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AreaNeedsAutismDeaf/BlindDevelopmental DelayEmotional Behavior DisorderHearing ImpairedMultiple DisabilitiesMild Mental DisabilityFunctional Mental DisabilityOther Health ImpairedOrthopedic ImpairmentSpecific Learning DisabilitySpeech Language ImpairmentTraumatic Brain InjuryVision Impairment
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Needed for Referral ARCRTIXMust complete eligibity requirements for HI and VIXXXMust meet eligibity requirements for at least TWO disability categories. XXXXXXXX
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Vision ScreeningXXXXXXXXXXXX
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Hearing Screening XXXXXXXXXXXX
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Motor Screening**X*
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Communication ScreeningXXXXXXXXXXXX
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Evaluation Planning Form
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Health, Vision, Hearing, and Motor AbilitiesMedical/Health**XX*XX
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Vision Exam
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Functional Vision/LMAX
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Braille Skills*
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Orientation & Mobility*
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Hearing Screening X
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Fine Motor**
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Gross Motor**
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Occupational Therapy*
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Physical Therapy*
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Behavior ObservationXXXXX
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Assistive Technology
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Other: Functional Listening Assessmentx
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General IntelligenceCognitive**XX
X (if Method A)
*
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Behavior Observation**XX*
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Communication Status. NOTE: MUST CHOOSE AT LEAST ONE AREA FROM RECEPTIVE, EXPRESSIVE, SPEECH SOUNDS, VOICE, FLUENCY, OR ORAL-MECHReceptive Language X*X *
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Expressive LanguageX*X*
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Speech Sounds**X*
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Ovoice*X
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Fluency*X
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Oral - Mech*X
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Hearing Screening
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Behavior ObservationX*X*
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Augmentative Comm.**
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Academic PerformanceBasic Reading*XX
X (if Method A)
*
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Reading Comprehension*XX
X (if Method A)
*
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Reading Fluency*XX
X (if Method A)
*
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Math Calculation*XX
X (if Method A)
*
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Math Reasoning*XX
X (if Method A)
*
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Oral Expression
X (if Method A)
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Listening Comprehension
X (if Method A)
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Written Expression*XX
X (if Method A)
*
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Performance Based Tests**
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Criterion Reference Tests**
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Curriculum Based Tests**
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Behavior Observations*XXX*
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Social Emotional StatusAdaptive Behavior***XX*
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Behavior ObservationsX*XXX*
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Behavior Rating ScaleX*X*X**
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Functional Behavior Assessment
*
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Vocational Evaluation/Transition NeedsVocational Aptitutde
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Interest Inventory
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Learning Style
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Behavior Observations
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Other Social Developmental HistoryXXXXXXXXXXXX
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RTIXXXXXXXXXXXX
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IEP Progress Data***********
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State Assessment Data**********
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X = Required
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* = Optional/As Needed
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Triangulate data/ use multiple sources to substantiate the existence of the disability
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Confirm the progress of the student is impeded by the disability to the extent that the student's educational perfomrance is significantly and consistently below the level of same aged peers.
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This document was created for training and professional learning purposes only. The information, examples, evaluation components, and eligibility considerations included within this resource are intended to model common evaluation and eligibility practices used during the special education referral, evaluation, and eligibility determination process under Kentucky regulations. This document is designed to support training for ARC chairpersons, school psychologists, special education teachers, related service providers, and multidisciplinary evaluation teams and should not replace professional judgment, district procedures, KDE guidance, federal or state regulations, ethical evaluation practices, or individualized decision-making by an Admissions and Release Committee (ARC).
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