A condition which includes one or more of the following characteristics is
present:

Yes   No   An inability to build or maintain satisfactory relationships with
                 peers and teachers;

Yes   No   Inappropriate types of behavior or feelings under normal circumstances,
                 including behaviors which are psychotic or bizarre in nature or behaviors
                 which are atypical and for which no observable reason exists;

Yes   No   A general, pervasive mood of unhappiness or depression, including
                 major depression and dysthymia, but excluding normal grief reactions;

Yes   No   A tendency to develop physical symptoms or fears associated with
                 personal or school problems, including separation anxiety, avoidant disorder
                 and overanxious disorder;

Yes   No   Schizophrenia.

The condition shall meet the criteria of having been present:

Yes   No   to a marked degree,

Yes   No   over a long period of time, and

Yes   No   adversely affecting the student's educational performance.

Yes   No   The student has been observed by two or more persons at separate
                 times and places, each of which cite and corroborate specific
                 behaviors which, in the aggregate, provide foundation for probable
                 concern for emotional disturbance; and

Yes   No   The local education agency has attempted at least two different
                 behavioral intervention techniques which may include, but are not
                 limited to, changes in the student's regular class schedule,
                 curriculum, and/or teacher, school counseling or use of community
                 resources.
 

Documentation of the observations and interventions shall include:

Yes   No   descriptions of procedures, durations of each, and results accruing
                 to each;

Yes   No   dated and signed documented anecdotal records of behavioral
                 observations made in multiple settings and showing that the
                 student's disability is evident in other than the school classroom
                 environment; and

Yes   No   a social or developmental history compiled directly from the
                 student's parents, or from records when the parents are not
                 available.
 

EXCLUSIONARY FACTORS:

The student may not be identified as having emotional disturbance if:
Delays in educational performance are primarily due to visual impairment,
hearing impairment, orthopedic impairment, cognitive delay, health factors,
cultural factors or limited educational opportunity; or

Common disciplinary problem behaviors (e.g., truancy, smoking, breaking
school conduct rules) are the sole criteria for determining existence of
emotional disturbance. Common disciplinary problem behaviors may exist in
conjunction with emotional disturbance, but cannot be used as the sole criteria
for recommending special education and related services.

The term emotional disturbance does not apply to children who are socially
maladjusted, unless it is determined that they have an emotional disturbance.
 

Student Name: _________________ CST Date: __________