on the Evaluation.

Eligibility Criteria Detail Screen

Eligibility Checklist Detail - Deaf Example

Field	Description	Validation
Eligibility Category Required	The area assessed. Options include: Autism Spectrum Disorder Deaf Deaf-Blindness Developmental Delay (Age 3 - 5) Development Delay (Age 6 - 8) Emotional Disability Hard of Hearing Intellectual Disability Multiple Disability Orthopedic Disability Other Health Disability Specific Learning Disability Speech or Language Disability Traumatic Brain Injury Visual Disability incl. Blindness	Options available are located in the Attribute Dictionary.
Sequence	Determines the sort order on the printed evaluation and on the list screen.	N/A
Print in Evaluation	Indicates this record will print on the evaluation.	N/A
Eligible	Indicates if the student is eligible to receive special ed services in that area.	N/A
Date of Eligibility Determination *Required	The date the determination was made.	* This field is required when Eligible is marked.

Criteria for Autism Spectrum Disorder (ASD)

Field	Validation
The student has a developmental disability affecting verbal and nonverbal communication skills (generally evident before the age of three). Required	Yes or No
Explain or reference data or evidence:	N/A
The student has a developmental disability significantly affecting social interaction (generally evident before the age of three). Required	Yes or No
Explain or reference data or evidence:	N/A
The student exhibits engagement in repetitive activities or stereotyped movements.	Yes or No
The student exhibits resistance to environmental change or change in daily routines.	Yes or No
The student exhibits unusual responses to sensory experiences.	Yes or No
Explain or reference data or evidence:	N/A
The student’s verbal and non-verbal communication skills and social interaction are adversely affecting the student's educational (academic achievement and/or functional) performance. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
The student’s educational performance is not adversely affected primarily due to an emotional behavioral disability.	N/A
ASSURANCES: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e., explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of Autism Spectrum Disorder that adversely affects the student's educational performance.	N/A
The student has educational needs that require specially designed instruction to participate and perform in the educational setting. Required	Yes or No
List and describe area(s) of educational needs:	N/A

Criteria for Deaf

Field	Validation
The student has a significant hearing loss, averaging greater than 70dB (decibels) in the speech frequencies (500 Hz to 4,000 Hz) Required	Yes or No
A current hearing evaluation was conducted by an audiologist to determine hearing loss. Required	Yes or No
Explain or reference data or evidence:	N/A
The hearing loss impairs the student's auditory processing of linguistic information through hearing, with or without amplification. Auditory processing means the ability to listen and understand spoken messages within the school environment. Required	Yes or No
The hearing loss is adversely affecting educational (academic achievement and/or functional) performance. Required	Yes or No
Areas impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of Deafness, that adversely affects the student’s educational performance. Required	Yes or No
The student has educational needs that require specially designed instruction to participate and perform in the educational setting. Required	Yes or No
List and describe area(s) of educational needs:	N/A

Criteria for Deaf-Blindness (D-B)

Field	Validation
*Met the criteria for Deaf or Hard of Hearing (attach Deaf or Hard of Hearing worksheet).* Required	Yes or No
Met the criteria for Visual Disability including Blindness (attach Visual Disability including Blindness worksheet) Required	Yes or No
Explain or reference data or evidence:	N/A
There is an adverse effect on communication. Required	Yes or No
Explain or reference data or evidence:	N/A
There is an adverse effect on developmental performance. Required	Yes or No
Explain or reference data or evidence:	N/A
There is an adverse effect on educational (academic achievement and/or functional) performance. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of Deaf-Blindness that adversely affects the student's educational performance. The combination of the hearing and visual impairments cause severe communication and other developmental and educational needs such that cannot be accommodated in special education programs solely for children with deafness or blindness.	N/A
The student has educational needs that require specially designed instruction to participate and perform in the educational setting. Required	Yes or No
List and describe area(s) of educational needs:	N/A

Criteria for Developmental Delay 3-5 (DD 3-5)

Field	Validation
Age: The child is between the ages of three (3) through five (5). Required	Yes or No
The child was observed in a variety of settings that includes the natural environment such as the child's home, with a parent or caregiver or an early education or care setting that includes peers who are typically developing. Required	Yes or No
The child was observed in involved in age appropriate play and learning activities that includes peers who are typically developing. If observation in these settings is not possible, observation in an alternative setting or observing via digital recordings is permitted (include dates and settings of observations): Required	Yes or No
List Observations	N/A
Cognitive development and adaptive behavior are delayed equivalent to 1.5 standard deviations below the mean when compared with the standard score expected for the chronological age. Required	Yes or No
ONE of the following areas is delayed equivalent to 1.5 standard deviations below a standard score. Required	Yes or No
Check boxes that apply	Options include: Communication Development – including speech and language development (all must be met) Motor Development – including fine motor, gross motor, sensory motor and perceptual motor (all must be met) Academic Development – emergent literacy – alphabet knowledge, phonological awareness, print knowledge, oral language and emergent writing (all must be met) Adaptive Behavior
*Patterns of learning deviate from age expectations (i.e. developmental milestones) across settings.** Required	Yes or No
At least one must be selected	Options include: Communication Development – including speech and language development (all must be met) Motor Development – including fine motor, gross motor, sensory motor and perceptual motor (all must be met) Academic Development – emergent literacy – alphabet knowledge, phonological awareness, print knowledge, oral language and emergent writing (all must be met) Adaptive Behavior
Explain or reference data or evidence:	N/A
The student has a developmental delay that is adversely affecting the student’s ability to participate in age appropriate activities. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of a Developmental Delay that adversely affects the student’s ability to participate in age appropriate activities.	N/A
The student has educational needs that require specially designed instruction to participate in age appropriate activities. Required	Yes or No
List and describe area(s) of educational needs.	N/A

Criteria for Developmental Delay 6-8 (DD 6-8)

Field	Description
Age: The child is between the ages of six (6) through eight (8). Required	Yes or No
The child was observed in the natural environment across multiple settings that includes peers who are typically developing. Required	Yes or No
The child was observed in involved in age appropriate play and learning activities that includes peers who are typically developing. If observation in these settings is not possible, observation in an alternative setting or observing via digital recordings is permitted (include dates and settings of observations): Required	Yes or No
List Observations	N/A
Have all other eligibility categories been considered before identifying the category of developmental delay? Required	N/A
At least three (3) of the following areas are delayed equivalent to 1.5 standard deviations below a standard score. Required	Yes or No
Check boxes that apply	Options include: Communication Development – including speech and language development (all must be met) Motor Development – including fine motor, gross motor, sensory motor and perceptual motor (all must be met) Academic Development Adaptive Behavior Cognition
*Patterns of learning deviate from age expectations (i.e. developmental milestones) across settings.** Required	Yes or No
At least three areas must be selected	Options include: Communication Development – including speech and language development (all must be met) Motor Development – including fine motor, gross motor, sensory motor and perceptual motor (all must be met) Academic Development Adaptive Behavior Cognition
Explain or reference data or evidence:	N/A
The student has a developmental delay that is adversely affecting the student’s ability to participate in age appropriate activities. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of a Developmental Delay that adversely affects the student’s ability to participate in age appropriate activities.	N/A
The student has educational needs that require specially designed instruction to participate in age appropriate activities. Required	Yes or No
List and describe area(s) of educational needs.	N/A

Criteria for Emotional Disability (ED)

Field	Validation
One or more of the characteristics exhibited over a long period of time and to a marked degree. Required	Yes or No
Check all boxes that apply:	Options include: An inability to learn that cannot be explained by intellectual, sensory, or health factors. An inability to build or maintain satisfactory interpersonal relationships with peers and teachers. Inappropriate types of behavior or feelings under normal circumstances. A general pervasive mood of unhappiness or depression. A tendency to develop physical symptoms or fears associated with personal or school problems.
Explain or reference data or evidence:	N/A
The disability category of Emotional Disability does not apply if characteristics that the student displays are primarily the result of cultural, or language differences or both. (check to confirm that this is true).	N/A
The characteristic(s) of an emotional disability are adversely affecting the student's educational (academic achievement and/or functional) performance. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of an Emotional Disability that adversely affects educational performance.	N/A
The student has educational needs that require specially designed instruction to participate and perform in the educational setting. Required	Yes or No
List and describe area(s) of educational needs:	N/A

Criteria for Hard of Hearing (HH)

Field	Validation
The student has a hearing loss (permanent or fluctuating), averaging 26 to 70 decibels(DB) in the speech frequencies (500Hz to 4000Hz). Required	Yes or No
A current hearing evaluation was conducted by an audiologist to determine hearing loss. Required	Yes or No
Explain or reference data or evidence:	N/A
The hearing loss impairs the student’s auditory processing of linguistic information through hearing, with or without amplification. Auditory processing means the ability to listen and understand spoken messages within the school environment. Required	Yes or No
The hearing loss is adversely affecting educational (academic achievement and/or functional) performance. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of Hard of Hearing that adversely affects the student’s educational performance.	N/A
The student has educational needs that require specially designed instruction to participate and perform in the educational setting. Required	N/A
List and describe area(s) of educational needs:	N/A

Criteria for Intellectual Disability

Field	Validation
The student has significantly impaired intellectual functioning: At least 2.0 standard deviations below the mean, on an individually administered, standardized measure of intellectual functioning with consideration given to the standard error of measurement for the assessment. Required	Yes or No
Significantly impaired adaptive behavior: At least 2.0 standard deviations below the mean on an individually administered standardized instrument or professionally recognized scales of adaptive behavior.* Required	Yes or No
There is a developmental history (birth through 18) that indicates significant impairment in intellectual functioning and a current demonstration of a significant impairment is present. Required	Yes or No
Explain or reference data or evidence:	N/A
The student’s intellectual disability and adaptive skill deficits are adversely affecting the student’s educational (academic and/or functional) performance. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of an Intellectual Disability that adversely affects the student's educational performance.	N/A
The student has educational needs that require specially designed instruction to participate and perform in the educational setting. Required	Yes or No
List and describe area(s) of educational needs:	N/A

Criteria for Multiple Disabilities (MD)

Before completing the Multiple Disabilities (MD) Criteria Worksheet, the worksheets for the other eligible criteria's need to be completed.

Field	Validation
There is documentation of the below evidence.	Yes or No
All must be checked:	Options include: Sub average general intellectual functioning three or more standard deviations below the mean Deficits in at least two adaptive skill areas Sub average intelligence and adaptive skill deficits were manifested during the developmental period
Student is eligible under one or more of the following categories and worksheets are included.	Yes or No
Check all that apply:	Options include: Autism Spectrum Disorder Deaf Hard of Hearing Orthopedic Disability Other Health Disability Visual Disability including Blindness
Assessment materials do not conclusively demonstrate eligibility criteria are met, but the team and parent documents the existence of concomitant disability.	Yes or No
Statement of concomitant disability and method used to determine eligibility:	N/A
Explain or reference data or evidence:	N/A
The student’s multiple disabilities adversely affect the student’s educational (academic and/or functional) performance. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of Multiple Disabilities that adversely affect the student's educational performance.	N/A
The student has educational needs that require specially designed instruction to participate and perform in the educational setting. Required	Yes or No
List and describe area(s) of educational needs:	N/A

Criteria for Disability Category Orthopedic Disability (OD)

Field	Validation
There is documentation of an Orthopedic Disability Required	Yes or No
Explain or reference data or evidence:	N/A
The student’s orthopedic disability adversely affects the student’s educational (academic and/or functional) performance. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of an Orthopedic Disability that adversely affects the student's educational performance.	N/A
The student has educational needs that require specially designed instruction to participate and perform in the educational setting. Required	Yes or No
List and describe area(s) of educational needs:	N/A

Criteria for Other Health Disability (OHD)

Field	Validation
The student has a health problem that is listed below:	Yes or No
Select one or both	Options include: Chronic (long-standing, continuous over time, or recurring frequently) Acute (severe or intense)
A medically fragile condition such as but not limited to asthma, attention deficit disorder or attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, sickle cell anemia, Tourette syndrome	Yes or No
The student has one or more of the limits listed below:	Yes or No
Check any that apply:	Options include: limited strength limited vitality limited alertness, (including heightened alertness to environmental stimuli with respect to the educational environment)
Explain or reference data or evidence:	N/A
The characteristics of the student’s Other Health Disability adversely affect educational (academic and/or functional) performance. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of an Other Health Disability that adversely affects the student's educational performance.	N/A
The student has educational needs that require specially designed instruction to participate and perform in the educational setting. Required	Yes or No
List and describe area(s) of educational needs:	N/A

Criteria for Specific Learning Disability (SLD)

Field	Validation
Section I. Eligibility Considerations
The student does not achieve adequately for the student’s age or to meet Hawaii approved grade-level standards in one or more of the following areas, when provided with learning experiences and instruction appropriate for the student’s age or Hawaii approved grade-level standards. Required	Yes or No
Check all that apply:	Options include: Oral Expression Basic Reading Skills Math Calculation Fluency Condition Listening Comprehension Reading Fluency Math Problem Solving Written Expression Reading Comprehension
The student demonstrates a severe discrepancy between actual achievement and intellectual ability by a difference of at least 1.5 standard deviations in one or more of the following areas: Required	Yes or No
Check all that apply:	Options include: Oral Expression Basic Reading Skills Math Calculation Fluency Condition Listening Comprehension Reading Fluency Math Problem Solving Written Expression Reading Comprehension
The student does not make sufficient progress to meet age or Hawaii approved grade-level standards in one or more of the areas, selected using a process based on the student’s response to scientific, research based interventions. Required	Yes or No
The student exhibits a pattern* of strengths and weaknesses in performance achievement or both relative to age, Hawaii approved grade level standards, or intellectual development relevant to the identification of a specific learning disability using appropriate assessments. Required	Yes or No
Explain or reference data or evidence:	N/A
Section II. Observation Requirement
There is documentation that the student was observed in the student’s learning environment to document the student’s academic performance and behavior in the area of difficulty. Required	Yes or No
One area must be checked:	Options include: An observation of the student’s academic performance in the area(s) of difficulty was completed before the student was referred for an evaluation. An observation of the student’s academic performance in the area(s) of difficulty was completed after the student was referred. For a student less than school age or out of school, the student was observed in an environment appropriate for the student of that age.
Explain or reference data or evidence:	N/A
Section III. Educational Performance
The specific learning disability is adversely affecting the student's educational (academic and/or functional) performance. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Section IV. Educationally Relevant Medical Findings
There are educationally relevant medical findings. Required	Yes or No
Explain or reference data or evidence:	N/A
Section V. Appropriate Instruction
Prior to or as a part of the referral process the team considered data to ensure that underachievement was not due to a lack of instruction in reading or math. Required	Yes or No
Each area must be checked:	Options include: the student was provided appropriate instruction in regulation educational settings, delivered by qualified personnel there is data based documentation of repeated assessments of achievement at reasonable intervals, reflecting formal assessment of student progress during instruction and data was provided to student's parents
Explain or reference data or evidence:	N/A
Section VI. Exclusionary Statement
The student does not have learning problems that are primarily the result of: 1. a visual, hearing, or motor impairment, 2. an intellectual disability, 3. an emotional disability, 4. cultural factors, an environmental or economic disadvantage, or 5. Limited English proficiency. Required	Yes or No
Section VII. Disability Category Criteria Determination
There is documented evidence of a Specific Learning Disability that adversely affects the student's educational performance.	N/A
Assurances	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of a Specific Learning Disability that adversely affects the student's educational performance.	N/A
Section VIII. Educational Needs
The student needs specially designed instruction to participate and perform in the educational setting. Required	Yes or No
List and describe area(s) of educational needs:	N/A

Criteria for Speech or Language Disability (SoLD)

Field	Validation
The student does not demonstrate Limited English Proficiency. Required	Yes or No
The student’s age, culture, language background, home language, and dialect were considered when determining a speech or language disability. Required	Yes or No
The student was observed in the natural environment using communication skills in interpersonal interactions and learning activities that includes peers who are typically developing and/or familiar adults. If observation in these settings is not possible, observation in an alternative setting or observing via digital recordings is permitted (include dates and settings of observations): Required	Yes or No
List Observations:	N/A
Data was gathered from multiple sources. Required	Yes or No
Explain or reference data or evidence:	N/A
There is documentation of a significant discrepancy from typical communication skills in at least one of the speech areas listed below. Required	Yes or No
Check all that apply:	Options include: Articulation or phonological condition or both Voice condition Fluency condition
There is documentation of a significant discrepancy from typical communication skills in the area of language. Required	Yes or No
All must be checked:	Options include: Data was collected from multiple sources A discrepancy of 1.5 standard deviations between the student's estimated cognitive level and performance on at least wo standardized measures in the areas listed below:
At least one area must be checked:	Options include: Semantics Grammar
Explain or reference data or evidence:	N/A
The speech or language disability is adversely affecting the student's educational (academic achievement or functional) performance. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of a Speech or Language Disability that adversely affects educational performance.	Yes or No
The student needs specially designed instruction to participate and perform in the educational setting. Required	Yes or No
List and describe area(s) of educational needs:	N/A

Criteria for Traumatic Brain Injury (TBI)

Field	Validation
There is medical evidence of an acquired injury caused by an external physical force resulting in total or partial functional disability or psychosocial impairment, or both. Required	Yes or No
There is medical evidence that the injury resulted in total or partial functional disability or psychosocial impairment, or both. Required	Yes or No
Explain or reference data or evidence:	N/A
The term Traumatic Brain Injury does not apply if the student's brain injuries are congenital or degenerative, or induced by birth trauma.	N/A
The traumatic brain injury (either open or closed) results in impairments in one or more areas such as those listed below. Required	Yes or No
At least one area must be checked:	Options include: Cognition Language Memory Attention Reasoning Abstract Thinking Judgement Problem Solving Sensory, Perceptual & Motor Abilities Psychosocial Behavior Physical Functions Information Processing Speech
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of a Traumatic Brain Injury that adversely affects educational performance.	N/A
The student has educational needs that require specially designed instruction to participate and perform in the educational setting. Required	Yes or No
List and describe area(s) of educational needs:	N/A

Criteria for Visual Disability including Blindness (VDB)

Field	Validation
Partially sighted: The student’s visual acuity is 20/70 to 20/200 in the better eye and with the best correction. Required	Yes or No
Blind: The student’s visual acuity is 20/200 in the better eye and with the best correction, or less, the subtended visual field of less than 20 degrees, regardless of central visual acuity. Required	Yes or No
Progressive visual impairment: The student has a progressive visual impairment, such as retinitis pigmentosa that will lead to eventual visual disability. Required	Yes or No
Explain or reference data or evidence:	N/A
The vision impairment is adversely affecting educational (academic achievement and/or functional) performance. Required	Yes or No
Area(s) impacted include:	N/A
Explain or reference data or evidence:	N/A
Assurances: The factors in determining if the student is a student with a disability is not based on:	Options include: Lack of appropriate instruction in reading, including the essential components of reading instruction (i.e. explicit and systematic instruction in phonemic awareness, phonics, vocabulary development, reading fluency including oral reading skills, and reading comprehension strategies) Lack of appropriate instruction in math Limited English proficiency (All assessments, materials and/or strategies used, considered cultural and linguistic differences and were used to measure evidence of a disability not English language skills.)
There is documented evidence of a Visual Disability including Blindness that adversely affects the student’s educational performance.	N/A
The student has educational needs that require specially designed instruction to participate and perform in the educational setting. Required	Yes or No
List and describe area(s) of educational needs:	N/A

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Evaluation Team Information

The Evaluation Team Information editor lists each member of the student's evaluation team and whether they agreed with the result of the evaluation.

The Team Member list is based on the Team Members tool. This editor is only available when Specific Learning Disability is a selected checklist on the Eligibility Checklist editor, as this prints at the end of that specific document.

Evaluation Team List Screen

Column Name	Description
Padlock Icon	The user currently working on the record.
Team Member	The name of the team member.
Title/Position	The role of the team member.
Agreed with Report	Indicates the team member agrees or disagree with the evaluation report.

Evaluation Team Detail Screen

Evaluation Team Information Detail

Field	Description	Validation
Team Member	The name of the Team Member.	This pulls from the Team Members tool.
Title/Position	The role of the team member	Read-only. This pulls from the Team Members tool.
Agreed with Report	Indicates the team member agrees or disagree with the evaluation report. Options include Yes or No.	N/A
Dissenting member(s) statement (specific to only SLD eligibility) *Required	A text area used to document the dissenting reason.	*This field is required to complete the editor. It also only displays when No is selected above.

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Eligibility Decision

The Eligibility Decision editor indicates if the student is eligible for special education services, the areas of eligibility, and the reasons that led to this conclusion.

Eligibility Decision Editor

Field	Description	Validation
The child is eligible for Special Education and Related Services. Required	Indicates if the student is eligible to receive special ed and/or related services.	Required in order to complete the editor. If Yes is selected, the rest of the editor required logic displays. If No is selected, the rest of the editor required logic disappears.
Eligibility Category Required	The area of eligibility. Options include: Autism Spectrum Disorder Deaf Deaf-Blindness Developmental Delay (Age 3 - 5) Development Delay (Age 6 - 8) Emotional Disability Hard of Hearing Intellectual Disability Multiple Disability Orthopedic Disability Other Health Disability Specific Learning Disability Speech or Language Disability Traumatic Brain Injury Visual Disability incl. Blindness	This is required in order to save the editor.
Previous Eligibility Category	If applicable, the previous eligibility of the student. Options include: Autism Spectrum Disorder Deaf Deaf-Blindness Developmental Delay (Age 3 - 5) Development Delay (Age 6 - 8) Emotional Disability Hard of Hearing Intellectual Disability Multiple Disability Orthopedic Disability Other Health Disability Specific Learning Disability Speech or Language Disability Traumatic Brain Injury Visual Disability incl. Blindness	N/A
Deaf	Indicates this is a secondary disability for the student.	Yes or No
Hard of Hearing	Indicates this is a secondary disability for the student.	Yes or No
Deaf-Blind	Indicates this is a secondary disability for the student.	Yes or No
Visual Impairment including Blindness	Indicates this is a secondary disability for the student.	Yes or No
Evidence of a Disability	A text field used to document evidence of the student's disability.	N/A

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Prior Written Notice

The Prior Written Notice editor is used to document meeting notices provided to the parent/guardian.

Prior Written Notice List Screen

Column Name	Description
Padlock Icon	The user currently working on the record.
Meeting Information	The type of meeting.
Date Provided to Parents	The date the notice was provided to the parent/guardian.
Print in Evaluation	Indicates this record will print on the Evaluation.

Prior Written Notice Detail Screen

Prior Written Notice Detail

Field	Description	Validation
Print in Evaluation	Indicates this record will print on the Evaluation.	N/A
Meeting Information	The type of meeting. Options include: Evaluation Process = Evaluation 504 or IDEA Eligibility = Eligibility Educational Plan / Program Development = IEP Discipline = Discipline	Options available are pulled from the Conference Actial > Conference Purpose/Actual Conference Date fields.
Date provided to parents Required	The date the notice was given to the parent/guardian.	N/A
Admin / Designee	Indicates who the Admin Designee was for the associated meeting if there was one.	Read only and pulls from the Conference Actual > Designee for Admin.
Description of proposed or refused action:	A text field used to document the propsed or refused action.	N/A
Explanation of why the action is proposed or refused:	A text field used to document why the action is proposed or refused.	N/A
Description of other options considered:	A text field used to describe other options considered.	N/A
Reasons these options were rejected:	A text field used to describe why these options were rejected.	N/A
Description of the evaluation procedures, tests, records, or reports used as a basis for the proposed/refused action:	A text field used to document the evidence used as a basis for the action.	N/A
Other relevant factors:	A text field used to document any other relevant factor.	N/A

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Initial Provision of SPED & Related Services

The Initial Provision of SPED & Related Services editor is used to document an initial provision sent to the parent/guardian.

Initial Provision of Special Education and Related Services Editor

Field	Description	Validation
Provided to Parent Date Required	The date this information was provided to the parent/guardian.	N/A
Contact Efforts This table is read only and displays the following columns: Contact Date Contacted By Contacted Method Contact Name All of these read only values come from the user selecting the "New" button and entering information on a side panel recording what Contact Efforts were made.
Contact Date	The date the parent/guardian was contacted.	N/A
Contacted By	The person who reached out to the parent/guardian.	N/A
Contact Method	The manner in which the parent/guardian was contacted. Options include: Telephone Personal Contact Regular Mail Return Receipt Requested Personally Delivered E-mail Fax	Options available are hard coded.
Contact Name	The name of the parent/guardian.	N/A
Relationship to Student	The relationship of the person to the student.	N/A
Outcome	The outcome of the contact attempt.	N/A
Contact Results
Consent Given	The parent/guardian's consent.	Yes or No
Consent Form Signed Date	The date the consent form was signed.	N/A
School Received Consent Form Date	The date the school received the consent form.	N/A
Name of Person Signing Consent Form	The name of the person who signed the consent form.	N/A
Revocation	Indicates consent was revoked.	N/A
Revocation Form Signed Date	The date consent was revoked.	* The field is required and only displays when the Revocation checkbox is marked.
Name of Person Signing Revocation Form	The name of the person who signed the revocation form.	* The field is required and only displays when the Revocation checkbox is marked.
School Received Revocation Form Date	The date the school received the revocation form.	* The field is required and only displays when the Revocation checkbox is marked.
Consent Revocation Reason	The reason for the consent revocation.	* The field is required and only displays when the Revocation checkbox is marked.

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Evaluation (Hawaii) [.2211 - .2231]

Editor Home

General Evaluation Information

Editor Types

Padlock Icon

Template Banks

Editors

Evaluation Status

Enrollment Information

Student Information

Parent/Guardian Information

Conference Announcement

Conference Announcement List Screen

Conference Announcement Detail Screen

Conference Notification

Conference Notification List Screen

Conference Notification Detail Screen

Conference Actual

Conference Actual List Screen

Conference Actual Detail Screen

Consent for Assessment

Assessment Report

Assessment Report List Screen

Assessment Report Detail Screen

Academic

Cognitive

Emotional Behavioral

Multi-Disciplinary

Observation

Occupational Therapy

Physical Therapy

Speech and Language

Reason for Referral

Summary and Interpretation of Evaluation Data

Exclusionary Factors

Eligibility Criteria Checklist

Eligibility Criteria List Screen

Eligibility Criteria Detail Screen

Criteria for Autism Spectrum Disorder (ASD)

Criteria for Deaf

Criteria for Deaf-Blindness (D-B)

Criteria for Developmental Delay 3-5 (DD 3-5)

Criteria for Developmental Delay 6-8 (DD 6-8)

Criteria for Emotional Disability (ED)

Criteria for Hard of Hearing (HH)

Criteria for Intellectual Disability

Criteria for Multiple Disabilities (MD)

Criteria for Disability Category Orthopedic Disability (OD)

Criteria for Other Health Disability (OHD)

Criteria for Specific Learning Disability (SLD)

Criteria for Speech or Language Disability (SoLD)

Criteria for Traumatic Brain Injury (TBI)

Criteria for Visual Disability including Blindness (VDB)

Evaluation Team Information

Evaluation Team List Screen

Evaluation Team Detail Screen

Eligibility Decision

Prior Written Notice

Prior Written Notice List Screen

Prior Written Notice Detail Screen

Initial Provision of SPED & Related Services

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