Education Adjustment Program (EAP) / EAP Verification Form – ASD (EAP 3 updated 2014)
Verification of Disability in the Education Adjustment Program Category of Autism Spectrum Disorder
Education Adjustment Program – Verification of Disability
Cover Sheet & Checklist
Student:Click here to enter text. / School:Click here to enter text. / Year Level:Click here to enter text.
Disability Category: Autism Spectrum Disorder
☐ / Initial Verification / (i.e. no previous verification)
☐ / Review / of an existing verification
☐ / Adding / a new category to an existing verification: / Adding / ☐HI / ☐ID / ☐PI / ☐VI / ☐SED
☐ / Removal / from an existing category: / Removing / ☐ASD / ☐HI / ☐ID / ☐PI / ☐SLI / ☐VI / ☐SED
☐ / Changing / from an existing category to a new category: / Change from / to ASD
☐ / Transferring / into the RI System from a Non-Catholic sector

Documentation Checklist: (All documents to be enclosed and ticked off by school to confirm inclusion in the submission.)

Process / School / RI Verifier / Comments
EAP Consent Form
(EAP 1updated 2013)
EAP Verification Form
ASD (EAP 3updated 2014)
PART A – Student Details
PART B – Evidence
Criterion 1
Section 1 – School to complete Student Details
Section 2 – Specialist Report
PART B –
Criterion 2
Educational impact and adjustments
Part B - Verification Outcome
School to complete Student Details
Verifier to sign the outcome
PART C –
Principal Request/Signature
Educational Planning Document (IEP, PLP, ISP) etc
(or equivalent school planning doc.)
If Review – include previous EAP
Confirmation Documentation
Additional Attachments:
Specialist’s reports/assessments

Members of the school team complete this form collaboratively, ensuring that relevant personnel have been involved in the data gathering and decisions relating to the impairment and activity limitations and participation restrictions for this student.

The verification form in each of the EAP categories consists of the following sections which must be completed:
  • PART A Student Details
  • PART B Evidence Supporting Verification of Disability
  • PART C Principal Request for Verification of Disability
Two (2) copies of this form and required attachments (outlined in Part B) to be submitted to:
The RI EAP Verification Team at the RI Equity Network meeting
Part A: Student Details
Last Name / Click here to enter text. / Date of Birth / Click here to enter text. /
First Name / Click here to enter text. / Gender / Click here to enter text. /
School / Click here to enter text. / Year Level / Click here to enter text. /
School Address / Click here to enter text. / School Phone / Click here to enter text. /
Contact person in school for this verification / Click here to enter text. / Position / Click here to enter text. /
Email Address / Click here to enter text. / Phone / Click here to enter text. /
Existing Categories:
☐Nil / ☐ASD / ☐HI / ☐ID / ☐PI / ☐SLI / ☐VI
This verification request is for:
☐ / Initial Verification (i.e. no previous verifications)
☐ / Review of an existing verification
☐ / Adding a new category to an existing verification
☐ / Changing EAP Category
☐ / Removal from an existing category
☐ / Transferring into RI College from a non-Catholic sector
Part B: Evidence Supporting Verification of Disability in the Education Adjustment Program Category of Autism Spectrum Disorder
Criterion 1: There is a medical diagnosis of Autism Spectrum Disorder
Section 1: STUDENT DETAILS – this section is be completed by the SCHOOL TEAM
Last Name: / Click here to enter text. / Date of Birth: / Click here to enter text. /
First Name: / Click here to enter text. / Gender: / Click here to enter text. /
Student Address: / Click here to enter text. /
School: / Click here to enter text. / Year Level: / Click here to enter text. /
School Phone: / Click here to enter text. / School Fax: / Click here to enter text. /
☐ / Other EAP verified disabilities: / Click here to enter text. /
☐ / Other existing medical diagnoses: / Click here to enter text. /
☐ / The following reports are attached for your information:
☐ / Teacher observations/reports / ☐ / Speech-Language Pathologist report/assessment
☐ / Specialist Staff (e.g. HOD, TLS Teacher) observations/reports / ☐ / Advisory Visiting Teacher report
☐ / Guidance Officer report/assessment / ☐ / Other (Specify) Click here to enter text.
Section 2: SPECIALIST REPORT – this section is to be completed by the SPECIALIST
For the purposes of the Education Adjustment Program category of Autism Spectrum Disorder, Criterion 1 requires the completion of this section by a suitably qualified medical specialist (registered Paediatrician, Psychiatrist, Neurologist).
☐ / I have assessed this student and with the information available, I am able to confirm a diagnosis of Autism Spectrum Disorder, as described by the DSM-5 diagnostic criteria.
I recommend:
☐ / no review of diagnosis
☐ / a review of diagnosis in: / ☐ / 3 years / ☐ / Other Click here to enter text.
OR
☐ / I have assessed this student and with the information available, I am not able to confirm a diagnosis of Autism Spectrum Disorder, as described by the DSM-5 diagnostic criteria.
I have attached my additional information/report that will assist with the educational planning for this student: / / Yes / / No
Signed / Date
Specialist’s Name / Medical Board Registration No: MED00
My Registered Area of Specialisation: / ☐ / Paediatrician / ☐ / Psychiatrist / ☐ / Neurologist
Address
Telephone Contact / Fax / Email

Criterion 2: The identified Autism Spectrum Disorder results in activity limitations and participation restrictions for the student at school requiring significant education adjustments.

This section is to be completed through a collaborative process which MUST include input from the student’s teacher/s.

Evidence of the educational impact of the identified impairment
The Prompts for ASD Criterion 2 Form can be used as a guide for the completion of this section
(
CURRICULUM
achieved curriculum / teaching strategies / staff resources / educational resources / specialist staff support
use of assistive technology / assessment/reporting
Describe the student’s functioning (activity limitations andparticipation restrictions) related to the autism spectrum disorder:
Outline the associated significant education adjustments that are currently in place for this student:
COMMUNICATION
receptive / expressive / pragmatics (language use) / speech / specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the autism spectrum disorder:
Outline the associated significant education adjustments that are currently in place for this student:
SOCIAL PARTICIPATION/EMOTIONAL WELLBEING
social/interaction skills / self-management strategies / individualised plans / use of social development resources / specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the autism spectrum disorder:
Outline the associated significant education adjustments that are currently in place for this student:
LEARNING ENVIRONMENT/ACCESS
classroom and non-classroom environment / organisational skills / sensory needs / transition skills / specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the autism spectrum disorder:
Outline the associated significant education adjustments that are currently in place for this student:
HEALTH AND PERSONAL CARE, SAFETY
health management / risk management / self-care skills / specialised self-care procedure / individualised plans / specialist staff support
Describe the student’s functioning (activity limitations and participation restrictions) related to the autism spectrum disorder:
Outline the associated significant education adjustments that are currently in place for this student:
Verification of Disability in the Education Adjustment Program Category of Autism Spectrum Disorder
Verification Outcome:
Student Name: Click here to enter text. / Date of Birth: Click here to enter text.
School: Click here to enter text. / Year Level: Click here to enter text.
To be completed by the Verifier:
Criterion 1: The student has a current relevant diagnosis from a specialist
There is a specific diagnosis from the DSM-5 diagnostic category of Autism Spectrum Disorder / ☐ / YES
☐ / NO
Criterion 2: The student’s documented diagnosis results in activity limitations and participation restrictions at school requiring significant educational adjustments.
There are documented activity limitations and participation restrictions relating to the student’s diagnosis / ☐ / YES
☐ / NO
Significant education adjustments are required and are related to the effects of the diagnosed condition and are not due to other factors / ☐ / YES
☐ / NO
Eligibility
☐ / The process indicated in the Religious Institute Colleges protocols has been followed and I confirm that this student meets DETE’s criteria for the category of Autism Spectrum Disorder
Ineligibility
☐ / The process indicated in the Religious Institute Colleges protocols has been followed and I confirm that this student does not meet DETE’s criteria for the category of Autism Spectrum Disorder
Comment:

Recommendation for review of eligibility: / Review required / ☐ / YES / ☐ / NO / Date:
Criterion 1 / ☐ / YES / ☐ / NO / Date:
Criterion 2 / ☐ / YES / ☐ / NO / Date:
Signed: / Date:
Name of Verifier:
Address:
Telephone contact: / Fax:
Email contact:
Part C: Principal Request for Verification of Disability in the Education Adjustment Program Category of Autism Spectrum Disorder
Verification of disability in the EAP category of Autism Spectrum Disorder according to DETE’s criteria is requested for the following student according to the details outlined in PART A and PART B of this report and the related attachments:
Student Name Click here to enter text.
School Click here to enter text. / Date of Birth Click here to enter text. / Year Level Click here to enter text.
In making this request I have ensured that:
  • the student is enrolled and attending the school

  • a completed EAP Consent Form (EAP 1) is kept in the student’s school file

  • discussions have been held with the parent and/or student regarding this verification and agreement to proceed has been reached

  • appropriate personnel have been involved in data gathering and reporting

  • processes are in place to support this student within the school

  • all documents for verification are complete

  • the original EAP documentation is kept in the student’s school file

  • copies of relevant documents will be sent to the EAP Verification Team as per RI processes.

Principal Name:
Principal Signature: / Date:

Copyright in this work is owned by the State of Queensland (Acting through the Department of Education, Training and Employment) and has been adapted by Religious Institute Colleges with consent.

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