Effective Evaluation
Resource Center
USE OF ELIGIBILITY DETERMINATION TEMPLATES
The Effective Evaluation Resource Center has developed a template of eligibility forms for each
of the 13 eligibility categories specified in Indiana Article 7 (511 IAC 4). These templates
include all necessary eligibility components or characteristics that the Case Conference
Committee must consider when determining whether a disability exists. Districts or special
education cooperatives should determine what evidence, criteria, and data sources are
acceptable and necessary to establish eligibility. This information can be added to the
provided templates. An example of a completed eligibility checklist, SLD Checklist with
Examples 2011, is available on the EERC website. For SLD, the checklist can include signatures
which would satisfy the Article 7 requirement (511 IAC 7-40-5(g)(2)(C)) for written certification
of the multidisciplinary team members’ opinion regarding the presence of a SLD.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Autism Spectrum Disorder (ASD) Checklist
Autism spectrum disorder is a lifelong developmental disability that includes autistic disorder, Asperger’s
syndrome, and other pervasive developmental disorders, as described in the current version of the American
Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders. Other characteristics often
associated include engagement in repetitive activities and stereotyped movements, resistance to
environmental change or change in daily routines, and unusual responses to sensory experiences.
(511 IAC 7-41-1)
1. Evidence that disability significantly affects verbal, nonverbal, or pragmatic communication
Evidence
A.
B.
C.
D.
No
Yes
No
Yes
No
Yes
Data Sources
A.
B.
C.
D.
2. Evidence that disability significantly affects social interaction skills
Evidence
A.
B.
C.
D.
Data Sources
A.
B.
C.
D.
3. Evidence of disability prior to three years of age
Evidence
A.
B.
C.
D.
Data Sources
A.
B.
C.
D.
4. Evidence of adverse effect on academic achievement and/or functional performance and student’s
need for specially designed instruction
No
Evidence
A.
B.
C.
D.
Data Sources
A.
B.
C.
D.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Yes
Educational Evaluation findings:
___ Yes, there is sufficient evidence of all criteria to support determination of an autism spectrum disorder.
___ No, there is not sufficient evidence of all criteria to support determination of an autism spectrum
disorder.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Blind or Low Vision (BLV) Checklist
Blind or low vision, which may be referred to as a visual impairment, means a disability that even with best
correction affects the student’s ability to use vision for learning. (511 IAC 7-41-2)
1. Evidence of a reduced ability or a complete inability to utilize the visual system to acquire
information.
No
Yes
Evidence
A.
B.
C.
D.
Data Sources
A.
B.
C.
D.
AND/OR
2. Evidence of reduction in field of vision.
No
Yes
Data Sources
A.
B.
C.
D.
A.
B.
C.
D.
3. Evidence of adverse effect on academic achievement and/or functional performance and student’s
need for specially designed instruction.
No
Evidence
A.
B.
C.
D.
Data Sources
A.
B.
C.
D.
Educational Evaluation findings:
___ Yes, there is sufficient evidence of all criteria to support determination of blind or low vision.
___ No, there is not sufficient evidence of all criteria to support determination of blind or low vision.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Yes
Cognitive Disability (CD) Checklist
A cognitive disability is manifested during the developmental period; is characterized by significant
limitations in cognitive functioning; is demonstrated through limitations in adaptive behavior; and adversely
affects educational performance. (511 IAC 7-41-3)
1. Evidence of significant limitations in cognitive functioning (two standard deviations below the mean
for mild cognitive disability; three standard deviations below the mean for moderate cognitive
disability; and four standard deviations below the mean for severe cognitive disability) that is
manifested during the developmental period.
No
Evidence
A.
B.
C.
D.
Yes
Data Sources
A.
B.
C.
D.
2. Evidence of delays in adaptive behavior across various environments and multiple sources
(consistent with a mild, moderate, or severe cognitive disability)
No
Evidence
A.
B.
C.
D.
Yes
Data Sources
A.
B.
C.
D.
3. Evidence of adverse effect on academic achievement and/or functional performance and student’s
need for specially designed instruction.
Evidence
A.
B.
C.
D.
No
Data Sources
A.
B.
C.
D.
Educational Evaluation findings:
___ Yes, there is sufficient evidence of all criteria to support determination of a mild/moderate/severe
(circle one) cognitive disability.
___ No, there is not sufficient evidence of all criteria to support determination of a cognitive disability.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Yes
Deaf-blind (DB) Checklist
Deaf-blind, which may be referred to as dual sensory impaired, are students that are both deaf and blind.
(511 7-41-5)
1. Evidence of a concomitant hearing and vision loss or reduction in functional hearing and vision
capacity
No
Yes
Evidence
Data Sources
A.
B.
C.
D.
A.
B.
C.
D.
2. Evidence of significant communication deficits
Evidence
No
Yes
Data Sources
A.
B.
C.
D.
A.
B.
C.
D.
3. Evidence of significant adaptive behavior deficits
Evidence
A.
B.
C.
D.
No
Yes
Data Sources
A.
B.
C.
D.
4. Evidence of adverse effect on academic achievement and/or functional performance and student’s
need for specially designed instruction
Evidence
A.
B.
C.
D.
No
Data Sources
A.
B.
C.
D.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Yes
Educational Evaluation findings:
___ Yes, there is sufficient evidence of all criteria to support determination of deaf-blind.
___ No, there is not sufficient evidence of all criteria to support determination of deaf-blind.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Developmental Delay (DD) Checklist
Developmental delay is a disability category solely for students who are at least three years of age and not
more than five years of age, or five years of age but not eligible to enroll in kindergarten. Developmental
delay means a delay of either two (2) standard deviations below the mean in one (1) of the following
developmental areas or one and one-half (1.5) standard deviations below the mean in any two (2) of the
following developmental areas: (1) Gross or fine motor development, (2) Cognitive development,
(3)Receptive or expressive language development, (4) Social or emotional development, (5) Self-help or other
adaptive development. (511-IAC 7-41-6)
1. Evidence of a delay in gross or fine motor development
No
Yes
Evidence
A.
B.
C.
D.
Data Sources
A.
B.
C.
D.
2. Evidence of a delay in cognitive development
Evidence
A.
B.
C.
D.
A.
B.
C.
D.
A.
B.
C.
D.
No
Yes
No
Yes
A.
B.
C.
D.
Data Sources
A.
B.
C.
D.
4. Evidence of a delay in social or emotional development
Evidence
Yes
Data Sources
3. Evidence of a delay in receptive or expressive language development
Evidence
No
Data Sources
A.
B.
C.
D.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
5. Evidence of a delay in self-help or other adaptive development
Evidence
A.
B.
C.
D.
No
Yes
Data Sources
A.
B.
C.
D.
6. Evidence of a delay of either two standard deviations below the mean in one of the developmental
areas or one and one-half standard deviations below the mean in any two of the developmental
areas.
No
Yes
Educational Evaluation findings:
___ Yes, there is sufficient evidence of all criteria to support determination of developmental delay.
___ No, there is not sufficient evidence of all criteria to support determination of developmental delay.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Deaf or Hard of Hearing (DHH) Checklist
Deaf or hard of hearing, which may be referred to as a hearing impairment, means a disability that, with or
without amplification, affects the student’s ability to use hearing for learning. Students who are deaf or hard
of hearing may use spoken language, sign language, or a combination of both. (511 IAC 7-41-4)
1. Evidence of a reduced ability or a complete inability to use hearing for developing language and
learning and/or developmental progress, with or without amplification
No
Yes
Evidence
Data Sources
A.
B.
C.
D.
2. Evidence that the hearing loss is:
A.
B.
C.
D.
permanent or
Evidence
Data Sources
A.
B.
3. Evidence that the hearing loss is:
profound
Evidence
A.
B.
mild
moderate
Evidence
A.
B.
moderately-severe
Data Sources
A.
B.
4. Evidence that the hearing loss is:
fluctuating
A.
B.
unilateral or
bilateral
Data Sources
A.
B.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
severe
5.
Evidence of adverse effect on academic achievement and/or functional performance and student’s
need for specially designed instruction.
No
Yes
Evidence
A.
B.
C.
D.
Data Sources
A.
B.
C.
D
Educational Evaluation findings:
___ Yes, there is sufficient evidence of all criteria to support determination of deaf or hard of hearing.
___ No, there is not sufficient evidence of all criteria to support determination of deaf or hard of hearing.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Emotional Disability (ED) Checklist
Emotional disability means an inability to learn or progress that cannot be explained by cognitive, sensory, or
health factors. The student exhibits one (1) or more of the following characteristics over a long period of
time and to a marked degree that adversely affects educational performance:
(1) A tendency to develop physical symptoms or fears associated with personal or school problems.
(2) A general pervasive mood of unhappiness or depression.
(3) An inability to build or maintain satisfactory interpersonal relationships.
(4) Inappropriate behaviors or feelings under normal circumstances.
(5) Episodes of psychosis. (511 IAC 7-41-7)
1. Evidence of a tendency to develop physical symptoms or fears associated with personal or school
problems, over a long period of time and to a marked degree
No
Yes
Evidence
A.
B.
C.
D.
Data Sources
A.
B.
C.
D.
2. Evidence of a general pervasive mood of unhappiness or depression, over a long period of time and
to a marked degree
Evidence
A.
B.
C.
D.
No
Yes
Data Sources
A.
B.
C.
D.
3. Evidence of an inability to build or maintain satisfactory interpersonal relationships, over a long
period of time and to a marked degree
Evidence
A.
B.
C.
D.
No
Yes
Data Sources
A.
B.
C.
D.
4. Evidence of inappropriate behaviors or feelings under normal circumstances, over a long period of
time and to a marked degree
Evidence
A.
B.
C.
D
No
Data Sources
A.
B.
C.
D
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Yes
5. Evidence of episodes of psychosis
No
Evidence
A.
B.
C.
D.
Yes
Data Sources
A.
B.
C.
D.
6. Evidence that Exclusionary Factors: cognitive, sensory, or health factors are NOT the primary factor
for underachievement
Evidence
A.
B.
C.
D.
No
Yes
Data Sources
A.
B.
C.
D.
7. Evidence of adverse effect on academic achievement and/or functional performance and student’s
need for specially designed instruction
Evidence
A.
B.
C.
D.
No
Data Sources
A.
B.
C.
D.
Educational Evaluation findings:
___ Yes, there is sufficient evidence of all criteria to support determination of an emotional disability.
___ No, there is not sufficient evidence of all criteria to support determination of an emotional disability.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Yes
Language or Speech Impairment (LI and/or SI) Checklist
Language impairments are characterized by impairments in the comprehension or expression of spoken or
written language resulting from organic or nonorganic causes that are nonmaturational in nature. Speech
impairments may include fluency, articulation, and voice disorders in the student’s speaking behavior in more
than one speaking task that are nonmaturational in nature, including impairments that are the result of
deficiency of structure and function of the oral peripheral mechanism. Students who are deaf or hard of
hearing or students with specific learning disabilities, who have language deficits or auditory processing
difficulties, are not eligible for services designed solely for students with language impairments in lieu of
services designed for students who are deaf or hard of hearing or students with specific learning disabilities.
(511 IAC 7-41-8)
1. Evidence of a language impairment affecting the student’s primary language systems , in one or
more of the following:
word retrieval
phonology
morphology
syntax
semantics, and or
pragmatics, that are nonmaturational in nature.
No
Evidence
Yes
Not Applicable
Data Sources
A.
B.
C.
D.
A.
B.
C.
D.
2. Evidence of a speech impairment affecting the student’s speaking behavior in more than one
speaking task that may include:
nonmaturational in nature.
fluency
articulation, and or
voice disorder, that are
No
Evidence
A.
B.
C.
D.
Yes
Not Applicable
Data Sources
A.
B.
C.
D.
3. Evidence that English Proficiency is NOT Primary Factor for language or speech delay. (A student
who is bilingual or multilingual may be a student with a language or speech impairment only if the
impairment is exhibited in all languages spoken by the student.)
No
Evidence
A.
B.
C.
D.
Data Sources
A.
B.
C.
D.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Yes
4. Evidence of adverse effect on academic achievement and/or functional performance and student’s
need for specially designed services.
Evidence
A.
B.
C.
D.
No
Yes
Data Sources
A.
B.
C.
D.
Educational Evaluation findings:
___ Yes, there is sufficient evidence of all criteria to support determination of a language impairment.
___ Yes, there is sufficient evidence of all criteria to support determination of a speech impairment.
___ No, there is not sufficient evidence of all criteria to support determination of a language and/or speech
impairment.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Multiple Disabilities (MD) Checklist
Multiple disabilities means coexisting disabilities that are lifelong and interfere with independent functioning, and it is
difficult to determine which disability most adversely affects educational performance. The term does not include
deaf-blind. (511 IAC 7-41-9)
1. Evidence of a significant cognitive disability
Evidence
A.
B.
C.
D.
A.
B.
C.
D.
A.
B.
C.
D.
No
Yes
No
Yes
A.
B.
C.
D.
Data Sources
A.
B.
C.
D.
3. Evidence of the disabilities’ impact on independent functioning
Evidence
Yes
Data Sources
2. Evidence of other, co-existing disability(ies)
Evidence
No
Data Sources
A.
B.
C.
D.
4. Evidence of adverse effect on academic achievement and/or functional performance and student’s
need for specially designed instruction.
No
Yes
Evidence
A.
B.
C.
D.
Data Sources
A.
B.
C.
D.
Educational Evaluation findings:
___ Yes, there is sufficient evidence of all criteria to support determination of multiple disabilities.
___ No, there is not sufficient evidence of all criteria to support determination of multiple disabilities.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Other Health Impairment (OHI) Checklist
Other health impairment means having limited strength, vitality, or alertness, including a heightened
alertness to environmental stimuli, that results in limited alertness with respect to the educational
environment (511 IAC 7-41-10).
1. Evidence of chronic or acute health problems, such as asthma, attention deficit disorder, or attention
deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning,
leukemia, nephritis, rheumatic fever, sickle cell anemia, and Tourette syndrome.
No
Evidence
A.
B.
C.
D.
Yes
Data Sources
A.
B.
C.
D.
2. Evidence of adverse effect on academic achievement and/or functional performance and student’s
need for specially designed instruction.
Evidence
A.
B.
C.
D.
No
Data Sources
A.
B.
C.
D.
Educational Evaluation findings:
___ Yes, there is sufficient evidence of all criteria to support determination an other health impairment.
___ No, there is not sufficient evidence of all criteria to support determination of an other health
impairment.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Yes
Orthopedic Impairment (OI) Checklist
An orthopedic impairment is a severe physically disabling condition that adversely affects educational
performance (511 IAC 7-41-11).
1. Evidence of a severe physically disabling condition, such as a congenital anomaly; a disease, such as
poliomyelitis or bone tuberculosis; or other causes, such as cerebral palsy, amputations, or
fractures or burns that cause contractures
No
Yes
Evidence
A.
B.
C.
D.
Data Sources
A.
B.
C.
D.
2. Evidence of adverse effect on academic achievement and/or functional performance and student’s
need for specially designed instruction
Evidence
A.
B.
C.
D.
No
Yes
Data Sources
A.
B.
C.
D.
Educational Evaluation findings:
___ Yes, there is sufficient evidence of all criteria to support determination an orthopedic impairment.
___ No, there is not sufficient evidence of all criteria to support determination of an orthopedic impairment.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Traumatic Brain Injury (TBI) Checklist
A traumatic brain injury is an acquired injury to the brain caused by an external physical force, resulting in
total or partial functional disability or psychosocial impairment, or both, that adversely affects a student’s
educational performance. The term does not apply to brain injuries that are:
(1) congenital or degenerative; or (2) induced by birth trauma (511 IAC 7-41-13).
1. Evidence of open or closed head injury
No
Yes
Evidence
Data Sources
A.
B.
C.
D.
A.
B.
C.
D.
2. Evidence of functional disability or impairment in one or more of the following areas:
cognition
language
memory
attention
reasoning
abstract thinking
judgment
problem solving
sensory, perceptual, and motor abilities
psychosocial behavior
physical functions
information processing and speech.
No
Evidence
A.
B.
C.
D.
Yes
Data Sources
A.
B.
C.
D.
3. Evidence of adverse effect on academic achievement and/or functional performance and student’s
need for specially designed instruction
Evidence
A.
B.
C.
D.
No
Data Sources
A.
B.
C.
D.
Educational Evaluation findings:
___ Yes, there is sufficient evidence of all criteria to support determination a traumatic brain injury.
___ No, there is not sufficient evidence of all criteria to support determination of a traumatic brain injury.
Effective Evaluation Resource Center, Blumberg Center, Indiana State University. (2012)
Yes