Scribd
Upload
146 views2 pages

Summary of Evaluation/Eligibility Worksheet-Other Health Impairment

The document summarizes screening and evaluation results for a student being considered for special education eligibility under the category of Other Health Impairment. Screenings included hearing, vision, and two academic interventions. Evaluations covered academic performance, functional skills, social/developmental history, medical factors, and other areas. As a result of these, the student's strengths and needs were identified. Documentation shows a chronic or acute health problem that limits the student's strength, vitality or alertness, adversely affecting educational performance. Evidence indicates the student requires specially designed instruction.

Uploaded by

Heidi Jorx
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
146 views2 pages

Summary of Evaluation/Eligibility Worksheet-Other Health Impairment

The document summarizes screening and evaluation results for a student being considered for special education eligibility under the category of Other Health Impairment. Screenings included hearing, vision, and two academic interventions. Evaluations covered academic performance, functional skills, social/developmental history, medical factors, and other areas. As a result of these, the student's strengths and needs were identified. Documentation shows a chronic or acute health problem that limits the student's strength, vitality or alertness, adversely affecting educational performance. Evidence indicates the student requires specially designed instruction.

Uploaded by

Heidi Jorx
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

DEC 3-OHI (1 of 2)

SUMMARY OF EVALUATION/ELIGIBILITY WORKSHEET-OTHER HEALTH IMPAIRMENT


Student: Student Name

DOB: 00 / 00 / 2000

School: School Name


Date

Instrument

00 / 00 / 2000
00 / 00 / 2000

Hearing Screening:
Vision Screening:

00 / 00 / 2000

Two research based


interventions to address
academic and/or
functional skill
deficiencies and
documentation of the
results of the
interventions:
Summary of conference
with parent(s) or
documentation of
attempts to conference:
Academic and,
Functional Observation
across settings:
Social/Developmental
History:
Educational Evaluation:
Medical Evaluation:
Other:

00 / 00 / 2000

00 / 00 / 2000
00 / 00 / 2000
00 / 00 / 2000
00 / 00 / 2000
00 / 00 / 2000

Grade: Grade
Summary of Required Screenings and Evaluations
Pass
Fail
dB (Intensity Level)
Hz (Frequencies)
Pass
Fail
Far R 20/
L 20/
Near R 20/
L 20/

As a result of the required screenings, evaluations, and review of existing information, what do we now know about
the student?
Strengths:
Needs:

Final 1-08

DEC 3-OHI (2 of 2)

Student: Student Name


School: School Name

DOB: 00 / 00 / 2000
Grade: Grade

Documentation of impairment in the following areas:


A chronic or acute health problem along with one or more of the following:
A) Limited strength:
B) Limited vitality:
C) Limited alertness, including heightened alertness to environmental stimuli that results in limited alertness with respect to the
educational environment:

What is the adverse effect on educational performance?

What evidence exists that the student requires specially designed instruction?

AFTER COMPLETING WORKSHEET, IEP TEAM MUST DETERMINE ELIGIBILITY.


(See Eligibility Determination Form)

Final 1-08

You might also like