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BISMARCK PUBLIC SCHOOLS SPECIAL EDUCATION DEPARTMENT

INTELLECTUAL DISABILITY WORKSHEET

Determination of Disability: (Student’s name) meets special education eligibility under the category of Intellectual
Disability due to significantly sub average general intellectual functioning and significantly impaired adaptive behavior that
adversely affects (Student’s name) educational performance.

Qualifying Criteria
A student is eligible for special education in the area of Intellectual Disability when (ALL must be evident):

[ ] Significantly impaired intellectual functioning, which is defined in most cases as two or more standard deviations
below the mean, with consideration given to the standard error of measurement for the test, on an appropriate
individually administered, standardized measure of intelligence; AND

[ ] Significantly impaired adaptive behavior* in the home and/or community determined by a composite score on an
individual standardized instrument to be completed with or by the child’s primary caretaker which measures two or more
standard deviations below the mean, with consideration given to the standard error of measurement for the test; AND
*Adaptive Behavior Skills to Consider:
[ ] Conceptual: language/communication, reading, writing, math, knowledge, and memory
[ ] Social: interpersonal skills, social responsibility, following rules, social problem solving
[ ] Practical: activities of daily living, safety, work tasks, schedules/routines, organizing;

[ ] Significantly impaired adaptive behavior* in the school, daycare center, residence, or program determined by a
composite score on an individual standardized instrument to be completed with or by the child’s teacher which measures
two or more standard deviations below the mean, with consideration given to the standard error of measurement for
the test; AND
*Adaptive Behavior Skills to Consider:
[ ] Conceptual: language/communication, reading, writing, math, knowledge, and memory
[ ] Social: interpersonal skills, social responsibility, following rules, social problem solving
[ ] Practical: activities of daily living, safety, work tasks, schedules/routines, organizing

[ ] Developmental history that indicates the delays in intellectual and adaptive behavior functioning were manifested
during the developmental period.

[ ] As part of the specific eligibility criteria, the Team must consider general determinant (exclusionary) factors: lack of
appropriate reading and math instruction, language proficiency, culture, socio-economic status, attendance, frequent
moves, incarceration, substance abuse, etc. must be discussed and determined to not be primary factors for the student’s
lack of performance.

Adverse Impact on Educational Performance:


[ ] The team must also consider the adverse effect of the disability on educational performance and the need for
specially designed instruction.

Data for determining eligibility was gathered from (List multiple resources; Not all may apply):
[ ] Cumulative file review
[ ] Review of previous interventions
[ ] Interview/Developmental History Information (Teacher, Parent, Student)
[ ] Age-Appropriate Systematic Observation(s) – Adaptive Behavior
[ ] Age-Appropriate Adaptive Behavior Characteristics Checklist
[ ] Tests (Intelligence Tests (required), Adaptive Behavior Rating Scales (required), NDSA, MAP, CBMs, etc.)
[ ] Assessment Instrument Selection Form for Intellectual Disability (intended for use prior to assessment planning)
[ ] Other: _____________________

Note: Untestable situations:


[ ] History of extremely low adaptive behavior and poor functioning
[ ] At least 2 years delayed in academic growth
[ ] Very slow rate of growth (significantly below grade-level expectations)
[ ] Has been requiring specialized instruction to learn even at that slower pace
[ ] Documentation of history of attempts to administer formal cognitive measures and description of limitations preventing
testing
LAST REVISED 3/18/16
BISMARCK PUBLIC SCHOOLS SPECIAL EDUCATION DEPARTMENT

LAST REVISED 3/18/16