Education Adjustment Program (EAP)
EAP Verification Form – ASD (EAP 3 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Autism Spectrum Disorder
Education Adjustment Program – Verification of Disability
Cover Sheet & Checklist
Student: Click here to enter text.
School: Click here to enter text.
Year Level: Click here to enter text.
Disability Category: Autism Spectrum Disorder
☐
☐
☐
☐
☐
☐
Initial Verification
Review
Adding
Removal
Changing
Transferring
(i.e. no previous verification)
of an existing verification
a new category to an existing verification:
from an existing category:
from an existing category to a new category:
into the RI System from a Non-Catholic sector
Adding
Removing ☐ASD
Change from
☐HI
☐HI
☐ID
☐ID
☐PI
☐PI
☐VI
☐SED
☐VI
☐SED
to ASD
☐SLI
Documentation Checklist: (All documents to be enclosed and ticked off by school to confirm inclusion in the submission.)
Process
EAP Consent Form
(EAP 1 updated 2013)
School
RI Verifier
Comments
EAP Verification Form
ASD (EAP 3 updated 2014)
PART A – Student Details
PART B – Evidence
Criterion 1
Section 1 – School to complete
Student Details
Section 2 – Specialist Report
PART B –
Criterion 2
Educational impact and adjustments
Part B - Verification Outcome
School to complete Student Details
Verifier to sign the outcome
PART C –
Principal Request/Signature
EAP Profile
Educational Planning Document
(IEP, PLP, ISP) etc
(or equivalent school planning doc.)
If Review – include previous EAP
Confirmation Documentation
Additional Attachments:
Specialist’s reports/assessments
Copyright in this work is owned by the State of Queensland (Acting through the Department of Education, Training and Employment) and has
been adapted by Religious Institute Colleges with consent.
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Education Adjustment Program (EAP)
EAP Verification Form – ASD (EAP 3 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Autism Spectrum Disorder
Members of the school team complete this form collaboratively, ensuring that relevant personnel have been involved in the data
gathering and decisions relating to the impairment and activity limitations and participation restrictions for this student.
The verification form in each of the EAP categories consists of the following sections which must be completed:



PART A Student Details
PART B Evidence Supporting Verification of Disability
PART C Principal Request for Verification of Disability
Two (2) copies of this form and required attachments (outlined in Part B) to be submitted to:
The RI EAP Verification Team at the RI Equity Network meeting
Part A: Student Details
Last Name
Click here to enter text.
Date of Birth
Click here to enter text.
First Name
Click here to enter text.
Gender
Click here to enter text.
School
Click here to enter text.
Year Level
Click here to enter text.
School Address
Click here to enter text.
School Phone
Click here to enter text.
Position
Click here to enter text.
Phone
Click here to enter text.
Contact person in school for this
verification
Click here to enter text.
Click here to enter text.
Email Address
Existing Categories:
☐Nil
☐ASD
☐HI
☐ID
☐PI
☐SLI
☐VI
This verification request is for:
☐
Initial Verification (i.e. no previous verifications)
☐
Review of an existing verification
☐
Adding a new category to an existing verification
☐
Changing EAP Category
☐
Removal from an existing category
☐
Transferring into RI College from a non-Catholic sector
Copyright in this work is owned by the State of Queensland (Acting through the Department of Education, Training and Employment) and has
been adapted by Religious Institute Colleges with consent.
P a g e |2
Education Adjustment Program (EAP)
EAP Verification Form – ASD (EAP 3 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Autism Spectrum Disorder
Part B: Evidence Supporting Verification of Disability in the Education Adjustment Program Category of Autism
Spectrum Disorder
Criterion 1: There is a medical diagnosis of Autism Spectrum Disorder
Section 1: STUDENT DETAILS – this section is be completed by the SCHOOL TEAM
Last Name:
Click here to enter text.
Date of Birth:
Click here to enter text.
First Name:
Click here to enter text.
Gender:
Click here to enter text.
Student Address:
Click here to enter text.
School:
Click here to enter text.
Year Level:
Click here to enter text.
School Phone:
Click here to enter text.
School Fax:
Click here to enter text.
☐
Other EAP verified disabilities:
☐
Other existing medical
Click here to enter text.
diagnoses:
The following reports are attached for your information:
Teacher observations/reports
☐
Specialist Staff (e.g. HOD, TLS Teacher) observations/reports
☐
Guidance Officer report/assessment
☐
☐
☐
☐
☐
Click here to enter text.
Speech-Language Pathologist report/assessment
Advisory Visiting Teacher report
Other (Specify) Click here to enter text.
Section 2: SPECIALIST REPORT – this section is to be completed by the SPECIALIST
For the purposes of the Education Adjustment Program category of Autism Spectrum Disorder, Criterion 1 requires the
completion of this section by a suitably qualified medical specialist (registered Paediatrician, Psychiatrist, Neurologist).
☐
I have assessed this student and with the information available, I am able to confirm a diagnosis of Autism Spectrum Disorder,
as described by the DSM-5 diagnostic criteria.
I recommend:
☐
☐
no review of diagnosis
a review of diagnosis in:
☐
☐
3 years
Other Click here to enter text.
OR
☐
I have assessed this student and with the information available, I am not able to confirm a diagnosis of Autism Spectrum
Disorder, as described by the DSM-5 diagnostic criteria.
Yes
I have attached my additional information/report that will assist with the educational planning for this student:
Signed
Date
Specialist’s Name
Medical Board Registration No: MED00
My Registered Area of Specialisation:
☐
Paediatrician
☐
Psychiatrist
☐
No
Neurologist
Address
Telephone Contact
Fax
Email
Copyright in this work is owned by the State of Queensland (Acting through the Department of Education, Training and Employment) and has
been adapted by Religious Institute Colleges with consent.
P a g e |3
Education Adjustment Program (EAP)
EAP Verification Form – ASD (EAP 3 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Autism Spectrum Disorder
Criterion 2: The identified Autism Spectrum Disorder results in activity limitations and participation restrictions for the student
at school requiring significant education adjustments.
This section is to be completed through a collaborative process which MUST include input from the student’s teacher/s.
Evidence of the educational impact of the identified impairment
The Prompts for ASD Criterion 2 Form can be used as a guide for the completion of this section
(http://education.qld.gov.au/students/disabilities/adjustment/verification/forms.html)
CURRICULUM
achieved curriculum
use of assistive technology
teaching strategies
staff resources
assessment/reporting
educational resources
specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the autism spectrum disorder:
Outline the associated significant education adjustments that are currently in place for this student:
COMMUNICATION
receptive
expressive
pragmatics (language use)
speech
specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the autism spectrum disorder:
Outline the associated significant education adjustments that are currently in place for this student:
SOCIAL PARTICIPATION/EMOTIONAL WELLBEING
social/interaction skills
self-management strategies
individualised plans
use of social development resources
specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the autism spectrum disorder:
Outline the associated significant education adjustments that are currently in place for this student:
LEARNING ENVIRONMENT/ACCESS
classroom and non-classroom environment
organisational skills
sensory needs
transition skills
specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the autism spectrum disorder:
Outline the associated significant education adjustments that are currently in place for this student:
HEALTH AND PERSONAL CARE, SAFETY
health management
risk management
self-care skills
specialised self-care procedure
individualised plans
specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the autism spectrum disorder:
Outline the associated significant education adjustments that are currently in place for this student:
Copyright in this work is owned by the State of Queensland (Acting through the Department of Education, Training and Employment) and has
been adapted by Religious Institute Colleges with consent.
P a g e |4
Education Adjustment Program (EAP)
EAP Verification Form – ASD (EAP 3 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Autism Spectrum Disorder
Verification of Disability in the Education Adjustment Program Category of Autism Spectrum Disorder
Verification Outcome:
Student Name: Click here to enter text.
Date of Birth: Click here to enter text.
School: Click here to enter text.
Year Level: Click here to enter text.
To be completed by the Verifier:
Criterion 1: The student has a current relevant diagnosis from a specialist
There is a specific diagnosis from the DSM-5 diagnostic category of Autism Spectrum
Disorder
☐
☐
YES
NO
Criterion 2: The student’s documented diagnosis results in activity limitations and participation restrictions at
school requiring significant educational adjustments.
YES
☐
There are documented activity limitations and participation restrictions relating to
the student’s diagnosis
NO
☐
YES
☐
Significant education adjustments are required and are related to the effects of the
diagnosed condition and are not due to other factors
NO
☐
Eligibility
The process indicated in the Religious Institute Colleges protocols has been followed and I confirm that this
☐
student meets DETE’s criteria for the category of Autism Spectrum Disorder
Ineligibility
The process indicated in the Religious Institute Colleges protocols has been followed and I confirm that this
☐
student does not meet DETE’s criteria for the category of Autism Spectrum Disorder
Comment:
Recommendation for review of
eligibility:
Review
required
☐ YES
☐ NO
Date:
Criterion 1
☐ YES
☐ NO
Date:
Criterion 2
☐ YES
☐ NO
Date:
Signed:
Date:
Name of Verifier:
Address:
Telephone contact:
Fax:
Email contact:
Copyright in this work is owned by the State of Queensland (Acting through the Department of Education, Training and Employment) and has
been adapted by Religious Institute Colleges with consent.
P a g e |5
Education Adjustment Program (EAP)
EAP Verification Form – ASD (EAP 3 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Autism Spectrum Disorder
Part C: Principal Request for Verification of Disability in the Education Adjustment Program Category of Autism
Spectrum Disorder
Verification of disability in the EAP category of Autism Spectrum Disorder according to DETE’s criteria is requested for the
following student according to the details outlined in PART A and PART B of this report and the related attachments:
Student Name Click here to enter text.
School Click here to enter text.
Date of Birth Click here to
enter text.
Year Level Click here to
enter text.
In making this request I have ensured that:

the student is enrolled and attending the school

a completed EAP Consent Form (EAP 1) is kept in the student’s school file

discussions have been held with the parent and/or student regarding this verification and agreement to proceed has
been reached

appropriate personnel have been involved in data gathering and reporting

processes are in place to support this student within the school

all documents for verification are complete

the original EAP documentation is kept in the student’s school file

copies of relevant documents will be sent to the EAP Verification Team as per RI processes.
Principal Name:
Principal Signature:
Date:
Copyright in this work is owned by the State of Queensland (Acting through the Department of Education, Training and Employment) and has
been adapted by Religious Institute Colleges with consent.
P a g e |6