CONDITION REPORT: Noncategorical Early Childhood
Yes No
The child is between the ages of 3-5.
The child meets the specific eligibility criteria for one of the following: (delete what does not apply)
Intellectual Disability
Yes No
When given a standardized, individually administered test of cognitive ability, the child
demonstrates significantly subaverage general intellectual functioning in which the
overall test score is at least two standard deviations below the mean, when taking into
consideration the standard error of measurement of the test.
Yes No
The child demonstrates concurrent deficits in at least two of the following areas of
adaptive behavior:
Communication
Home living
Use of Community resources
Functional academic skills
Leisure
Safety
Yes
Self-care
Social and interpersonal skills
Self-direction
Work
Health
No
The child’s deficits are manifested during the developmental period.
By reason of the identified disability, the child needs special education and related
services.
(If no, explain.)
Emotional Disturbance
Yes
No
At the present time, the characteristics that Xxx exhibits are of sufficient severity,
intensity, and/or duration to meet criteria for the condition of emotional disturbance.
Specifically, Xxx exhibits one or more of the following characteristics over a long
period of time and to a marked degree: (give an explanation under each criterion of
why the student does or does not meet it)
(1) an inability to learn which cannot be explained by intellectual, sensory, or
health factors: (explain)
(2) an inability to build or maintain satisfactory interpersonal relationships with
peers and teachers: (explain)
(3) inappropriate types of behavior or feelings under normal circumstances:
(explain)
(4) a general pervasive mood of unhappiness or depression: (explain)
(5) a tendency to develop physical symptoms or fears associated with personal or
school related problems: (explain)
Yes
No
The emotional disturbance adversely affects the student’s educational performance.
By reason of the identified disability, the child needs special education and related
services.
(If no, explain.)
Autism
Yes
No
It has been determined that Xxx exhibits characteristics of autism* -- a developmental
disability significantly affecting verbal and nonverbal communication and social
interaction, generally evident before age three. Other characteristics often associated
with autism are engagement in repetitive activities and stereotyped movements,
resistance to environmental change or change in daily routines, and unusual responses
to sensory experiences.
*Students with all pervasive developmental disorders are included under this category.
If the student also is a student with an emotional disturbance, please explain:
Yes
No
The autism disorder adversely affects the student’s educational performance.
By reason of the identified disability, the child needs special education and related
services.
(If no, explain.)