Autism Eligibility Checklist

  1. Evaluations and Assessments

All 5 questions below MUST be answered yes as required by state criteria.

  1. Yes or No - Was a comprehensive psychological evaluation completed that included assessment of intellectual functioning and adaptive behavior?
  2. Yes or No – Was an educational evaluation completed to include an assessment of educational performance and current functioning levels?
  3. Yes or No – Was a communication evaluation completed to include assessment of verbal and non-verbal communication, prosody, and pragmatic language utilizing both formal and informal measures?
  4. Yes or No – Were behavioral evaluations completed to include assessment of social interaction and participation, peer and adult interactions, capacity to relate to others, stereotypical behaviors, resistance to change, atypical responses to sensory stimuli, persistent preoccupation with or attachment to objects or other behaviors often associated with autism?
  5. Yes or No – Was the developmental history assessed to include developmental differences and delays and age of onset, which is typically before the age of three?
  1. Eligibility

All 3 questions/characteristics below MUST be answered yes as required by state criteria.

  1. Yes or No – Developmental Rates and Sequences – Does the student exhibit delays, arrests, and or inconsistencies in the acquisition of motor, sensory, social, cognitive, or communication skills?
  2. Indicate which area or areas the student has delays, arrests, or inconsistencies – motor, sensory, social, cognitive, or communication skills? ______
  3. Yes or No - Social Interaction and Participation – Does the student display difficulties and/or idiosyncratic differences in interacting with people and participating in events?
  4. Yes or No – Communication (verbal and/or non-verbal) – Does the student display a basic deficit in the capacity to use verbal language for social communication, both receptively and expressively?

* Other areas that may be affected but NOT required for eligibility

  1. Yes or No – Sensory processing – Does the student exhibit unusual, repetitive, or unconventional responses to sensory stimuli of any kind?
  2. Yes or No – Repertoire of activities and interests – Does the student engage in repetitive activities and/or display marked distress over changes, insist on following routines and a have a persistent preoccupation with or attachment to objects?
  1. Other Considerations:
  1. Yes or No – Does the student have emotional disturbance that should be considered as a determinant factor impacting the student’s educational performance?
  2. If yes, the student MAY NOT eligible for Autism.
  3. Yes or No – Are there exclusionary factors that need to be considered prior to eligibility determination?
  4. If yes, the student MAY NOT be eligible for Autism.
  1. Educational Performance (academic, behavioral, and functional)
  1. Yes or No – Does the disability adversely affect the educational performance, and specially designed instruction is needed?

a) If yes, indicate how the educational performance is adversely affected - ______

______

b) If no, the student is NOT eligible for Autism

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