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(School or District Letterhead)



Student Name: Date of Birth: Age at Evaluation: Race & Gender: Student CMS ID #: Examiner: School: Referred By: Referral Status: (initial/re-evaluation) Grade and Placement: Grade(s) Repeated: Report Date:


List evaluation components included in the report completed by you and/or others (e.g., EC teacher, speech/language pathologist). Delete components not employed in the current evaluation of the student. · · · Cognitive Ability Adaptive Behavior Behavioral/Emotional Functioning · · · Educational Achievement Health History Social History · · Psychomotor Development Language Functioning


Statements of specific concerns should be noted in this section. Pre-referral information, Intervention Team and regular education interventions should be included here. For re-evaluation, include information from the IEP Team meeting such as evaluation components requested and why, and a summary of the information the Team reviewed. The Reason for Referral should contain a question that can answered by the evaluation process supported by assessment and objectively verifiable observations and conclusions.


Information noted here should be linked to the referral concerns. The following types of information may be included: review of cumulative school records, previous retentions, attendance information, NC EOG test scores, grades, summary of


previous assessment results, personal information of significance to the evaluation, developmental/medical history, and family/social information. If the assessment is a re-evaluation, include the area of certification, level of service, and when initially identified. Include a brief summary of previous evaluation information such as tests administered, scores, assumed validity of results, and unique characteristics of the child noted in the previous evaluation. Information included that might be considered sensitive or highly confidential should be validated. Information obtained from third party reports should be noted as such. In cases that you feel a more detailed review of background information may be warranted, you may want to consider presenting it in subsections such as HOME, DEVELOPMENT, HEALTH, and SCHOOL.


Wechsler Intelligence Scale for Children- Fourth Edition (WISC-IV) Wechsler Adult Intelligence Scale- Third Edition (WAIS-III) Woodcock-Johnson Test of Cognitive Abilities- Third Ed. (WJ-III Cog.) Stanford-Binet- Fifh Edition (SB5) Differential Ability Scales- Second Edition (DAS-II) Kaufman Assessment Battery for Children- Second Edition (KABC-II) Das-Naglieri Cognitive Assessment System (CAS) Bender Visual Motor Gestalt Test- Second Edition (Bender-II) Developmental Test of Visual-Motor Integration- 5th Edition (VMI-5) Behavior Assessment System for Children- Second Edition (BASC-2) Conners' Parent Rating Scale-Third Edition (CPRS-3) Conners' Teacher Rating Scale-Third Edition (CTRS-3) Vineland Adaptive Behavior Scales- Second Edition (Vineland-II) Vineland- II Teacher Rating Form Adaptive Behavior Assessment System- Second Edition (ABAS-II) Scales of Independent Behavior- Revised (SIB-R) Parent Interview Teacher Interview Observation(s)

DATA REVIEWED: Screening: Results:

Vision Hearing Language Health Pass Pass Pass Pass Fail Fail Fail Fail

Dates Admin.

Woodcock-Johnson Test of Achievement- Third Ed. (WJ-III Ach.) Wechsler Individual Achievement Test- Second Edition (WIAT-II)


Diagnostic Achievement Battery- Third Edition (DAB-3) Young Children's Achievement Test (YCAT) Test of Early Reading Ability- Third Edition (TERA-3) Test of Early Mathematics Ability- Third Edition (TEMA-3) Test of Early Written Language- Second edition (TEWL-2) Test of Written Language- Third Edition (TOWL-3) Kaufman Test of Educational Achievement- Second Edition (KTEA-II) Clinical Evaluation of Language Fundamentals- Fourth Ed. (CELF-4) Social/Developmental History Evaluation Report Observation(s)


Report test session behaviors and observations, student's approach to problem solving, ease of verbalization, level of confidence, interpersonal interaction and comfort level, etc. Include a statement of validity regarding the data obtained and how the preceding variables contributed to or interfered with the student's resulting test performances. Describe your experience of working with this student in a one-on-one session. Indicate what appeared to work well in eliciting the child's best performance. If the obtained scores do not appear to be a valid representation of the area measured, use this section of the report to describe how test session behaviors prevented valid measurement.


WISC-IV Verbal Comprehension Index (VCI) Perceptual Reasoning Index (PRI) Working Memory Index (WMI) Processing Speed Index (PSI) Full Scale IQ WISC-IV Subtests (X = 10, SD = 3) VCI Scaled Score Similarities Vocabulary Comprehension WMI Scaled Score Digit Span Letter-Number Sequencing WAIS-III Standard Score Verbal IQ Performance IQ Full Scale IQ Verbal Comprehension (VCI) Confidence Range Percentile Rank Standard Confidence Percentile Score Range Rank

PRI Block Design Picture Concepts Matrix Reasoning PSI Coding Symbol Search

Scaled Score

Scaled Score


Perceptual Organization (POI) Processing Speed (PS) WAIS-III Verbal Scaled Score Vocabulary Similarities Arithmetic Digit Span Information Comprehension Letter-Number Sequencing

Performance Scaled Score Picture Completion Digit Symbol-Coding Block Design Matrix Reasoning Picture Arrangement Symbol Search Object Assembly

DAS-II School-Age Form Standard Score Percentile General Cognitive Ability Special Nonverbal Composite Core Subtests Recall of Designs Word Definitions Pattern Construction Matrices Verbal Similarities Sequential & Quantitative Reasoning SB5 IQ Scales Standard Score Percentile Nonverbal IQ Verbal IQ Full Scale IQ WJ-III NU Cognitive Standard Score Verbal Ability Thinking Ability Cognitive Efficiency General Intellectual Ability Percentile Rank T scores (X = 50, SD = 10)


VMI-5 Standard Score Visual Motor Integration Visual Perception Motor Coordination Bender-II Standard Score Age Score Percentile Rank Visual Motor Age Score Percentile Rank


Motor Perception


Behavioral rating scales use the statistical properties of the normal curve distribution as do cognitive ability and achievement tests, yet are expressed in T scores. T scores have a mean or average of 50 and a standard deviation of 10 (X = 50, SD = 10). Please note that scores followed by an asterisk (*) fall within the At Risk range and scores followed by two asterisks (**) fall within the Clinically Significant range. BASC-2: Parent Rating Scales (PRS); Teacher Rating Scales (TRS) TRS T Score TRS T Score Clinical Scales PRS T Score (Teacher 1) (Teacher 2) Externalizing Problems Hyperactivity Aggression Conduct Problems Internalizing Problems Anxiety Depression Somatization Atypicality Withdrawal Adaptive Skills Study Skills Leadership Social Skills School Problems Attention Problems Learning Problems Behavioral Symptoms Index BASC-2 Self Report of Personality Clinical Scales T Score Clinical Maladjustment Anxiety Atypicality Locus of Control Social Stress Somatization School Adjustment Attitude to School Attitude to Teacher Sensation Seeking

Clinical Scales Personal Adjustment Depression Sense of Inadequacy Relation with Parents Interpersonal Relations Self-Esteem Self-Reliance Emotional Symptoms Index

T Score


Conners' Rating Scales- 3: Parent (CPRS-3); Teacher (CTRS-3) Scale Composite CPRS-3 T Score CTRS-3 T Score #1 CTRS-3 T Score #2


Vineland-II Survey (Parent) Domain Scores Standard Score Communication Skills Daily Living Skills Socialization Skills Motor Skills Adaptive Behavior Composite Vineland-II Teacher Rating Form Domain Scores Standard Score Communication Skills Daily Living Skills Socialization Skills Motor Skills Adaptive Behavior Composite ABAS-II Skill Areas Communication Community Use Functional Academics Home/School Living Health and Safety Leisure Self-Care Self-Direction Social (Work) General Adaptive Composite Parent Form Scaled Score Teacher Form Scaled Score Percentile Range Percentile





WJ-III Tests of Achievement Subtest Cluster Grade Equiv. Reading Math Written Language WIAT-II Subtest Cluster Reading Math Language Writing Standard Score Percentile Rank

Grade Equiv.

Standard Score

Percentile Rank

TOWL-3 Subtest Cluster Spontaneous Language Contrived Language Written Language Quotient

Grade Equiv.

Standard Score

Percentile Rank


A primary goal of the Discussion section is to draw a thread from the referral concern, background information, and assessment data weaving a unified tapestry of the child's overall educational performance characteristics. Each paragraph should elaborate upon and provide additional information resulting in conclusions about the child's key school related learning needs. The vast majority of the information in the written report relates to referral questions and the student's learning needs. Information included in this section of the report should promote understanding of the child's unique strengths and weaknesses. Consider the curricular implications of the background information, parent interview, observations and assessment data. Discuss the meaning of the score configurations in comparison with and relation to the cognitive ability instrument administered. Describe school skills relative to both NC Standard Course of Study grade level expectations and school progress in light of what a child of his/her general cognitive ability typically would be anticipated to have achieved. This may be a good place to describe how a child who may have demonstrated specific information processing difficulties might be expected to perform. In the academic performance section, include a discussion the relationship of obtained assessment data to classroom observation(s), work samples, teacher reports, etc. Present information about how the child's visual motor development may impact classroom performance. State how the child's visual motor development compares to the child's level of cognitive functioning.


For children referred because of possible intellectual disability consideration, discuss to what extent the child's level of development of adaptive skills may limit school progress. Compare adaptive skill development to the child's level of cognitive functioning. Discussion of behavioral rating scales and other behavioral data is perhaps where a school and clinical evaluation report may differ most. The focus of a school psychological evaluation report is on how the learning process is disrupted by the presence, absence, or deficits in particular behaviors rather than a clinical diagnosis of a specific syndrome or disorder.


In the summary statement be sure it is clear that the IEP Team makes the determination for eligibility and services. Statements regarding eligibility and placement should defer to the IEP Team. SAMPLE SUMMARY STATEMENTS: (Student) exhibits characteristics often associated with (seriously emotionally disabled, specific learning disabled, etc.) children such as............ The following recommendations may be considered by the IEP Team in making eligibility determinations and in developing (student's) IEP: OR Assessment results, and other available sources of information such as work samples, school performance history, and lack of response to targeted, research-based interventions in the regular education setting , suggest that (student) achieves best in a learning environment focusing on (cite specific examples such as hands-on learning activities, frequent repetition and drill, small teacher-pupil ratio, slower paced presentation, etc) where teaching strategies can be tailored to address (student's) unique learning needs such as (give specific examples: short attention span, poor processing of orally presented information, emotional outbursts to routine daily stressors, etc.) The IEP Team may wish to consider the following recommendations in making a final determination as (student's) eligibility for the Exceptional Children Program and services. Specific recommendations should have a whole child focus rooted in the documented information in the previous sections of the written report.

Name, Degree, Credential Job Title (Student Services Specialist, School Psychologist) DPI Certification (Psychologist Level II or III) State Board Licensure (Licensed Psychologist, Psychological Associate)



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