Eligibility Worksheets

Student’s Name: _____________________________________ DOB: __________
School: _______________________ Grade: __________ Conf. Date: __________
WORKSHEET FOR AUTISM

(Category 17)
 ELIGIBILITY CRITERION: Evidence of Autism
________ A. The student has a developmental disability significantly affecting

communication (verbal and nonverbal) and social interaction, generally
evident before age three. The student may have one or more of the
following other characteristics often associated with autism:
 Engagement in repetitive activities and stereotyped movements.
 Resistance to environmental change or change in daily routines.
 Unusual responses to sensory experiences.
The Team may not identify a student as having autism if the student’s educational
performance is adversely affected primarily because the student has an
Emotional Disturbance.
 ELIGIBILITY CRITERION: Essential Conditions and Need for Special Education

(All must be met)
________A. Information was gathered from a variety of sources.
________B. The student's special education eligibility is not due to a lack of

instruction in reading or math, or limited English proficiency.
________C. The student's disability adversely affects his/her educational

performance.
________D. The student needs special education and related services because of the
above disability.
State of Hawaii - Draft 1/19

May 22, 2000
WORKSHEET FOR DEAF-BLINDNESS

(Category 13)
 ELIGIBILITY CRITERION: Evidence of Deaf-Blindness

(All must be met)
________A. The student meets the criteria under the category of Deafness or
Hearing Impairment
________B. The student meets the criteria under the category of Visual Impairment
________C. The student's concomitant hearing and visual impairments cause severe
communication, educational and other developmental delays.

(All must be met)

instruction in reading or math, or to limited English proficiency.
________C. The student needs special education and related services because of the
above disability.

May 22, 2000
WORKSHEET FOR DEAFNESS

(Category 10)
 ELIGIBILITY CRITERION: Evidence of Deafness
________A. The student has a hearing loss averaging greater than 70 decibels
in the speech frequencies (500 to 4000 Hz) and:
 The hearing loss impairs the student's auditory processing of

linguistic information through hearing, with or without amplification.
OR
 The hearing loss adversely affects the student's educational

performance.

(All must be met)

above disability.

May 22, 2000
WORKSHEET FOR DEVELOPMENTAL DELAY

For Students Age Three through Five
(Category 19)
 ELIGIBILITY CRITERION: Evidence of Developmental Delay

(One of the following must be met)
________A. Cognitive development and adaptive behavior are delayed

1.5 standard deviations below the mean.
________B. One of the following areas is delayed 1.5 standard deviations below the
mean:
 Motor Skills (including fine motor, gross motor, sensory motor

and perceptual motor development)
 Communication Skills (including speech and language
development)
 Academic Skills (i.e. Pre-academic/Readiness skills)
 Adaptive Behavior
________C. The student's patterns of learning deviate from chronological age

expectations across settings even though the assessment data do not
conclusively satisfy the above requirements. (See attached Eligibility
Report for alternative means for determination and/or supporting data.)

(All must be met)

above disability.

May 22, 2000
WORKSHEET FOR DEVELOPMENTAL DELAY

For Students Age Six through Eight
(Category 19)
 ELIGIBILITY CRITERION: Evidence of Developmental Delay

(One must be met)
________A. Three of the following areas are delayed 1.5 standard deviations below a
mean standard score expected for chronological age.
 Motor Skills (including fine motor, gross motor, sensory motor

and perceptual motor development)
 Communication Skills (including speech and language
development)
 Academic Skills
 Adaptive Behavior
 Cognition
________B. The student's patterns of learning deviate from chronological

age expectations across settings even though the assessment data do not
conclusively satisfy the above requirements. (See attached Eligibility
Reports for alternative means for determination and/or supporting data.)

(All must be met)


performance.
above disability.

May 22, 2000
WORKSHEET FOR EMOTIONAL DISTURBANCE

(Category 6)
 ELIGIBILITY CRITERION: Evidence of Emotional Disturbance
________A. The student exhibits one or more of the following characteristics over a
long period of time and to a marked degree that adversely affect the
student’s educational performance:
 An inability to learn that cannot be explained by intellectual,

sensory or health factors.
 An inability to build or maintain satisfactory interpersonal

relationships with peers and teachers (e.g. isolation, lack of friends,
withdrawal, inappropriate social interactions, avoidance of adults,
etc.).
 Inappropriate types of behavior or feelings under normal

circumstances (e.g. avoidance or aggressiveness in play, anxiety, etc.).
 A general pervasive mood of unhappiness or depression (e.g.

dysthymia).
 A tendency to develop physical symptoms or fears associated

with personal or school problems.
Category includes schizophrenia. Social maladjustment is not the sole basis for
determining emotional disturbance.

(All must be met)

instruction in reading or math or to limited English proficiency.

performance.
above disability.
May 22, 2000

May 22, 2000
WORKSHEET FOR HEARING IMPAIRMENT

(Category 9)
 ELIGIBILITY CRITERION: Evidence of Hearing Impairment
________A. The student has a hearing loss, whether permanent or fluctuating,

averaging 26 to 70 decibels in the speech frequencies (500 to 4000
Hz) and:
 The hearing loss impairs the student's auditory processing of

linguistic information, with or without amplification.
OR
 The hearing impairment adversely affects the student's

educational performance.

(All must be met)

above disability.

May 22, 2000
WORKSHEET FOR MENTAL RETARDATION

(Category 1)
 ELIGIBILITY CRITERION: Evidence of Mental Retardation

(All must be met)
________A. The student has sub-average general intellectual functioning as

demonstrated by evidence of intellectual functioning 2 or more
standard deviations below the mean.
________B. The sub-average intellectual functioning exists concurrently with deficits

in at least two adaptive skills areas.
________C. The sub-average intellectual functioning and deficits in adaptive skill

areas were manifested during the developmental period.

(All must be met)

instruction in reading or math, or the result of limited English
proficiency.

performance.
above disability.

May 22, 2000
WORKSHEET FOR MULTIPLE DISABILITY

(Category 14)
 ELIGIBILITY CRITERION: Evidence of Multiple Disability

The student has concomitant impairments which, in combination, cause severe
educational needs. (All must be met)
________A. The student has sub-average general intellectual functioning, as demonstrated by

evidence of intellectual functioning three or more standard deviations below the mean
score expected for chronological age.
________B. The sub-average intellectual functioning exists concurrently with deficits in at least two
adaptive skills areas.
________C. The sub-average intellectual functioning and deficits in adaptive skill areas were
manifested during the developmental period.
________D. The student is not eligible under the category of Deaf-Blind.
________E. The student is eligible under one or more of the following disability categories.
 Autism
 Deafness
 Hearing Impairment
 Orthopedic Impairment
 Other Health Impairment
 Visual Impairment including
Blindness
If assessment materials would not conclusively demonstrate eligibility, the team may find the student
eligible under this category if the criteria A, B, C are met and the team documents the existence of
concomitant impairment. (See attached Eligibility Report for supporting data and the basis and method
used for determining eligibility.)

(All must be met)
________B The student's special education eligibility is not due to a lack of instruction in reading
or math, or to limited English proficiency.
________C. The student's disability causes severe educational needs.
________D. The student needs special education and related services because of the above disability.

May 22, 2000
WORKSHEET FOR ORTHOPEDIC IMPAIRMENT

(Category 11)
 ELIGIBILITY CRITERION: Evidence of Orthopedic Impairment
_______A. There is medical evidence that a severe orthopedic impairment exists.
The term includes impairments caused by:
 Congenital anomaly: ______________________________

(e.g. clubfoot, absence of limbs, etc.)
 Disease: ________________________________________
(e.g. poliomyelitis, bone tuberculosis, etc.)
 Other cause: _____________________________________
(e.g. cerebral palsy, amputations, etc.)

(All must be met)


performance.
above disability.

May 22, 2000
WORKSHEET FOR OTHER HEALTH IMPAIRMENT

(Category 16)
 ELIGIBILITY CRITERION: Evidence of Other Health Impairment
________ The student has limited strength, vitality or alertness, including a

heightened alertness to environmental stimuli.
The above condition results in limited alertness in the educational
environment that is due to chronic or acute health problems or a
medically fragile condition (e.g. asthma, attention deficit disorder or
attention deficit hyperactivity disorder, diabetes, epilepsy, heart condition,
hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, sickle
cell anemia, etc.).

(All must be met)


performance.
above disability.

May 22, 2000
WORKSHEET FOR SPECIFIC LEARNING DISABILITY

(Category 5)
 ELIGIBILITY CRITERION: Evidence of Specific Learning Disability

(One must be met)
________A. The student demonstrates a severe discrepancy between academic
achievement and intellectual ability on standardized tests by a difference
of 1.5 standard deviations in one or more of the following areas:
 Oral Expression Measure of Intellectual Ability

 Listening Comprehension
 Basic Reading Skills _____________________________
 Reading Comprehension
 Mathematics Calculation _____________________________
 Mathematics Reasoning
 Written Expression _____________________________
________B. Although the standardized tests do not conclusively satisfy the above
requirements, the team has used alternative means for determining a
severe discrepancy between intellectual ability and academic
achievement. This may include evidence of deficits in one or more basic
psychological processes.
The documentation of eligibility shall include a statement of the area, the

degree, the basis and method used in determining the discrepancy as well
as:
1) Data obtained from standardized tests;

2) Information provided by the parent;
3) Information provided by the student’s current teacher;
4) Evidence of the student’s performance in the classroom
obtained from observations and work samples;
5) Consideration of the student’s age, particularly for young
student; and
6) Any additional relevant information, such as the student’s
performance on group test scores.

May 22, 2000
WORKSHEET FOR SPECIFIC LEARNING DISABILITY

(Category 5)

(All must be met)
________B. The severe discrepancy between the student's ability and achievement is
not primarily the result of visual/hearing/motor impairment; mental
retardation; emotional disturbance or environmental, cultural or
economic disadvantage.
________C. The student has been provided with learning experiences appropriate for
the student's age and ability levels. The student's special education
eligibility is not due to a lack of instruction in reading or math, or to
limited English proficiency.
________D. The student's disability adversely affects his/her educational

performance.
________E. The student needs special education and related services because of the
above disability.

May 22, 2000
Documentation of Eligibility for Specific Learning Disabled (SLD):
1) (a) There is a severe discrepancy between ability and achievement in the area(s) of:
_________________________________________________________________.
(b) The basis for determining eligibility is:
2) Relevant behavior (if any) noted during the observation of this student:
3) Relationship or impact of this behavior on student’s academic functioning:
4) Educationally relevant medical findings (if any):
5) Determination of the team regarding other possible factors affecting learning (e.g. the
effects of environmental, cultural and/ or economic disadvantage on learning):
6) It is the consensus of this team that __________________________________

has a specific learning disability. This discrepancy is not primarily the result of
visual/hearing/motor impairment; mental retardation; emotional disturbance; or
environmental, cultural or economic disadvantage. This disability is not correctable
without special education and related services.
Each team member certifies that this report reflects his/her conclusion.
 Yes  No
 Yes  No
 Y  N
es o
 Y  N
es o
 Y  N
es o
 Y  N
es o
 Yes  No

May 22, 2000
 Yes  No

May 22, 2000
WORKSHEET FOR SPEECH/LANGUAGE IMPAIRMENT

(Category 12)
 ELIGIBILITY CRITERION: Evidence of Speech-Language Impairment

(Both must be met)
________A. There is a significant problem in the comprehension and/or production

of an oral communication system, which is below expectation based on
the student's other developmental or cognitive abilities.
________B. The problem is evident in one or more of the following areas:
 Articulation and/or phonological condition.

 Voice condition.
 Fluency condition.
 Language conditions as documented by:
____ Multiple sources of data and
____ A discrepancy of 1.5 standard deviations between the
student's estimated cognitive level and performance on at least two
standardized measures in the areas of semantics and/or grammar.

(All must be met)


performance.
above disability.

May 22, 2000
WORKSHEET FOR TRAUMATIC BRAIN INJURY

(Category 18)
 ELIGIBILITY CRITERION: Evidence of Traumatic Brain Injury
________A. There is medical evidence that the student has an acquired injury to the
brain caused by an external physical force resulting in total or partial
functional disability and/or psychosocial impairment.
The traumatic brain injury is either an open or closed head injury resulting
in impairments in one or more of the following areas such as:
 Cognition  Language
 Memory  Attention
 Reasoning  Abstract Thinking
 Judgment  Problem Solving
 Sensory, Perceptual & Motor Abilities  Psychosocial Behavior
 Physical Functions  Information Processing
 Speech
The student may not be identified as having a traumatic brain injury if the brain injury is
congenital or degenerative, or induced by birth trauma (note: also excludes stroke).

(All must be met)


performance.
above disability.

May 22, 2000
WORKSHEET FOR VISUAL IMPAIRMENT

Including Blindness
(Category 7)
 ELIGIBILITY CRITERION: Evidence of Visual Impairment Including Blindness

(One must be met)
________A. Partially sighted. The student 's visual acuity is 20/70 to 20/200 in the
better eye and with best correction.
________B. Blind. The student's visual acuity is 20/200 in the better eye and with the
best correction, or less; or the student has a restricted visual field of less
than 20 degrees, regardless of central visual acuity.
________C. Functional visual impairment. The student has a significant eye condition
(e.g. nystagmus) that is so severe that it interferes with visual functions
(e.g. visual fixation, focusing, and tracking).
________D. Progressive visual impairment. The student has a progressive visual

impairment (e.g. retinitis pigmentosa) that will lead to eventual visual
impairment.

(All must be met)

instruction in reading and math, or to limited English proficiency.
________C. The student's impairment in vision even with the best correction
adversely affects his/her educational performance.
above disability.

May 22, 2000

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Student’s Name: _____________________________________ DOB: __________

School: _______________________ Grade: __________ Conf. Date: __________

WORKSHEET FOR AUTISM

 ELIGIBILITY CRITERION: Evidence of Autism

________ A. The student has a developmental disability significantly affecting

 Engagement in repetitive activities and stereotyped movements.

 Resistance to environmental change or change in daily routines.

 Unusual responses to sensory experiences.

 ELIGIBILITY CRITERION: Essential Conditions and Need for Special Education

________A. Information was gathered from a variety of sources.

________B. The student's special education eligibility is not due to a lack of

________C. The student's disability adversely affects his/her educational

State of Hawaii - Draft 1/19

School: _______________________ Grade: __________ Conf. Date: __________

WORKSHEET FOR DEAF-BLINDNESS

 ELIGIBILITY CRITERION: Evidence of Deaf-Blindness

 ELIGIBILITY CRITERION: Essential Conditions and Need for Special Education

________A. Information was gathered from a variety of sources.

________B. The student's special education eligibility is not due to a lack of

State of Hawaii - Draft 2/19

School: _______________________ Grade: __________ Conf. Date: __________

WORKSHEET FOR DEAFNESS

 ELIGIBILITY CRITERION: Evidence of Deafness

 The hearing loss impairs the student's auditory processing of

 The hearing loss adversely affects the student's educational

 ELIGIBILITY CRITERION: Essential Conditions and Need for Special Education

________A. Information was gathered from a variety of sources.

________B. The student's special education eligibility is not due to a lack of

State of Hawaii - Draft 3/19

School: _______________________ Grade: __________ Conf. Date: __________

WORKSHEET FOR DEVELOPMENTAL DELAY

 ELIGIBILITY CRITERION: Evidence of Developmental Delay

________A. Cognitive development and adaptive behavior are delayed

 Motor Skills (including fine motor, gross motor, sensory motor

________C. The student's patterns of learning deviate from chronological age

 ELIGIBILITY CRITERION: Essential Conditions and Need for Special Education

________A. Information was gathered from a variety of sources.

________B. The student's special education eligibility is not due to a lack of

State of Hawaii - Draft 4/19

School: _______________________ Grade: __________ Conf. Date: __________

WORKSHEET FOR DEVELOPMENTAL DELAY

 ELIGIBILITY CRITERION: Evidence of Developmental Delay

 Motor Skills (including fine motor, gross motor, sensory motor

________B. The student's patterns of learning deviate from chronological

 ELIGIBILITY CRITERION: Essential Conditions and Need for Special Education

________A. Information was gathered from a variety of sources.

________B. The student's special education eligibility is not due to a lack of

________C. The student's disability adversely affects his/her educational

State of Hawaii - Draft 5/19

School: _______________________ Grade: __________ Conf. Date: __________

WORKSHEET FOR EMOTIONAL DISTURBANCE

 ELIGIBILITY CRITERION: Evidence of Emotional Disturbance

 An inability to learn that cannot be explained by intellectual,

 An inability to build or maintain satisfactory interpersonal

 Inappropriate types of behavior or feelings under normal

 A general pervasive mood of unhappiness or depression (e.g.

 A tendency to develop physical symptoms or fears associated

 ELIGIBILITY CRITERION: Essential Conditions and Need for Special Education

________A. Information was gathered from a variety of sources.

________B. The student's special education eligibility is not due to a lack of

________C. The student's disability adversely affects his/her educational

School: _______________________ Grade: __________ Conf. Date: __________

State of Hawaii - Draft 7/19

School: _______________________ Grade: __________ Conf. Date: __________

Student’s Name: ___________________________ DOB:

School: ___________ Grade: Conf. Date:

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