Bismarck Public Schoolsspecial Education Department

BISMARCK PUBLIC SCHOOLSSPECIAL EDUCATION DEPARTMENT

ORTHOPEDIC IMPAIRMENT WORKSHEET

DETERMINATION OF DISABILITY: (Student’s name) meets eligibility for special education under the category of Orthopedic Impairment as defined as a severe orthopedic impairment that adversely affects (Student’s name) educational performance. The term includes impairments caused by congenital anomaly (e.g., clubfoot, absence of some member, etc.), impairments caused by disease (e.g., poliomyelitis, bone tuberculosis, etc.), and impairments from other causes (e.g., cerebral palsy, amputations, and fractures or burns that cause contractures).

Qualifying Criteria:

The following criteria must be met prior to an evaluation team determining a child to have an orthopedic impairment:

[ ] An orthopedic impairment has been diagnosed and documented by a qualified professional; AND

[ ] The evaluation team conducts assessment procedures, and/or uses existing data to specifically describe those characteristics (i.e.,physical limitations) of a child’s orthopedic or medical condition that adversely impacts educational performance; AND

[ ] The team documents the resulting need for specially designed instruction, the type of instruction required, and why it cannot be provided by general education.

Adverse Impact on Educational Performance:

[ ] Documentation of adverse impact on educational performance resulting in the need for specially designed instruction, the type of instruction required, and why it cannot be provided by general education.

Data for determining eligibility was gathered from (List multiple resources; Not all may apply):

[ ] Cumulative file review

[ ] Review of previous accommodation, modifications, and/or interventions

[ ] Review of classroom based assessments

[ ] Interview Information (Teacher, Parent, Student)

[ ] Observation(s) (e.g., classroom, large group, small group, etc.) Date(s): ______

[ ] A review of the student’s health history, including verification of medical diagnosis

[ ] Checklists and/or Tests:.(i.e., Brigance Screen, Peabody Developmental Motor Scale, Day-C, Carolina Test of Gross Motor Development)

[ ] Other: ______

NOTE: A minimum of one observation in area of disability required (best practice would be three observations)

LAST REVISED 2/6/17