CHARLES COUNTY PUBLIC SCHOOLS
DEPARTMENT OF SPECIAL EDUCATION
Language (Receptive or Expressive) Eligibility Checklist
Name of Student:
School:
☐Y ☐N 1.
Date of Birth:
Date of Eligibility Determination:
Documentation is present of consistent, inappropriate use of one or more of the following
structures of language:
Scores of 1.5 standard deviation or greater below the mean on one or more areas of language
corroborated by more than one measure by standardized tests of semantics, syntax,
morphology, and pragmatics.
OR
Demonstrates atypical language behaviors, e.g. errors in word retrieval, pragmatics or
significant difficulty expressing wants and needs as measured by an oral language sample,
informal testing, checklist, and/or by documented observation of the student’s behavior.
Evaluation source/date:
AND, Documentation of Educational Impact Form and other documentation as needed such as informal testing,
speech samples, and other educational evidence supplied by the educator that demonstrates the adverse impact
of the language disorder upon the student’s success in the educational setting in one or more of the areas listed
below. Examples of impact include:
☐Y ☐N 4. ACADEMIC IMPACT (ability to benefit from the curriculum) demonstrated by communication
problems in the areas of reading, math, language arts, content, or other (
) as
documented by academics below grade level, documentation of difficulty with language-based
activities, observation of difficulty comprehending information presented orally, or
documentation of difficulty conveying information orally.
☐Y ☐N 5. SOCIAL IMPACT (ability to interact with peers and/or adults) demonstrated by communication
problems which interfere with the ability to be understood, difficulty
initiating/maintaining/terminating interactions, teasing by peers due to language difficulties, or
observation of student demonstrating embarrassment and/or frustration regarding
communication problems.
☐Y ☐N 6. VOCATIONAL IMPACT (applicable to students who participate in vocational or job-related
activities) demonstrated by inability to understand/follow oral directions, inappropriate
responses to coworker or supervisor comments, inability to answer/ask questions in a
coherent/concise manner.
The IEP team used the above interpretation of the evaluation data to determine:
☐ The student has a language impairment which adversely impacts his/her education
and is eligible for specifically designed instruction and related services (IEP).
☐ The student has a language impairment but it does not adversely impact his/her
education; therefore, the student is not eligible for an IEP.
☐ The student does not have a language impairment 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