PLAINVILLE COMMUNITY SCHOOLS
SIMSBURY PUBLIC SCHOOLS
Worksheet for Determination of Eligibility for
Special Education Services under the Classification of Autism
Name: __________________________ Grade: ______ Date: ___________
The student should meet the criteria below to be eligible for special education services under the classification of autism.
The student:
A. has been evaluated by a professional with appropriate training, using an autism specific instrument, and must be found to be functioning in the range of autistic spectrum disorders Yes No
B. demonstrates a disability that adversely affects educational performance as evidenced by professional judgment and/or scores that fall significantly below average (-1.5 SDs) in all of the following areas: social interaction, verbal/nonverbal communication and atypical behaviors. Yes No
C. does not perform effectively in the social or academic area most of the time, despite the provision of general education accommodations and supports. Yes No
Results of the Evaluation:
Impairment that Evidenced
adversely affects by:
educational Observation performance (O), Clinical
Judgment (CJ) and/or Formal Area Testing (FT)
Social Interaction
-Deficits in nonverbal communication (eye gaze, gesture) Yes No NA O CJ FT
-Limited efforts to establish joint attention or share
experience Yes No NA O CJ FT
-Significant deficits in social/emotional reciprocity Yes No NA O CJ FT
-Lack of developmentally appropriate peer relations Yes No NA O CJ FT
-Lack of developmentally appropriate symbolic
play/imagination Yes No NA O CJ FT
-Inability to make functional adjustment to the
social environment Yes No NA O CJ FT
*Does the student meet the criteria of demonstrating at least two characteristics from this area?
Yes No
Communication
-Significant deficits in receptive language Yes No NA O CJ FT
-Significant deficits in expressive language Yes No NA O CJ FT
-Significant deficits in pragmatic language Yes No NA O CJ FT
*Does the student demonstrate at least one characteristic from this area? Yes No
Atypical Behaviors
-Restricted or repetitive interests Yes No NA O CJ FT
-Stereotyped, repetitive movements Yes No NA O CJ FT
-Adherence to nonfunctional routines Yes No NA O CJ FT
*Does the student demonstrate at least one characteristic from this area? Yes No
(children under age 5 who have ASD may not exhibit atypical behaviors to this requirement may be waived)
Rule Out/Eliminate Other Factors
Other causes/contributing factors such as medical problems, environmental or cultural factors, and emotional disturbance have been ruled out as the primary cause of the student's educational difficulties
Yes No
Based on the above, does the student meet the criteria for classification under the category of Autism?
Yes No
The PPT has reviewed the information presented and has made the determination that the student met the criteria for eligibility for special education services as defined in IDEA and Connecticut statutes.
Yes No
SIGNATURE TITLE
________________________________________________________ General Education Teacher
________________________________________________________ Examiner/special education instruction
________________________________________________________ Examiner/pupil personnel services
________________________________________________________ Administrator
________________________________________________________ Other ________________________________________________________
________________________________________________________ Other ________________________________________________________
If this report does not reflect a team member’s conclusion s/he must indicate below her/his reasons and conclusion.
Name Title Signature
Reason(s) and conclusion:
Reference: State of Connecticut Department of Education Guidelines for Identification and Education of Children and Youth with Autism (2005)
11/1/09
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- eligibility checklist for the impairment of autism
- special education eligibility criteria and evaluation for
- autism worksheet 1 of 2
- category definitions and eligibility criteria
- dsm iv criteria title add e
- draft general eligibility form vdoe
- plainville community schools
- is special education the right service
Related searches
- teaching philosophy for community college
- why should community colleges be free
- why community college is bad
- why are community colleges bad
- why community college is better
- new haven community schools employment
- richmond community schools indiana
- new haven community schools jobs
- first community bank 1 community place va
- south lyon community schools skyward
- lake station community schools website
- lake station community schools edison