Document date: 10/22/15Eligibility

Students Name: Alexander Jackson

Native Lang: English
District: Jefferson

Report All Disability Categories

Page 2 of

District ID:
State ID:
Grade: pk Sex: M
Ethnicity: Asian
Birth Date: 2/10/12
Age: 3
School: Jefferson Elementary, Kidz Corner

2. SUMMARY OF FINDINGS/ADVERSE EFFECTS ON EDUCATIONAL PERFORMANCE

A. Assessments
Parent or Adult Student Report
Strengths:
Needs:
Area assessed:

Procedure or test used:

Evaluator:

Title:

Date:

Results (Strengths & Needs):

Area assessed:

Procedure or test used:

Evaluator:

Title:

Date:

Results (Strengths & Needs):

B. Did lack of appropriate instruction in reading or math inhibit the access to and progress in the general
curriculum? A student cannot be determined eligible for special education if the determinant factor is lack of
instruction in math or reading (including phonemic awareness, phonics, vocabulary development, comprehension
and fluency). Address the following factors regarding access to instruction:
Lack of appropriate instruction in reading
(phonemic awareness, phonics, fluency,
comprehension, vocabulary)

Explain:

Lack of appropriate instruction in math

Explain:

January 2007

Form 380b
Copy to the confidential folder, each service provider, and the parent or adult student.