Educational Disability Eligibility Form
Student Name
Date of Birth
Student ID
School
Grade
Eligibility Information
Disability Category
Autism
Deaf-Blindness
Deafness
Emotional Disturbance
Hearing Impairment
Intellectual Disability
Multiple Disabilities
Orthopedic Impairment
Other Health Impairment
Specific Learning Disability
Speech or Language Impairment
Traumatic Brain Injury
Visual Impairment
Date of Evaluation
Eligibility Team Members
Assessment/Evaluation Summary
Eligibility Decision
Eligible
Not Eligible
Decision Rationale/Comments