REV-8/11
Cumberland County
IDEA
OTHER HEALTH IMPAIRMENT IDENTIFICATION FORM
Student's Last Name, First Name / SchoolStudent's Date of Birth / Student's Grade
Teacher's Name / Date
CRITERIA FOR DETERMINING ELIGIBILITY UNDER OTHER HEALTH IMPAIRMENT
1. / The student exhibits limited strength (inability to perform typical or routine tasks at school), vitality (inability to sustain effort or endure throughout an activity) or alertness (inability to manage and maintain attention, to organize or attend, to prioritize environmental stimuli, including a heightened alertness to environmental stimuli) that results in a limited alertness with respect to the educational environmentAND
2. / Is due to chronic or acute health problems
AND
3. / Adversely affects the student’s educational performance.
REPORT
(IF CONSIDERING ADD/ADHD START WITH QUESTION #2)
1. / Does the student have chronic or acute health problems such as: asthma, diabetes, epilepsy, heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, sickle cell anemia?Verification (medical report):
Have the health problems been present for at least 6 months (verification)? / yes
yes / no
no
2. / Does the student exhibit symptoms that indicate the possibility that the student has an attention deficit disorder and/or attention deficit hyperactivity disorder (as defined by DSM-IV)? If so:
A. Have at least six of the DSM-IV symptoms of inattention and / or hyperactivity / impulsivity persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level?
Verification:
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
Verification:
C. Some impairment from the symptoms is present in two or more settings.
Verification:
D. The team agrees that the symptoms are not exclusively related to a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder.
Verification:
If the team has answered no to A, B, C or D, student is not eligible for special education services as a student with attention deficit disorder or attention deficit hyperactivity disorder / yes
yes
yes
yes
yes / no
no
no
no
no
3. / The IEP Team has determined that there is an adverse effect on educational performance as noted on the Determination of Adverse Effect Form. / yes / no
4. / Relevant information noted during the observation(s)
5. / Is the impact of the student’s health impairment correctable through accommodations of the student’s regular education program (if so, student is not eligible for special education services as a student with a health impairment)?
Verification: / yes / no
6. / Is the impact of the student’s health impairment correctable only through specially designed instruction (if so, student is eligible for special education services as a student with a health impairment)? / yes / no
ELIGIBILITY DECISION: It is the conclusion of the pupil evaluation team that this Student IS / IS NOT eligible for special education as a student with a health impairment.
I certify that this report reflects my conclusions.
Name / TitleName / Title
Name / Title
Name / Title
Name / Title
Name / Title
Name / Title
Name / Title
Name / Title
Name / Title
Name / Title
I certify that this report does not reflect my conclusion.
Name / Title
Name / Title
Name / Title
Name / Title
As parents of a student with a disability you have protections under the procedural safeguards, which are enclosed, of the Maine Special Education Regulations. Sources for parents to contact to obtain assistance in understanding the provisions of these regulations call: Director of Special Services,Gorham School Department, (207-222-1002, fax 207-839-5001 or ), Department of Education, Division of Special Services (207-624-5950, fax 207-624-5900 or or Special Needs Parent Information Network at 1800-870-SPIN.
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C:\Users\User\Desktop\Special Ed Forms 09-10\OHI Eval Report 8-11.doc