Emotional Disability Eligibility Checklist Name of Student: Date of Birth: School: Date of Eligibility Determination: Y N 1. Documentation, through an evaluation by a certified school psychologist, a licensed psychologist, and/or a psychiatrist, of an emotional condition that is exhibited by or one more of the following characteristics, exhibited over a long period of time and to a marked degree all that apply): An inability to learn that cannot be explained by intellectual, sensory, or health factors; An inability to build or maintain satisfactory interpersonal relationships with peers and teachers; Inappropriate types of behavior or feelings under normal circumstances; A general pervasive mood of unhappiness or depression; or A tendency to develop physical symptoms or fears associated with personal or school problems. Emotional disability includes schizophrenia. The term does not apply to children who are socially maladjusted; unless it is determined they have an emotional disability. Evaluation source/date: Y N 2. Documentation of an educational evaluation that the disability has an adverse effect on student functioning on academic and/or adaptive functioning within the school setting. (including observations and performance measures) Measures used: Y N 3. The evaluation documents that the Emotional Disability interferes with the student’s ability to function in an educational program using conventional instructional materials and techniques. Y N 4. Documentation from the evaluation that the student’s emotional disability is not PRIMARILY caused by visual or auditory acuity deficits or motor deficits, intellectual disability, language or learning disability, environmental or economic disadvantage, or cultural difference. The IEP team used the above interpretation of the evaluation data to determine: The student has an Emotional Disability that adversely impacts his/her developmental progress and is eligible for specifically designed instruction and related services (IEP). The student has an Emotional Disability but it does not adversely impact his/her developmental progress; therefore, the student is not eligible for an IEP. The student does not have an Emotional Disability and is not eligible for an IEP. Evaluation data was insufficient to determine eligibility. Additional assessments and/or data will be obtained/collected in the area(s) of:
Emotional Disability Eligibility Checklist Name of Student: Date of Birth: School: Date of Eligibility Determination: Y N 1. Documentation, through an evaluation by a certified school psychologist, a licensed psychologist, and/or a psychiatrist, of an emotional condition that is exhibited by one or more of the following characteristics, exhibited over a long period of time and to a marked degree all that apply): An inability to learn that cannot be explained by intellectual, sensory, or health factors; An inability to build or maintain satisfactory interpersonal relationships with peers and teachers; Inappropriate types of behavior or feelings under normal circumstances; A general pervasive mood of unhappiness or depression; or A tendency to develop physical symptoms or fears associated with personal or school problems. Emotional disability includes schizophrenia. The term does not apply to children who are socially maladjusted; unless it is determined they have an emotional disability. Evaluation source/date: Y N 2. Documentation of an educational evaluation that the disability has an adverse effect on student functioning on academic and/or adaptive functioning within the school setting. (including observations and performance measures) Measures used: Y N 3. The evaluation documents that the Emotional Disability interferes with the student’s ability to function in an educational program using conventional instructional materials and techniques. Y N 4. Documentation from the evaluation that the student’s emotional disability is not PRIMARILY caused by visual or auditory acuity deficits or motor deficits, intellectual disability, language or learning disability, environmental or economic disadvantage, or cultural difference. The IEP team used the above interpretation of the evaluation data to determine: The student has an Emotional Disability that adversely impacts his/her developmental progress and is eligible for specifically designed instruction and related services (IEP). The student has an Emotional Disability but it does not adversely impact his/her developmental progress; therefore, the student is not eligible for an IEP. The student does not have an Emotional Disability and is not eligible for an IEP. Evaluation data was insufficient to determine eligibility. Additional assessments and/or data will be obtained/collected in the area(s) of: