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Planning and Placement Team Worksheet

to Determine Eligibility for Special Education

Due to an Emotional Disturbance

This summary of assessment findings is to be completed by the Planning and Placement Team

(PPT) in accordance with procedures defined in the “ED Definition Criteria” section of the

Guidelines for Identifying and Educating Students with Emotional Disturbance. Attach this

completed form to the assessment records.

1. Alternative Strategies Prior to Referral

Document practices, strategies, supports and interventions implemented at each level as

appropriate:

UNIVERSAL:__________________________________________________________________

______________________________________________________________________________

TARGETED:___________________________________________________________________

______________________________________________________________________________

INTENSIVE:___________________________________________________________________

______________________________________________________________________________

Sources of Evidence for the characteristic(s) and limiting criteria :

______________________________________________________________________________

Have alternative strategies been attempted and found inadequate to address the student’s areas of

need? __ Yes __ No

2. Characteristics and Limiting Criteria

Limiting Criteria

Characteristic has been exhibited over a long period of time (duration) __ Yes __ No

Characteristic has been exhibited to a marked degree (i.e., significantly greater frequency and/or

intensity than seen in peer group) __ Yes __ No

Characteristic has an adverse effect on educational performance __ Yes __ No

Characteristics Limiting Criteria

Check all that apply (student must manifest at least

one characteristic)

Long

Time

Marked

Degree

Adverse Effect on

Educational

Performance

a. Inability to learn, which cannot be

explained by intellectual, sensory or other

health factors

b. Inability to build or maintain satisfactory

interpersonal relationships with peers and

teachers

c. Inappropriate types of behavior or feelings

under normal circumstances

d. A general pervasive mood of unhappiness

or depression

e. A tendency to develop physical symptoms

or fears associated with personal or school

problems

Characteristics

At least one characteristic has been checked. ___ Yes ___No

All three limiting criteria have been checked for at least one characteristic ___ Yes ___No

All three limiting criteria must be checked for at least one characteristic in order to qualify for

special education eligibility as a student with ED.

Sources of evidence for the characteristic(s) and limiting criteria:

______________________________________________________________________________

Social Maladjustment and Emotional Disturbance

If the student exhibits social maladjustment, does he or she also demonstrate the condition of

emotional disturbance? (Refer to section 2, page 25, “A Note Regarding Students with Social

Maladjustment” in the Guidelines for Identifying and Educating Students with Emotional

Disturbance [2011]) ___ Yes ___ No*

___ N/A

*If “No,” the student does not meet the requirements for this criterion.

3. Elimination of Other Possible Causes

Are any of the following considered primary causes of educational and behavioral problems?

temporary situational stressors ___ Yes ___ No

intellectual impairment ___ Yes ___ No

learning disabilities ___ Yes ___ No

medical problems ___ Yes ___ No

environmental stressors ___ Yes ___ No

If all other possible causes are checked “No,” the student meets the requirements for this

criterion.

4. Social, Cultural and Linguistic Considerations

Has the team considered the following in the analysis and interpretation of data, and determined

that each factor does not have a significant influence on the emotional and behavioral

functioning of the student?

social characteristics and influences ___ Yes ___ No

cultural characteristics and influences ___ Yes ___ No

linguistic characteristics and influences ___ Yes ___ No

“Yes” must be checked for each to indicate that the above factors do not significantly

influence the student’s behavior or emotional status.

Sources of Evidence:

______________________________________________________________________________

Conclusion

Does the PPT conclude that the student meets the criteria for having an emotional disturbance as

defined in Connecticut statutes? ___ Yes ___ No

Note: Best practice suggests that dissenting opinions be documented in the IEP, Prior Written

Notice and may be indicated in notes or minutes of the PPT meeting..

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Planning and Placement Team Worksheet to Determine Eligibility (State of ConnecticutDepartment of Administrative Services)

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