CHARLES COUNTY PUBLIC SCHOOLS DEPARTMENT OF SPECIAL EDUCATION
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:
☐ Delay 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 parts of objects or things that move.
☐ Resistance to environmental change.
☐ Unusual responses to sensory experiences.
Source/Documentation:
The IEP team used the above interpretation of the evaluation data to determine:
☐ The student meets the criteria for an educational disability of Autism Spectrum Disorder (a total of six or more items from the above ) and is eligible for specifically designed instruction and related services (IEP).
☐ The student meets the criteria for an educational disability of Autism Spectrum Disorder but it does not adversely impact his/her developmental progress; therefore, the student is not eligible for an IEP.
☐ The student does not meet the criteria for an educational disability of Autism Spectrum Disorder 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:
SE 07/13