Other Health Impairment Checklist
I.
Evaluations and Assessments
All 3 questions MUST be answered yes as required by state criteria.
1. Yes or No – Was a medical evaluation from a licensed doctor or clinical psychologist (current within one
year for initials) provided that indicates a diagnosis/prognosis of the child’s health impairment?
2. Yes or No – Does the medical evaluation report document the impact of the diagnosis/prognosis on the
vitality, alertness or strength of the child?
3. Yes or No – Was a comprehensive developmental or educational assessment completed to document
deficits in pre-academic or academic functioning, adaptive behavior, social/emotional development,
motor, or communication skills resulting from the health impairment?
II.
Eligibility
Both questions MUST be answered yes as required by state criteria.
1. Yes or No – Does the medical evaluation report document chronic or acute health problems that result
in significant limits to the child’s strength, vitality or alertness?
2. Yes or No – Does the developmental or educational assessment indicate deficits in at least one of the
following areas: pre-academic or academic functioning, adaptive behavior, social/emotional
development, and motor, or communication skills?
III.
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?
a. If yes, the student MAY NOT be eligible for OHI.
2. Yes or No – Does the student have an intellectual disability that should be considered as a determinant
factor impacting the student’s educational performance?
a. If yes, the student MAY NOT be eligible for OHI.
3. Yes or No – Are there exclusionary factors that need to be considered prior to eligibility determination?
a. If yes, the student MAY NOT be eligible for OHI.
IV.
Adversely Affects 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 Other Health Impaired
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