Yes   No   Meets the criteria in ARM 10.16.1124 for visual impairment;

Yes   No   Meets the criteria in ARM 10.16.1123 for speech-language impairment;

Yes   No   Meets the criteria in ARM 10.16.1119 for hearing impairment or
                 in ARM 10.16.1118 for deafness; and

Yes   No   Is experiencing severe delays in communication and other developmental
                 and educational skills such that services designed solely for students with
                 deafness or for students with blindness would not meet the student's
                 educational needs.

Student Name: _________________ CST Date: __________