Summary of Eligibility for Other Health Impaired Rev. 7/13

Summary of Eligibility for Other Health Impaired Rev. 7/13

Yes / No / Evaluation Included:
Information gathered from parent(s)/guardian(s), teacher(s), and the student, when appropriate, support the results of the observations and standardized instruments. (If no, attach documentation.)
The student’s parent(s) or guardian(s) were notified about the amount and nature of student performance data that would be collected and the general education services that would be provided, interventions for increasing the student’s rate of progress, and the parental or guardian right to request an evaluation.
Student has been diagnosed within the past 12 months by a Florida physician qualified to assess the student’s medical condition
An educational evaluation (curriculum based evaluation, RtI data, standardized test results and/or additional evaluation as recommended by team) identifies educational and/or environmental needs.
Yes / No / Is lack of performance and/or rate of progress PRIMARILY THE RESULT OF / Specify the documentation supporting each factor:
Limited English Proficiency
Lack of appropriate instruction
Yes / No / All of the following statements should be answered “Yes” to make a determination of “Eligible” in the area of Other Health Impaired.
Response to scientific, research-based instruction/intervention is inadequateOR
Intensive interventions are demonstrated to be effective, but require sustained and substantial effort OR
Intensive interventions were not recommended due to the nature and severity of the health impairment. (The evaluation team, including the parent, did not recommend tiered interventions. Meeting held onDATE.) A supervisor must be invited to and/or give written input for the team meeting where this is discussed.
The student demonstrates evidence of eligibility for Other Health Impaired. Diagnosed health impairment results in reduced efficiency in schoolwork because of a temporary or chronic lack of strength, vitality or alertness.(Evidenced by information gathered from parents, teacher, student, if appropriate, observation, and results of standardized norm-referenced instruments, if appropriate.)
The student demonstrates a need for special education services over and above what is provided through general education.
Yes / N/A / AdditionalTeam Recommendations:
Current eligibilities/related services:
Further action:
Signatures of group determining eligibility. Each of the following individuals certifies their agreement with the determination of eligibility and assures that this determination was made in accordance with subsection (6) of Rule 6A-6.0331. Please sign over your title or write in your position.
ESE Director/Designee / Parent / Parent
General Education Teacher / ESE Teacher / Speech/Language Pathologist
School Psychologist / Other: Name/Position / Other: Name/Position
School Based Administrator / Other: Name/Position / Other: Name/Position
The following team members DISAGREE with the conclusion of the group. Attach a separate statement presenting each member’s conclusion.
Name/Position / Name/Position / Name/Position