Autism Spectrum Disorder Eligibility Checklist Name of Student: Date of Birth: School: Date of Eligibility Determination: Y N 1. Documentation of delays with on-set generally prior to age three in at least one of the following areas: Social Interaction Language used for social communication Symbolic or imaginative play Evaluation source/date: Y N 2. Impairment in social interaction in at least two (2) of the areas below: Marked impairment in the use of nonverbal behavior (e.g. eye gaze, facial expressions, body postures, gestures, etc.) Failure to develop peer relationships appropriate to developmental level. Lack of spontaneous seeking to share enjoyment, interests, or achievement with others (e.g., giving items, pointing, showing). Lack of social and emotional reciprocity. Source/Documentation:: Y N 3. Impairment in communication in at least one (1) of the areas below: in or lack of development of spoken language. Marked impairment in the ability to initiate and sustain conversation with others. Stereotyped and repetitive use of language or idiosyncratic language. Lack of varied, spontaneous make-believe play or social imitative play appropriate for developmental level. Source/Documentation: Y N 4. Impairment in Behavior/Restricted repertoire of activities and interests in at least one (1)of the areas below: Stereotyped and restricted patterns of interest that are abnormal in intensity or focus. Inflexible adherence to specific functional routines or rituals. Stereotyped and repetitive motor movements. Persistent preoccupation with of objects or things that move. Resistance to environmental change. Unusual responses to sensory experiences. Source/Documentation:
Autism Spectrum Disorder Eligibility Checklist Name of Student: Date of Birth: School: Date of Eligibility Determination: Y N 1. Documentation of delays with on-set generally prior to age three in at least one of the following areas: Social Interaction Language used for social communication Symbolic or imaginative play Evaluation source/date: Y N 2. Impairment in social interaction in at least two (2) of the areas below: Marked impairment in the use of nonverbal behavior (e.g. eye gaze, facial expressions, body postures, gestures, etc.) Failure to develop peer relationships appropriate to developmental level. Lack of spontaneous seeking to share enjoyment, interests, or achievement with others (e.g., giving items, pointing, showing). Lack of social and emotional reciprocity. Source/Documentation:: Y N 3. Impairment in communication in at least one (1) of the areas below: in or lack of development of spoken language. Marked impairment in the ability to initiate and sustain conversation with others. Stereotyped and repetitive use of language or idiosyncratic language. Lack of varied, spontaneous make-believe play or social imitative play appropriate for developmental level. Source/Documentation: Y N 4. Impairment in Behavior/Restricted repertoire of activities and interests in at least one (1)of the areas below: Stereotyped and restricted patterns of interest that are abnormal in intensity or focus. Inflexible adherence to specific functional routines or rituals. Stereotyped and repetitive motor movements. Persistent preoccupation with of objects or things that move. Resistance to environmental change. Unusual responses to sensory experiences. Source/Documentation: