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INITIAL ASSESSMENT REPORT

STUDENT: DATE OF REPORT:

DOB: CASE MANAGER:
PARENTS: SCHOOL:
EVALUATOR: DISTRICT:

Reason for referral and background information {no underline, capitalization, or space
between heading and text per APA style}
*** is a *** grade student who was referred by his/her school team to determine if *** meets the
educational eligibility criteria for Autism Spectrum Disorder (ASD). The reported areas of
concern include ***'s difficulty with (put team’s concerns here)

{Include the following:

-source of referral
-concerns and purpose of eval
-prior assessments, diagnosis, category or elig.
-previous interventions, placement
-family history of relevant diagnosis
-medical
-include strengths if known}

Evaluation requirements for ASD

In order to receive educational services as a student with ASD, an evaluation must be conducted
and the team must determine that the student meets the ASD educational criteria, that ASD has
an adverse impact on the developmental progress or educational performance of the student, and
that the student needs special education services.

Evaluation requirements include at least three observations of the student in multiple

environments on at least two different days, one observation must involve direct interaction with
the student, a developmental profile, a communication assessment that addresses the
communication characteristics of ASD, a medical or health assessment statement, and an
assessment using a behavior rating tool or alternative assessment instrument that identifies
characteristics associated with ASD.

{Only include this if a medical diagnosis exists:}

It should also be noted that the educational definition of ASD as set out in the OARs is not the
same used by the medical profession. As compared to the criteria listed in this report for
educational ASD, the medical profession uses definitions described in the Diagnostic and

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Statistical Manual (DSM-V) of the American Psychiatric Association to diagnose autism and
related spectrum disorders. For this reason, it is possible for a student to be diagnosed medically
with autism spectrum disorder, yet not be found eligible to receive special education services
under the educational definition of ASD.

Assessment Procedures
Procedure Conducted by Date
Developmental Profile
Teacher Interview
File Review
Observations
Behavior Rating Tool

Findings from interviews/file review/observations

ASD, for educational purposes, is identified by the combination of behavior characteristics
exhibited in each of the following four areas: impairments in communication, impairments in
social interaction, patterns of behavior, interests and/or activities that are restricted, repetitive, or
stereotypic, and unusual responses to sensory information. In addition, each of these behaviors
must be characteristic of ASD, inconsistent or discrepant from the student’s development in
other areas and documented over time and intensity. (OAR 581-015-005)

{Option here includes incorporating:

Bullets of characteristics, if you prefer, but narrative is needed to describe behaviors observed
to support the characteristics bulleted.
Be sure to include typical and atypical characteristics.}

Communication
Individuals with ASD have difficulty using language to communicate which can result in total
lack of or delay of the development of spoken language. There is usually no attempt to compensate
through the use of gestures or mime. There may be a marked impairment in the ability to initiate or
sustain a conversation with others, stereotyped and repetitive use of language, idiosyncratic
language, and lack of variety, spontaneous make-believe play or social imitative play appropriate to
developmental level.

Developmental Profile
{This section for each of the four areas should include the information gathered from parent
(or caregiver), teacher interview and file review. It can be divided into 2 sections with
headings:
-From parent (or caregiver)
-From file}

Current Profile
{This section for each of the four areas should include description of observations and
interview from parent, teachers or staff who know student well.}

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Social Interaction
Individuals with ASD tend to have difficulties with social nuances, nonverbal communication,
lack skills in developing meaningful interactions and relationships with peers and adults in their
world. There may be impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze,
facial expression, use of conventional gestures to regulate social interaction; a lack shared
enjoyment, interests, or achievements with other people.

Developmental Profile

Current Profile

Patterns of Behavior, Interests and/or Activities that are Restricted,

Repetitive or Stereotypic
Individuals with ASD may show a scattering of skills and may have skipped some normal
developmental steps. Objects may hold unusual value or may be used in a limited or restricted
way. Individuals with ASD may demonstrate exceptional skills or knowledge in areas of high
interest. encompassing preoccupation with one or more areas of interest that is abnormal either in
intensity or focus, an inflexible adherence to specific, nonfunctional routines or rituals, may
demonstrate stereotyped and repetitive motor manners (e.g., hand or finger flapping or twisting, or
complex whole-body movements) Changes and/or transitions may be extremely difficult.

Developmental Profile

Current Profile

Responses to Sensory Information

ASD affects the ability of the body to take in information through the sensory system and
understand the message. The individual may be over or under sensitive to touch, lights, sounds,
movements, or other visual stimulation. This may result in some unusual behaviors including
repetitive movements, obsessions or unusual fears.
{This section should include information from the Sensory Profile, if administered, the
sensorimotor subtest results from the ASDS, if administered, with comments on auditory,
visual, tactile, vestibular, oral sensory, olfactory, proprioceptive processing that may have or
still be impacting the student.}

Developmental Profile

Current Profile

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Behavior Rating Tool

Autism Behavior Checklist (ABC)

The ABC is a subtest of the Autism Screening Instrument for Educational Planning (ASIEP-3).
The ABC is a 47 item behavioral checklist describing very specific behaviors typical of autistic
individuals. The raw score (total # of items endorsed) is converted to a standard score &
percentile rank. A standard score of ≤ 84 indicates an Unlikely probability of autism. Scores of
85-89 indicate the Possibility of autism and scores ≥ 90 are indicative of a Very Likely
probability of autism. * received a standard score of - (--%ile) indicating a -- Probability of
autism.

Autism Diagnostic Observation Schedule 2 (ADOS2)

The Autism Diagnostic Observation Schedule 2 (ADOS2) is a standardized observation designed

to assess behaviors related to autism or Autistic Spectrum Disorders. The ADOS2 consists of 5
modules that can be used to evaluate individuals at different developmental levels and
chronological ages from 12 months of age to adults. Structured activities and materials provide
standard contexts in which social interactions, communication and other behaviors relevant to
pervasive developmental disorders are likely to appear. –‘s Comparison Score of * falls in the
[high, moderate, low, minimal-to-no evidence] for autism/autism spectrum disorder indicating
that -’s behaviors are/are not similar to those observed in children with a diagnosis of autistic
disorder/autism spectrum disorder/non-spectrum diagnosis.

*When administering the Toddler Module (ages 12-30 months) the overall total score correlates
with moderate-to-severe concern, mild-to-moderate concern, or little-to-no concern.

Autism Screening Instrument for Educational Planning –Third Edition (ASIEP-3)

The Autism Screening Instrument for Educational Planning –Third Edition (ASIEP-3) was
designed to help professionals identify individuals with autism and to provide information
needed to develop appropriate educational plans. The ASIEP-3 is comprised of the ABC
(Autism Behavior Checklist) and 4 standardized informal subtests. – was administered the
Interaction Assessment/Educational Assessment/Prognosis of Learning Rate/Sample of Vocal
Behavior subtest (appropriate for individuals functioning at a language and social age between 3
months and 49 months). The [Sample of Vocal Behavior evaluates expressive speech at the
preverbal and emerging language level. Interactive Assessment elicits an individual’s social
responses in a controlled setting with stimuli presented in a systematic fashion. Educational
Assessment is designed to accumulate information that will be of direct value in curriculum
placement. Prognosis of Learning Rate examines an individual’s learning acquisition rate in
terms of responses required to learn a two-step black-white sequencing task.] Percentiles
provide an index of performance, indicating how a given individual compares with the
standardization sample.

Autism Spectrum Rating Scales (ASRS):

The ASRS was designed to help professionals identify individuals with Autism Spectrum
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Disorder and/or to provide information on the effectiveness of a particular intervention. The
ASRS consists of a 70 or 71 item questionnaire (addressing Social/Communication, Unusual
Behaviors, and Attention/Self-Regulation -Self-Regulation is not a component in the 6-18 year
old version) completed by a parent and teacher/caregiver for students ages 2-5 years or 6-18
years. Scores in the Slightly Elevated Range and higher are considered consistent with ASD. *
received a standard score of – (-%ile) indicating [Very Elevated, Elevated, Slightly Elevated,
Average, Low] (levels of concern when compared to the normative group) score.

Childhood Autism Rating Scale 2 Standard Version (CARS-2 ST)

The CARS-2 ST is a 15 item scale that asks responders to rate an individual on a scale from 1-4
in key areas related to autism diagnosis. For students under 12 years of age, scores of 30 or
above are indicative of autism. For students 12 years and older, scores of 28 or above are
considered to be indicative of autism. * obtained a standard score of -, which is in the -
percentile and indicates: (likely not autistic, mild-moderate level of behaviors related to autism
spectrum disorder, severe level of behaviors related to autism spectrum disorder )

Childhood Autism Rating Scale 2 High Functioning Version (CARS-2 HF)

The CARS-2 HF is a 15 item scale that asks responders to rate an individual on a scale from 1-4
in key areas related to high functioning autism or Asperger Syndrome. Scores of 28 or above are
considered to be indicative of autism. * obtained a standard score of -, which is in the -
percentile and indicates: (likely not autistic, mild-moderate level of behaviors related to autism
spectrum disorder, severe level of behaviors related to autism spectrum disorder )

Summary
{Include a general description of presence of and/or absence of characteristics in each of four
areas. May include description of how underlying characteristics of ASD impact student’s
functioning at school in one or more of these domains: academic/social/emotional}
Please note that the combination of behaviors that were reported and observed may support the
presence of ASD within the educational definition, however, this report is only one of the
documents required by the Oregon Administrative Rules (OAR). The evaluation team must meet
and review this report along with other pertinent information to determine ***’s eligibility for
special education services.

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Specialist’s name
Autism Specialist
Columbia Regional Program
503 Contact info