Orthopedic Impairment Checklist
I.
Evaluations and Assessments
Both questions MUST be answered yes as required by state criteria.
1.
Yes or No – Was a current medical evaluation (within one year) from a licensed doctor of medicine
provided?
2. Yes or No – Was a comprehensive educational evaluation completed including assessments of academic
functioning, social/emotional development, adaptive behavior, motor, or communication skills?
a. If assessment indicates significant deficit(s) in cognitive/academic functioning, a psychological
evaluation shall be given.
II.
Eligibility
Both questions MUST be answered yes as required by state criteria.
1.
Yes or No – Does the current medical evaluation document the diagnosis/prognosis of the student’s
orthopedic impairment, defined as impairments caused by congenital anomalies (deformity or absence
of some limb, etc.), disease (muscular dystrophy, bone tuberculosis, etc.), or other causes (cerebral
palsy, amputations, fractures or burns that cause contractures, etc.)?
2. Yes or No – Does the comprehensive educational assessment (or the psychological evaluation, if
applicable) indicate the adverse effect of the orthopedic impairment on the student’s educational
performance in at least one of the following areas: pre-academic or academic functioning, adaptive
behavior, social/emotional development, motor or communication skills?
a. Indicate the area(s) adversely affected: _______________________________________
III.
Other Considerations
1.
Yes or No – Does the child’s intellectual functioning fall below the criteria outlined for a student with a
Mild Intellectual Disability?
a. If yes, the student should not be served in a program designed for orthopedic impairments, but
should be supported in other programs by the OI teacher.
2. Yes or No – Are there exclusionary factors that need to be considered prior to eligibility determination?
a. If yes, the student MAY NOT meet eligibility criteria for Orthopedic Impairment.
IV.
Educational Performance
1.
Yes or No – Does the disability adversely affect the educational performance and is specially designed
instruction needed?
a. If yes, indicate how educational performance is adversely affected - ______________________
______________________________________________________________________________
b. If no, the student is NOT eligible for Orthopedic Impairment.
**Note: Students served in a program for orthopedic impairments should be functioning no lower than criteria outlined
for mild intellectual disabilities programs. For those students with orthopedic impairments served in other special
education programs due to the severity of their sensory or intellectual disability, support by the OI teacher regarding the
implications of the student’s orthopedic impairment may be appropriate.
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