CHARLES COUNTY PUBLIC SCHOOLS
DEPARTMENT OF SPECIAL EDUCATION
Other Health Impairment Eligibility Checklist
Name of Student:
School:
☐Y ☐N
1.
Date of Birth:
Date of Eligibility Determination:
Documentation is present of a comprehensive evaluation by a licensed physician, licensed
psychologist, or certified school psychologist of a health impairment that limits the student
in the area of (check all that apply):
☐Strength
☐ Vitality
☐Alertness ( including a heightened alertness to
environmental stimuli that results in limited alertness with respect to the educational
environment)
Indicate chronic or acute health condition:
☐ asthma
☐ attention deficit hyperactivity disorder
☐ diabetes
☐ epilepsy
☐ heart condition
☐ hemophilia
☐ leukemia
☐ lead poisoning
☐ nephritis
☐ rheumatic fever
☐ sickle cell anemia ☐ Tourette syndrome
☐ other__________________________
Evaluation source/date:
☐Y ☐N 2.
There is documentation of an educational evaluation which documents an adverse effect on
educational performance due to one or more of the documented characteristics of the Other
Health Impairment. (including observations and performance measures)
Measures used:
☐Y ☐N 3.
The evaluation documents that the health impairment interferes with the student’s ability to
function in an educational program using conventional instructional materials and
techniques.
The IEP team used the above interpretation of the evaluation data to determine:
☐ The student has an Other Health Impairment that adversely impacts his/her developmental
progress and is eligible for specifically designed instruction and related services (IEP).
☐ The student has an Other Health Impairment but it does not adversely impact his/her
developmental progress; therefore, the student is not eligible for an IEP.
☐ The student does not have an Other Health Impairment 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