EARLY INTERVENTION/EARLY CHILDHOOD SPECIAL EDUCATION

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					                         EARLY CHILDHOOD SPECIAL EDUCATION
                      3-Year Evaluation Referral and Observation Summary
 Child’s Name: ________________________________ Person completing Obs/Ref: __________________
 Age: ________ DOB: _______________Site: ___________________________________________________
 Date of Obs./Ref: _______________________         Languages spoken by child: ________________________
 Date of initial Eligibility: __________________    Interpreter needed?  No  Yes (List Lang below)
  File Review & Eligibility to be done at site               Language: ___________________________
 Child is motivated by: ____________________________________________________________________
 Medical Diagnosis ___________________________________________________________________
Area of current                 Present skill levels based on 20 minute observation
   concern?
   Cognitive
     Y/N
   Adaptive
     Y/N
    Social
     Y/N
  Fine Motor
     Y/N
 Gross Motor
     Y/N
Communication
  Receptive
  Language
    Y/N
Communication
  Expressive
  Language
    Y/N
    Speech
     Y/N
  Classroom/
 Group setting

 Is a regional eligibility being considered for this child?  Yes  No
 Check box for each of the following regional services involved: Hearing Autism Vision
 Orthopedic Nursing Regional Staff Member: ___________________________________
 Date 3 year re-eval Regional Referral submitted:__________________________ (attach copy)
 If you would like Eval team to include Regional re-eval components in Assessment Plan,

 Please list: ______________________________________________________________________________

 Any other pertinent information: ____________________________________________________________
                                                                           U:vss/forms/Observation Summary and Eval Ref
                                                                                                        Updated: 5/3/07
 Submit to evaluation secretary at least 90 days prior to child’s third birthday to ensure timely
                                           completion of evaluation.


                               EI/ECSE EVALUATION CHECKLIST


Guidelines for a child receiving early intervention services who needs an evaluation to determine
ECSE eligibility (3-Year).

    NOTE: A child only needs to be evaluated in areas of suspected delay. Evaluation does not need to be
    done in areas of original EI eligibility, unless the team or the family has concerns in the specific
    developmental area.

Discuss the need for additional testing with the family at an IFSP meeting. For 3-year re-evaluations, discuss
the process for determining ECSE eligibility and write the steps in the Transition Plan on the Family Outcomes
page of the IFSP.

The evaluation team secretary will send notification of upcoming ECSE 3-yr evaluations. If you do not
receive notification of an upcoming 3-year evaluation for child under your service coordination, please
notify the evaluation team secretary as soon as possible at
(503) 614-1610.

       Complete or review curriculum-based assessment and/or data in selected areas of development to
        support suspected typical development or developmental delays.
       Discuss need or recommendation for re-evaluation with family at an IFSP meeting.
       Send the completed evaluation Referral form (on back) to evaluation team secretary:

If regional services need to be initiated or renewed please follow Regional Referral checklist.


When the above paperwork has been received, the evaluation team secretary will schedule an IFSP
meeting with the family to develop an assessment plan and complete the evaluation.

Results of the evaluation will be given to the site to determine eligibility or non-eligibility.




                  Talk with coordinator for more clarification if needed.
               If ever in doubt, call Evaluation Team !!! (503) 614-1610




                                                                                    U:vss/forms/Observation Summary and Eval Ref
                                                                                                                 Updated: 5/3/07

				
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