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

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