Lafourche Parish Schools Pupil Appraisal Services Multidisciplinary Evaluation Report

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Dec 11, 2013 (4 years and 21 days ago)

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Autism Initial Evaluation


1

Name:


Case No.:








08/2013



Lafourche Parish Schools

Pupil Appraisal Services

Multidisciplinary Evaluation Report


Disseminated to Supervisor of Special Education

on

Click here to enter a date.




Name:


Parent/Guardian:


Case #:


Address:


DOB:


CA:




Race:

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item.

Sex:

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Phone #:



Louisiana
School District:

Lafourche Parish

School:

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Grade:


Date Evaluation Coordinator Assigned
:


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Teacher:



P
RIMARY
E
XCEPTIONALITY
:

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(
F
or
Multiple Disabilities
, identify:
(Concomitant impairments qualifying under:

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;
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)

O
THER
:

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; (
Delete
extra drop down boxes if not needed.
)
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;


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I
MPAIRMENT
(S) OR
C
ONDITION(S)
:






A
DDITIONAL

S
ERVICES

N
EEDED
:


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; (
Delete extra drop downs if not needed.
)
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;

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;
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;

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;
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QUALIFIES FOR SPECIAL EDUCATION
SERVICES
:


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The Evaluation Coordinator has rated the factors that may affect the reliability of the evaluation for the total
evaluation process.



Rating Scale:

1 → No interference

2 → Little interference

3 → Some interference


4 → Significant interference


Factor

Rating

Comments

/
Additional Information
*

A. Communication Barrier



B. Environmental Conditions



C. Rapport



D. Motivation



E. Length of Examination



F. Race



G. Sex




(
*
a
dditional information

deemed necessary and included in body of report
)


Autism Initial Evaluation


2

Name:


Case No.:








08/2013

REASON FOR REFERRAL:


Firstname was referred for evaluation by the School Building Level Committee (SBLC) to consider eligibility
for Special Education services.
IF APPLICABLE:

A parent/guardian request f
or evaluation had been
submitted.

OR

Firstname was referred by the School Building Level Committee (SBLC) for an individual evaluation.
Firstname was receiving services in the state of
Choose an item.

under

the exceptionality of __ due to
impairments/conditions including __. Firstname is currently receiving services in Lafourche Parish on an
interim basis, pending completion of a Louisiana evaluation.


SCREENING RESULTS:
(copy and paste this check where n
eeded



)








Date



At
-
Risk


Adequate for

Evaluation Purposes

Vision:


Click here to enter a date.







Gross Motor:


Click here to enter a date.







Social/Emotional/Behavioral:


Click here to enter a date.







Educational:


Click here to enter a date.






Hearing Screening/Assessment:

Screening results indicated no hearing concerns.

OR

Results of the hearing screening indicated a need for further assessment (i.e., were not definitive, failed, unable
to be conditioned to testing). A referral was made to the Lafourche Parish Audiology Department. Results of
the
Audiological Assessment

ar
e found within the body of this report.
OR

Results of the
Audiological
Assessment
conducted on
Click here to enter a date.

r
evealed __.


Sensory Processing Screening
/Assessment and Fine Motor Screening/Occupational Therapy Assessment
:

A referral was made to an Occupational Therapist to assess not only motor difficulties but also sensory
processing difficulties including visual symptoms, auditory symptoms, tactile symptoms, vestibular (balance)
symptoms, olfactory (smell) and gustatory (
taste) symptoms, proprioceptive (movement) symptoms, motor
planning difficulties, and attention/arousal difficulties. Results of the
Occupational Therapy Assessment

are
found within the body of this report.


IF APPLICABLE

Health Screening:


Results of th
e health screening indicated a need for further health assessment by the School Nurse. After a
review of medical information rec
eived, it was determined that an Individual
Health Plan
(IHP)
will be
developed by the School Nurse.

OR

After

a review of medical information received, it was determine
d that
Firstname does not require a
n Individual Health

Plan
(IHP)
at this time.


Speech/Language Screening/Assessment:

A referral was made to the Speech/Language Pathologist of the school. Resul
ts of the
Speech/Language
Assessment

are found within the body of this report.


Autism Initial Evaluation


3

Name:


Case No.:








08/2013

OR

Due to the student’s non
-
verbal means of communication, an Augmentative/Alternative Communication
Assessment was also conducted by the Speech/Language Pathologist to determin
e needs and modes of
communication. Results are found within the
Speech/Language Assessment
.



Occupational Therapy Screening/Assessment:

A referral was made to the Occupational Therapist of the school to address
S
ensory
P
rocessing

and
Fine Motor

difficul
ties and document all observed symptoms.



Assistive Technology Screening:

No assistive technology concerns noted.

OR

Assistive technology
needs should be considered due to

concerns noted in __.


Orientation and Mobility Screening:

No orientation and
mobility concerns noted.

OR

Orientation and mobility services are deemed necessary due to __.


EDUCATIONAL HISTORY AND INTERVENTIONS:

Review of Grade Progression:

A review of Firstname’s cumulative records revealed he/she received Early Steps services, received
Choose an
item.

services through the pre
-
school program, attended pre
-
kindergarten, kindergarten, was retained in __
grade(s), and is currently enrolled in

the __ grade at the initiation of this evaluation.


Louisiana Literacy Program (LLP)
:

Firstname’s universal dyslexic screening using the
Louisiana Literacy Profile (LLP)

was completed in 20__
while enrolled in the __ grade. Results indicated Firstname
demonstrated __ out of 6 characteristics of dyslexia
which does/does not indicate concern.
(Any student receiving 5 or more fails out of 6 possible passes is at risk
for Dyslexia.
)


OR


Firstname’s universal dyslexic screening using the
Louisiana Literacy

Profile (LLP)

was completed in 20__
while enrolled in the __ grade.


INCLUDE BAR GRAPH HERE (OPTIONAL)


Firstname was able to exhibit behavior regularly in __% of objectives assessed. He/She was making progress
with __%. He/She had not yet exhibited _
_% of the LLP objectives.



Autism Initial Evaluation


4

Name:


Case No.:








08/2013

Objectives of concern:
OPTIONAL:

Firstname’s early literacy skills will be reassessed and documented at the
end of the 20__
-
20__ school year.


Dyslexia screening results indicated Firstname demonstrated __ out of 6 characteristics of dyslexia which
does/does not indicate concern.
(Any student receiving 5 or more fails out of 6 possible passes is at risk for
Dyslexia.
)


OPTIONAL

Review of School
Building Level Committee (SBLC) pre
-
referral activities
:

Firstname’s case was discussed at
the following School Building Level Committee (SBLC)/Response to
Intervention (RTI) meetings:
(Include dates and recommendations.)



Click here to enter a date.

SBLC/RTI meeting reviewed/discussed/recommendations
(repeat to include all
meeting dates/data)





Firstname’s
Choose an item.

participated in the School Building Level Committee (SBLC).

OR

Firstname’s
Choose an item.

did

not participate in the School Building Level Committee (SBLC); however, contact
was made on
Click here to enter a date.

by means of __.


At the

Click here to enter a date.

SBLC meeting, the committee reviewed Firstname’s progress, interventions, and
g
rades. A review of Firstname’s previous interventions indicated intense, consistent assistance in the area of
reading skills: phonics, phonemic skills, site vocabulary, oral reading fluency, and comprehension skills.
AND/OR

A review of Firstname’s previ
ous interventions indicated intense, consistent assistance in the area of
math skills: math problem solving, numerical operations, and math fluency. The educational screening revealed
that Firstname did not make adequate progress despite interventions and

his/her progress compared to his/her
classroom peers was in the lower percentile of his/her __ grade class. Therefore, it was recommended to
proceed with a full evaluation due to academic concerns and lack of adequate progress in the RTI process.


Atte
ndance:

Firstname’s attendance for the 20__
-
20__ school year is considered to be satisfactory. As of
Click here to enter a
date.
, records indicated he/she accumulated __ early check
-
outs, __ tardies, __ excused absences, and __
unexcused absences.

OR

Firstname’s attendance for the 20__
-
20__ school year is considered to be unsatisfactory. As of
Click here to enter a
date.
, records indicated he/she accumulated __ early check
-
outs, __ tardies, __ excused absences, and __
unexcused absences. Parent rep
ort indicated that Firstname’s absence from school was due to __. (i.e.,
Firstname’s health. family problems which warranted caregiving away from home.) Parent reported that
Firstname’s absences were unavoidable and attempts were made during his/her absen
ces to make up work
missed. Firstname’s absences are not considered a primary factor contributing to his/her learning problems.


Discipline Records:


Autism Initial Evaluation


5

Name:


Case No.:








08/2013

As of
Click here to enter a date.
,

a review of Firstname’s Disciplinary Report revealed __ disciplinary infract
ions for
behaviors including __
. Of the referrals, __
resulted in
Suspension(s) out of school and __
resulted in
In
-
School
Suspension(
s). He/She was placed
at
the
North Positive

Action School Site (North P.A.S.S.), an alternative
educational program for suspended, expelled, and excluded students

__ times for a total of __ days.

This
placement is designed to allow students to continue their education in a strict, highly structure
d environment.


Report Card Grades:

A review of Firstname’s r
eport card grades
for past and current school years follows
:



PRE
-
KINDERGARTEN


20__
-
20__



AREA

1
st

MARKING
PERIOD

2
nd

MARKING
PERIOD

3
rd

MARKING
PERIOD

4
th

MARKING
PERIOD

Personal

and Social Development

Adjust to new situations, transitions





Participate in Classroom activities





Follow classroom rules





Follow classroom routines





Follow directions





Show responsibility for behavior





Share, cooperate,
respect others





Develop friendships with others





Health and Physical Development

Demonstrate basic gross motor skills





Demonstrate basic fine motor skills





Demonstrate self
-
help skills





Demonstrate cleanliness





English Language

Arts Development

Carry on a conversation about topic,
thought, or idea





Retell part of a story in sequence





Identify the front and back cover of a book





Recognize that print is read left to right and
top to bottom





Name at least 26 of the

52 letter is isolation





Recognize and produce rhyming
words/sounds





Recognize words with a common initial
(first) sound





Demonstrate writing skills





Use new vocabulary





Mathematics Development


Autism Initial Evaluation


6

Name:


Case No.:








08/2013

Count by ones to 20





Identify
numerals 0
-
10





Count a set of objects from 1
-
10 and
matches the correct numeral to the set





Compare sets of objects using
same/different and more/less/fewer





Recognize, copy, and extend patterns





Sort concrete objects by more than one
attribute





Name four basic shapes






* = Not Assessed, Y = Achieved, P = Progressing, N = No Evidence of Progressing





KINDERGARTEN


20__
-
20__


AREA

Mathematics

1
st

MARKING
PERIOD

2
nd

MARKING
PERIOD

3
rd

MARKING
PERIOD

4
th

MARKING
PERIOD

Counting and Cardinality

Count by ones to 100





Count by tens to 100





Count sets of 20





Write how many objects are in a set





Count forward from a given number to 100





Compare sets within 10 using
greater/less
than





Compare two written numbers (1
-
10)





Operations and Algebraic Thinking

Solve addition and subtract word problems
within 10.





Decompose (break apart) numbers to 10





Fluently add and subtract within 5





Determine the
number that makes 10 when
added to a given number





Numbers and Base Ten

Compose (put together) and decompose
(break apart) the numbers 11 to 19 into tens
and ones





Measurement and Data

Describe and compare objects by length or
weight





Classify (sort) and count objects within 10






Autism Initial Evaluation


7

Name:


Case No.:








08/2013

Geometry

Describe placement of objects using
potential words





Identify shapes as flat or solid





Flat Figures

Names: Square, circle, triangle, rectangle,
hexagon





Describe shapes of objects (#
of sides, # of
corners)





Solid Figures

Names: Cubes, cones, cylinders, spheres





* P = Progressing; Y = Achieved




AREA

Language Arts

1
st

MARKING
PERIOD

2
nd

MARKING
PERIOD

3
rd

MARKING
PERIOD

4
th

MARKING
PERIOD

Reading Foundations

Name

all uppercase/lowercase letters





Say the sounds of all letters





Follow words from left to right, page by
page





Recognize/produce rhyming words





Isolate and pronounce sounds in a c
-
v
-
c
word





Read high frequency sight words





Read
emergent reader text with purpose and
understanding





Reading Literature

Retell a familiar story





Identify the character, setting, and major
events





Identify the parts of a book (front cover,
back cover, title page)





Identify the role of an author and illustrator
of a story





Writing

Print all uppercase and lowercase letters





Write a sentence using capitalization and
punctuation





Name end punctuation





Spell
simple word phonetically





Use
drawings and words to respond to text






Autism Initial Evaluation


8

Name:


Case No.:








08/2013

Speaking and Listening

Share my thoughts, feelings, and ideas
clearly when I speak.





* P = Progressing; Y = Achieved


1st

THROUGH __ G
rade

(HISTORY
-

Change grade identified for years repeated. Copy
/paste
table if need more columns.)




SUBJECT

1
st

Grade

2
nd

Grade

3
rd

Grade

4
th

Grade

5
th

Grade

6
th

Grade

20__
-
20__

20__
-
20__

20__
-
20__

20__
-
20__

20__
-
20__


20__
-
20__


Reading







Language







Spelling







Math







Science







Social Studies







Social Living







P.E.







Art/Music







French







Days Absent








CURRENT REPORT CARD GRADES

-

__ Grade


SUBJECT

1
st

MARKING
PERIOD

2
nd

MARKING
PERIOD

3
rd

MARKING
PERIOD

4
th

MARKING
PERIOD

Reading





Language





Spelling





Math





Science





Social Studies





Social Living





P.E.





Art/Music





French





Days Absent







Review of Standardized Test S
cores:

After a thorough review of available cumulative
school
records for
Firstname
, there

were no standardized tests to
review.

OR

A review of available cumulative school records for Firstname revealed the following:


Autism Initial Evaluation


9

Name:


Case No.:








08/2013


Review of Standardized Test Scores:

A review of available cumulative school records for Skyler revealed the following:


DSC:
(Criterion Referenced, State Level Assessment)

The
Developmental Skills Checklist (DSC)

is a comprehensive checklist that evaluates a wide range of skills in
Pre
-
Kindergarten children. It measures language, mathematical concepts and operations, fine and gr
oss motor,
visual, memory, auditory skills, printing, writing, and social and emotional skills. Students are assessed three
times throughout the school year (Fall, Winter, and Spring). The following charts compare Firstname’s math
and reading scores to t
he average scores of his peers at
Choose an item.

School.



Mathematical Concepts and Operations



Pre
-
Reading



(
EDIT DATA
: Data currently in graph should be filled in with data specific to your student and his/her school
performance. To edit data in graphs, single click your curser within the graph. When the green “Chart Tools”
tab appears, click on the “Design” tab to ac
cess “Edit Data.” For more help manipulating the graph to fit your
data, refer to the “MASTERS Tips and How To’s” sheet.)


In the general educational curriculum, Firstname appears to be making
Choose an item.
progress in Mathematical
Concepts and Operati
ons. He/She scored __ in the Fall, __ in the Winter and __ in the Spring. The
Choose an item.

School Pre
-
Kindergarten mean scores were __ in the Fall, __ in the Winter, and __ in the Spring. Firstname
0
10
20
30
40
Fall
Winter
Spring
7

11

26

4

26

30

Firstname
Peers
0
20
40
60
80
100
Fall
Winter
Spring
23

36

59

7

32

94

Firstname
Peers

Autism Initial Evaluation


10

Name:


Case No.:








08/2013

(also) appears to be making
Choose an item.

progre
ss in Pre
-
Reading skills. He/She scored __ in the Fall, __ in the
Winter, and __ in the Spring. The
Choose an item.

School Pre
-
Kindergarten mean scores were __ in the Fall, __ in
the Winter, and __ in the Spring. Although Firstname is making
Choose an it
em.

progress in Mathematical
Concepts and Operations and Pre
-
Reading skills, his/her scores remain depressed compared to his peers.


AEPS, Level
I

and
II
: (
Criterion Referenced, State Entry/Exit Assessment and District Level Progress
Monitoring Assessme
nt)

The
Assessment Evaluation and Programming System for Infants and Children (AEPS) Level I

(birth to 3)
and
Level II
(age 3 to 6)

is an assessment and curriculum planning tool for children ages birth to 6. It identifies
the student’s current skill level
s in six areas of development (Fine Motor, Gross Motor, Adaptive, Cognitive,
Social
-
Communication, and Social). Results are as follows:



Assessment Evaluation and Programming System for Infants and Children (AEPS)

Area of
Development

Date

Date

Date


Date


Date


Date


Date

Fine Motor








Gross Motor








Adaptive








Cognitive








Social
-
Communication








Social










Overall Score










i
LEAP/LEAP
:

(
Criterion Referenced,
State Level Assessment)



i
LEAP

Date of
Testing:

Spring 20__

Grade

3


Area

Scaled Score (100
-
500)

Achievement Level

English/Language Arts


Choose an item.

Mathematics


Choose an item.

Science


Choose an item.

Social Studies


Choose an item.



LEAP

Date of Testing:

Spring

20__

Grade

4


Area

Scaled Score (100
-
500)

Achievement Level

English/Language Arts


Choose an item.

Mathematics


Choose an item.

Science


Choose an item.

Social Studies


Choose an item.



LEAP

Date of Testing:

Summer 20__

Grade

4



Autism Initial Evaluation


11

Name:


Case No.:








08/2013

Area

Scaled
Score

(100
-
500)

Achievement Level

English/Language Arts


Choose an item.

Math


Choose an item.



i
LEAP

Date of Testing:

Spring 20__

Grade

5


Area

Scaled Score (100
-
500)

Achievement Level

English/Language Arts


Choose an item.

Mathematics


Choose an item.

Science


Choose an item.

Social Studies


Choose an item.



i
LEAP

Date of Testing:

Spring 20__

Grade

6


Area

Scaled Score (100
-
500)

Achievement Level

English/Language Arts


Choose an item.

Mathematics


Choose an item.

Science


Choose an item.

Social Studies


Choose an item.



i
LEAP

Date of Testing:

Spring 20__

Grade

7


Area

Scaled Score (100
-
500)

Achievement Level

English/Language Arts


Choose an item.

Mathematics


Choose an item.

Science


Choose an item.

Social Studies


Choose an item.



LEAP

Date of Testing:

Spring

20__

Grade

8


Area

Scaled Score (100
-
500)

Achievement Level

English/Language Arts


Choose an item.

Mathematics


Choose an item.

Science


Choose an item.

Social Studies


Choose an item.



LEAP

Date of Testing:

Summer 20__

Grade

8


Area

Scaled
Score

(100
-
500)

Achievement Level

English/Language Arts


Choose an item.

Math


Choose an item.



i
LEAP

Date of Testing:

Spring 20__

Grade

9


Area

Scaled Score (100
-
500)

Achievement Level

English/Language Arts


Choose an item.

Mathematics


Choose an item.



Autism Initial Evaluation


12

Name:


Case No.:








08/2013

GEE:

(
Criterion Referenced,
State Level Assessment)



GEE

Date of Testing:

Spring

20__

Grade

10


Area

Scaled Score (100
-
500)

Achievement Level

English/Language

Arts


Choose an item.

Mathematics


Choose an item.



GEE

Date of Testing:

Spring

20__

Grade
11


Area

Scaled Score (100
-
500)

Achievement Level

Science


Choose an item.

Social Studies


Choose an item.


STAR

Reading/Math

(
Norm
-
Referenced
,
National Level Progress Monitoring Assessment
)
:


(add additional
rows to report

multiple administrations)



STAR Reading




Administration Date

Grade Equivalent

Percentile

Scaled Score

Click here to enter a date.









STAR Math




Administration
Date

Grade Equivalent

Percentile

Scaled Score

Click here to enter a date.





CHOOSE from DIBELS 6
th

Ed (below) or

DIBELS NEXT

(which follows)
:

Dynamic Indicators of Basic Early Literacy Skills, 6
th

Edition (DIBELS 6
th

Ed.
)

(Criterion
Referenced,
District

Level Progress Monitoring Assessment):

DIBELS 6
th

Ed.

is an individually administered standardized assessment of critical reading skills.


There are
seven different assessments, which include Initial Sound Fluency, Phoneme Segmentation Fluency, Le
tter
Naming Fluency, Nonsense Word Fluency, Oral Reading Fluency, Retel
l

Fluency, and Word Use
Fluency.


Assessments given depend on upon the grade the student is in.


DIBELS 6
th

Ed.

screening identifies three

levels of instructional recommendations:

Benchmark



The student assesses within the benchmark range.


No intervention is needed.

Strategic



The student assesses in the range that shows
Some R
isk

or
Emerging S
kills
.


Students need 10 to 20
minutes of “additional” intervention in specific areas
that need improvement.

Intensive



The student assesses in the range that shows
H
igh
R
isk

or
D
eficit

in skills.


Students need 30 or
more minutes of intensive intervention daily.


OPTIONAL:
Request
DIBELS Data System: Student History Report

and
DIBELS Ind
ividual Student
Performance Profile

from DIBELS contact at school and copy/paste into report
rather than filling in tables.



Autism Initial Evaluation


13

Name:


Case No.:








08/2013

Firstname was assessed on __/__/20__ in __ grade.


The following assessments were used: __.


No scores are
reported for __ as this/
these assessment(s) is/are not normed at this time. His/Her results are as follows:



DIBELS, 6
th

Ed.

Kindergarten



Fall

__/__
/
20__

Winter

__/__/20__

Spring

__/__/20__

Kindergarten
End of Year

AREA

SCORE

SCORE

SCORE

Expectation

Initial Sound Fluency




25

Letter Naming Fluency




40

Phoneme Segmentation Fluency




35


CLS

WRC

CLS

WRC


Nonsense Word Fluency






25 CLS

Word Use Fluency





*discontinued

TNT


Test Not Taken







DIBELS, 6
th

Ed.

1
st

Grade



Fall

__/__/20__

Winter

__/__/20__

Spring

__/__/20__

AREA

SCORE

SCORE

SCORE

Letter Naming Fluency




Phoneme Segmentation Fluency





CLS

WRC

CLS

WRC

CLS

WRC

Nonsense Word Fluency








Correct

Errors

Correct

Errors

Oral Reading Fluency






Retell Fluency




Word Use Fluency




*discontinued

TNT


Test Not Taken






DIBELS, 6
th

Ed.

2
nd


Grade



Fall

__/__/20__

Winter

__/__/20__

Spring

__/__/20__

AREA

SCORE

SCORE

SCORE


CLS

WRC





Nonsense Word Fluency






Correct

Errors

Correct

Errors

Correct

Errors

Oral Reading Fluency







Retell Fluency




Word Use Fluency




*discontinued





Autism Initial Evaluation


14

Name:


Case No.:








08/2013

TNT


Test Not Taken



DIBELS, 6
th

Ed.

3
rd


Grade



Fall

__/__/20__

Winter

__/__/20__

Spring

__/__/20__

AREA

SCORE

SCORE

SCORE


Correct

Errors

Correct

Errors

Correct

Errors

Oral Reading
Fluency







Retell Fluency




Word Use Fluency




*discontinued

TNT


Test Not Taken






DIBELS, 6
th

Ed.

4
th


Grade



Fall

__/__/20__

Winter

__/__/20__

Spring

__/__/20__

AREA

SCORE

SCORE

SCORE


Correct

Errors

Correct

Errors

Correct

Errors

Oral
Reading Fluency







Retell Fluency




*discontinued

TNT


Test Not Taken





Categories of “At Risk”, “Some Risk”, and “Low Risk” are used when progress toward an established benchmark is being
measured. Categories “Deficit”, “Emerging”, and
“Established” are used when the established final predicting benchmark for
the task is being measured.



DIBELS’ 6
th

Ed.

overall
instruct
ional recommendation was that Firstname

was “__


__”, which means that
he/she was
at/
below grade level and

does not need/

needs additional

remediation especially in the are
a(s) of __
.




OR

Dynamic Indicators of Basic Early Literacy Skills (DIBELS Next)

(Criterion
Referenced,
District

Level Progress Monitoring Assessment):

DIBELS Next

is an individually admin
istered standardized assessment of critical reading skills. There are
seven different assessments, which include First Sound Fluency, Letter Naming Fluency, Phoneme
Segmentation Fluency, Nonsense Word Fluency, Oral Reading Fluency, Retelling Fluency, and
Retell Quality of
Response. Different assessments are given depending on which grade the student is in.
His/Her results are as
follows:


DIBELS Next

screening identifies three levels of instructional recommendations:

At

or Above Benchmark Scores



The st
udent is likely to need
Core Support

to achieve subsequent early
literacy goals.

Below Benchmark Scores



The student is likely to need
Strategic Support

to achieve subsequent early literacy
goals.


Autism Initial Evaluation


15

Name:


Case No.:








08/2013

Well Below Benchmark Scores



The student is likely to need
Intensive Support

to achieve subsequent early
literacy goals.


OPTIONAL:
Request
DIBELS Data System: Student History Report

and
DIBELS Individual Student
Performance Profile

from DIBELS contact at school and copy/paste into r
eport
rather than filling in tables.


Firstname was assessed on __/__/20__ in __ grade.


The following assessments were used: __.


No scores are
reported for __ as this/these assessment(s) is/are not normed at this time. His/Her results are as follows:


Kindergarten (
20__
)

DIBELS Next


Score

Fall

Benchmark
Score


Score

Winter

Benchmark
Score


Score

Spring

Benchmark
Score

First Sound Fluency


10


30

N/A

Not Assessed

Letter Naming Fluency


No Criteria


No Criteria


No Criteria

Phoneme Segmentation
Fluency

N/A

Not Assessed


20


25

Nonsense Word Fluency

N/A

Not Assessed


17


28


1
st

Grade (
20__
)

DIBELS Next


Score

Fall

Benchmark
Score


Score

Winter

Benchmark
Score


Score

Spring

Benchmark
Score

Letter Naming Fluency


No Criteria

N/A

Not Assessed

N/A

Not Assessed

Phoneme Segmentation Fluency


40

N/A

Not Assessed

N/A

Not Assessed

Nonsense Word Fluency


27


43


58

Words Correct

N/A

Not Assessed


23


47

Accuracy

N/A

Not Assessed


78%


90%

Retell

N/A

No Criteria

N/A

No Criteria


15


2
nd

Grade (
20__
)

DIBELS Next


Score

Fall

Benchmark
Score


Score

Winter

Benchmark
Score


Score

Spring

Benchmark
Score

Nonsense Word Fluency


54

N/A

Not Assessed

N/A

Not Assessed

Words Correct


52


72


87

Accuracy


90%


96%


97%

Retell


16


21


27

Retell Quality
of Response

N/A

Not Assessed


2


2


3
rd

Grade (
20__
)

DIBELS Next


Score

Fall

Benchmark
Score


Score

Winter

Benchmark
Score


Score

Spring

Benchmark
Score

Words Correct


70


86


100

Accuracy


95%


96%


97%

Retell


20


26


30


Autism Initial Evaluation


16

Name:


Case No.:








08/2013

Retell Quality of Response


2


2


3

Daze


8


11

19



4
th

Grade (
20__
)

DIBELS Next


Score

Fall

Benchmark
Score


Score

Winter

Benchmark
Score


Score

Spring

Benchmark
Score

Words Correct


90


103


115

Accuracy


96%


97%


98%

Retell


27


30


33

Retell Quality of Response


2


2


3

Daze


15


17


24


DIBELS Next

overall instructional recommendation was that Firstname was __ for the __ benchmarking and __
for the __ benchmarking. This means that he/she was at grade level/below grade level and needs
additional/substantive intervention especially in the area(s) of
__.
(list areas student was intensive in)


Peer Comparison:

__
(Teacher’s Name)

__ grade class profile, using
DIBELS Next

results, places Firstname at the __ percentile of
the __ grade classroom population for Oral Reading Fluency.




(
EDIT DATA
: Dat
a currently in graph should be filled in with data specific to your student and his/her class
performance. To edit data in graph, single click your curser within the graph. When the green “Chart Tools” tab
appears, click on the “Design” tab to access “Ed
it Data.” For more help manipulating the graph to fit your data,
refer to the “MASTERS Tips and How To’s” sheet.)


His/Her

scores were well below the class average scores which were above the benchmark requirement of __
WPM. __ grade students will be exp
ected to read __ WPM at the
Choose an item.

benchmark assessment.

0
20
40
60
80
100
120
140
Peer 1 - 117
Peer 2 - 78
Peer 3 - 73
Peer 4 - 52
Peer 5 - 43
Peer 6 - 41
Peer 7 - 40
CLASS MEAN - 34.0
Peer 8 - 33
Peer 9 - 32
Peer 10 - 24
BENCHMARK GOAL - 23
Peer 11 - 22
Peer 12 - 22
Peer 13 - 21
Peer 14 - 18
Peer 15 - 16
Peer 16 - 16
Peer 17 - 14
Peer 18 - 10
Firstname - 7
Peer 20 - 0
At or Above Benchmark
Below Benchmark
Well Below Benchmark

Autism Initial Evaluation


17

Name:


Case No.:








08/2013

AND/OR

Universal screening data of class peers revealed Firstname fell at the __ percentile in
Choose an item.
. When
comparing Firstname’s
Choose an item.

scores

to the universal screening data, his/her score was considered
substantially depressed when compared to his/her same age peers and therefore is in need of intervention.
Firstname scored at
Choose an item.
. He/She ranked __ out of __ students. The clas
s mean was __.


It appears that Firstname is making inadequate progress in the general educational curriculum.

OR

In the general educational curriculum, Firstname appears to be making adequate progress in __; however, his/her
progress in __ is considered i
nadequate for __ grade.



Interventions:

The School Building Level Committee (SBLC) initiated data gathering for Firstname on __/__/20__. (He/She
had __ behavior infractions at that time.) The data collected was submitted to the School Building Level
Committee on __/__/20__. Concerns included __. A review of Tiered interventions follows:


T
ier

1

Classroom interventions attempted to address the referral concern included:

(Discuss intervention, length of time applied, and results
. Examples follow.
)



Restructuring the classroom/school environment



Peer buddy/assistance



Preferential seating



Allowing for breaks/movement in class (errand, classroom job, etc.)



Parent/Guardian contact (meetings, notes, phone calls, etc.)



Repeated directions



Directions given
in more than one way



Redirection



Use of close proximity and frequent eye contact



Use of calm neutral tone when speaking



Break down assignment into small manageable parts until completion



Frequent acknowledgment and praise of appropriate behavior observed



U
se of classroom visual aids (number line/manipulatives, math facts chart, spelling rules chart, etc.)



Allowed to subvocalize



Use of visual reminders



Classroom management procedures



School Wide Positive Behavior Intervention Support (SWPBIS)


Tier 2

Because there was continued concern in the area of __, further intervention was conducted to address this
specific area.

For the intervention,
Firstname received __ in addition to the Tier 1 intervention(s). The
intervention continued for __ weeks. Chan
ges or adjustments to the intervention included __. Progress was
monitored and reported to the care givers/parents through the Response to Intervention Committee. Results

Autism Initial Evaluation


18

Name:


Case No.:








08/2013

indicated that Firstname continued to exhibit difficulty in the area of __ and requ
ired more intensive
intervention.


(Discuss intervention, length of time applied, and results
. Examples follow.
)



Accommodations of student’s instructional program (instruction in lower level materials, one
-
to
-
one
instruction, small group instruction, chan
ge of program/class, etc.)



Behavior Support Plan (BSP) specific to student and behavior(s) of concern



Consultation Services



Group Counseling Support



School Wide Positive Behavior Intervention Support (SWPBIS) procedures individualized for the student


Tier

3

Firstname was moved to Tier 3 and provided with __. The intervention continued for __ weeks. Changes or
adjustments to the intervention included __. Firstname’s progress was monitored and reported to the care
givers/parents through the Response to In
tervention Committee.


(Discuss intervention, length of time applied, and results
. Examples follow.
)



Response to Intervention

(RTI) support given to student
(academics, behavior, speech)



Behavior Intervention Plan

(BIP) specific to student and behavior(
s) of concern



Individual Counseling Support



Individual
Check In/Check Out


IF APPLICABLE:

These programs, according to the State of Louisiana Department of Education and the
Florida Center for Reading Research have been shown to assist in the remediation of the five essential
components of reading: phonics, phonemic awareness, fluency, compreh
ension, and vocabulary.


There is evidence that Firstname has received intervention services specific to the identified referral concern(s).
Documentation indicated that intervention(s) was/were scientifically research
-
based, implemented with fidelity
as
documented by permanent products and occurred for a sufficient length of time. Firstname’s performance
was monitored at regular intervals and reports of his/her progress were provided to Firstname’s parents.


Results of the intervention(s) implemented to
address these academic concerns were analyzed and were found to
Choose an item.

OR

The intervention requirement was waived after a thorough review and analysis by the multi
-
disciplinary team
determined that previously conducted interventions met the requ
irements for evaluation.


Upon review of the intervention(s) implemented, it was determined that the intervention(s) was/were
specific to
the identified referral concern(s),
scientifically research
-
based; implemented with fidelity as documented by
permanent products;
implemented for a sufficient length of time;
progress monitored at reasonable intervals; and
Firstname

did/did not show adequate progress based on local or nation
al norms.



Progress Monitoring/Rate of Improvement:

Results of Firstname’s progress monitoring revealed that he/she is making less progress than students at the 10
th

percentile. His/Her Ratio of Deficiency is __. A Ratio of Deficiency greater than 2.0
is considered of concern.

Autism Initial Evaluation


19

Name:


Case No.:








08/2013

Compared to peer expectations for Rate of Improvement (ROI= __), Firstname’s Rate of Improvement is __
which is not adequate to close the achievement gap without sustained and substantial intervention. At this rate,
Firstname wo
uld require an additional __ weeks of intervention to reach the __ grade benchmark of __ at the end
of the year.

OR

Results

of Firstname’s progress monitoring revealed that his/her Rate of Improvement, __, was slightly greater
than that of his/her grade le
vel peers, __. His/Her rate is greater than that of students at the 10
th

percentile.
His/Her ratio of Deficiency, __, indicates progress faster than expected.


INSERT

Progress Monitoring GRAPH here and explain results
:


(Request
DIBELS Student
Progress
Monitoring Graph

from DIBELS contact at school and copy/paste into
report
.
)


Firstname’s performance on __ administered in his/her Tier 3 intervention is illustrated in the graph presented
above. His/Her performance during the intervention revealed a mean

of __% accuracy and a median of __%
accuracy with a goal of __% accuracy.


Results of Firstname’s progress revealed that his/her rate of progress relative to peers was not adequate to close
the achievement gap without sustained and substantial intervent
ion. Therefore, further educational assessment is
required and will be included within the contents of this report.


In reviewing the appropriateness and effectiveness of the documented intervention, the multidisciplinary team
determined that the interve
ntion met the requirements as stated in the Procedures for Evaluation.


REVIEW OF PREVIOUS E
VALUATIONS:

A review of previous evaluations

revealed the following:


Date of Evaluation
:

Type of Evaluation
:
Choose an item.

Primary
Exceptionality(ies)
:

Other(s):

Impairment(s) or Condition(s)
:

Additional Service(s)

Needed
:


(copy and paste as needed for each
additional
evaluation)


IF APPLICABLE:

Firstname was receiving special education services in the state of __ under the classification
of
__
.

Pending the results of this evaluation, an interim IEP was written based on records rec
eived from __
until
a determination of needs based on Louisiana criteria for classification could be made. Due to the specialized
and individual assistance that Firstn
ame has received in special education, no further intervention was deemed
necessa
ry. Firstname’s Individualized E
ducation Plan was written to address grade level standards and
systematically measured and documented to address areas of need.


Firstname wa
s privately evaluated by __ of __ on __/__/20__ due to __.


Autism Initial Evaluation


20

Name:


Case No.:








08/2013


Firstname was evaluated for 504 services on __/__/20__. Results of evaluation indicated a need for an
accommodation plan. He/She met criteria as having a disability (
state disability (ies)
) and

has been receiving
services through an Individual Accommodation Plan (IAP).

OR

Firstname did not meet the criteria as having a disability and will continue Tier 1/2 intervention(s) to address
concerns.


EVALUATION CONCERNS:

Ev
aluation concerns were noted in the areas of
(delete those that do not apply)

reading, math, other academic
difficulties, social/behavior problems, health problems, fine motor difficulties, gross motor difficulties, visual
difficulties, hearing difficultie
s, speech/language difficulties, suspected giftedness, suspected talent in
music/theatre/visual arts, and __. A parent/guardian request for evaluation was submitted.

OR

(copy and paste this check where needed



)


Reading



Visual Difficulties


Math



Hearing Difficulties


Other Academic Difficulties



Speech/Language Difficulties


Social/Behavior Problems



Giftedness


Health Problems



Talent in:


Motor Difficulties in:




Music



Fine Motor




Theatre



Gross Motor




Visual Arts


Parent
Request



Other:



Referral

Source Communication concerning specific problems or exceptional skills:

Communication with __, Firstname’s
Choose an item.
, on
Click here to enter a date.

revealed concerns with
Firstname’s __.
(expand on concerns here…)


(Include
this section if not previously reviewed in the optional section

Review of School Building Level
Committee (SBLC) pre
-
referral activities
.

found on Page 3.
)

Parent
/Guardian Participation in School Building Level Committee:

Firstname’s
Choose an
item.

participated in a School Building Level Committee (SBLC) meeting held on
Click here
to enter a date.

and gave permission to proceed with an individual evaluation indicating concern for Firstname in
the areas of __.

OR


Firstname’s
Choose an item.

did not participate in the School Building Level Committee meeting on
Click here to
enter a date.
; however, contact was made by phone to discuss the committee’s screening decision to refer
Firstname for an individual evaluation and obtain permission.

Contact with __ revealed concerns for Firstname
in the areas of __.


EVALUATION PROCEDURE
S
:
(Refer to specific descriptions found within document
.
)


Autism Initial Evaluation


21

Name:


Case No.:








08/2013

Ev
aluation procedures utilized during the course of this evaluation included the following:
(delete those
that do
not apply

or use box below
)

review of educational records, medical concerns, review of interventions attempted,
family interviews, teacher interviews, student interviews, curriculum based assessment, norm
-
referenced
diagnostic procedures, criterion
-
referenced diagnostic procedures, rating scales, student observations, and __.

OR

(copy and paste this check where needed



)


Educational Records



Student Observation


Medical Records



Curriculum Based Assessment


Interventions



Rating Scales


504 Determination



Norm
-
Referenced Diagnostic Procedures


Teacher Interview



Criterion
-
Referenced Diagnostic Procedures


Family Interview



Other:



Student Interview






TEACHER INTERVIEW:


In
formation obtained on
Click here to enter a date.

from __, F
irstname’s teacher for __, indicated that Firstname
demonstrates:

(copy and paste this check where needed



)



YES


NO

Appropriate behavior during teacher
-
directed instruction





Appropriate behavior during independent seatwork





Appropriate behavior during non
-
instructional time:


transition in class






transition between classes






R
ecess






L
unch






B
us





Appropriate peer interactions





Appropriate teacher/faculty interactions





Compliance to
school/classroom rules





Completion of class work





Completion of home work





Desire to work to best of ability





Participation in class discussions/activities





Prepared for class with proper books/materials





Positive attitude





Happy demeanor







Comments:



Areas of Concern:





Autism Initial Evaluation


22

Name:


Case No.:








08/2013

Instructional Methods:



Areas of Strength

and
Low Achievement
:

Relative academic strengths were noted in the areas of

__.



Relative academic difficulties
and low achievement
were noted in the areas
of __. Resulting support needs
include __.


Achievement Motivation Scale:


The
Achievement Motivation Scale

was completed by his/her teacher on
Click here to enter a date.

to address his/her
motivation. Results indicated
Choose an item.

motivation.

Choose an item.

results may be due to __.


F
urther assessment with Firstname
’s teacher(s) was/were conducted in order to determine if any disturbances
exist

that adversely affect his/her

educational performance:

Communication:





Social Interaction:




Restricted Interests/Stereotypical Behaviors:







STUDENT OBSERVATIONS IN CUSTOMERY ENVIRONMENTS:

An observation of
Firstname

was conducted on
Click here to enter a date.

at ___:___, while at home/attending _
_.
Firstname’s __
was/were present and they were engaged in __.
He/She
d
isplayed clean/neat body
-
care.

The
house/__ was clean, neat, comfortably cool/warm, well lit/poorly lit. Firstname was dressed comfortably for the
temperature and activities he/she engaged in.
Durin
g a
__

minute
unstructured observation of Firstname in this
setting, he/she was observed to (move about freely from one activity to the next/remain confined to designated
areas, respond appropriately/inappropriately to parent/__ requests, cooperate when re
directed, interact
appropriately/inappropriately with his/her peers/sibling(s), initiate/not initiate play, initiate/not initiate verbal
interaction, interact appropriately/inappropriately to parent/__ interaction, play appropriately/inappropriately
with t
oys, remain/not remain alert and attentive to the task at hand.) Time spent engaged in structured activities
revealed __. Time spent during unstructured activities revealed __.


An observation of
Firstname

was conducted on
Click here to enter a date.

a
t

__:__, during __. The class was
engaged in
center time/
independent seatwork activities
/
a teacher directed lesson on __. During a 15

minute
timed sample, utilizing 10 second

intervals, he/she was on
-
task during __

percent of the observed intervals as

Autism Initial Evaluation


23

Name:


Case No.:








08/2013

co
mpared to __

percent on
-
task behavior of __

randomly selected, same
-
sex peer(s).
Firstname

was
engaged
appropriately in his/her center activity/
seated appropriately and still in his/her designated seat with the proper
materials out. He/She was dressed to

code and displayed clean/neat body
-
care. He/She was alert and attentive,
cooperative, followed directions, and volunteered participation. It was noted that he/she was able to make timely
transition,
interact with peers, play cooperatively with peers, pl
ay appropriately with toys,
keep up with the pace
of the class,
interact with the teacher, follow the rules of the center,
and complete his/her work. He/She did not
seem distracted nor did he/she distract others. Off
-
task behavio
r included __. Firstname

was/was not able to
successfully participate in the class activity.


STUDENT INTERVIEW:

A student interview was attempted with Firstname; however, due to the young age/significant communication
problem(s)/or __ the interview was not possible to complete.


OR

A

student interview held on
Click here to enter a date.

with Firstname revealed


OR

(Alternate Student Interview)

A

student interview held on
Click here to enter a date.

with Firstname revealed:

(copy and paste this check where
needed



)


步猠獣s潯o


YES


SOMETIMES


NO

Feels successful in school







Indicates adequate peer relationships







Indicates adequate teacher relationships







Indicates adequate behavior at school







Indicates adequate behavior at home









Favorite subject is
:




Appears to have the most difficulty with:




Home activities include:




Future plans include:




When given three wishes, Firstname would like:

1.

2.

3.



Autism Initial Evaluation


24

Name:


Case No.:








08/2013

(
Additional comments
)




CURRICULUM BASED ASSESSMENT
:

(See attached
identification
of
ASSESSMENT
INSTRUMENTS/TECHNIQUES

that follow report findings.)

Curriculum Based Assessment (CBA) may be conducted in various areas, including reading, math, and written
language. CBA uses instructional materials actually used in Firstna
me’s classroom and school to determine at
what point a student reaches frustration and at what point is best for the student to learn without being
overwhelmed. Finding these levels helps determine if he/she is presently being taught at his/her most effec
tive
ability of achievement.


(
OPTIONAL
:
when educational assessments conducted
by
teacher
are used to
provide measures of student’s
performance in the general curriculum
)

A thorough review of the educational assessments conducted with Firstname throug
h his/her classroom and
school can be found within the
EDUCATIONAL HIS
T
ORY AND INTERVENTIONS

section of the report.


(
OPTIONAL:
when conducting

CBA alone or in addition to measures conducted by teacher
)

CHOOSE FROM INSTRUMENTS BELOW:

(
DST: R
eading/Math)

Curriculum Based A
s
sessment was utilized on
Click here to enter a date.

to
further assess

Firstname’s level of
performance in
the
academic areas

of reading and math
. The
Diagnostic Screening Test (DST: Reading)

and
(DST: Math)

were administered to Firstname. Results are as follows:


The
Diagnostic Screening Test: Reading (DST: Reading)

was utilize to determine instructional levels in the
area of reading. The
DST: Reading

is an untimed, norm
-
referenced reading assessment which

assesses Word
Reading, Passage Comprehension, Listening Comprehension, and Phonic and Word Attack proficiency. Word
Reading measures the student’s ability to read aloud words from a list of words that increase in difficulty. To
assess Passage Comprehensi
on, the student is required to read short passages and orally respond to orally
presented questions pertaining to the passage. Passages and comprehension questions are read aloud to the
student to obtain the Listening Comprehension score.


The Word Readi
ng list is grouped to assess and analyzing Phonic and Word Attack errors to obtained an
estimated phonic and word attack proficiency.


Grade Level Scores:

READING SKILL

GRADE EQUIVALENT

Comfort Reading Level


Instructional Reading Level


Frustrational
Reading Level


Comprehension Level


Listening Level


Phonic Level


Sight Level



Autism Initial Evaluation


25

Name:


Case No.:








08/2013

Phonic/Sight Ratio



Results of Firstname’s performance on the
DST: Reading

indicated that Firstname:

(delete those that do not
apply)



Reads best phonetically



Reads best
by sight alone



Reads best by combining phonics and sight methods



Requires instruction with word attack rules: (c
-
v/c, v/r, v/l, v
-
v, c
-
v
-
c, si.e)



Requires a listening comprehension skill building program



Requires a conventional vocabulary building program



The
Diagnostic Screening Test: Math (DST: Math)

was utilize to determine instructional levels in the area of
math. The
DST: Math

is an untimed, norm
-
referenced math assessment which assesses math calculation skills
(addition, subtraction, multiplication
, division) and specialized conceptual and computational skills (money,
time, percent, U.S. Measurement).


Grade Level Scores:

MATH SKILL

GRADE EQUIVALENT

CONSOLIDATION INDEX

Addition



Subtraction



Multiplication



Basic Computation Skills



Division



Money



Time. Percent



U.S. Measurement



Specialized Skills



Process



Sequencing




Firstname’s Consolidation Index Score of
__
suggest

__


.90
-
1.00 a good solid knowledge of the concept involved up to that grade equivalent
level.

.75
-
.89 gaps are present in the development sequence of that concept and a review of errors is warranted.


Below .75 an extremely spotty development sequence of skills relative to that concept area. A complete
remedial review of the whole

area should be undertaken.


Results of Firstname’s performance on the
DST: Math

indicated that Firstname requires skills building exercise
in the following areas:
(delete those that do not apply)



When to apply each basic process



Figuring next number in a

sequence



Completing simple computation (1+3=_, 4
-
2=_, 2X4=_)


Autism Initial Evaluation


26

Name:


Case No.:








08/2013



Utilizing more difficult number facts (582+317= _)



Preforming special manipulations: (carrying, re
-
grouping, remainders)



Computations with zeros understood (101
-
21= _)



Computation with decimals
understood (2.9+1=_)



Basic process in fraction computation (1/2 X1/2=_)



Manipulation in fractions: Reducing, common denominators, mixed fractions)


(Reading/Math Level Indicators)


Curriculum Based Assessment was utilized on
Click here to enter a date.

t
o further assess Firstname’s level of
performance in the academic areas of reading and math. The
Reading Level Indicator (RLI)

and
Math Level
Indicator (MLI)

were administered to Firstname. Results are as follows:


The
Reading Level Indicator (RLI)

was u
tilized to determine instructional levels in the area of reading. The
RLI

is an untimed, norm
-
referenced reading assessment which assesses both comprehension and vocabulary
development. To assess student comprehension, the student is required to determin
e the target word that is
missing from a sentence based on context, vocabulary knowledge, and parts of speech. This measures the
student’s ability to comprehend a sentence as a whole thought or unit. To assess vocabulary, the student is
required to read
a target word then determine the meaning of that word from a list of response choices. Results
of Firstname’s performance on the
RLI

indicated that his/her independent reading level is on a __ grade level.
Firstname’s instructional reading level was found to be on a __ grade level.


The
Math Level Indicator (MLI)

was utilized to determine instructional levels in the area of math. The

MLI

is
an untimed, norm
-
referenced math assessment which assesses both math calculation and math reasoning. Seven
Skill clusters are assessed on the
MLI
. They are: addition and subtraction of whole numbers, multiplication and
division of whole numbers,
operations with fractions, operations with decimals, algebra, word problems, and
concepts and communications. Firstname’s performance on the
MLI

indicated that Firstname is instructional on
a __ grade level in the area of math.


(
Review of Writing Sample
s
)

A

review of writing samples revealed that
Firstname is able to copy sentence starters and provide the missing
word/words to complete sentences. Firstname writes neatly. His/Her letter formation, letter size, and word
spacing is adequate. He/She is ab
le to copy correct capitalization of beginning words and provide the capital
letter for the first letter of his/her name. He is able to provide a period at the end of his sentence. Firstname
works slowly with writing tasks and rarely provides additional s
entences to elaborate beyond the starter
sentence. He/She will occasionally draw a picture to further describe the topic. Errors include spelling
difficulties ( ), omission of words, and sentence order errors. Firstname’s errors interfere with his/her
ability to
adequately conveying ideas.


PRESENT LEVEL OF ACADEMIC FUNCTIONING
:

(See attached
identification
of
ASSESSMENT
INSTRUMENTS/TECHNIQUES

that follow report findings.)

INSERT
write
-
up from
Educational Diagnostician



Autism Initial Evaluation


27

Name:


Case No.:








08/2013

IF APPLICABLE

PRESENT LEVEL OF ADAPTIVE
BEHAVIOR
FUNCTIONING:
(See attached identification of
ASSESSMENT INSTRUMENTS/TECHNIQUES

that follow report findings.)

INSERT
write
-
up from School Social Worker


PSYCHOLOGICAL ASSESSMENT:

(See attached
identification
of
ASSESSMENT
INSTRUMENTS/TECHNIQUES

that follow report findings.)


Family
/Care Giver Input:

In
formation obtained on
Click here to enter a date.

during an interview held with __, Firstname’s
Choose an item.

,
indicated that Firstname


F
urther assessment with Firstn
ame
’s parent/guardian was conducted in order to determine if any disturbances
exist

that adversely affect Firstname
’s educational performance:

Communication:




Social Interaction:




Restricted Interests/Stereotypical Behaviors:



Emotional and
Cultural/Linguistic Factors:

There were no emotional or cultural factors thought to be causing or contributing to Firstname’s problems.

OR

Emotional or cultural factors thought to be causing or contributing to Firstname’s problems include __.


D
evelopmental Scales:

The
Autism Diagnostic Observation Schedule
, Second Edition

(ADOS
-
2
)

is
a

semi
-
structured, standardized
observational assessment
of communication,
social interaction, play,
and
restricted and repetitive behavior
, used
with i
ndividuals
from one
-
year old with no speech to verbally fluent adults
.
The
ADOS
-
2

provides examiners a
means of presenting various activities that elicit behaviors directly related to symptoms associated with autism
spectrum disorder. Through observation, behaviors

are coded

to obtain
an overall score and its corresponding
range of concern when considering a diagnosis of autism
, autism
spectrum
, and non
-
spectrum. Autism and
autism spectrum classifications are
based on severity, with autism indicating more pronounce
d symptoms were
observed.
The
ADOS
-
2

focuses on functional domains: Communication, Reciprocal Social Interaction, and
Restricted and Repetitive Behaviors.
Firstname was administered

Choose an item.

Results from this

administration of the
ADOS
-
2

on
Click here to enter a date.

are

reviewed below.


SOCIAL AFFECT

(SA)


Autism Initial Evaluation


28

Name:


Case No.:








08/2013

Communication
:

Delete modules leaving only the one used:
(Toddler Module
, Module 1
)

Frequency of
spontaneous vocalization directed to others, pointing, gestures.
(Module 2
)


Pointing
;

descriptive, conventional,
instrumental, or informational gestures.
(Module 3)

Reporting of events; conversation, descriptive,
conventional, instrumental, or informational gestures.
(Module 4)

Stereotyped/idiosyncratic use of words or
phrases; convers
ation; descriptive, conventional, instrumental, or informational gestures; emphatic or emotional
gestures.


Firstname

was observed to


(U
se notes taken during
Observation

and reference behaviors from the
Part A.

Language and Communication

section of
Coding

to report what was observed.)


Reciprocal Social Interaction
:

Delete modules leaving only the one used:
(Toddler Module)

Unusual eye
contact, facial expression directed to others,
integration of gaze and other behaviors during social overtures,
sha
red enjoyment in
interaction,
response to name, ignore, requesting,
showing, spontaneous initiation of joint
attention, r
esponse to joint attention,
quality of social overtures
, amount of social overtures


Parent/Caregiver
,
overall quality of rapport
.

(M
odule 1)


Unusual eye contact, facial expression directed to others,
integration of
gaze and other behaviors during social overtures,
shared enjoyment in
interaction, showing, spontaneous
initiation of joint attention, response to joint attention, quality of social overtures.
(Module 2)

Unusual eye
contact, facial expression directed to others,

shared enjoyment in interaction, showing, spontaneous initiat
ion of
joint attention, quality of social overtures, amount of reciprocal social communication, overall quality of rapport.

(Module 3)

Unusual eye contact, facial expression directed to
examiner
,

shared enjoyment in interaction, quality
of social overtur
es, quality of social response, amount of reciprocal social communication, overall quality of
rapport.
(Module 4)

Unusual eye contact, facial expression directed to
examiner
,

comments on others’
emotions/empathy, responsibility, quality of social overtur
es, quality of social response, amount of reciprocal
social communication.





Firstname

was observed to


(
U
se notes taken during
Observation

and reference behaviors from the
Part B.
Reciprocal Social Interaction

section of
Coding

to report what was observed.)



RESTRICTED AND REPETITIVE BEHAVIOR (RRB)

Restricted and Repetitive Behaviors
:

Delete modules leaving only the one used:
(Toddler Module)

In
tonation
of v
ocalizations or verbalizations, unusual sensory interest in play
material/person, hand and finger
movements/posturing, unusually repetitive interests or stereotyped behaviors.

(Module 1)


In
tonation of
vocalizations or verbalizations, stereotyped/idiosyncratic use of words or phrases, unusual sensory interest in
play m
aterial/person, hand and finger and other complex mannerisms, unusually repetitive interests or
stereotyped behaviors.
(Module 2)

Stereotyped/Idiosyncratic use of words or phrases, unusual sensory interest
in play material/person, hand and finger and oth
er complex mannerisms, unusually repetitive interests or
stereotyped behaviors.
(Module 3)

Stereotyped/Idiosyncratic use of words or phrases, unusual sensory interest
in play material/person, hand and finger and other complex mannerisms, excessive intere
st in unusual or highly
specific topics/objects or repetitive behaviors.
(Module 4)

Not used for Module 4.






Firstname

was observed to


(Use notes taken during
Observation

and reference behaviors from the
Part
D
.

Stereotyped Behaviors and
Restricted Interests

section

of
Coding

to report what was observed.)

(Toddler Module)


Autism Initial Evaluation


29

Name:


Case No.:








08/2013

According to this administration of the
ADOS
-
2

the
Overall Total (SA + RRB)

revealed

Choose an item.

(Module 1
, 2, 3, & 4
)

According to this administration of the
ADOS
-
2

the
Overall Total (SA + RRB)

revealed an
ADOS
-
2

classification of
Choose an item.


Additional observational data collected during this administration of the ADOS
-
2 is reviewed below. These
domains are not used when calculating the
Overall Total

s
core.


Play
:

Delete modules leaving only the one used:

(Toddler Module)

Functional play with objects,
imagination/creativity, functional and symbolic imitation.

(Module 1
, Module 2
)


Functional play with objects,
imagination/creativity
.

OR

Imagination
:

(Module 3
, Module
4
)

Imagination/creativity.



Firstname

was observed to


(Use notes taken during
Observation

and reference behaviors from the
Part C
.

Play

o
n the Toddler Module and Modules 1 & 2 o
r

Part C. Imagination

on Module 3 & 4
of
Coding

to report what
was observed.)


Other Behaviors
:

(Toddler Module)

Overactivity, fussiness/irritability, aggression and disruptive behavior,
anxiety.



OR

Other
Abnormal
Behaviors
:


Delete modules leaving only the one used:
(Module 1
, Module 2
)

Overactivity;
tantrums, aggression, negative or disruptive behavior; anxiety.
(Module 3
, Module 4
)

Overactivity/agitation;
tantrums, aggression, negative or disruptive behavior; anxiety.



Firstname

was observed to


(Use notes taken during
Observation

and reference behaviors from the
Part E
.

Other Behaviors

o
n Toddler Module o
r

Part E. Other Abnormal Behaviors

o
n Module 1, 2, 3 & 4 o
f
Coding

to
report what was observed.)


R
esults obtained from th
is administration of the
ADOS
-
2

indicate
that Firstname

displays the characteristics of a
child with Autism.
OR

Results obtained from this administration of the
ADOS
-
2

do not support
the

educational
exceptionality

of Autism.


OPTION

The
Childhood Autism Rating Scale (CARS)

is a 15
-
item behavioral rating scal
e developed to identify children
with autism. It further distinguishes children with autism in the mild to moderate range from children with
autism in the moderate to severe range. The rating scales include:

(I)

Relating to people: this is a rating of how the

child behaves in a variety of situations involving
interaction with other people

(II)

Imitation: this rating is based on how the child imitates both verbal and nonverbal acts

(III)

Emotional response: this is a rating of how the child reacts to both pleasant and unp
leasant situations.
It involves the determination of whether or not the child’s emotions or feelings seem appropriate to
the situation.


Autism Initial Evaluation


30

Name:


Case No.:








08/2013

(IV)

Body Use: this scale represents a rating of both coordination and appropriateness of body movements
and includes such d
eviations as posturing, spinning, tapping and rocking, toe
-
walking, and self
-
directed aggression.

(V)

Object Use: this is a rating both of the child’s interest in toys or other objects, and his uses of them.

(VI)

Adaptation to Change: this scale concerns difficulti
es in changing established routines or patterns and
difficulties in changing from one activity to another.

(VII)

Visual Response: this is a rating of unusual visual attention patterns found in many autistic children
and includes the child’s response when he is r
equired to look at objects or material.

(VIII)

Listening Response: this is a rating of unusual listening behavior or unusual responses to sounds. It
involves the child’s reaction to both human voices and other types of sound.

(IX)

Taste, Smell, and Touch Response and Use: this is a rating of the child’s response to stimulation of
taste, smell, and touch senses (including pain).

(X)

Fear or Nervousness: this is a rating of unusual or unexplainable fears. It also includes rating the
abse
nce of fear under conditions where a normal child at the same developmental level would be
likely to show fear or nervousness.

(XI)

Verbal Communication: this is a rating of all facts of the child’s use of speech and language. Assess
not only the presence or ab
sence of speech but also the peculiarity, bizarreness, or inappropriateness
of all elements of the child’s utterances when speech is present.

(XII)

Nonverbal Communication: this is a rating of the child’s nonverbal communication through the use
of facial express
ion, posture, gesture, and body movement. It also includes the child’s response to the
nonverbal communication of others.

(XIII)

Activity Level: this rating refers to how much the child moves about in both restricted and
unrestricted situations.

(XIV)

Level and Consist
ency of Intellectual Response: this rating is concerned both with the general level
of intellectual functioning and with the consistency of evenness of functioning from one type of skill
to another.

(XV)

General Impressions: this is intended to be an overall ra
ting of autism based on your subjective
impression of the degree to which the child is autistic as defined by the other 14 items.


After the child has been rated on each of the 15 items, a total score is computed by summing the 15 individual
ratings. The child’s final Classification is based on information from all 15 items.

Children with scores below
30
are categorized as non
-
autist
ic while those with scores of 30 and above are categorized as autistic. Scores
ranging from 30 to 36.5 indicate mild to moderate autism while scores ranging from 37 to 60 indicate severe
autism.


The
CARS

was administered to __ on
Click here to enter a dat
e.
. Firstname’s
Total Score
of __ indicates that he/she
falls in the
Choose an item.

range.


OPTION

The
Gilliam Autism Rating Scale
-
Second Edition

(GARS
-
2)

is a behavioral checklist that helps identify persons
who are autistic. It is comprised of three subtests which include Stereotyped Behaviors, Communication, and
Social Interaction. Each subtest is comprised of 14 items describing behaviors that are sym
ptomatic of autism.

Autism Initial Evaluation


31

Name:


Case No.:








08/2013

Additionally, there is a Developmental Component which is in interview form to evaluate the child’s
development during early childhood.


The first subtest, Stereotyped Behaviors, describes stereotyped behaviors, motility disorders, and

other unique
and strange behaviors. Communication, the second subtest, describes verbal and nonverbal behaviors that are
symptomatic of autism. Social Interaction is the third subtest and evaluates the person’s ability to relate
appropriately to people,

events, and objects. The final portion of the test, the Parent Interview, attempts to verify
that an individual demonstrated delays or abnormal functioning prior to the age of three.


By comparing Firstname’s scores with the normative sample, which was c
omposed entirely of individuals
diagnosed as autistic, the probability of autism can be estimated. The best overall estimate of a subject’s
behavior is the Autism Index. This standard score takes into account all the symptomatic behavior of autism
measur
ed on the
GARS
-
2
. The Autism Index mean for the normative sample is 100 with a standard deviation of
15. The higher the Autism Index score, the greater the probability that the individual has autism.


An Autism Index score of 69 or below indicate autis
m to be possible, but unlikely. An Autism Index score of 70
to 84 is below the mean for the normative sample, but may possibly indicate that an individual has autism. An
Autism Index score between 85 and 100 represents a high likelihood of autism.


Resul
ts of the first three subscales of the
GARS
-
2
, administered to Firstname’s teacher/parent
on
Click here to enter
a date.

was as follows:


GILLIAM AUTISM RATING SCALE
-
SECOND EDITION


SUBTEST

PERCENTILE

STANDARD SCORE

Stereotyped Behaviors


Choose an
item.

Communication


Choose an item.

Social Interact


Choose an item.

AUTISM INDEX


Choose an item.


The results obtained from the
GARS
-
2

revealed an Autism Index of _
_ indicating that Firstname’s probability o
f
autism is
Choose an item.
.


GILLIAM AUTISM RATING SCALE
-
S
ECOND EDITION

(Parent Interview)

The following behaviors were not observed during Firstname’s first 3 years of life and represent delays in
Social
Interaction
:

(DELETE THOSE THAT DO NOT APPLY)



Reaching out or preparing to be p
icked up when the parent attempted to lift the child.



Crying or becoming upset when left unattended in his or her crib, playpen, or other area.



Crying or becoming upset when picked up or held.



Crying or becoming upset when handed from one adult to another.



Attempting to join family members in group activities.


The following behaviors were not observed during Firstname’s first 3 years of life and represent delays in
Language Used in Social Interaction
:

(DELETE THOSE THAT DO NOT APPLY)


Autism Initial Evaluation


32

Name:


Case No.:








08/2013



Using single words by

16 months of age.



Using meaningful, communicative phrases by age 2.



Developing normally in terms of language (i.e., cooing, babbling, and speaking without any interruption
or regression).



Following directions (i.e., appearing to understand what to do when

told to do something
.



Appearing to have normal hearing.


The following behaviors were not observed during Firstname’s first 3 years of life and represent abnormal
functioning in
Social Interaction
:

(DELETE THOSE THAT DO NOT APPLY)



Smiling at parents or s
iblings when smiled at or played with.



Crying when approached by unfamiliar persons during the first year.



Engaging in imitative play before age 3 (e.g., played pat
-
a
-
cake, peekaboo).



Seeming to tune people out and to be in his or her own world.



Spending a

great amount of time alone when he or she could have been with others.


The following behaviors were not observed during Firstname’s first 3 years of life and represent abnormal
functioning in
Language Used in Social Interaction
:

(DELETE THOSE THAT DO NO
T APPLY)



Responding to his or her name when called (e.g., turn and look at the person)



Asking for things or using gestures to communicate what he or she wanted.



Following simple directions (e.g., “come here,” “give me a hug,” “wave bye
-
bye”).



Appearing to
understand what to do when told to do something.



Indicating (showing facial concern) when a parent or sibling cried or was distressed.


The following behaviors were not observed during Firstname’s first 3 years of life and represent abnormal
functioning in

Symbolic or Imaginative Play
:

(DELETE THOSE THAT DO NOT APPLY)



Engaging in pretend play (e.g., play with dolls, action heroes, toy animals appropriately).



Pretending he or she was someone else (e.g., Mommy or Daddy, action hero).



Pretending that an
object was something else (e.g., a broomstick as a horse
-
placing the broomstick
between legs and pretending to ride).



Pretending that he or she had an imaginary friend or animal.



Playing with dolls, pretending that they were real persons.


OPTION

The
Gilli
am A
sperger’s Disorder Scale (GADS)
is
a behavior rating scale
used for the assessment of individuals
ages 3 through 22 who present unique behavioral problems. Its purpose is to help
identify those individuals who
have
Asperger’s Disorder. The
GADS

has thirty
-
two clearly stated items divided into
four
subscales which
describe specific, observable, and measurable behaviors. Each subscale

is composed of items describing
behaviors that are characteristic of Asperger’s Disorder. The

four subscales of
the
GADS

include

Social
Interaction, Restricted

Patterns of Behavior, Cognitive Patte
rns, and Pragmatic Skills.



Social Interaction: These items describe social interactive behaviors, expression of communicative
intent, and cognitive and emotional behavi
ors.



Restricted Patterns: These items describe restricted and stereotyped patterns of behavior



Cognitive Patterns: These items evaluate speech, language, and cognitive skills


Autism Initial Evaluation


33

Name:


Case No.:








08/2013



Pragmatic Skills: These items are concerned with how the subject understands a
nd uses language in a
social context.

By comparing
Firstname
’s scores with the normative sample, which was composed entirely of individuals
diagnosed as having Asperger’s Disorder, the probability of Asperger’s Disorder can be estimated. The best
overal
l estimate of a subject’s behavior is the Asperger’s Disorder Quotient. This standard score takes into
account all the ratings across the four subscales. The Asperger’s Disorder Quotient mean for the normative
sample is 100 with a standard deviation of 1
5. The higher the Asperger’s Disorder Quotient score, the greater
the probability that the individual has Asperger’s Disorder.


An Asperger’s Disorder Quotient score of 69 or below indicate Asperger’s Disorder to be possible, but unlikely.
An Asperger’
s Disorder Quotient score of 70 to 79 is below the mean for the normative sample, but may
possibly indicate that an individual has Asperger’s Disorder. An Asperger’s Disorder Quotient score of 80 or
higher represents a high likelihood of Asperger’s Disord
er.


Firstname’s teacher, __, served as rater.
Results of the
GADS

administered on
Click here to enter a date.

are as
follows:


GILLIAM A
SPERGER’S DISORDER SCALE


SUBTEST

PERCENTILE

STANDARD SCORE

Social Interaction


Choose an item.

Restricted
Patterns of Behavior


Choose an item.

Cognitive Patterns


Choose an item.

Pragmatic Skills


Choose an item.

ASPERGER’S

䥎fEu


Choose an item.


Behavior
s frequently observed by teacher:


The results obtained from the
GADS

revealed an A
sperger’s Quotient Score of
__ indicating that Firstname’s
probability o
f
Asperger’s

is
Choose an item.
.


The
Parent Interview Form

was completed by
Firstname
’s
__

and revealed the following information:

Firstname has/has never
been diagnosed as having a

developmental delay.

LANGUAGE DEVELOPMENT:

COGNITIVE DEVELOPMENT:

SELF
-
HELP SKILLS:

ADAPTIVE BEHAVIOR:

CURIOSITY ABOUT THE ENVIRONMENT:

What specific behaviors seem the most in
dicative of Asperger’s Disorder?




Autism Initial Evaluation


34

Name:


Case No.:








08/2013

Do the behaviors occur only i
n certain situations or activities, or
do they occur in all settings?



Does the person display the behavio
rs regardless of who is present?


Could the behaviors be the result of another handicapping condition?


Have any evaluations been done
to rule out the other condition, such as Pervasive Developmental Disor
der or
other mental disorders?


What evaluations?


Are problems noted in both social interaction and restricted, repetitive, and stereotyped patterns of behavior,
interests, and
activities?


Of these two problem areas, which one (social interaction or repetiti
ve patterns) is most affected?


What are the problems?


How severe are these problems?


How do these problems interfere with normal functioning?



Attenti
on/Activity Level
:
(IF APPLICABLE)

(USE IF ADD/ADHD IS ADDRESSED
)

The
Attention Deficit Disorders Evaluation Scale


Third Edition (ADDES
-
3), Home & School Versions
,

provides a measure of the characteristics of
Attention
-

Deficit/Hyperactivity Disorder

as recognized by the
American Psychiatric Association
.

The characteristics are defined as a persistent pattern of inattention and/or
hyperactivity
-
impulsivity that is more frequent and severe than is typically observed in individuals at a
comparable leve
l of development.
The scale has two subscales, Inattention and Hyperactive
-
Impulsive, which
are based on the current subtypes of Attention
-
Deficit/Hyperactivity Disorder. The subscales include a total of
60 items rated through input based on observation
of the student
by a parent/guardian at home and by teachers
within the school setting.
The standard score represents a mean of 10 and a standard deviation of 3. Standard
scores of 7 through 13 are considered statistically average while standard scores of

6 and below or above 13 are
more than one standard deviation from the mean and are considered statistically atypical. A subscale standard
score below 4 indicates a serious level of concern.


The
A
DDES
-
3

was completed by Firstname
’s
parent/guardian and
teacher
(
s
)

during the month of
__

in
20
__
.
The following is a review of those ratings:


ATTENTION DEFICIT DISORDERS EVALULATION SCALE 3
rd

Edition



RATER


DATE

SUBSCALES


PERCENTILE

RANK

Inattention

Hyperactive
-
Impulsive












Autism Initial Evaluation


35

Name:


Case No.:








08/2013

















A
review of the ratings revealed __.


The Inattentive subscale measures inattention which was evidenced through ratings including __.


The
Hyperactive
-
Impulsive Subscale measures hyperactivity
-
impulsivity which was evidenced through ratings
including __.


Cognitive/
Intellectual Functioning:

Formal and informal assessment of
Firstname’s
educational functioning
did

not indicate significant delays;
therefore, fo
rmal intellectual assessment was
not warranted.


OR

Formal
and informal
asse
ssment of Firstname’s
educational functioning

and adaptive
behavior

revealed
significant deficits
. However,
due to disturbances identified in communication; relating to people, events, and/or
objects; and restricted repetitive and/or stereotyped patterns of behaviors, interests, and/or activities, these
disturbances cannot be ruled out as the primary cause of hi
s/her cognitive functioning delays. Therefore,
formal
intellectual assessment was

not conducted at this time.


OR

Formal and informal assessment of Firstname’s
educational functioning
and adaptive
behavior

indicated
significant delays
. Disturbances

in communication; relating to people, events, and/or objects; and restricted
repetitive and/or stereotyped patterns of behaviors, interests, and/or activities, are not determined to be the
primary cause of his/her cognitive functioning delays. Therefore,

formal intellectual assessment was

conducted
to further assess his/her intellectual functioning level.


IF APPLICABLE

M
EDICAL INFORMATION
:

INSERT
write
-
up from School Social Worker



IF APPLICABLE
:

If the results of the hearing screening are not definitive,
a
student
being considered for
Autism
shall

be referred to an audiologist.

AUDIOLOGICAL ASSESSMENT

RESULTS:

(See attached identification of
ASSESSMENT
INSTRUMENTS/TECHNIQUES

that follow report fi
ndings.)

INSERT

write
-
up from Audiologist

AND

verify that instruments/techniques used are listed under
ASSESSMENT INSTRUMENTS/TECHNIQUES that follows report findings.



SPEECH/LANGUAGE ASSESSMENT RESULTS:

(See attached identification of
ASSESSMENT
INSTRUMENTS/TECHNIQUES

that follow report findings.)


Autism Initial Evaluation


36

Name:


Case No.:








08/2013

INSERT
write
-
up from
Speech/Language Pathologist
:
Speech/Language assessment must be conducted to
meet Au
tism procedures for evaluation.

V
erify that instruments/techniques used are listed under
ASSESSMENT INSTRUMENTS/TECHNIQUES that follows report findings.


OCCUPATIONAL THERAPY ASSESSMENT RESULTS:

(See attached identification of
ASSESSMENT
INSTRUMENTS/TECHNIQUES

that follow report findings.)

INSERT
write
-
up from
Occupational Therapist
:
Occupational Therapy assessment must be conducted to
meet Au
tism procedures for evaluation.

V
erify that instruments/techniques used are listed under
ASSESSMENT INSTRUMENTS/TECHNIQUES that follows report findings.



IF APPLICABLE

PHYSICAL THERAPY ASSESSMEN
T
:

(See attached
identification
of
ASSESSMENT
INSTRUMENTS/TECHNIQUES

that follow report findings.)

INSERT
write
-
up from Speech/Language Pathologist

AND
verify that instruments/techniques used are listed
under ASSESSMENT INSTRUMENTS/TECHNIQUES that follows

report findings.


IF APPLICABLE

ADAPTED PHYSICAL EDUCATION ASSESSMENT
:

(See attached
identification
of
ASSESSMENT
INSTRUMENTS/TECHNIQUES

that follow report findings.)

INSERT
write
-
up from APE Teacher
AND
verify that instruments/techniques used are listed

under
ASSESSMENT INSTRUMENTS/TECHNIQUES that follows report findings.


***INSERT ANY OTHER COMPONENTS HERE REQUESTED DURING THE COURSE OF THIS
EVALUATION***


IF APPLICABLE


OPTIONAL

VOCATIONAL ASSESSMENT:
(See attached
identification
of
ASSESSMENT
INSTRUMENTS/TECHNIQUES

that follow report findings.)

During student interviews, Firstname voiced an interest in __. A vocational inventory was conducted with
Fi
rstname to discover further careers

of interest
to explore and consider in
his/her
vocational
p
lanning.



Firstname was administered the
Reading
-
Free Vocational Interest Inventory, Second Edition (R
-
FVII:2)
on
Click here to enter a date.

to assist in his/her educational and vocational planning. According to the results of the
inventory, a
H
igh
d
egree of interest was rated in

occupations involving __.
Above Average interest was rated in
occupations involving __. A review of
occupational interest
areas is as
follow
s
:
(delete those areas that do not
apply)




Automotive interests
involve a
preference for occupations involving parking, cleaning, polishing,
lubricating, and refueling trucks, buses and automobiles as well as other related servicing and
maintenance activities.



Building Trades interests
involve a preference for occupations involv
ing mechanical activities such as
assembly, repair, construction, and installation work using hand tools, machinery, and light or heavy
equipment.


Autism Initial Evaluation


37

Name:


Case No.:








08/2013



Clerical interests
involve a preference for occupations involving running errands, sorting and delivering
letters, packages, and general messages; furnishing workers with clerical supplies, and performing all
routine tasks in an office, library, or printing firm.



Animal Care interests
involve a preference for occupations involving feeding, watering, shelteri
ng,
exercising and grooming animals, and cleaning quarters and equipment.



Food Service interests

involve a preference for occupations involving preparation and serving of food,
and clean
-
up tasks in kitchens and dining areas in restaurants, hotels, clinics
, morgues, or related health
care facilities.



Patient Care interests

involve a preference for occupations involving attending to the physical comfort,
safety, and appearance of patients, and performing routine tasks in hospitals, clinics, morgues, or relat
ed
health care facilities.



Horticulture interests
involve a preference for occupations involving planting, tilling, cultivating,
gathering and harvesting plant life or products, and caring for such areas as gardens, cemeteries, grounds,
and parks.



Housekee
ping interests

involve a preference for occupations involving cleaning and upkeep of building
interiors, furniture, and equipment in hotels, motels, stores, and other facilities, and cleaning tasks in and
around private households.



Personal Service interes
ts
involve a preference for occupations involving helping, assisting, and serving
people in a broad range of services.



Laundry Service interests

involve a preference for occupations involving dry cleaning, laundering,
pressing, ironing, dyeing, and repair
of clothing, furnishings, and accessories in commercial laundries,
dry cleaners, launderettes, or private households.



Materials Handling interests
involve a preference for occupations involving those occupations dealing in
warehousing, loading or
unloading, sorting, stacking and hauling or delivering or merchandise.


An

analysis of the interest areas on the scale revealed a cluster score in the Above Average range in the area(s)
of __. A review of this occupational interest area follows:
(delete
those that do not apply)




Mechanical

interest reveals a preference for job tasks characterized by the use of machines and tools
and/or the building of mechanical objects. Jobs in this field to consider include tool and die maker,
machinist, plumber, autom
obile mechanic, T.V. repairer, lathe operator, electrician, finish carpenter,
printer, watch repairer, upholsterer, and carper installer.





Outdoor

interest reveals a preference for job tasks characterized by work or activity which would keep an
individual outside for most of the work day. Jobs in this field to consider include dairy farmer, fruit
picker, flower grower, bus and taxi driver, forester, naturalist, fisher, athletic coach and instructor,
nursery worker, hunter, fish and game warden,
and parking lot attendant.





Mechanical
-
Outdoor

interest reveals a preference for job tasks characterized by work involving
machines and tools in the outdoors. Jobs in this field to consider include telephone line person, engineer,
welder, surveyor, tree surgeon, gardener, lumber worker, house framer,

sheet metal worker, construction
worker, roofer, brick layer and mason, sign installer, road maintenance worker, and fence installer.




Autism Initial Evaluation


38

Name:


Case No.:








08/2013



Food Service
-
Handling Operations
interest reveals a preference for job tasks characterized by
manual/physical wo
rk and the delivery of personal services to individuals that would require little to no
physical contact is made. Jobs in this field to consider include stevedore, grocery bagger, fork lift
operator, dairy products driver, grocery store stock clerk, glass

washer/carrier, hot food packer, kitchen
helper, lunch truck driver, meat cutter, vending machine attendant, food/beverage delivery truck, fast
foods cook, and food server.




Clerical
-
Social Service

interest reveals a preference for job tasks characteri
zed by occupations involving
office and clerical work; laundering operations; and vocational activities providing assistance and
personal service to others. Jobs in this field to consider include barber, hospital attendant, receptionist,
host/hostess, bea
utician, nurse, occupational therapist, postal clerk, stenographer, clerk/typist, laundry
worker, file clerk, computer operator, and shirt presser.



Firstname should be encouraged to continue exploring career possibilities as his/her interests cha
nge and he/she
continues to build upon his/her academic knowledge and life experiences. He/She

should be provided with
opportunit
ies for
ongoing vocational guidance

while considering his/her
assessed level of cognitive functioning
and academic achievement
, as well as

his/
her motivation and
future
de
sires.


OR

During student interviews, Firstname voiced an interest in __. A vocational inventory was conducted with
Fi
rstname to discover further careers

of interest
to explore and consider in
his/her
vocationa
l
planning.


Firstname was administered the
Self
-
Directed Search, Form E, 4
th

Edition

on
Click here to enter a date.

to assist in
his/her educational and vocational planning.

Those jobs
he/
she
identified
as

already

having

interest in
included
__
. According to the results of the inventory,
Firstname’s
Summary Code was “
__
,”
__
.
This
Summery Code

i
s
used to explore jobs specific to his/her interests and likes/dislikes. Upon reviewing options specific to this
Summery Code, Firstname
indicated int
erest in the following occupations:
__
.


Firstname should be encouraged to continue exploring career possibilities as his/her interests change and he/she
continues to build upon his/her academic knowledge and life experiences. He/She

should be provided w
ith
opportunit
ies for
ongoing vocational guidance

while considering his/her
assessed level of cognitive functioning
and academic achievement, as well as

his/
her motivation and
future
de
sires.


IF APPLICABLE



REQUIRED
after the student’s 15
th

birthday

ANALYSIS OF TRANSITIONAL NEEDS:

Firstname’s expressed occupational interests include __. Strengths/limitations noted which could affect
Firstname’s future plans include __. Vocational experiences include __. Outcomes of these experiences
revealed __.

Physical limitations and/or medical needs include __.

For post
-
secondary outcomes, see Target Areas for Transition Planning
.


INTEGRATED SUMMARY O
F FINDINGS:

Firstname is a __ year old student in the __ grade attending
Choose an item.

School. He/She wa
s referred to the
SBLC and was recommended for an individual evaluation to address concerns regarding __.


Autism Initial Evaluation


39

Name:


Case No.:








08/2013


Educationally, Firstname’s academic achievement, as assessed by the
Choose an item.

revealed

__.



INSERT IF APPLICABLE

Adaptive behavior
assessment results as measured by the

Choose an item.

indicated functioning within the __
range. This suggests adequate/delayed functioning for his/her chronological age.


Formal and informal assessment of
Firstname’s
educational functioning
did

not in
dicate significant delays;
therefore, fo
rmal intellectual assessment was
not warranted.


OR

Formal and informal assessment of Firstname’s
educational functioning

and
adaptive behavior

revealed
significant deficits. However, due to disturbances identified in communication; relating to people, events, and/or
objects; and restricted repetitive and/or stereotyped patterns of behaviors, interests, and/or activities, these
disturbances cann
ot be ruled out as the primary cause of his/her cognitive functioning delays. Therefore,
formal
intellectual assessment was

not conducted at this time.


OR

Formal and informal assessment of Firstname’s
educational functioning and adaptive behavior
i
ndicated
significant delays. Disturbances in communication; relating to people, events, and/or objects; and restricted
repetitive and/or stereotyped patterns of behaviors, interests, and/or activities, are not determined to be the
primary cause of his/her

cognitive functioning delays. Therefore,
formal intellectual assessment was

conducted
to further assess his/her intellectual functioning level.

Firstname’s overall level of
intellectual
functioning was
measured to be in the __ range on the

Choose an ite
m.
.


The overall adaptive behavior functioning is comparable to the assessed level of intellectual functioning.
Intellectual functioning was assessed to be __ standard deviations below the mean, indicating a mild

/ moderate

/
severe

/ profound degree of

impairment. Evidence exists that Firstname’s academic or pre
-
academic functioning
levels are generally commensurate with the assessed level of intellectual ability.


According to the
Autism Diagnostic Observation Schedule (ADOS)
, the
Communication + Soci
al Interaction
Total
score was

Choose an item.

the cutoff score for a diagnosis of Autism. This score was

Choose an item.

the

autism spectrum cut
-
off. This/These scores would indicate Firstname does/does not display behaviors
characteristic of Autism/autism spectrum disorder (Asperger’s Disorder and Pervasive Developmental Disorder).

AND/OR


According to the
Childhood Autism Ra
ting Scale (CARS)
, Firstname’s score of __ indicates that he/she falls in
the __ range.

AND/OR

According to results obtained from the
Gilliam Autism Rating Scale (GARS)
, an Autism Index of ___ indicates
Firstname’s probability of Autism is __.

AND/OR

According to results obtained from the
Gilliam Asperger’s Disorder Scale,

an Asperger’s Quotient Score of ___
indicates that Firstname’s probability of Asperger’s is __.


INSERT IF APPLICABLE


Autism Initial Evaluation


40

Name:


Case No.:








08/2013

A review of results obtained from the
Attention Deficit Disorder
s Evaluation Scale


Third Edition (ADDES
-
3), Home & School Versions

revealed __.


Family input and medical information revealed __. Information collected indicates that the deficits occurred
during the developmental period.


There were no emotional or c
ultural factors thought to be causing or contributing to Firstname’s problems.

OR

Emotional or cultural factors thought to be causing or contributing to Firstname’s problems include __.


Include summary of other assessments . . . (Audiological Evaluation
(if applicable), Speech/Language
Assessment, and Occupational Therapy Assessment).


The results of the evaluation data appear to be a reliable estimate of Firstname’s academic, social, adaptive,
intellectual, and communication skills. Furthermore, it is t
he opinion of this evaluation coordinator and the
multidisciplinary team that the following factors did not interfere with the evaluation: communication barrier,
environmental conditions, rapport, motivation, length of examination, race, culture, and sex.



It was also determined that Firstname’s learning problems are not due primarily to certain factors which include
other disabling condition; lack appropriate explicit and systematic instruction in reading which includes the
essential components of readi
ng instruction: phonics, phonemic awareness, fluency, comprehension, and
vocabulary; lack of appropriate instruction in math; limited English proficiency; lack of educational opportunity;
emotional stress in the home or school; or environmental or economi
c disadvantage.


AREAS OF STRENGTH:


Based on overall assessment results obtained during the course of this evaluation, the following areas of strength
were identified:






AREAS OF WEAKNESS/LOW ACHIEVEMENT:

Based on overall assessment results obtained duri
ng the course of this evaluation, the following areas of
weakness and low achievement were identified:






ELIGIBILITY DETERMINATION
:

Firstname does not meet the criteria for any defined exceptionality according to the
Louisiana Bulletin 1508
Pupil
Appraisal Handbook
.

OR

Firstname meets the criteria for the exceptionality of
Autism

according to the
Louisiana Bulletin 1508 Pupil
Appraisal Handbook

due to disturbances found in all three (3) of the following categories:


1.

Communication
:
(minimum of
2



delete those areas not used to qualify)


Autism Initial Evaluation


41

Name:


Case No.:








08/2013



disturbances in the development of spoken language



disturbances in conceptual development



marked impairment in the ability to attract another’s attention, to initiate, or to sustain a socially
appropriate conversatio
n



disturbances in shared joint attention



stereotypical and/or repetitive use of vocalizations, verbalizations and/or idiosyncratic language



echolalia with or without communicative intent



marked impairments in the use and/or understanding of nonverbal and/o
r symbolic communication



prosody variances including, but not limited to, unusual pitch, rate, volume and/or other intonational
contours



scarcity of symbolic play


2.

Relating to people, events, and/or objects:

(minimum of
4



delete those areas not used to qualify)



difficulty in developing interpersonal relationships appropriate for developmental level



impairments in social and/or emotional reciprocity, or awareness of the existence of others and their
feelings



developmental
ly inappropriate or minimal spontaneous seeking to share enjoyment, achievements,
and/or interests with others



absent, arrested, or delayed capacity to use objects/tools functionally, and/or to assign them symbolic
and/or thematic meaning



difficulty genera
lizing and/or discerning inappropriate versus appropriate behavior across settings
and situations



lack of/or minimal varied spontaneous pretend/make
-
believe play and/or social imitative play



difficulty comprehending other people’s social/communicative intentions, interests, or perspectives



impaired sense of behavioral consequences


3.

Restricted, repetitive and/or stereotyped patterns of behaviors, interests, and/or activities
:
(minimum of
2



delete those areas not used to qualify)



unusual patterns of interest and/or topics that are abnormal either in intensity or focus



marked distress over change and/or transitions



unreasonable insistence on following specific rituals or routines



stereotyped
and/or repetitive motor movements



persistent preoccupation with an object or parts of objects


Firstname also meets the criteria for the secondary exceptionality of

__
according to the
Louisiana Bulletin
1508 Pupil Appraisal Handbook
.


The results of this

evaluation did not indicate a need for related services / indicate a need for
(delete those that do
not apply)

Speech/Language Therapy, Adapted Physical Education, Occupational Therapy, Physical Therapy,
Assistive Technology, DPI/Support Services, ___.


EXTENSION:


An extension was not required in order to complete this evaluation within timelines.


Autism Initial Evaluation


42

Name:


Case No.:








08/2013

OR

Due to their being fewer than 60 business days remaining in the school year, an
En
d of the Year Extension

was
required in order to complete this evaluation.

(The number of days used between the parental signature and June 1 (the SER official beginning date for
summer) will be subtracted from the 60 business days, and the timelines will begin again on Septembe
r 1 (the
SER official ending date for summer.)


OR

Due to __
(i.e., illness, death, natural disaster, catastrophe, awaiting specialized diagnostic/medical assessment,
awaiting report from another school district, etc.)
, a
Parentally Approved Extension

was
taken on
Click here to
enter a date.

in order
to complete this evaluation
.

(If the LEA is making sufficient progress to ensure a prompt completion of the evaluation but needs extended
time to assess the student in all areas of suspected exceptionality,

the parent and the LEA may agree to a specific
time when the evaluation will be completed.)


EVALUATION DISCREPAN
CIES:

There were no evaluation discrepancies.

OR

Evaluation discrepancies should be noted in __.





Autism Initial Evaluation


43

Name:


Case No.:








08/2013


MULTIDISCIPLINARY EVALUATION REPORT

RECOMMENDATIONS
:


NEED

TYPE SERVICE

RECOMMENDED STRATEGIES





















































































Autism Initial Evaluation


44

Name:


Case No.:








08/2013


ASSESSMENT INSTRUMENTS/TECHNIQUES:

A description of the Lafourche Parish School
System evaluation process is provided to assist in understanding
the procedure as prescribed by Louisiana Bulletin 1508.


When a learning and / or behavior problem is evident in a student, and interventions attempted by the teacher
have not been successful
, the School Building Level Committee (SBLC) made up of teachers and other
personnel provide input in working toward a solution. If regular education attempts are not successful, the
SBLC may refer the student for assessment by Pupil Appraisal.


Pupil A
ppraisal assessments are conducted to determine if the student qualifies for Special Education services.
Parental permission is required before a Pupil Appraisal assessment can begin, and is also required before a child
can receive Special Education servi
ces.


Pupil Appraisal personnel use a variety of approaches, with some of the typical procedures described below.
Because assessments are individualized to the specific student and concern, not all of these will be used in a
particular assessment, and som
e assessments may require methods not listed.


Academic and/or Behavioral Interventions

-

Interventions are changes designed to overcome a problem.
Interventions are usually coordinated by Pupil Appraisal to determine if the problem situation can be resol
ved
using regular education resources, before considering qualification for Special Education. If the problem has not
significantly improved, the assessment team may then proceed to norm
-
referenced testing.


Curriculum Based Assessment

-

Curriculum Based
Assessment (CBA) may be conducted in various areas,
including reading, math, and written language. CBA uses instructional materials actually used in the student’s
classroom and school to determine at what point a student reaches frustration and at what po
int is best for the
student to learn without being overwhelmed. Finding these levels helps determine if the student is presently
being taught at his/her most effective ability of achievement.


Norm
-
referenced Testing

-

This assessment method compares a st
udent to a national cross
-
section of students,
called a norm group. By comparing the scores obtained by the student to an average of the scores obtained by
students of the same age in the norm group, an impression of how the student performs from a broade
r
perspective is possible than using CBA alone. Scores based on norm
-
referenced tests are also how qualifications
for Special Education are stated. A list of norm
-
referenced tests are cited which are comprised of intelligence
tests, academic achievement
tests (measuring what the student has learned in instructional areas), and an
adaptive behavior scale (measuring daily living skills).


Criterion
-
referenced Testing

-

This assessment method evaluates a student’s mastery based on an objective
standard or achievement level. Criterion
-
referenced tests attempt to determine a student’s performance level in
relation to a defined area of information the student has been ex
posed to. Criterion
-
referenced testing is useful
when assessing how well a student has learned the material they have been presented and are expected to have
mastered.


Academic

Achievement
:

Diagnostic Screening Test: Reading (DST: Reading)




Diagnost
ic Screening Test: Math (DST: Math)




Reading Level Indicator (RLI)




Math Level Indicator (MLI)




Woodcock
-
Johnson III Test of Achievement (WJ
-
III)


Autism Initial Evaluation


45

Name:


Case No.:








08/2013

Kaufman Test of Educational Achievement, Second Edition (KTEA
-
II)

Wechsler Individual Achievement Test,
Third Edition (WIAT
-
III)





Young Children’s Achievement Test (Y
-
CAT)




Test of Word Reading Efficiency
, Second Edition

(TOWRE

2
)




Test of Written Language, Fourth Edition (TOWL
-
4)




Adaptive

Behavior
:

Adaptive
Behavior Assessment System, II (ABAS
-
II)

Vineland Adaptive Behavior Scale, Second Edition (Vineland
-
II) (Parent/Caregiver

Rating and Teacher Rating)



Intelligence
:



Wechsler Preschool and Primary Scales of Intelligence, Third Edition (WPPSI
-
III)





Wechsler Intelligence Scale for Children, Fourth Edition (WISC
-
IV)





Kaufman
-
Brief Intelligence Test, Second Edition (K
-
BIT2)

Stanford
-
Binet Intelligence Test, Fifth Edition (SBV)




Universal Nonverbal Intelligence Test (UNIT)




Wechsler
Nonverbal Scale of Ability (WNV)




Test of Nonverbal Intelligence, Second Edition (TONI
-
2)

Behavior

Rating
Scales
:

Reynolds Child Depression Scale

Reynolds Adolescent Depression Scale


Second Edition (RADS
-
2)

Attention Deficit Disorders Evaluation Scale
-
Third Edition (ADDES
-
3) (Home and



School Versions)




Behavior Assessment System for Children, Second Edition (BASC 2)

Behavior Assessment System for Children, Second Edition, Self
-
Report
-
Adolescent

(SRP
-
A)

Piers
-

Harris Children’s Self
-

Concept Sca
le


Second Edition (PH
-
2)

Autism Diagnostic Observation Schedule, Second Edition (ADOS
-
2)

Childhood Autism Rating Scale (CARS)

Gilliam Autism Rating Scale


Second Ed
ition (GARS
-
2)

Gilliam Asperger's Disorder Scale

(
GADS
)





Connors Rating Scales
-

Revised




Behavior Disorders Identification Scale (BDIS) (Home and School Versions)





Developmental
:

Bay
ley Scales of Infant and Toddler Development, Third Edition (Bayley 3)

Learning Accomplishment Profile
-
Diagnostic Edition (LAP
-
D)


Early Learning Ac
complishment Profile (E
-
LAP)




Audiology
:


Pure Tone Audiometry (threshold); air Pure Tone




Audiometry (threshold); bone

Speech Reception Audiometry; threshold

Speech Discrimination Audiometry; discrimination

Tympanometry (Impedance Testing)




Condit
ioned Play Audiometry (Visual Reinforcement Audiometry)

Otoa
coustic Emission Testing (inner ear function)

Auditory Processing Testing

Fitting and Verification of Auditory Trainers

Speech



Language
:



P
reschool Language Scale
s, Fifth Edition (PLS
-
5)

Clinical Evaluation of Language Fundamentals Preschool



Second Edition (CELF P
-
2)


Autism Initial Evaluation


46

Name:


Case No.:








08/2013

Clinical Evaluation of Language Fundamentals



Fourth Edition (CELF
-
4)

Receptive
-
Expressive Emergent Language
Test


Third Edition (REEL
-
3)

The Rossetti Infant
-
Toddler Langu
age Scale

Test of Language Development



Primary, Fourth Edition

(TOLD
-
P:4)

Test of Language Development


Intermediate, Fourth Edition (TOLD
-
I:4)

Oral and Written Language Scales
, Second Edition (OWLS
-
II)




Comprehensive Assessment of Spoken Language

(CASL)

Bracken Basic Concept Scale


Revised (BBCS
-
R
)

Test of Problem Solving, Third Edition (TOPS
-
3)

Peabody Picture Vocabulary Test
, Fourth Edition (PPVT
-
4)

Expressive Vocabulary Test, Second Edition (EVT
-
2)

Test of Pragmatic Language, Second Edition (
TOPL
-
2)

Functional Communication Profile



Revised (FCP
-
R)

Voice Rating Scales

Stuttering
Problem
Profile

(SPP)

Stuttering Severity Instrument



Fourth Edition (SSI
-
4)

Goldman
-
Fristoe Test of Articulation

2

(GFTA
-
2)

Weiss Comprehensive Articulation Test

(WCAT)

Khan
-
Lewis Phonological Analysis
, Second Edition (KLPA
-
2)

Oral Motor Exam


Fine Motor
:


Beer
y
-
Buktenica Developmental Test of Visual
-
Motor Integration, 6th Edition (Berry

VMI 6th Edition
)

Fine Motor Checklist (FMC)

Self
-
Care Checklist (SCC)

Sensor
y Profile

Print Tool

Manual Muscle testing/Range of Motion



Gross Motor
:

Louisiana Competency Test for Adapted Physical Education (CTAPE)


Louisiana Motor Assessment for Preschoolers (LaMAP)


CTAPE and LaMAP Assessment Supplement (CLAS)

Gross Motor
Evaluation

Vocational

Inventories
:


The Reading
-
Free Vocational Interest Inventory, 2
nd

Edition




Self
-
Directed Search, Form E, 4
th

Edition











Autism Initial Evaluation


47

Name:


Case No.:








08/2013


MULTIDISCIPLINARY TEAM COMPOSITION:

We certify that this report represents the best integrated description of the student at this time. The evaluation
meets the criteria for eligibility and required evaluation procedures for the exceptionality(ies) listed on the front
page of this document.


SIGNATURES:


Name


Position








Evaluation Coordinator






















*See attached
Documentation of Eligibility Determination

form for parent/guardian participation in staffing.