SLD Exclusionary Factors Checklist
Directions: Section §300.309 of the Individuals with Disabilities Education Improvement Act (IDEIA, 2014) mandates that Exclusionary Factors be considered, documented, ruled-out and as the primary cause of academic struggle prior to, and during the assessment process. Read each exclusionary factor and the accompanying questions and select Y (yes) or N (no) for each. Check each source of data used to measure the impact of each factor.
EXCLUSIONARY FACTOR: VISION
YES
NO
Does the student have a history of difficulties with vision?
Does the student wear glasses? If yes, does the student routinely wear glasses during instruction?
Has the student complained about not being able to see?
Has the school nurse conducted a Near-Vision Screener (within the past year)?
Did school nurse conduct a Far-Vision Screener (within the past -year)?
If yes, date of screening and its findings:
Did an ophthalmologist/optometrist conduct a formal vision test?
If yes, date and its findings:
Has the student been diagnosed with a vision disorder/disturbance?
If so, explain:
Does the student experience difficulty copying? Do they mis-align numbers, move closer to visual stimuli, squint or rub eyes when reading or using computers?
Sources of Data Used to Measure the Impact of this Exclusionary Factor (Check all that apply)
Review of Records
Parent Information
Health Screener
Teacher Information
Classroom Observation
Doctor's Report
Student Interview
Informal Vision Test
Comments:
EXCLUSIONARY FACTOR: HEARING
YES
NO
Does the student have a history of difficulties with hearing (including chronic ear infections, have tubes)?
Does the student wear hearing aides/devices? If yes, does the student routinely wear hearing device during instruction?
Has the student complained about not being able to hear?
Did school nurse conduct a hearing screener (within 1-year)?
If yes, date and findings:
Did an audiologist conduct a formal hearing test?
If yes, date and findings:
Does the student frequently request things be repeated orally? Do they misarticulate words, move closer to the source of a sound?
Has there been a determination between Auditory Discrimination and Hearing Difficulty?
Sources of Data Used to Measure the Impact of this Exclusionary Factor (Check all that apply)
Review of Records
Parent Information
Health Screener
Teacher Information
Classroom Observation
Audiologist Report
Student Interview
Test of Oral Language
Informal Hearing Test
Comments:
EXCLUSIONARY FACTOR: MOTOR SKILLS
YES
NO
Does the student have a history of motor difficulties?
Does the student exhibit fine motor difficulties?
If yes, please note:
Does the student exhibit gross motor difficulties?
If yes, please note:
Has the student been assessed by an OT and/or PT?
If yes, date and findings:
Does the student utilize motoric assistive devices?
If yes, please list:
Have assistive devices been utilized (e.g., weighted pencils, pencil grips, slant boards)?
Does the student exhibit motor difficulties in the classroom (e.g., illegible writing, serious difficulty with letter and number formation; difficulties with fine motor tasks such as using scissors or tracing lines)?
Sources of Data Used to Measure the Impact of this Exclusionary Factor (Check all that apply)
Review of Records
Parent Information
Health Screener
Teacher Information
Classroom Observation
Doctor's Report
Student Interview
Work Samples
Writing Passages
Fine Motor Assessment
Informal Motor Assessment
Comments:
EXCLUSIONARY FACTOR: INTELLECTUAL DISABILITY
YES
NO
Does the student exhibit sub-average intelligence (70 or below)?
IQ Score:
Date of testing:
Does the student exhibit severe deficits in 2 or more adaptive behavior skills (communication, social, self-care)?
If yes, please list:
Has adaptive behavior been recently assessed?
Date
Does student exhibit severe deficits in academic achievement? (70 or below?)
In which areas:
Is the student’s performance equally depressed in all academic areas?
Did these manifest during the developmental period?
Sources of Data Used to Measure the Impact of this Exclusionary Factor (Check all that apply)
Review of Records
Parent Information
Health Screener
Teacher Information
Classroom Observation
Doctor's Report
Student Interview
Work Samples
Intelligence/Cognitive Test
Achievement Test
Adaptive Test
Test of Oral Language
Comments:
EXCLUSIONARY FACTOR: EMOTIONAL DISTURBANCE
YES
NO
Does the student have a documented history of behavioral difficulties?
Are the student’s learning problems primarily the result of his/her behavior?
Have behavioral interventions been tried and progress monitoring data collected?
If yes, describe the outcome:
List interventions attempted hitherto:
Has a recent psychological assessment been conducted?
Date:
Has behavioral observations been conducted in multiple settings?
Findings:
Is there a history of a lack of motivation?
Is there evidence of possible emotional stress? E.g., Loss of parent/family member, loss of home, placement in foster care system, or other traumatic life event?
Sources of Data Used to Measure the Impact of this Exclusionary Factor (Check all that apply)
Review of Records
Parent Information
Health Screener
Teacher Information
Classroom Observation
Psychological Report
Student Interview
Work Samples
Intelligence/Cognitive Test
Achievement Test
Adaptive Test
Test of Oral Language
RTI Data
Behavioral Check
COVID-19 Impact Checklistlist
Comments:
EXCLUSIONARY FACTOR: CULTURAL
YES
NO
Is the student from a culture other than that which dominates in the school, community, or society where the student resides?
Do the family and school have conflicting educational and behavioral expectations for the student?
Are there conflicting social responses based on cultural expectations (not making eye contact, not speaking in class or volunteering, limited interaction with other students during group activities)?
Does the student have limited experience with the dominant local/school culture?
Is the student new to the United States?
If so, how long has he/she been in the United States?
How long has the student been exposed to the school system in the United States?
Was the student enrolled in school prior to entering the United States?
If so, how long?
Does the student have limited experience being taught in English?
Has miscommunication occurred between parents and school due to cultural and/or ethnic differences?
Do cultural/language barriers reduce or prevent parental involvement with the child’s schooling?
Are previously administered standardized assessments valid, taking into consideration the student’s culture?
Does the student have limited involvement in groups, associations, and activities?
Sources of Data Used to Measure the Impact of this Exclusionary Factor (Check all that apply)
Review of Records
Parent Information
Teacher Information
Classroom Observation
Classroom Observation
Student Interview
Comments:
EXCLUSIONARY FACTOR: ECONOMIC AND ENVIRONMENTAL DISADVANTAGED
YES
NO
Does the student reside in an economically depressed area?
Does the family have a low family income?
Do the parents work multiple jobs and have limited time for involvement?
Does the student have access to educational resources and materials at home (technology-computer, I-pad or tablet, smart phone, video gaming systems)?
How much access to technology and resources?
Minimal
Moderate
Extensive
Does the student have adequate access to health and nutrition (annual visits to dr., dentist, free or reduced lunch)?
Does the student have appropriate monitoring and supervision at home (to include routine times for school work and meals, adequate supervision, academic learning, and bedtime)?
Is the child exposed to a large number of at-risk factors (e.g., violence, crime, pollution, excessive number of people in the home, homelessness-past or present, etc.)?
Does the student have access to environmental conditions conducive to learning (e.g., space to study, adequate sleep, etc.)?
Does the student have adequate opportunities to participate in extracurricular activities (e.g., boy scouts, girl scouts, team sports, etc.)?
Does the student have adequate opportunity for educational experiences (trips to museums, library, zoo, etc.)?
Is there a history or current status of homelessness with student or family?
Are the parent or guardian unable to provide educational support?
Do circumstances prevent the student from receiving the help they require (e.g., glasses replaced, tutoring, prescriptions filled)?
Is there a history of educational neglect?
Is there a history of frequent transition (e.g., joint custody)?
Are there lifestyle factors that might undermine the student’s academic performance (e.g., forced to work)?
Explain:
Sources of Data Used to Measure the Impact of this Exclusionary Factor (Check all that apply)
Review of Records
Parent Information
Health Screener
Teacher Information
Classroom Observation
Doctor's Report
Coded At-Risk
Attendance Record
Free/Reduced Lunch
COVID-19 Checklist
Comments:
EXCLUSIONARY FACTOR: LIMITED ENGLISH PROFICIENCY
YES
NO
What is the dominant language spoken at home per the Home Language Survey:
Does the student speak both English and the dominant language at home?
Has someone validated the results of the Home Language Survey (e.g., parent interview, home visit)?
Oral Proficiency Score in native language:
in English:
s the student currently in a bilingual program?
If so, describe:
Has the student received bilingual instruction in the past?
If so, length and description:
What is the total number of years that the student has been exposed to English Instruction?
Basic Interpersonal Communication Skills (BICS) testing:
Cognitive Academic Language Proficiency (CALP) testing:
s there a specific dialect or cultural influences that might affect the student’s ability to speak or understand English?
Describe:
Sources of Data Used to Measure the Impact of this Exclusionary Factor (Check all that apply)
Home Language Survey
Language Background Checklist
Academic Language Exposure Checklist
Test of Language Proficiency
Teacher Information
Parent Information
Review of Records
RTI Data
Classroom Observation
Student Information
COVID-19 Checklist
Comments:
EXCLUSIONARY FACTOR: ADEQUATE INSTRUCTION IN READING AND MATH
YES
NO
Does the student have a documented history of excessive absences (including tardies and school suspensions)?
Explain:
Is there documented history of frequent mobility (e.g., migrant workers, military families, etc.)?
Is there documented history that the student has received instruction from highly qualified teachers?
Has the child received homeschool instruction?
How long?
Has the school documented the use of research-based instructional strategies with student?
Has student's response to instruction been documented through the collection of progress monitoring data?
Has documentation been provided to show a strong match between grade level curricula and the student’s skill level?
Has the student had interrupted schooling (e.g., mid-year relocation)?
Has the student been exposed to nontraditional education curriculum (e.g., homeschooling)?
Does the student have a new teacher (e.g., past 6-months)?
Did the student engage in virtual instruction for a period of time?
Describe:
Has the student changed schools often?
Sources of Data Used to Measure the Impact of this Exclusionary Factor (Check all that apply)
Teacher Information
Parent Information
Review of Records
Health Screener
Student Information
Classroom Observation
COVID-19 Checklist
Formal Achievement Test
RTI Monitoring Data
Attendance Records
Comments:
Other Comments:
Additional Notes: