CENTRALIZED EVALUATION TEAM REPORT
Name:
D.O.B.:
Grade:
Current Placement:
Age:
Date of Report:
Centralized Evaluation Team Members:
Reason for Referral:
Methods of Assessment:
Observation:
School Record Review:
Teacher Review:
Parent Interview:
Childhood Autism Rating Scale (CARS):
Definition of Autism Spectrum Disorder:
According to the Autism Society of America, autism is a complex developmental disability that
typically appears during the first three years of life. The result of a neurological disorder that
affects the function of the brain, autism impacts normal development of the brain in areas of
social interaction and communication skills. Children and adults with autism typically have
difficulty in verbal and non-verbal communication, social interaction and leisure and play
activities. Throughout the body of this report we have assessed behaviors and reviewed
information as they relate to Autism Spectrum Disorder.
Background and Social History:
Review of Educational Criteria for Autism Spectrum Disorder according to Rule # 340.1715:
Yes
No
1. There is evidence of a lifelong developmental disability, related to Autism
Spectrum Disorder that adversely affects a student’s educational performance in
one or more of the following performance areas: (If Yes, please specify.)
Yes No
a. Academic
b. Behavioral
c. Social
Yes
No
2. The suspected disability is characterized by qualitative impairments in
reciprocal social interactions, qualitative impairments in communication, and
restricted range of interests/repetitive behavior related to Autism Spectrum
Disorder and shall include ALL of the following:
Yes No
a. Qualitative impairments in reciprocal social
interactions related to Autism Spectrum Disorder. (if yes,
must specify at least 2)
b. Qualitative impairments in communication related to
Autism Spectrum Disorder. (if yes, must specify at least 1)
c. Restricted, repetitive, and stereotyped behaviors related
to Autism Spectrum Disorder. (if yes, must specify at
least 1)
d. Determination may include unusual or inconsistent
response to sensory stimuli, in combination with
subdivisions, (a), (b), and (c) above.
Yes
No
3. There is not a primary diagnosis of emotional impairment such as
schizophrenia. (Although Autism Spectrum Disorder may exist concurrently
with other diagnoses or areas of disability, to be eligible under this rule,
emotional impairment shall not be a primary diagnosis.)
Yes
No
4. The suspected disability is not due to the lack of instruction in reading and
math, nor to limited English proficiency.
Yes
No
5. This student requires special education programs/services under the criteria of
Autism Spectrum Disorder.
Yes
No
We recommend to the IEPT that this student is eligible for special education programs/services
under the Autism Rule (R340.1715).