Eligibility Determination Documentation (IDEA)

Confidential Student Education Record

Student Name: [student name] DOB: [date of birth] Student ID: [student ID] Grade: [grade] School: [school name] District: [district name]

Meeting Type: [Initial Eligibility / Reevaluation / Change in Eligibility / Exit]

Meeting Date: [date] Time: [start time]–[end time] Location/Format: [in-person / virtual] Interpreter: [interpreter name and language / N/A]

Evaluation Window: [start date] through [completion date] Decision Date: [date if different from meeting date]

(If any identifier is unavailable, enter "Unknown at time of meeting" rather than leaving blank.)

Reason for Eligibility Determination

• [Referral source]
• [Primary concerns in plain language]
• [Suspected disability category or categories under consideration]
• [Key contextual factors relevant to interpretation]

(List 2–6 items anchoring the referral question. State suspected categories without implying conclusion.)

Team Members and Participation

Name	Role/Title	Present	Participation Mode	Signature
[name]	[role/title and credential if relevant]	[Present / Absent / Excused / Written input only]	[in-person / virtual / phone / written]	[signature / on file]

(Include parent/guardian, general education teacher, special education teacher/provider, LEA representative, evaluation-results interpreter, and related service providers as applicable. If parent not present, document method of participation or reason for absence. If any required member is excused, document written agreement and whether their area was discussed.)

Procedural Documentation

• Consent for evaluation: Date obtained: [date] Scope: [areas evaluated]
• Evaluation materials provided to parent: Date: [date] Method: [delivery method]
• Procedural safeguards: Provided [date] / [access method reference]
• Prior written notice: To be issued separately by [date/method]

(If these elements are captured in a separate attached procedural form, replace this section with: "Procedural documentation on file; see Attachment [identifier].")

Data Sources Considered

Data Source	Date	Domain	Key Finding(s)	Limitation(s)	Relevance to Eligibility
[source type and title]	[date]	[domain assessed]	[decision-relevant summary with plain-language interpretation of scores]	[validity, linguistic, or other limitations]	[how this informs eligibility]

(Include all sources: records reviewed, interviews, observations, standardized assessments, curriculum-based measures, and educationally relevant health information. Clearly distinguish reported information from observed/tested information. If a needed domain lacks data, document what was attempted, why unavailable, and whether additional data are required.)

Integrated Summary of Findings

Strengths and Assets

• [Strength or protective factor]
• [Strength or protective factor]
• [Strength or protective factor]

(Include at least 2–3 strengths.)

Needs and Barriers

• [Primary needs tied to school functioning]
• [Cross-setting consistency observations]
• [Educationally relevant medical findings]

(If results are mixed, explicitly state what is consistent versus inconsistent and the implications for certainty. Cite medical diagnoses as "reported diagnosis" with source and date—do not diagnose beyond educational eligibility scope.)

Eligibility Analysis

Disability Category Criteria

Category: [disability category name] Determination: [Meets / Does Not Meet / Insufficient Data]

• Criterion 1: [criterion text or label] — Evidence: [mapped evidence with source/date]
• Criterion 2: [criterion text or label] — Evidence: [mapped evidence with source/date]
• Criterion 3: [criterion text or label] — Evidence: [mapped evidence with source/date]

(Repeat this block for each category under consideration. Map evidence to each locally defined criterion and cite data sources by date/type. If criteria are not met, state which criterion failed and why.)

Exclusionary Factors Addressed

Factor: [exclusionary factor name]
Evidence Reviewed: [specific documentation]
Team Conclusion: [Not primary determinant / May contribute but not primary / Cannot rule out]
Impact on Eligibility Certainty: [statement of impact]

(Repeat for each applicable factor: adequacy of instruction/opportunity to learn, attendance/access, language acquisition and linguistic appropriateness of evaluation, cultural/environmental factors, sensory/health considerations including vision/hearing screening status. Do not declare a factor "ruled out" without explicit evidence documented.)

Educational Impact Statement

[Description of how disability-related needs affect access, participation, and progress in academic and functional performance despite typical instruction and supports]

Supporting Data Points:

• [Concrete example tied to school data with setting, frequency, and severity]
• [Additional example with specificity about triggers and supports]

Need for Special Education

• Supports previously attempted: [interventions, accommodations, differentiation tried and student response pattern]
• Why specially designed instruction is needed: [intensity, explicit instruction, individualized goals, specialized methodologies, related services required]

(If student needs only related services without special education, document this distinction clearly.)

Conclusion: Therefore, the team concludes [statement of need for specially designed instruction].

Team Determination

Determination: [Eligible / Not Eligible]

Eligibility Category(ies): Primary: [category] Secondary: [category if applicable]

Effective Date: [date]

Consensus: [Unanimous / Dissenting member(s): [names] — attach written statement]

If Not Eligible—Alternative Pathway: [General education plan / MTSS continuation / Section 504 consideration / Referral to outside evaluation / Other]

(This section must always be included.)

Determination Rationale

Key Evidence:

• [Most relevant data point]
• [Most relevant data point]
• [Most relevant data point]

(Include 2–4 key evidence bullets.)

Why Criteria Are/Are Not Met: [1–2 short paragraphs explaining criteria determination]

Why Exclusionary Factors Are Not Primary: [1 short paragraph addressing exclusionary factors]

Why Educational Impact Exists: [1 short paragraph describing educational impact]

Why Special Education Is/Is Not Needed: [1 short paragraph explaining need determination]

(Use plain language accessible to families. Avoid jargon and define any necessary terms. Use "The team reviewed..." framing.)

Next Steps

If Eligible:

Action	Owner	Timeline	Notes
[action item]	[responsible person/role]	[deadline/date range]	[relevant considerations]

(Include IEP development date/timeframe, priority need areas, related services to consider, assistive technology or behavior support considerations, and any immediate safety considerations.)

If Not Eligible: [Recommended general education supports with owner, conditions for re-referral, and any additional data to be gathered]

Attachments and Distribution

Documents Provided to Parent/Guardian: [Yes / No] Method: [secure email / portal / paper] Date: [date]

Attachments:

• [Document title and date]
• [Document title and date]

(List all attachments: evaluation reports, observation notes, intervention logs, parent input statement, dissenting statements, procedural documents. If any attachment is pending, document: "Pending—will provide by [date]; responsible party: [name].")

SLD Addendum

(Include this section ONLY when Specific Learning Disability is considered as an eligibility category.)

SLD Determination: [Student has SLD / Student does not have SLD]

Basis for Determination: [Statement confirming multiple data sources used]

Observation Summary: [Behavior observed during academic performance in areas of difficulty and relationship to academic functioning]

Achievement/Progress Pathway Used: [Insufficient achievement with insufficient progress to meet age/grade standards / Pattern of strengths and weaknesses]

Other Factors Considered: [Team's determination regarding effects of vision/hearing/motor disabilities, intellectual disability, emotional disturbance, cultural factors, environmental/economic disadvantage, limited English proficiency]

If Intervention-Response Process Used:

• Instructional strategies implemented: [list of strategies]
• Student-centered data collected: [description of data]
• Parent notification elements: [documentation per local requirements]

Team Member Certification: [Each group member certifies the report reflects their conclusion / Attach separate statement for any member whose conclusion differs]