1

SPECIAL EDUCATION DEPARTMENT

CONEJO VALLEY UNIFIED SCHOOL DISTRICT
1400 East Janss Road
Thousand Oaks, CA 91362
(805) 497-9511

PSYCHOEDUCATIONAL REPORT
CONFIDENTIAL
TRIENNIAL

NAME XXXXX YYYYY BIRTH DATE

SCHOOL Conejo Elementary AGE 9-9
GRADE 4 SEX Male
TEACHER Mrs. Wonderful ADDRESS 123 N. Skyline Dr.#12 Thousand
Oaks CA 91362
REPORT DATE 1/2/12 PHONE 805) 123-4567

The following report was developed to assist the IEP team in determining eligibility and need for special education
and related services according to the code of Federal Regulations, Sections 300.304 to 300.306. A student shall
qualify as an individual with exceptional needs of the results of the assessment demonstrate that the degree of
impairment requires special education. The decision as to whether or not the assessment results demonstrate
that the degree of the students impairment requires special education shall be made by the IEP team, including
assessment personnel. The IEP team shall take into account all relevant material which is available on the
student. No single score of product of scores shall be used as the sole criterion for the decision of the IEP team
as to the students eligibility for special education. (From CCR 5 Sec. 3030)

PRIMARY LANGUAGE DETERMINATION:

English Language Learner

The Bilingual Background Questionnaire for Parents of Bilingual Students was used to obtain
information from the parents regarding language use in the home, as well as health and developmental
history. This was completed as an interview conducted over the phone by the schools ESL Facilitator
with the father. XXXXXs father reported that parents speak Spanish 100% of the time at home and
that XXXXX does not speak Spanish, but instead English. Mr. YYYYY reported that he and XXXXXs
mother sometimes have difficulty understanding XXXXX, as he mixes both Spanish and English when
he speaks. He reported that other people do not always understand XXXXX when he speaks. He is
not able to answer yes and no questions appropriately. Since he entered school, Mr. YYYYY has
noticed that XXXXX speaks much more English than Spanish. It was reported that XXXXX will initiate
conversation with other children in English. There is no history of speech/language problems in the
family. However, Mr. YYYYY reported that he, himself had academic difficulties when he was in
school. It was also reported that XXXXX lacks self-esteem.

CONFIDENTIAL
 2

If ELL, current level of English proficiency based on the California English Language Development Test
(CELDT):
Beginning
Early Intermediate
Intermediate
Early Advanced
Advanced
DOMAIN 2010 2009 2008
Listening Intermediate Intermediate Early Intermediate
Speaking Intermediate Advanced Early Intermediate
Reading Beginning Beginning n/a
Writing Beginning Early Intermediate n/a
TOTAL Beginning Early Intermediate Early Intermediate

The Woodcock-Munoz Language Survey Revised, Normative Update was administered in order to
determine current language proficiency in both English and Spanish.

XXXXX was born in the United States and has lived here his entire life. His first language was Spanish.
At home, XXXXX reports to speak Spanish (less than 25% of the time) and English (about 75% of the
time). He reports that his parents speak Spanish (about 75% of the time) and English (less than 25%
of the time). In informal social situations and in the classroom, XXXXX speaks English. He has been
exposed to academic instruction in English at school since Kindergarten (4 years).

XXXXX was administered this test by two different assessors. The Speech and Language Pathologist
administered the English version. The School Psychologist administered the Spanish version.
XXXXXs conversational proficiency seemed typical for his age level in English. Whereas in Spanish,
XXXXXs conversational proficiency was limited. Although XXXXX was cooperative throughout testing
he appeared fidgety and restless at times.

XXXXXs score on the Oral Language Scale in English was Limited (Level 3). Oral Language
measures listening and speaking, including language development and verbal reasoning. His
performance is comparable to that of the average individual at age 6-3. Oral language tasks below the
age 5-3 level will be quite easy for XXXXX; those above the age 7-4 level will be quite difficult for him.

XXXXXs score on the Oral Language Scale in Spanish was Negligible (Level 1). His performance is
comparable to that of the average individual at age 2-11. Oral language tasks below the age 2-4 level
will be quite easy for him; those above the age 3-8 level will be quite difficult for him. However,
inspection of his test scores shows significant variability in Spanish oral language performance.
Performance on the vocabulary test was significantly lower than performance on the verbal reasoning
test.

For his age level, XXXXX performs parallel oral language tasks with 1% success in Spanish and with
34% success in English.

CONFIDENTIAL
 3

Test/CLUSTER CALP LEVEL PERCENTILE STANDARD CALP

ENGLISH RANK SCORE
Picture Vocabulary - 12 82 -
Verbal Analogies - 4 74 -
ORAL LANGUAGE Limited 4 74 3
Test/CLUSTER CALP LEVEL PERCENTILE STANDARD CALP
SPANISH RANK SCORE
Vocabulario sobre - <0.1 30 -
dibujos
Analogias verbales - 2 69 -
LENGUAJE ORAL Negligible <0.1 42 1

Materials and procedures were provided in a form most likely to yield accurate information on what
the child knows and can do academically, developmentally, and functionally.

Assessment(s) administered in: English, with allowance for responses in Spanish as needed on some
tests, by a bilingual school psychologist.

REASON FOR REFERRAL____________________________________________________________

XXXXX was referred for a full psychoeducational assessment as part of an early triennial evaluation, as
requested by his parents. The last complete evaluation was conducted in March 2010. The purpose of
this current evaluation is to determine eligibility and to determine if his current placement and services
continue to be appropriate.

XXXXX is being evaluated for continued special education consideration.

PREVIOUS ELIGIBILITY: Speech/Language Impaired

CONFIDENTIAL
 4

BACKGROUND
INFORMATION__________________________________________________________

ENVIRONMENTAL, CULTURAL, AND ECONOMIC INFORMATION:

Health, developmental, and social information was obtained from XXXXXs parents. Additional
information was obtained through a review of school records.

XXXXX currently lives with his mother and father, Hugo and Lidia YYYYY. Mr. YYYYY is disabled does
not work outside of the home. Mrs. YYYYY is employed cleaning houses. Also living in the home is
XXXXXs sister, Sophia (5 years).

XXXXXs parents reported the following in terms of XXXXXs behavior at home:

Attention: not good
Activity level: variable
Eating habits: normal
Temperament: depends on how he is feeling
Relationship with sibling: normal
Relationship with friends: normal, very friendly

EDUCATIONALLY RELEVANT HEALTH AND DEVELOPMENTAL INFORMATION:

The previous report indicated that XXXXX is the result of a normal pregnancy and delivery. Developmental
milestones were met within expected limits.

Health/medical history: XXXXX has a history of inattention. He has been diagnosed with ADHD
(Attention Deficit Hyperactivity Disorder). He has been prescribed Vyvanse 30 mg. to be taken in the
morning prior to school each day. XXXXX is under the medical care of Dr. Gwen Hoffer,
Developmental Behavioral Pediatrics, Clinical Del Camino Real Ventura.

XXXXX is also prescribed Singular for nasal allergy and Miralax for constipation. He is also allergic to
cats.

There is a family history of diabetes.

XXXXX has not had any major accidents or injuries.

Current vision and hearing results:

The vision test performed on 9/14/11 indicated L 20/50 and R 20/100. XXXXX now wears glasses.
The hearing screening performed on 9/14/11 indicated hearing within the normal range.

CONFIDENTIAL
 5

EDUCATIONAL BACKGROUND:

ATTENDANCE HISTORY-
XXXXX is a 9-year old 4th grader at Conejo Elementary School. He has attended Conejo Elementary
School since Kindergarten. XXXXX attended Roots and Wings preschool.

He has received tutoring since Second Grade.

XXXXX has been receiving special education services since March 2010 as a student with a
Speech/Language Impairment. XXXXX has received DIS speech since March 2010.

Current services: DIS Speech/Language

OTHER RELEVANT EDUCATIONAL HISTORY-

STAR:
Grade 3 Grade 2
English Language Arts Far Below Basic 252 Below Basic 265
Math Basic 319 Basic 333

BEHAVIORAL OBSERVATIONS:

OBSERVATIONS IN CLASSROOM AND OTHER APPROPRIATE SETTINGS, INCLUDING

RELATIONSHIP OF BEHAVIOR TO STUDENTS ACADEMIC AND SOCIAL FUNCTIONING:

XXXXX was observed in his classroom on 9/7/11 during Math. He was seated at the front of the
classroom, closest to the teacher. XXXXX appeared focused, listening to the teachers aide
giving directions.

XXXXX was again observed in Mrs. Peases 4th grade class on October 5, 2011 from 11:30-
12:00pm. He was sitting up front close to the white board and overhead projector. The teacher
was directing a large classroom activity when she asked students to take out their completed
assignments. The teachers aide checked XXXXXs paper and gave him credit. XXXXX and his
classmates waited patiently for the teachers aide to check everyones assignment. The class
was then asked to pull out their math workbook. XXXXX took out his workbook quickly. His
teacher asked many questions that he raised his hand to answer. XXXXX was given tickets for
raising his hand and answering questions correctly. XXXXX continued to pay attention to the
teacher speaking while following the lesson on the overhead.

CONFIDENTIAL
 6

BEHAVIOR DURING TESTING, INCLUDING RELATIONSHIP OF BEHAVIOR TO THE RELIABILITY

OF THE CURRENT ASSESSMENT RESULTS:

XXXXX presented himself in a polite manner. He was compliant with examiner instructions and was
able to follow all directions. Rapport was established somewhat easily. However, XXXXX did not
initiate conversations with the examiner. There was limited spontaneous conversation. XXXXXs ability
to sustain attention and remain focused in the one-on-one setting was appropriate. His activity level
was age-appropriate.

Test results appear to be valid measures of his ability and achievement.

ASSESSMENT INFORMATION:

SOURCES OF DATA USED:

Review of cumulative records
Statewide Testing and Reporting results (STAR program)
Work Samples
Existing assessment reports (list below)
Date Type Assessor
3/2010 Psychoeducational Assessment Report Elizabeth Farley, CVUSD

Parent interview
Teacher survey or interview
Other data sources
New Assessments (see following section)
Name of new assessments administered:
Woodcock-Munoz Language Survey Revised, Normative Update
Sentence Completion Test (psychologist)
Conners-3 (psychologist)
Family Drawing and School Drawing (psychologist)
Observation (psychologist)
Student Interview (psychologist)
Piers-Harris 2 (psychologist)
Wechsler Individual Achievement Test Third Edition (special education teacher)
Teacher Evaluation (classroom teacher)

CONFIDENTIAL
 7

Student was assessed in all areas of suspected disability.

All tests and materials included those tailored to assess specific areas of educational need.
All assessments were selected and administered so as not to be discriminatory on racial, cultural, or
sexual bias.
Each instrument was used for the purpose for which it was designed and is valid and reliable.
Each instrument was administered by trained and knowledgeable personnel.
Each instrument was given in accordance with the test instructions provided by the producers of the
assessments.
All tests were selected and administered to best ensure that they produce results that accurately
reflect the students abilities, not the students impairments, including impaired sensory,
manual, or speaking skills.
Explanation or ant of the above that are not checked:___________N/A_____________________

PREVIOUS TESTING:

An initial psychoeducational assessment was performed in March 2010. The results are as follows:

KABC-2
SUBTEST Scaled Score Age Equivalent Range
Story Completion 3 5:4
Triangles 11 9:0
Block Counting 7 6:6
Pattern Reasoning 7 6:9
Hand Movements 5 4:6
NONVERBAL INDEX 76 Below Average

BVAT-NU
CLUSTER/Test Standard Score %ile
Bilingual Verbal Ability 72 3
English Language Proficiency 70 2
Picture Vocabulary 80 9
Oral Vocabulary 82 11
Verbal Analogies 78 7

Comprehensive Test of Phonological Processing (CTOPP):

Date 3/18/10 Age 8-2

SS
Phonological Awareness 88
Elision 7
Sound Blending 9

CONFIDENTIAL
 8

Phonological Memory 94
Memory for Digits 6
Nonword Repetition 12
Rapid Naming 112
Rapid Digit Naming 12
Rapid Letter Naming 12

Developmental Test of Visual-Motor Integration Fifth Edition (VMI-5):

Date 3/11/10 Age 8-2

Standard Score 89
Percentile 23

Test of Visual Perceptual Skills Third Edition (TVPS-3):

Date 3/18/10 Age 8-2

Standard Score
Visual Discrimination 7
Visual Memory 2
Visual-Spatial Relationships 5
Visual Form Constancy 5
Basic 74
Visual Sequential Memory 12
Sequencing 110
Visual Figure-Ground 5
Visual Closure 9
Complex 85

Overall 82

CONFIDENTIAL
 9

Conners Parent Rating Scale Third Edition: Long Version

Date 3/18/10 Age 8
Completed by: parent (Spanish translation and transcribed into English form by psychologist)
* Scores over 70 are significant *
T Score Range
Oppositional 70 Markedly Atypical
Cognitive Problems/Inattention 72 Markedly Atypical
Hyperactivity 72 Markedly Atypical
Anxious-Shy 79 Markedly Atypical
Perfectionism 52 Average
Social Problems 64 Mildly Atypical
Psychosomatic 67 Moderately Atypical
Conners ADHD Index 79 Markedly Atypical
Conners Global Index: Restless/Impulsive 68 Moderately Atypical
Conners Global Index: Emotional Lability 65 Mildly Atypical
Conners Global Index: Total 69 Moderately Atypical
DSM-IV: Inattentive 76 Markedly Atypical
DSM-IV Hyperactive-Impulsive 78 Markedly Atypical
DSM-IV: Total 79 Markedly Atypical

Conners Teacher Rating Scale Third Edition: Long Version

Date 3/18/10 Age 8
Completed by: Lorraine Epstein
* Scores over 70 are significant *
T Score Range
Inattention 53 Average
Hyperactivity/Impulsivity 63 Mildly Atypical
Learning Problems/Executive Functioning 62 Mildly Atypical
Learning Problems (subscale of LE) 73 Markedly Atypical
Executive Functioning (subscale of LE) 49 Average
Aggression 51 Average
Peer Relations 41 Slightly atypical
Conners 3 Global Index Total 53 Average
DSM-IV-TR ADHD Inattentive 53 Average
DSM-IV-TR ADHD Hyperactive-Impulsive 61 Mildly Atypical
DSM-IV-Conduct Disorder 56 Average
DSM-IV-TR Oppositional Defiant Disorder 42 Slightly Atypical

CONFIDENTIAL
 10

CURRENT RESULTS OF ASSESSMENT/PRESENT LEVELS OF ACADEMIC ACHIEVEMENT

AND RELATED DEVELOPMENTAL NEEDS:

Standard Score Scaled Score Qualitative Descriptor

130 and above 16-20 Very Superior
120-129 14-15 Superior
110-119 12-13 High Average
90-109 8-11 Average
80-89 6-7 Low Average
70-79 4-5 Borderline
69 and below 0-3 Intellectually Deficient

TEACHER REPORT: Susan Pease, General Education 4th Grade Teacher

Distractibility: Moderate - Extreme~ short attention span, lack of concentration, tunes in and
out

Perceptual Problems: Moderate~ difficulty in accurately duplicating letters: has a strong font when
writesnot readable

Conceptual Problems: Extreme~ difficulties in remembering ideas and concepts, written words,
arithmetic processes; limited vocabulary; difficulty in expressing self

Emotionality: Moderate~ excessive anxiety

Social Problems: None~ has a great smile and sense of humor

SOCIAL-EMOTIONAL/BEHAVIORAL FUNCTIONING:

For is family drawing, XXXXX drew a picture of himself with his mother, father, and sister. He drew
himself and his sister, sitting on the couch, watching television. He drew his mother in the kitchen,
cooking, and his father sitting at a desk working on the computer.

For his school drawing, XXXXX drew a picture of himself at recess playing soccer on the field. XXXXX
reported to feel happy at school.

CONFIDENTIAL
 11

XXXXX was also given the Sentence Completion Task. His sentences reflect a happy child who enjoys
school. Some of his sentences were:
When I go to bedI read a book.
Boysare my friend.
My motheris happy.
I feelhappy.
I cantplay games on school days.
Readingis fun.
I needto get better.
I am best whenI play soccer.
I hatework.
Schoolis fun.
I likesoccer.
I am happy whenI am in school.
I am veryhappy in school.
Ican play sports.
When it is darkI pray.
My teacheris very nice with me.

The Piers-Harris 2 was administered to assess XXXXXs self-concept. On this measure, XXXXX
responded that he is a happy person, is smart, a leader in games and sports, is well behaved in
school, is strong, and likes who he is. XXXXX also responded yes to the statement My parents
expect too much of me. XXXXX appears to have answered the questions honestly, as the
Inconsistency Index and Response Bias Index were within the average (interpretable) range. XXXXX
appears to have a good self-concept.

Piers-Harris Childrens Self-Concept Scale Second Edition:

Date 9/8/11 Age 9

T scores below 40 are regarded as a serious indicator of low self-esteem.

T Score
Behavioral Adjustment 46
Intellectual/School Status 51
Physical Appearance and Attributes 52
Freedom from Anxiety 51
Popularity 50
Happiness and Satisfaction 51
Total 49

CONFIDENTIAL
 12

The Conners 3 is an assessment tool used to obtain observations about a students behavior in the
school and in the home setting. This instrument is designed to assess ADHD and its most common co-
morbid problems in children and adolescents. XXXXXs teacher and parents completed the Conners-3.

On the teacher form, scores on the Validity scales do not indicate a positive, negative or inconsistent
response style. The T -score: Learning Problems (subscale) (T = 72) was very elevated indicating
many more concerns than are typically reported. The teacher reported that XXXXXs problems
seriously affect his functioning very frequently (rating = 3) in the academic setting. Based on the
teachers ratings, the Conners 3 ADHD Index score is borderline (58% probability of an ADHD
classification).

Conners 3 - Teacher:
Date 9/7/11 Age 9
Completed by: Susan Pease (4th grade teacher)
T Score
Inattention 60 High Average
Hyperactivity/Impulsivity 43 Average
Learning Problems/Executive Functioning 60 High Average
Learning Problems 72 Very Elevated
Executive Functioning 49 Average
Defiance/Aggression 44 Average
Peer Relations 50 Average
ADHD Predominantly Inattentive Type 51 Average
ADHD predominantly Hyperactive Type 43 Average
Conduct Disorder 45 Average
Oppositional Defiant Disorder 44 Average
Conners 3GI: Restless/Impulsive 51 Average
Conners 3GI: Emotional Lability 44 Average
Conners 3GI: Total 49 Average

Conners 3 - Parent:
Date 9/1/11 Age 9
Completed by: Hugo YYYYY (father)

*Caution should be used when interpreting this parent report, as the Inconsistency Index indicates that
responses to similar items showed a possible inconsistent responses style.

The T-scores for the following Conners 3-P Content scales were very elevated (i.e., T-score = 70),
indicating many more concerns than are typically reported: Inattention (T = 87) and Learning Problems (T =
90).

The Symptom Count was probably met and the T-score was elevated or very elevated (i.e., T-score = 65)
for the following DSM-IV-TR Symptom scale: ADHD Predominantly Inattentive Type (T = 73).

The parent reports that XXXXX YYYYYs problems seriously affect his functioning very frequently (rating =
3) in the academic setting, and often (rating = 2) in the home setting.

CONFIDENTIAL
 13

Based on the parents ratings, further investigation was suggested/recommended for issues with anxiety.
Based on the parents ratings, further investigation was suggested/recommended for issues with
Depression.

T Score
Inattention 87 Very Elevated
Hyperactivity/Impulsivity 53 Average
Learning Problems 90 Very Elevated
Executive Functioning 54 Average
Defiance/Aggression 59 Average
Peer Relations 44 Average
ADHD Predominantly Inattentive Type 73 Very Elevated
ADHD predominantly Hyperactive Type 54 Average
Conduct Disorder 44 Average
Oppositional Defiant Disorder 56 Average
Conners 3GI: Restless/Impulsive 48 Average
Conners 3GI: Emotional Lability 54 Average
Conners 3GI: Total 50 Average

CONFIDENTIAL
 14

PRE-ACADEMIC/ACADEMIC SKILLS:
Wechsler Individual Achievement Test Third Edition (WIAT-III):
Date 10/20/11 Age 9-9
Age Norms Reported Given by Joan Shayer, Learning Center Teacher

Composite Standard Score Percentile Rank Range

Oral Language 78 7 Below Average

Listening Comprehension 79 8

Oral Expression 82 12

Reading

Word Reading 79 8

Reading Comprehension 72 3

Written Expression 84 14 Below Average

Sentence Composition 83 13

Essay Composition 96 39

Spelling 83 13

Mathematics 86 18 Average

Math Problem Solving 84 14

Numerical Operations 90 25

Math Fluency-Addition 101 53

Math Fluency-Subtraction 90 25

Math Fluency-Multiplication 85 16

Math Fluency 91 27 Average

XXXXXs academic achievement was evaluated by Joan Shayer, Learning Center Teacher, with the
WIAT-III. This test focused on the areas of reading, math, and written language. XXXXXs scores are
compared to age level peers nationally.

CONFIDENTIAL
 15

Overall, academic testing shows that XXXXX has low average skills in the areas of math and math
fluency. Oral language and written expression skills fall within the below average range. Basic reading
skills (word reading) falls within the below average range, while reading comprehension skills fall within
the well below average range.

OVERALL SUMMARY AND RECOMMENDATIONS

___________________________________________________

This assessment was conducted due to parents request and as part of an early triennial evaluation.
Continued special education eligibility is being considered.

SUMMARY OF ASSESSMENT:

Current results indicate ..

Cognitive abilities: most likely fall within the below average range. Nonverbal IQ: 76

Academic skills levels as demonstrated by standard scores:

a. Reading well below average to below average

b. Math average
c. Written Expression below average

Academic Skills as demonstrated by classroom performance/grades/group test scores:

In the general education setting, XXXXX performs well below grade level peers in
the areas that involve reading comprehension. In math calculation, he performs
slightly below grade level or at grade level.
STAR results from 3rd grade indicate Far Below Basic skills in English Language
Arts and Basic skills in Math

Social-emotional functioning: XXXXX is a sweet child who puts forth good effort. He has a
strong desire to do well in school. He can at times present as anxious and nervous. His
attention and distractibility, although much improved, continue to significantly impact his ability
to access the general education curriculum, most specifically in the area of Language arts.

Speech/Language functioning: Current testing shows deficits in auditory memory and word
relationships. Some of his expressive skills are within the average range. Please refer to
Speech/Language assessment report.

Processing Delays are most likely exhibited in the following areas:

attention

No severe discrepancies between measured cognitive ability and academic achievement are
evident at this time.

CONFIDENTIAL
 16

Other: XXXXX has a diagnosis of ADHD. Although improvement in attention and focus has
been noted since he has been prescribed Vyvanse, he continues to struggle with accessing the
general education curriculum in the area of reading, specifically reading comprehension and
basic reading skills.

Second language factors: XXXXX is an English Language Learner.

SUMMARY OF ASSESSMENTS, INCLUDING FACTORS AFFECTING EDUCATIONAL

PERFORMANCE:

Previous results indicate that XXXXXs nonverbal cognitive functioning falls within the below average
range. Current academic assessment results indicate significant weakness in the areas of reading
comprehension and written expression.

XXXXX presents as a student with significant attention difficulties. His inability to remain on task for
required length of time significantly impacts his ability to access the general education curriculum.

RECOMMENDATIONS TO ENABLE STUDENT TO BE INVOLVED IN AND PROGRESS IN

GENERAL EDUCATION CURRICULUM:

Optimize seating arrangement (away from windows and doorways, near front)
Provide a quiet environment
Acknowledge attention deficits as a component of students learning profile
Provide external cueing to maintain attention
Provide instruction in short blocks (5 to 15 minutes)
Reward on-task behaviors
Provide for individual or small group instruction
Preview or Frontload activities purpose and anticipated timeline.

Instruct student to:

Watch the instructor
Sit where least distracted
Pay attention to established cues
Work at a study carrel or other low distraction area personal office
Have something to squeeze to release stress
Communicate with teacher when feeling extremely distractible

ELIGIBILITY:

CONFIDENTIAL
 17

Indicators of possible disability or continuing disability:

Other Health Impairment:
Federal
P.L. 105-17 (IDEA), Title 34, CFR, 300.7(c)(9)
Other health impairment means having limited strength, vitality or alertness, including a heightened
alertness to environmental stimuli, that results in limited alertness with respect to the educational
environment, that
(i) Is due to chronic or acute health problems such as asthma, attention deficit disorder or
attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead
poisoning, leukemia, nephritis, rheumatic fever, and sickle cell anemia; and
(ii) Adversely affects a childs educational performance.
2. State
CCR, Title 5, Section 3030(a)
A pupil has limited strength, vitality or alertness, due to chronic or acute health problems, including
but not limited to a heart condition, cancer, leukemia, rheumatic fever, chronic kidney disease, cystic
fibrosis, severe asthma, epilepsy, lead poisoning, diabetes, tuberculosis and other communicable
infectious diseases, and hematological disorders such as sickle cell anemia and hemophilia which
adversely affects a pupils educational performance. In accordance with Section 56026(e) of the
Education Code, such physical disabilities shall not be temporary in nature as defined by Section
3001(v).

Currently, a severe discrepancy does not exist between previously tested cognitive ability and current
academic functioning. However, at this time, XXXXX appears to meet the eligibility requirements for
special education services under the eligibility criteria of Other Health Impaired (OHI). A secondary
eligibility of Speech/Language disability may need to be considered. It is the examiner's
recommendation that speech designated instructional services continue to be provided and that the
team consider specialized academic instruction in the areas of reading and written language in the
Learning Center.

The IEP team will need to determine if this disability adversely affects his educational performance and
functioning cannot be corrected without continued special education and related services.

Possible special education and related services needed or additions or modifications to current
services needed to meet goals and participate in general curriculum/appropriate activities
(include basis for determination of need):

The IEP team will need to determine how XXXXX's educational needs can best be met and if special
education services continue to be required in order for him to be successful at school.

The IEP team will meet to discuss assessment results as well as to discuss educational planning and
placement, which may include special education. All test results from the multi-disciplinary team
members assessment will be considered before a conclusion can be reached regarding whether
students needs require special education and related services, which cannot be provided with
modification of the regular school program. The purpose of this report is to provide information to assist
the team in making that decision.

Need for specialized services and equipment (required for low incidence):__No____

CONFIDENTIAL
 18

Person completing this report:

______________________ __________________
Elizabeth Farley, M.S. Date
School Psychologist

Other assessors contributing to this report:

Name Title
Joan Shayer Special Education Teacher
Martha Vaughan Speech/Language Pathologist

CONFIDENTIAL