Education Adjustment Program (EAP)
EAP Verification Form – SED (EAP 9 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Social Emotional 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: Social Emotional 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
☐ASD
Removing ☐ASD
Change from
☐HI
☐HI
☐ID
☐ID
☐PI
☐PI
☐SLI
☐SLI
☐VI
☐VI
☐SED
To SED
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)
EAP Verification Form
SED (EAP 9 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 Professional Reasoning
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
School
RI Verifier
Comments
Education Adjustment Program (EAP)
EAP Verification Form – SED (EAP 9 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Social Emotional 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
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Date of Birth
Click here to enter text.
First Name
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Gender
Click here to enter text.
School
Click here to enter text.
Year Level
Click here to enter text.
School Address
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School Phone
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Position
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Phone
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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 Brisbane Catholic Education and Religious Institute Colleges with consent.
P a g e |1
Part B: Evidence Supporting Verification of Disability in the Education Adjustment Program Category of
Social Emotional Disorder
Criterion 1: The student has a current relevant diagnosis from a medical specialist (must be a
paediatrician, psychiatrist or neurologist).
Section 1: Student details (this section to be completed by the school)
Last Name
Date of Birth
First Name
Gender
School
Year Level
School Phone
School Fax
Section 2: Medical specialist report (this section to be completed by the specialist)
I have assessed this student and with the information available, am able to confirm the diagnosis, as described by the DSM-5
diagnostic criteria of (please mark as applicable):
Neurodevelopmental Disorders:
Attention Deficit/Hyperactivity Disorder:
Predominantly Inattentive Presentation
Predominantly Hyperactive/Impulsive
Presentation
Combined Presentation
N.B. A diagnosis of ADHD alone does not meet QCEC
criteria for verification unless it co-exists with another
clinically diagnosed social emotional diagnosis. If so
please mark the other diagnosis on this page.
Anxiety Disorders:
Feeding & Eating Disorders:
Separation Anxiety Disorder
Anorexia Nervosa
Selective Mutism
Bulimia Disorder
Disruptive, Impulse Control & Conduct
Disorders:
Specific Phobia
Social Anxiety Disorder
Oppositional Defiant Disorder
Panic Disorder
Conduct Disorder
Agoraphobia
Personality Disorder:
Generalised Anxiety Disorder
Tic Disorders:
Tourette's Disorder
Type:
Unspecified Anxiety Disorder
Persistent (Chronic) Motor or Vocal Tic Disorder
Obsessive-Compulsive & Related Disorders
Schizophrenia Spectrum & other Psychotic Disorders:
Obsessive - Compulsive Disorder
Schizophrenia
Body Dysmorphic Disorder
Bipolar & Related Disorders:
Bipolar Disorders
Depressive Disorders:
Other: DSM-5 social emotional diagnosis
Trauma & Stressor - Related Disorders:
Reactive Attachment Disorder
Major Depressive Disorder
Posttraumatic Stress Disorder
Persistent Depressive Disorder (Dysthymia)
Adjustment Disorders
I have assessed this student and with the information available, am NOT able to confirm a social emotional diagnosis, as described by the DSM-5
diagnostic criteria.
I acknowledge that in making a DSM-5 diagnosis for this student that the following have been considered and affirmed:
* Multiple sources of data about the student's behavioural and emotional functioning have been considered.
* The effects of the condition are exhibited in at least two different settings, one of which is school related.
* The student's behavioural or emotional responses are markedly different from appropriate age, cultural or ethnic norms.
* Performances in areas such as self care, social relationships, personal adjustment, academic progress and classroom behaviour or work adjustment have
been adversely affected.
* The diagnosed condition is not a temporary, expected response to stressors in the student's environment and would persist even with individual
intervention.
I recommend a review of diagnosis in:
1 year
2 years
3 years
Other
I have attached additional information/reports that will assist with the educational planning for this student:
Signed
Date
Sign here
My Medical Board Registration No:
Name
My Registered Area of Specialisation:
Paediatrician
Psychiatrist
Address
Fax
Telephone contact
Yes
Email
Neurologist
No
Education Adjustment Program (EAP)
EAP Verification Form – SED (EAP 9 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Social Emotional
Disorder
Criterion 2: The identified Social Emotional 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 SED Criterion 2 Form can be used as a guide for the completion of this section
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 social emotional 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 social emotional 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 social emotional 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 social emotional 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 social emotional 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 Brisbane Catholic Education and Religious Institute Colleges with consent.
P a g e |3
Education Adjustment Program (EAP)
EAP Verification Form – SED (EAP 9 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Social Emotional
Disorder
Proposal for Verification in the EAP Category of Social Emotional Disorder
(To be completed by the School Guidance Officer or Consulting Psychiatrist, Paediatrician)
Student Name: Click here to enter text.
Date of Birth: Click here to enter text.
Profession Specific Quality Assurance Decision Making:
Provide a statement summarising the evidence considered when making a proposal for verification in the EAP
category of Social Emotional Disorder, or removal of an existing verification in the EAP category of Social
Emotional Disorder.
Criteria
Applicable details – Please complete
There are activity limitations and participation
restrictions resulting from the diagnosed
condition
Confirmed
☐ YES
☐ NO
The activity limitations and participation
restrictions resulting from the condition are
sufficiently severe to require significant
education adjustments
☐ YES
☐ NO
Adjustments related to the effects of the
diagnosed condition have been put into place
and programs implemented using the schools
usual resources and these were found to be
insufficient to meet the student’s needs.
☐ YES
☐ NO
Comments:
Following the QCEC criteria and RI Colleges’ Equity Network processes, I have gathered, documented and
considered all available data for this student and with the information I am able to:
☐
Propose the verification of Social Emotional disorder as described by the QCEC criteria
☐
Propose the removal of the existing verification of Social Emotional Disorder as described by the QCEC
criteria
School Guidance Officer or Consulting Psychologist or Psychiatrist
Name: Click here to enter text.
Signature:
Email:
Date:
Click here to enter text.
Click here to enter text.
Phone: Click here to enter text.
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 Brisbane Catholic Education and Religious Institute Colleges with consent.
P a g e |4
Education Adjustment Program (EAP)
EAP Verification Form – SED (EAP 9 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Social Emotional
Disorder
Verification Outcome:
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.
To be completed by the Verifier:
Criterion 1: The student has a current relevant diagnosis from a specialist
☐
☐
There is a relevant and documented diagnosis from the DSM-5
YES
NO
Criterion 2: The student’s documented social and emotional 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 the criteria for the QCEC category of Social Emotional Disorder
Ineligibility
The process indicated in the Religious Institute Colleges protocols has been followed and I confirm that this
☐
student does not meet the criteria for the QCEC category of Social Emotional 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 Brisbane Catholic Education and Religious Institute Colleges with consent.
P a g e |5
Education Adjustment Program (EAP)
EAP Verification Form – SED (EAP 9 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Social Emotional
Disorder
Part C: Principal Request for Verification of Disability in the Education Adjustment Program Category of Social
Emotional Disorder
Verification of disability in the EAP category of Social Emotional Disorder according to QCEC’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 Brisbane Catholic Education and Religious Institute Colleges with consent.
P a g e |6
Education Adjustment Program (EAP)
EAP Verification Form – SED (EAP 9 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Social Emotional
Disorder
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 Brisbane Catholic Education and Religious Institute Colleges with consent.
P a g e |7