NO NAME COMMUNITY SCHOOLS
CENTRALIZED EVALUATION TEAM REPORT
Name:
D.O.B.:
Drew
00-00
Grade:
N/A
Current Placement: ECDD
Age: 3
Date of Report:
Centralized Evaluation Team Members:
Kelly, Ed.S., School Psychologist
Kathy, M.A., Speech Pathologist
Pam, M.S.W., C.S.W. School Social Worker
Reason for Referral:
Drew was referred by the SSS team due to struggles with social interactions. He has a current educational
eligibility is ECDD.
Methods of Assessment:
Observation:
Drew was observed by the Centralized Evaluation Team in a variety of settings including school and home
on multiple occasions.
School Record Review:
There is minimal school history on Drew. Drew’s parent’s moved here from Iowa and he was not
attending a program there. Immunizations are up-to-date.
Teacher Interview:
ECDD Teacher reports that Drew struggles with social interactions, has frequent melt-downs, and has
almost zero ability to communicate wants and needs. He will adhere to the schedule of the classroom if
presented visually.
Parent Interview:
Drew’s parents report that he will sometimes interact with siblings if it is something he likes to do. When
the siblings are doing anything that does not interest Drew, he will not engage with them. Parents have
had concerns about Drew’s behavior from 2 years on. The parents have a written report from Dr. Noso
that indicates that he may have Autism Spectrum Disorder.
Childhood Autism Rating Scale (CARS):
On the CARS rating scale, he scored a total score of 27.
Definition of Autism Spectrum Disorder:
According to the Autism Society of America, autism is a complex developmental disability that typically
appears during the first three years of life. The result of a neurological disorder that affects the function of
the brain, autism impacts normal development of the brain in the areas of social interaction and
communication skills. Children and adults with autism typically have difficulty in verbal and non-verbal
communication, social interaction and leisure and play activities. Throughout the body of this report we
have assessed behaviors and reviewed information as they relate to autism spectrum disorder.
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Background and Social History:
Review of Educational Criteria for Autism Spectrum Disorder according to Rule # 340.1715:
Yes No
X
1. There is evidence of a lifelong developmental disability, related to autism spectrum disorder
that adversely affects a student’s educational performance in one or more of the following
performance areas: (If yes, please specify.)
Yes No
a. Academic
X
X
b. Behavioral
c. Social
X
Yes No
X
2. The suspected disability is characterized by qualitative impairments in reciprocal social
interactions, qualitative impairments in communication, and restricted range of
interests/repetitive behavior related to autism spectrum disorder and shall include ALL of
the following:
Yes No
a. Qualitative impairments in reciprocal social interactions related to autism
X
spectrum disorder (if yes, must specify at least 2).
X
b. Qualitative impairments in communication related to autism spectrum disorder
(if yes, must specify at least 1
X
c. Restricted, repetitive, and stereotyped behaviors related to autism spectrum
disorder (if yes, must specify at least 1).
X
d. Determination may include unusual or inconsistent response to sensory
stimuli, in combination with subdivisions (a), (b), and (c) above.
Yes No
X
3. There is not a primary diagnosis of emotional impairment such as schizophrenia. Although
autism spectrum disorder may exist concurrently with other diagnoses or areas of disability, to be eligible under
this rule, emotional impairment shall not be a primary diagnosis.)
X
X
4. The suspected disability is not due to the lack of instruction in reading and math, nor to
limited English proficiency.
5. This student requires special education programs/services under the criteria of Autism
Spectrum Disorder.
We recommend to the IEPT that this student is eligible for special education programs/services under the
autism rule (R340.1715). X Yes
No
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