Enter District Name Here
Functional Mental Disability (FMD)
Eligibility Determination Form
Attachment to Admissions and Release Committee (ARC) Conference Summary
Initial Determination of Eligibility for this Re-Determination of Eligibility for this Category of
Category of Disability Disability
Student’s Full Name: SSID:
Date of Birth: Date of Eligibility Determination:
School:
The ARC determines a student to have a functional mental disability and is eligible for specially designed
instruction and related services when:
Complete
During The ARC compared and analyzed evaluation data and documents the following interpretation:
ARC
Y N 1a. Cognitive functioning is at least three standard deviations below the mean.
Y N 1b. Adaptive behavior is at least three standard deviations below the mean.
Y N 1c. A severe deficit exists in overall academic performance including acquisition, retention
and application of knowledge.
Insufficient
Y N 1d. Manifestation is typically during the developmental period.
Y N 2. Evaluation information confirms there is an adverse effect on educational performance.
Y N 3. Evaluation information confirms lack of instruction in reading and math is not a
determinant factor in the eligibility decision.
Y N 4. Evaluation information confirms limited English proficiency is not a determinant factor in
the eligibility decision.
On the following page provide supporting documentation that demonstrates the ARC:
• Used multiple sources to triangulate the data and substantiate the existence of the disability; and
• Confirmed the progress of the student is impeded by the disability to the extent the student’s educational
performance is significantly and consistently below the level of similar age peers.
Page |1 Functional Mental Disability Eligibility Determination Form
Revised 2016
Functional Mental Disability
Eligibility Determination Form
Student’s Full Name: SSID:
Supporting Documentation:
The ARC used the interpretation of the evaluation data documented above to determine:
The student meets the eligibility criteria for a functional mental disability, which adversely impacts his/her
education, and is eligible for specially designed instruction and related services.
The student does not meet the eligibility criteria for a functional mental disability and is not eligible for
specially designed instruction and related services.
The student has a functional mental disability, but it does not adversely impact his/her education; therefore,
the student is not eligible for specially designed instruction and related services.
Evaluation data are insufficient to determine eligibility. Additional assessments and data will be obtained
in the area(s) of:
The ARC will reconvene by to review and determine eligibility.
Page |2 Functional Mental Disability Eligibility Determination Form
Revised 2016
