Special Education

Minimum Requirements of a Response to Intervention Program (RtI)

Appendix B

Documentation of the Determination of Eligibility for a Student Suspected of Having a Learning Disability

Section 200.4(j)(5) of the Regulations of the Commissioner of Education requires that the committee on special education (CSE) prepare a written report of the determination of eligibility of a student suspected of having a learning disability that contains a statement of the following information:

  1. The CSE has reviewed the individual evaluation results for ________________, which indicate that the student:
    __ has a learning disability requiring special education services.
    __ does not have a learning disability.
  2. This decision was based on the following sources, including aptitude and achievement tests, parent input, and teacher recommendations, as well as information about the student’s physical condition, social or cultural background, and adaptive behavior in accordance with section 200.4(c)(1) of the Regulations:

  3. The relevant behavior noted during the observation of the student and the relationship of that behavior to the student’s academic functioning indicate:

  4. The educationally relevant medical findings, if any, indicate:

  5. To ensure that underachievement in a student suspected of having a learning disability is not due to lack of appropriate instruction in reading or mathematics, the CSE must, as part of the evaluation procedures pursuant to section 200.4(b) and (c), consider:
    __ data that demonstrate that prior to, or as part of, the referral process, the student was provided appropriate instruction in regular education settings, delivered by qualified personnel.
    __ data-based documentation of repeated assessments of achievement at reasonable intervals, reflecting formal assessment of student progress during instruction, which was provided to the student's parents.
  6. The CSE has determined, consistent with section 200.4(j)(3) of the Regulations, that:
    __ the student does not achieve adequately for the student’s age or to meet State-approved grade-level standards in one or more of the following areas: oral expression, listening comprehension, written expression, basic reading skills, reading fluency skills, reading comprehension, mathematics calculation, mathematics problem solving;
    __ the student either does not make sufficient progress to meet age or State-approved grade-level standards in one or more of the areas identified in this paragraph when using a process based on the student’s response to scientific, research-based intervention pursuant to section 100.2(ii);
    __ exhibits a pattern of strengths and weaknesses in performance, achievement, or both, relative to age, State-approved grade level standards or intellectual development that is determined by the CSE to be relevant to the identification of a learning disability, using appropriate assessments consistent with section 200.4(b).
    __ the student’s learning difficulties are not primarily the result of a visual, hearing or motor disability; mental retardation; emotional disturbance; cultural factors; environmental or economic disadvantage; or limited English proficiency. 
  7. Complete this item if the student has participated in a process that assesses the student’s response to scientific, research-based intervention.
    __ The following instructional strategies were used and student-centered data was collected:
    __ Document how parent’s were notified about the amount and nature of student performance data that will be collected and the general education services that will be provided; strategies for increasing the student’s rate of learning; and the parents’ right to request an evaluation for special education programs and/or services.
  8. CSE Member Certification of the Determination of a Learning Disability:
    The determination of eligibility for special education for a student suspected of having a learning disability must be made by the CSE, which must include the student’s regular education teacher and a person qualified to conduct individual diagnostic examinations of students (such as a school psychologist, teacher of speech and language disabilities, speech/language pathologist or reading teacher).  Each CSE member must certify in writing whether the report reflects his or her conclusion.  If not, the member must submit a separate statement presenting his or her conclusions.
Title Signature Agree Disagree
District Representative       
Parent of Student        
Regular Education Teacher       
Special Education Teacher       
School Psychologist                     
Parent Member              
Others: Specify        


Last Updated: November 9, 2010