Yes   No   The student is diagnosed by a qualified medical practitioner that
                 the impairment substantially limits normal function of muscles and
                 joints due to congenital anomaly, disease or permanent injury, and

Yes   No   adversely affects the student's ability to learn or participate in the
                 general education curriculum.

Specific examples of the adverse impact of the orthopedic impairment on the
student's educational performance:
________________________________________________________________
________________________________________________________________
________________________________________________________________

Documentation of:

Yes   No   The effect of the orthopedic impairment on the student's ability to
                 participate in educational programs, including vocational and
                 physical education programs;

Yes   No   the effect of medications, treatments or other medical interventions
                 on the student's educational performance; and

Yes   No   the results of a physical therapy and/or occupational therapy
                 evaluation which describes the need for therapy as related to
                 educational performance.
 

Student Name: _________________ CST Date: __________