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  • 1. Autism Spectrum Disorder . . . . . . . . . . . . . . . . . . . Referral Information Packet School Age Northwest Regional Education Service District Related Services 5825 N.E. Ray Circle Hillsboro, Oregon 97124-6436 503-614-1428 Fax 503-614-1285
  • 2. Northwest Regional Education Services District Pre-referral Process Referral for Initial and Re-evaluation Autism Spectrum Disorder Assessment 1. Complete both sides of Request for Regional Services and Evaluation for Eligibility form. This can be accessed at http://www.nwresd.k12.or.us/specialed/pdf/RegSvcRequestForm.xls. Send this form with the Parent Consent form to your Administrator. Be sure to contact any specialist conducting testing to determine which testing instruments they will be using for their assessments. 2. Obtain Parental Consent Assessment for Autism Spectrum Disorder 1. ASD Profile to be completed by autism spectrum disorder specialist or other qualified person in the area of autism spectrum disorder:  Documentation of the presence of characteristics indicative of autism during early development  Record, review, and/or parent review  Standardized autism rating scale  Observations and direct-interaction 2. Functional Communication Assessment completed by a Speech Language Pathologist 3. Additional assessments to determine the impact of the disability, i.e., cognitive/academic testing, O.T. evaluation, etc. to be completed by designated specialists. 4. Medical Statement or Health Assessment to be obtained from medical provider prior to meeting. 5. Case Manager schedules meeting with educational team and parents and completes eligibility form prior to meeting. 6. Complete eligibility meeting and return copies of these documents to Regional Programs:  Eligibility form  Meeting notes  Medical statement  Functional Communication Report  Additional reports 7. If student is found eligible, conduct an IEP and include information from ASD Specialist to determine appropriate consult hours and for programming and goal suggestions, as needed.
  • 3. NorthwestRegionalESD – Autism Spectrum DisorderProgram Northwest Regional Education ServiceDistrict 5825 N.E. RayCircle Hillsboro, Oregon 97124-6436 503-614-1428 Fax 503-614-1285 Evaluation and Eligibility Checklist Student __________________________ ID#_______________ Date__________ School _____________________Case Manager ___________________________ Team Member Responsible Required for Eligibility Date needed by Date Completed or Information already obtained District Case Manager Pre-referral Checklist (with SAT team and/or classroom teacher) District Case Manager Contact ASD Specialist and SLP District Case Manager Arrange for additional assessments to be completed in other areas of suspected disability &/or educational planning purposes (as determined by the referring team) District Case Manager Meeting for Permission to Evaluate.(Signature for: observations, developmental history, file review, parent/staff interviews, *appropriate ASD rating scale, and functional communication assessment) District Case Manager Medical Statement (Info or parent to send in). Must have in by the eligibility meeting and within one year of meeting date. Speech/Language Pathologist (SLP) Functional Communication Assessment (This counts as 1 of the required observations) District Case Manager Schedule eligibility determination meeting with team members, including parents ASD Specialist 2-3 observations to occur on at least 2 different days (SLP can also conduct an observation if needed) ASD Specialist Developmental History (Parent Interview and/or portions of the ASD Rating Scale) ASD Specialist 1 interactive observation with student ASD Specialist File Review ASD Specialist Teacher/Staff Interview (optional) ASD Specialist ASD Rating Scale (specific scale that will be used should be designated on Permission to Evaluate form) ASD Specialist ASD report District Case Manager Facilitate eligibility meeting and include dates on the ASD Eligibility Statement page 1 District Case Manager Distribute copies of all forms and reports whether eligible or not, to appropriate offices, including Regional Programs Support Staff (fax: 503-614-1285) District Case Manager Set up IFSP/IEP and facilitate
  • 4. NorthwestRegionalESD – Autism Spectrum DisorderProgram Northwest Regional Education ServiceDistrict 5825 N.E. RayCircle Hillsboro, Oregon 97124-6436 503-614-1428 Fax 503-614-1285 Triennial Evaluation/File Review Student’s Name: __________________________ Date ofBirth: _____________ School _____________________Case Manager ___________________________ The team has discussed the contents ofthe file and determined the following documents are present and accurately describe the child. Additional Information needed? If YES: *Name of Document *Date Additional Information needed? If NO: *Name of Document *Date 1. A developmentalprofile, which describesthe child’s historicaland current characteristics,associatedwith an autismspectrumdisorder If YES: ASD may conductparent interviews which could be used to update thefile and satisfythis requirement. ASD (SLP/Psych/others may interviewparent as well) ASD: Previous Parent interview,developmental history,outsideagencyreports,etc. 2. At least two observations of the child’s behaviorin multiple environments,on at least two different days. If YES: ASD will observeat least three times and interact with the child who satisfies items 2and 3. ASD (SLP/Psych/others may observe also) ASD: But, if nothing has changed andno one has doubts aboutthe child’s eligibility,previous observations can satisfythis requirement. New observations by ASDare not required 3. Direct interaction with the child was documented(One observation/interaction). If YES: See previous. See previous. 4. An assessment offunctional communication to addressthe communication characteristics of autismspectrumdisorder,which includes but is not limited to measures oflanguage semantics and pragmatics. If YES: FunctionalCommunication Assessment SLP SLP: An appropriatefunctional communication assessment,addressing(at minimum) semantics andpragmaticsin natural settings must be datedwithin the past6years and accurately describe the child. May ormay not include standardized assessments. Current descriptionofthe child’s pragmaticsand semantics can be reflected onthe PLEP and deficits addressed in the goals. 5. A medical statement orhealth assessmentstatementindicating whetherthere is any physical factors that may be affecting the child’s educationalperformance. If YES: MedicalStatement Case Manager Case Manager: But unless anythinghas changed,medically,statements datedwithin 6 years are acceptable. *Unchanging conditions need only to be documentedonce (i.e.: CP, Down Syndrome,blindness,deafness,etc. 6. An assessment using an appropriate behavioralrating tool or an alternative assessment instrument that identifies characteristics associated with autismspectrumdisorder. If YES: An appropriate ASD rating tool ASD ASD: An appropriateASDrating tooldated within the past 6years and accurately describes the child. Current description ofthe child’s ASD characteristics can be reflected onthe PLEP and/oran ASDreport and deficitsshould be addressedin the goals. Optional: Additionalevaluationsor assessments that is necessary to identify the child’s educationalneeds. If YES: Additionalassessments,OT,othermotor assessments,hearing,augmentative– communication, sensory profile. CASE MANAGER, PSYCH, OT, MOTOR, etc. VARIOUS: Academic or behavioral assessments,progress toward IEPgoals, classroommeasures,OT,othermotor assessments,hearing,augmentative– communication,sensory profile
  • 5. GUIDE TO COMMON SCHOOL AGE ASD CHARACTERISTICS Child Name: Age: Person Completing this checklist: Position: How long have you worked with this child? Current Eligibility: Medical Diagnosis (if any): COMMUNICATION  understands language in a literal/concrete way  repeats same questions/statements  needs additional time to process information  uses language ‘scripts’ from TV, videos or people in the environment  unaware of listener’s interest or understanding of topic  difficulty initiating/sustaining social interactions  avoidant or fleeting eye contact  unusualspeech patterns (speed,volume, tone); speaks in ‘adult-like’ manner  better at decoding than reading comprehension Others observations: ____________________________________________________________ SOCIAL RELATING/UNDERSTANDING  difficulty reading nonverbal and social cues  awkward attempts at relating and difficulty maintaining relationships  prefers company of adults  seems unaware of how words/actions affect others  seems unaware of physical boundaries  attends to objects more than people  struggles with group games and activities  withdraws, remains aloof or acts ‘stand-offish’ in group situations Others observations: ____________________________________________________________ PATTERNS OF BEHAVIOR  difficulty with change (place to place, activity to activity or new experiences)  repetitive activities (pacing, finger flipping, flapping, noises)  generally naïve, honest and compliant when understands expectations  unmotivated by typical reinforcers  strict adherence to rules  talks excessively about own interests  relies on routines or rituals; can be inflexible  has to finish one activity before starting another  requires step-by-step directions in order to meet expectations or complete tasks  perfectionist or afraid to try new things Other observations:_____________________________________________________________
  • 6. SENSORY  overly sensitive to certain sounds ormay ‘tune out’auditory input  seeks or makes noise for enjoyment  sensitive to touch or certain textures/seeks objects of certain textures  enjoys being squeezed or hugged  resistant to grooming activities  high/low pain threshold  restricted food repertoire  over reacts to certain smells/sniffs things  notices visual detail/patterns, likes lights/shiny objects  distracted by too much visual stimulation  unaware of body in space; may run or bump into objects or people  needs to swing, rock or move  difficulty with paper/pencil activities, shoe tying  over/underreacts to sensory information  walks on toes Other observations:_____________________________________________________________ COMMON LEARNING CHARACTERISTICS  difficulty with language based instruction  unable to see the ‘big picture’  strong visual learner  difficulty with the ‘how’ and ‘why’  uneven learning profile  unusualmemory for certain things,especially in area of interest  difficulty with attending,processing and multi-step directions  poor independent work skills, group work may be difficult  difficulty organizing time, space,materials HAVE YOU TRIED?  Structuring Time (individual/group schedule,prior notice of change)  Structuring Space (established/preferential seating,alternative setting)  Structuring Material (graphic organizers, guided notes,visually defined beginning/end) Comments: ___________________________________________________________________

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