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Name: Completed by:

(please print)

School: DOB Date:

OPERATIONAL CRITERIA WORKSHEET - DEAF-BLINDNESS Child with a disability means a child evaluated in accordance with procedures set forth in the federal and state special education regulations who has been determined as a result of the evaluation to have autism, deafblindness, a developmental delay, a hearing impairment or deafness, intellectual disability, multiple disabilities, an orthopedic impairment, other health impairment, an emotional disability, a specific learning disability, a speech or language impairment, a traumatic brain injury, or a visual impairment or blindness, who by reason thereof, needs special education and related services. The following disability definition, areas to be assessed, and criteria for eligibility are based upon the Individuals with Disabilities Education Improvement Act (IDEIA). I. DEFINITION. Deaf-blindness means concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational problems that they cannot be accommodated in special education programs solely for deaf or blind children. II. BASIC AREAS TO BE ASSESSED
1. 2. 3. 4. 5. Hearing Vision Communication skills General intellectual ability Developmental skills Educational skills Educational accommodations 6. Environmental and cultural factors 7. Adaptive evaluation 8. Observation results

III. CRITERIA. A student with deaf-blindness will meet all the following criteria. For each criterion indicate yes or no and provide additional information as appropriate. Use responses to complete the Essential Deliberations on the Eligibility Minutes.
. _____ A. . _____ B.

. _____ C.

The student qualifies for a special education program for hearing impairment according to Henrico County criteria. The student qualifies for a special education program for visual impairment according to Henrico County criteria. The student has a severe communication need in the areas of voice fluency, expressive language, receptive language, or articulation. Specify areas and severity rating: Due to severe communication and educational/developmental needs, the student requires specially designed instruction to address identified deficit areas that warrant intervention through special education. Specify instruction required:

. _____ D.

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Name: Completed by:
(please print)

School: DOB Date:

OPERATIONAL CRITERIA WORKSHEET - DEVELOPMENTAL DELAY Child with a disability means a child evaluated in accordance with procedures set forth in the federal and state special education regulations who has been determined as a result of the evaluation to have autism, deafblindness, a developmental delay, a hearing impairment or deafness, intellectual disability, multiple disabilities, an orthopedic impairment, other health impairment, an emotional disability, a specific learning disability, a speech or language impairment, a traumatic brain injury, or a visual impairment or blindness, who by reason thereof, needs special education and related services. The following disability definition, areas to be assessed, and criteria for eligibility are based upon the Individuals with Disabilities Education Improvement Act (IDEIA). I. DEFINITION. According to state regulations, developmental delay means a disability affecting a child age two through six, inclusive, who: 1) is experiencing developmental delays, as measured by appropriate diagnostic instruments and procedures, in one or more of the following areas: physical development, cognitive development, communication development, social or emotional development, or adaptive development; and 2) who, by reason thereof, needs special education and related services. State guidelines indicate that the developmental delay label is reserved for children who do not clearly meet the diagnostic criteria for another disability category. II. BASIC AREAS TO BE ASSESSED
1. Vision 2. Hearing 3. Cognitive ability Motor skills Social/adaptive 4. Communication skills 5. Observation results

III. CRITERIA. A student with developmental delay will meet all the following criteria. For each criterion indicate yes or no and provide additional information as appropriate. Use responses to complete the Essential Deliberations on the Eligibility Minutes.
. _____ A. . _____ B.

The student is below age seven (mandatory). State students chronological age: The student has a significant delay (a standard score of 70 or below) in one or more of the following areas: Documented Evidence of Adverse Educational Impact (circle Yes or No) Yes No Yes No Yes No Yes No

Developmental Area Cognitive ability Motor skills Social-adaptive behavior Communication skills Specify area(s) of significant delay:
. _____C.

Instrument

Standard Score

The student does not qualify for any other disability label, except speech/language impaired as a secondary label. If a developmental delay is documented in the area of communication skills, specify why the student does not qualify solely for services under speech/language impairment:

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. _____ D.

Due to delays in specific developmental areas:

. ____ 1. The preschool-aged student requires services to address developmental readiness for

school that cannot reasonably be provided solely by the parent; or

.____ 2. The school-aged student requires instructional accommodations to address identified

deficit areas that cannot reasonably be provided solely through regular education. Specify evidence of adverse educational impact and/or accommodations required and why regular education cannot provide: