Autism Eligibility Checklist
Date___________________
School________________________
Student_________________________________________
Grade________
Informant________________________________
I am gathering information to prepare for this student’s re-evaluation for Autism Services. Please
complete and return to __________________________ in written or electronic form as soon as you
can.
__________________________________________________________________________________
Directions: CHECK appropriate choice after each question
SOCIAL SKILLS:
Yes
No
Sometimes
Yes
No
Sometimes
Does the student initiate social interactions with peers?
Verbally?
Physically?
Does the student initiate social interactions with adults?
Verbally?
Physically?
Does the student have friends?
Does the student talk or interact in small group settings?
Does the student talk or interact in large group settings?
Are they engaged with peers in recess/free time activities?
If yes, approximately for how many minutes?
Addition comments or information:
ATTENDING SKILLS:
Does the student follow verbal directions given to the class?
Does the student appear not to understand verbal directions?
Does the student follow written directions given to the class?
Does the student follow directions given individually?
Does the student manage self from one activity to another?
Is the student distracted during work?
If yes, distracted by what?
How many minutes can the student work independently?
Addition comments or information:
WORK SKILLS:
Yes
No
Sometimes
Yes
No
Sometimes
Does the student organize their work materials?
Does the student get the work done and turned in as expected?
Does the student start tasks independently?
Does the student work through the task independently?
Does the student hand in homework as expected?
Addition comments or information:
COMMUNICATION SKILLS:
Does the student ask for help when needed?
Does the student participate in class discussions?
Does the student make eye contact with adults in class?
Does the student stay on topic?
Does the student have a favorite topic of interest?
If yes, what is it?
Does the student respond to verbal questions?
Addition comments or information:
SENSORY ISSUES:
Do noises bother the student?
If yes, are they loud noises?
If yes, are they repetitive noises?
If yes, are they unexpected noises?
Does the student prefer to listen to music while working?
Does the student carry most materials in their backpack vs. using a
locker? (middle/high only)
Does the student navigate the hallways with a crowd?
(middle/high only)
Does the student have a difficult time with food choices?
If yes, do they prefer soft food?
If yes, do they prefer crunchy food?
Does the student prefer the same foods when given a choice?
Does the student have any clothing issues?
If yes, do they wear the same clothes?
If yes, do they complain about their clothing?
Does the student seemed bothered by shoes and/or socks?
Does the student bite nails, pick skin etc?
Yes
No
Sometimes
Does the student have any toileting or hygiene issues?
If yes, what are they?
Addition comments or information:
1) What does the child do well?
2) What bothers the student?
How is this student different from his/her typical peers in the following areas?
Impairments in Communication: expressive/receptive
Repetitive Behaviors: planning, organization, schedule changes, transitions, cause/effect, getting started
and finishing tasks, open ended assignments, literal interpretation, perseverations.
Impairments in Social Interaction: peers vs. adults, group work, social greetings, reciprocal
conversation,
Unusual Responses to Sensory Information: activity level, ability to focus, fine and gross motor,
sensitivities.