Required State Forms - Adverse Effect Form

See our list of commonly used acronyms

If the first step is the determination of disability and there is no indication of a disability, is this form necessary?
No, this form is unnecessary if there is no disability.


Is it necessary to complete the Adverse Effect Form and the Speech/Language Eligibility Form?
No. The Adverse Effect Form is not utilized when the Speech/Language Eligibility Form is being completed.

Do we need to use this form if we are considering speech and language as a related service?


Do we have to complete this form for LD even though we have already discussed adverse effect through the LD form?
No. The Adverse Effect Form is not utilized when the Learning Disability Evaluation Report is being completed.


Is it necessary to duplicate information on the Adverse Effect Form that is in other places?
Yes. If evidence was used and it supported/did not support an adverse effect, state the evidence and the score on the form even if it appears elsewhere. The Adverse Effect Form is intended to be a free-standing form that is not dependent on references to other documents.


Can "see report" or a reference to the name of the report on the form be used in place of scores and/or results?
No. The form is intended to be a stand-alone form and so must include scores and/or results. It is not sufficient to only reference an evaluation report or other document. It is permissible to either write “N/A” or leave a question blank if it was not part of the adverse effect determination.


Is it necessary to put the same information on the Adverse Effect Form and the Written Notice?
No. Reference the Adverse Effect Form in the Written Notice and attach the form to the Written Notice.


Where should the form be referenced in the Written Notice?
The Adverse Effect Form should be referenced under section #3 (“Describe each evaluation procedure, assessment, record, or report the School Administrative Unit (SAU) used as a basis for the proposed or refused action(s)”) and attached to the Written Notice.


Will the Department consider altering the Written Notice form (perhaps a subsection to #3) to document adverse effect for eligibility meetings only?
No. Altering the Written Notice form to document adverse effect for eligibility meetings would result in a cumbersome Written Notice. SAUs might find that objectionable for the multitude of other Written Notices that don’t require adverse effect documentation. Attaching the Adverse Effect Form to the Written Notice will eliminate the need to replicate the adverse effect data in the Written Notice.


What determines adverse effect (e.g. skills 1 standard deviation/1.5 standard deviation below the norm)?
It is up to the Individulized Education Program (IEP) Team to determine adverse effect given the following definition in MUSER: “The word ‘adverse’ means ‘harmful, impeding, obstructing, or detrimental.’ To ‘adversely affect’ means to have a negative impact that is more than a minor or transient hindrance, evidenced by findings and observations based on data sources and objective assessments with replicable results. An adverse effect on educational performance does not include a developmentally appropriate characteristic of age/grade peers in the general population.”


Do “partially meets” or “potentially clinically significant” data sources meet the level of adverse effect, or do the scores need to be “does not meet” or “clinically significant”?
The IEP Team should consider the definition of “adverse effect” referenced in the previous question.


If an SAU dismisses a student from special education, and if the SAU does not consider/verify all categories (#s 1-10) on the Adverse Effect Form, will the SAU set itself up for a problem?
The IEP Team must consider each category (#1-10), indicate yes, no or N/A, and verify a yes or no finding. There is nothing in MUSER that requires a determination to be based on data from every possible data category. The IEP Team must have data from a sufficient number of sources to make a judgment of adverse effect.


Will parents understand why all of the categories are not verified during the process?
It might be necessary to explain it to parents.

Should any of the 10 questions be given more weight than others?
The decision to give more consideration to certain assessments and/or data sources in the determination of adverse effect is an IEP Team decision.


Where does IQ go to be considered for diagnosis?
IQ scores could be a consideration in a determination of a disability but would not typically be part of a consideration of adverse effect.


Could examples of the different data sources be listed within each question (i.e. WIAT, WJ-R, NECAP, NWEA, PSAT)?
See the Determination of Adverse Effect Information Sheet for examples of data sources within each of the data categories.


How does the “Adverse Effect Form” bring the IEP Team to the question of whether or not specially designed instruction is needed (like the LD form does)?
Section III of the Adverse Effect form addresses this question.


Do we fill out this form at every annual review or only at the triennial and initial?
The form does not have to be completed annually. It must be completed only when initial or continued eligibility is at issue.

Do we fill out this form when we are dismissing a student from special education services?
Yes. A student is dismissed from special education services with the same procedures by which a student becomes qualified for services.


When do we need to begin to use this form?
Nov. 1, 2011

Are there samples on the DOE website?
Not at this time.

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