Emotional Behavior Disorder Checklist
I.
Evaluations and Assessments
All 5 questions MUST be answered yes as required by state criteria.
1. Yes or No – Was a comprehensive psychological evaluation completed including assessments of
educational performance and social/emotional functioning?
2. Yes or No – Was documentation provided of pre-referral interventions including counseling,
modification of the regular program or alternative placement available to all children, and data based
progress monitoring of results?
3. Yes or No – Was a report of behavioral observations conducted over a significant period of time
provided?
4. Yes or No – Was a social history provided, including information regarding the history of the child’s
current problem(s) and the professional services that have been considered or provided from outside
the school setting?
5. Yes or No – Was documentation and written analysis of duration, frequency, and intensity of one or
more of the characteristics of emotional/behavioral disorders provided?
II.
Eligibility
1. Yes or No - Does the student exhibit an emotional disorder, characterized by excesses, deficits, or
disturbances of behavior in one or more of the following areas, with sufficient duration, frequency and
intensity?
a. _____ An inability to build or maintain satisfactory interpersonal relationships
b. _____ An inability to learn that is not explained by intellectual, sensory, or health factors
c. _____ Consistent or chronic inappropriate behavior or feelings under normal circumstances
d. _____ Displayed pervasive mood of unhappiness or depression
e. _____ Displayed tendency to develop physical symptoms, pains, or unreasonable fears associated
with personal or school problems.
III.
Other Considerations
1. Yes or No – Does the student have intellectual, sensory or health factors that should be considered as
the primary cause of the student’s adverse educational performance?
2. Yes or No – Is there evidence that the student’s difficulty is NOT emotionally based?
a. If yes, the student is NOT eligible for Emotional/Behavior Disorder
3. Yes or No – Are there exclusionary factors that need to be considered prior to eligibility determination?
a. If yes, the student MAY NOT be eligible for Emotional/Behavior Disorder
IV.
Educational Performance (academic, behavioral and functional)
1. Yes or No – Does the disability adversely affect the student’s educational performance, and is specially
designed instruction needed?
a. If Yes, indicate how the educational performance is adversely affected - ___________________
______________________________________________________________________________
b. If No, the student is NOT eligible for Emotional Behavior Disorder
**Note: The term does not include children with social maladjustment unless it is determined that they are also children with EBD. A child whose
values and/or behavior are in conflict with the school, home or community or who has been adjudicated through the courts or other involvement
with correctional agencies is neither automatically eligible for nor excluded from EBD placement. Classroom behavior problems and social
problems, e.g., delinquency and drug abuse, or a diagnosis of conduct disorder, do not automatically fulfill the requirements for eligibility for
placement.
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