CHARLES COUNTY PUBLIC SCHOOLS
DEPARTMENT OF SPECIAL EDUCATION
Emotional Disability Eligibility Checklist
Name of Student:
School:
☐Y ☐N
1.
Date of Birth:
Date of Eligibility Determination:
Documentation, through an evaluation by a certified school psychologist, a licensed
psychologist, and/or a psychiatrist, of an emotional condition that is exhibited by one or
more of the following characteristics, exhibited over a long period of time and to a marked
degree (check all that apply):
☐An inability to learn that cannot be explained by intellectual, sensory, or health factors;
☐ An inability to build or maintain satisfactory interpersonal relationships with peers and
teachers;
☐Inappropriate types of behavior or feelings under normal circumstances;
☐ A general pervasive mood of unhappiness or depression; or
☐ A tendency to develop physical symptoms or fears associated with personal or school
problems.
Emotional disability includes schizophrenia. The term does not apply to children who are
socially maladjusted; unless it is determined they have an emotional disability.
Evaluation source/date:
☐Y ☐N 2.
Documentation of an educational evaluation that the disability has an adverse effect on
student functioning on academic and/or adaptive functioning within the school setting.
(including observations and performance measures)
Measures used:
☐Y ☐N 3.
The evaluation documents that the Emotional Disability interferes with the student’s ability
to function in an educational program using conventional instructional materials and
techniques.
Documentation from the evaluation that the student’s emotional disability is not PRIMARILY
caused by visual or auditory acuity deficits or motor deficits, intellectual disability, language
or learning disability, environmental or economic disadvantage, or cultural difference.
☐Y ☐N 4.
The IEP team used the above interpretation of the evaluation data to determine:
☐ The student has an Emotional Disability that adversely impacts his/her developmental
progress and is eligible for specifically designed instruction and related services (IEP).
☐ The student has an Emotional Disability 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 Emotional Disability 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