Special Education Report

SPECIAL EDUCATION REPORT

Student Information

Student Name:

Date of Birth:   Student ID:

Referral and Assessment Overview

Referral Date:   Referral Source:

Assessment Instruments and Results

Instruments administered (check all that apply):

Cognitive assessment    Academic achievement tests    Speech-language evaluation

Occupational therapy assessment    Behavioral/social-emotional assessment    Classroom observations

Eligibility Determination

Eligibility Status: Eligible    Not eligible

Disability Categories (check all that apply):

Specific Learning Disability    Other Health Impairment    Speech/Language Impairment

Autism    Intellectual Disability    Emotional Disturbance

Date of Eligibility Determination:

Present Levels of Academic Achievement and Functional Performance (PLAAFP)

Strengths, Needs, and Impact

Annual Goals and Short-Term Objectives

Provide measurable annual goals with criteria for mastery and methods for monitoring progress. Include up to three representative goals below.

Special Education Services, Supplementary Aids, and Program Placement

List recommended services, frequency, provider, start date, and location. Include accommodations, related services, and assistive technology.

Start Date:   Location/Setting:

Start Date:   Location/Setting:

Least Restrictive Environment

Placement recommendation (check all that apply):

Regular education classroom with supports    Resource room services    Self-contained special education classroom

Homebound or hospital instruction    Residential placement    Other

Behavioral Considerations

Behavior Intervention Plan required: Yes    No

Transition Planning (if applicable)

Student age 14 or older (or as required by local policy): Yes    No

Parent / Guardian Input and Procedural Notices

The evaluation documented in this report reflects consideration of records, observations, assessment data, and parent/guardian input. The team considered whether the student’s academic and functional needs are primarily due to lack of appropriate instruction or other factors. This determination is made in accordance with applicable special education law and local policy. Signatures below indicate that the contents of this report were reviewed and discussed with the parent/guardian or adult student; signature does not by itself constitute consent for placement or services unless otherwise indicated on required consent forms.

Report Completed Date:

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