Oregon Department of Education
Public Service Building
255 Capitol Street NE
Salem, OR 97310-0203
Office of Student Learning & Partnership
Date
mm/dd/yy
STATEMENT OF ELIGIBILITY FOR SPECIAL EDUCATION
(AUTISM SPECTRUM DISORDER 82)
PAGE 1 OF 2
Student’s Name
Birthdate
School
Date of Initial Eligibility
The team has obtained the following assessments (attach documentation 1-9):
1.
The team has reviewed existing information, including information from the parent(s), the student’s cumulative records, and previous
individualized education programs or individualized family service plans. Evaluation documentation includes relevant information from these
sources used in the eligibility determination.
____________
Date Reviewed
2.
A developmental profile describing the student’s historical and current characteristics that are associated with Autism Spectrum
Disorder:
Examiner
3.
Profile Used
Date Conducted
At least three observations of the child’s behavior in multiple environments on at least two different days
Examiner
4.
Date Reviewed
Date Conducted
Date Reviewed
A direct interaction with the child (may be used as one of the observations):
_______________________________________________________ ________________________________ __________________________
Examiner
5.
7.
_________________________
Date Conducted
___________________________
Date Conducted
_________________________
Date Reviewed
__________________________
Date Reviewed
An assessment using an appropriate behavioral rating tool or an alternative assessment instrument:
_______________________
Assessment
________________________
Date Conducted
___________________________
Date Reviewed
________________________
Date Conducted
___________________________
Date Reviewed
Assessments to determine the impact of the disability:
__________________________
Examiner
9.
_______________________
Assessment
A medical statement or a health assessment statement:
____________________________________________________
Physician, Nurse Practitioner, or Physician’s Assistant
__________________________
Examiner
8.
Date Reviewed
An assessment of communication to address the communication characteristics of Autism Spectrum Disorder:
_______________________________
Speech - Language Pathologist
6.
Date Conducted
_______________________
Assessment
Additional assessments necessary to identify the student’s educational needs:
__________________________
Examiner
Form 581-5148l-P (rev 7-05)
_______________________
Assessment
________________________
Date Conducted
___________________________
Date Reviewed
STATEMENT OF ELIGIBILITY FOR SPECIAL EDUCATION
(AUTISM SPECTRUM DISORDER 82)
PAGE 2 OF 2
Student’s Name ___________
Date
The student meets the following criteria:
Exhibited Impairments:
Characteristic of Autism
Spectrum Disorder:
Inconsistent or Discrepant with the
Student’s Development in Other Areas:
Documented Over Time
and/or Intensity:
Communication
yes
no
yes
no
yes
no
Social Interaction
yes
no
yes
no
yes
no
Patterns of Behaviors, Interests, and/or
Activities that are Restricted, Repetitive,
or Stereotypic
yes
no
yes
no
yes
no
Unusual Responses to Sensory
Experiences
yes
no
yes
no
yes
no
The team has determined that:
yes
no
yes
no
1. The student’s disability has an adverse impact on the student’s educational performance when the student is at the age of eligibility
for kindergarten through age 21, or has an adverse impact on the student’s developmental progress when the child is age three
through kindergarten; and,
2. The student needs special education services.
3.
The team has considered the student’s special education eligibility, and determined that the eligibility:
is
is not due to a lack of appropriate instruction in reading, including the essential components of reading instruction
(phonemic awareness, phonics, vocabulary development; reading fluency/oral reading skills; and reading comprehension
strategies);
is
is not due to a lack of instruction in math; and
is
is not due to limited English proficiency.
4. The team has considered the student’s special education eligibility, and determined that the student’s primary disability
is
is not an emotional disturbance.
The team agrees that this student
does
does not qualify for special education with the eligibility of Autism Spectrum Disorder.
Signatures of Team Members
Title
A copy of the evaluation report and the eligibility statement has been provided to the parent(s).
Form 581-5148l-P (rev 7-05)
Agree
Disagree
STATEMENT OF ELIGIBILITY FOR SPECIAL EDUCATION
(AUTISM SPECTRUM DISORDER 82)
This form is used to:
 Document whether the student meets the eligibility criteria for autism spectrum and the basis for that
determination in accordance with 20 USC §1414(b)(4) and (5);

Meet the requirements of OAR 581-015-0051, OAR 581-015-0053, and 34 CFR 300.7 regarding the need to
establish eligibility for special education services, to the extent these requirements are not inconsistent with 20
USC §1414(b)(4) and (5);

Document the date that initial eligibility was established and the date that the eligibility is re-established;

Provide a place for the team to sign the statement and indicate whether or not each member agrees or disagrees
with the eligibility determination;

Document that the parent was given a copy of evaluation report(s) and eligibility statement.
Directions:
1. Enter the date the form was completed by the team.
2. Enter the student’s complete legal name; do not use a nickname.
3. Enter student's school.
4. Enter the student’s date of birth.
5. Enter the date of initial eligibility.
6.
Document completion of the required evaluation elements:
a. The team must review existing information, including information from the parent(s), the student’s cumulative
records, previous IEPs or IFSPs, state assessment information, and other relevant information. Document
the date this information is reviewed by the team.
b. Developmental profile;
c. At least three observations of the student’s behavior. The observations must occur in multiple environments,
on at least two different days, and be completed by one or more licensed professionals knowledgeable about
the behavioral characteristics of autism spectrum disorder;
d. A direct interaction with the student (may be used as one of the observations);
e. Communication assessment;
f. Medical or health assessment;
g. Autism behavior rating assessment;
h. Assessment of the impact of the disability;
i. Additional assessments to determine educational needs; and,
j. Complete checklist for exhibited impairments in each of the listed areas (continued on page 2 of Statement
Eligibility):
i.
Impairments in communication;
ii.
Impairments in social interaction;
iii.
Patterns of behavior, interests, and/or activities that are restricted, repetitive, or stereotypic; and,
iv.
Unusual responses to sensory experiences.
Note: If the team is using existing data, indicate the assessment information used, and the date the team determines
this information to be currently valid. Attach documentation of each evaluation.
7.
Indicate if the student meets the eligibility criteria.
A child shall not be determined to be a child with a disability if the determinant factor is lack of instruction in
reading or math or due to limited English proficiency. Indicate if the student’s special education needs are due to:
8.
Form 581-5148l-P (rev 7-05)
a.
b.
c.
A lack of appropriate instruction in reading, including in the essential components of reading (as defined in
section 1208(3) of the Elementary and Secondary Education Act of 1965) The “Essential Components of
Reading Instruction” means “explicit and systematic instruction in:
i.
Phonemic awareness;
ii.
Phonics
iii.
Vocabulary development;
iv.
Reading fluency, including oral reading skills; and
v.
Reading comprehension strategies
A lack of instruction in math; or
Limited English proficiency.
Indicate the team’s consideration of an emotional disturbance. A student may not be eligible for special education
services on the basis of an autism spectrum disorder if the student’s primary disability is an emotional disturbance.
However, a student with autism spectrum disorder as a primary disability may also have an emotional disturbance as
a secondary disability. Note: If a team suspects an emotional disturbance, the team must conduct an evaluation for
emotional disturbance. If the team does not suspect an emotional disturbance, the team may check “is not” without
conducting an evaluation for emotional disturbance.
9.
10. Have each team member (including the parents) sign the form, indicating his/her title, and whether he/she agrees
or disagrees with the eligibility determination.
11. Place a copy of this form with all attachments into the student’s file.
12. Give a copy of the evaluation report and eligibility statement to the parent(s).
Form 581-5148l-P (rev 7-05)