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					Instructions for completing the Summary for Self Report


Using the Child Data Record Form, transfer data for each item for each Indicator on the appropriate worksheet in the
Summary for Self Report.

Each indicator is labeled on the tabs at the bottom of the Summary for Self Report.

For each indicator, list the child's name.

List date of IFSP, date of birth, and/or date of referral, SC initial if indicated.

For each item,place an "x" in the cell to indicate "yes" or "no". Each worksheet has a self calculator for each item.
Total number of files and number of files that meet compliance will be calculated and the number will be auto-filled in
the appropriate cell. Total percentage of compliance will be calculated and auto-filled into the appropriate cell.

Save report as "Program name summary self report 2011"

This form must be used and submitted for each program.
                                                                  Summary Form for Self Report




                                                                                        1. Did ALL services on the IFSP
    Indicator 1 -Timely Delivery of Services Summary                                   begin within 45 calendar days of
                                                                                                                              Was service
Children and families receive all services on their IFSP in                                the signature on the IFSP                            If services were
                                                                                                                            delivery delayed
a timely manner (within 45 days of the parent consent to                               AND/OR Did the IFSP service(s)                           late, have ALL
                                                                                                                           due to exceptional
 the IFSP OR if the planned start date is greater than 45                              with a planned start date greater                        services
                                                                                                                                 family
   days of the parent consent, the service started on or                                than 45 days from the date the                          started?
                                                                                                                            circumstances?
     before the planned start date for that service).                                   parent signed the IFSP start on
                                                                                       or before the planned start date?


                                                                Service
                                                              Coordinator   Date of
                      Child's Name                              Initials     IFSP            YES               NO           YES        NO         YES      NO
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                                                                  Summary Form for Self Report



24
25


                                                                                                       Divided by
                                                                                                                         0
      Number of children and families who received all services on the IFSP                          sample size of:
                                                                                                 0
     in a timely manner. Include delays due to family circumstances.                                    Equals
                                                                                                                       #DIV/0!
                                                                                                     compliance of:
Summary Form for Self Report
                     Summary Form for Self Report




Documentation
was used to verify
Actual Start Date
(progress note,
eval report, etc)




  YES       NO
Summary Form for Self Report
Summary Form for Self Report
Summary Form for Self Report
                                                           Summary Form for Self Report




                                                                                              1. Are all services on
                Indicator 2 -Natural Environments                                                                        2. If no, does the IFSP include an approp
                                                                                              the IFSP provided in
     Children and families receive early intervention in natural                                                       justification with timelines for transitioning
                                                                                              home or community
                           environments.                                                                                                   into the NE?
                                                                                                 based settings?



                                                                     Service
                                                                   Coordinator
                           Child's Name                              Initials  Date of IFSP     YES          NO           YES           NO
           1
           2
           3
           4
           5
           6
           7
           8
           9
       10
       11
       12
       13
       14
       15
       16
       17 sara
       18 susie
       19 maria
       20
       21
       22
       23
       24



FFY 2010                                                                                                                                 Name of EIP
                                                             Summary Form for Self Report



       25


                                                                                                       Divided by
            1. Number of children and families who received all services on the IFSP in home or                           Equals
                                                                                                  0   sample size   0
            community based settings.                                                                                   compliance
                                                                                                           of:
                                                                                                                            of:




FFY 2010                                                                                                                    Name of EIP
                                                               Summary Form for Self Report



                                                                                                   Divided by
           a. If no, does the IFSP include an appropriate justification with timelines for                            Equals
                                                                                              0   sample size   0
           transitioning back into the NE?                                                                          compliance
                                                                                                       of:
                                                                                                                        of:




FFY 2010                                                                                                                Name of EIP
                                 Summary Form for Self Report




             2. If no, does the IFSP include an appropriate
           justification with timelines for transitioning back
                               into the NE?




                                               N/A




FFY 2010                                                         Name of EIP
           Summary Form for Self Report




                    #DIV/0!




FFY 2010                                  Name of EIP
           Summary Form for Self Report




                    #DIV/0!




FFY 2010                                  Name of EIP
                                                                          Summary Form for Self Report




                                                                                                                           Arizona Site Review Child File Data Summary Form

                                                                                                                                                    d. Are all the
 Indicator 3 - Child Outcomes Summary               Percent                                                                                     outcomes written to
                                                                                                          b. Are all the  c. Are the outcomes
   of infants and toddlers with IFSPs who demonstrate        1. Does the IFSP                                                                    support the child’s        e. Are all the
                                                                                                       outcomes specific     reflective of the
  improved a )positive social-emotional skills (including   include outcomes    a. Are ALL outcomes                                                 participation,       outcomes discipline
                                                                                                      so that everyone on family's resources,
 social relationships; b) acquisition and use of knowledge that are expected        measureable?                                                  independence or            and jargon
                                                                                                        the team knows        priorities and
and skills (including early language/communication) ; and to be achieved?                                                                      relationships within a           free?
                                                                                                       what to work on?         concerns?
   c) use of appropriate behaviors to meet their needs.                                                                                        routine or activity the
                                                                                                                                               family has identified?

                        Child's Name                         YES       NO       YES         NO           YES       NO        YES             NO    YES         NO          YES
    2
    2
    3
    4
    5
    6
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                                                                     divided by sample                Equals compliance
        1.Number of IFSPs that contain outcomes:               0                             0                                     #DIV/0!
                                                                          size of:                            of:




FFY 2010                                                                                                                                                             Name of EIP
                                                                      Summary Form for Self Report



     a. Number of IFSPs that contain outcomes that are            divided by sample              Equals compliance
                                                              0                          0                           #DIV/0!
     measurable:                                                       size of:                          of:
     b. Number of IFSPs with outcomes specific so that            divided by sample              Equals compliance
                                                              0                          0                           #DIV/0!
     everyone on the team knows what to work on:                       size of:                          of:
     c. Number of IFSPs that contain outcomes that are
                                                                  divided by sample              Equals compliance
     reflective of the parent's resource priorities and       0                          0                           #DIV/0!
                                                                       size of:                          of:
     concerns:
     d. Number of IFSPs that contain outcomes that are
                                                                  divided by sample              Equals compliance
     written to support the child's participation,            0                          0                           #DIV/0!
                                                                       size of:                          of:
     independence or relationships within family routines:
     e. Number of IFSPs that contain outcomes that are            divided by sample              Equals compliance
                                                              0                          0                           #DIV/0!
     discipline and jargon free:                                       size of:                          of:
     f. Number of IFSPs that contain outcomes that are free       divided by sample              Equals compliance
                                                              0                          0                           #DIV/0!
     of passive words:                                                 size of:                          of:
     g. Number of IFSPs that contain outcomes that are            divided by sample              Equals compliance
                                                              0                          0                           #DIV/0!
     attainable within 3-6 months.                                     size of:                          of:
     2. Number of IFSPs that contain a statement of the
                                                                  divided by sample              Equals compliance
     child's present level of development for all             0                          0                           #DIV/0!
                                                                       size of:                          of:
     developmental areas:
      a. Number of IFSPs that contain a statement of the          divided by sample              Equals compliance
                                                              0                          0                           #DIV/0!
     child's current status that is described functionally:            size of:                          of:




FFY 2010                                                                                                                       Name of EIP
                                                                            Summary Form for Self Report




na Site Review Child File Data Summary Form


                                                     f. Are all the                            2. Does the IFSP
                                                                                                                  a. Is the statement
                              e. Are all the       outcomes free of       g. Are all the     contain a statement
                                                                                                                      of the child's
                           outcomes discipline      passive words      outcomes attainable   of present levels of
                                                                                                                     current status
                               and jargon        (improve, maintain,        within 3-6       development for all
                                                                                                                        described
                                  free?             increase, and           months?             developmental
                                                                                                                      functionally?
                                                      decrease)?                                    areas?                                Service
                                                                                                                                        Coordinator
                                                                                                                                          Initials
                                        NO         YES        NO         YES        NO         YES        NO        YES        NO




           FFY 2010                                                                                                                                   Name of EIP
           Summary Form for Self Report




FFY 2010                                  Name of EIP
                                                                          Summary Form for Self Report




                                                                                                                                      3. Is there
                                                                      a. Does the family                                            documentation
                                                                          assessment                          a. Are the services that the contents
                                                   1. Does the IFSP       include the        2. Is there          and supports    of the IFSP have
                                                   contain a family         parents’      documentation of      identified in the      been fully
                                                        directed        perceptions of   services necessary    IFSP designed to    explained to the       4. Is there
    Indicator 4- Family Outcomes Summary           assessment that        their child’s  to meet the needs        enhance the       parents: Prior      documentation
 Percent of families participating in Part C who      includes the    abilities and needs of the child and       capacity of the    Written Notice      that parent(s)
  report that early intervention services have          family’s           related to     family, including    family in meeting was given prior to    provided Consent
   helped their family a) know their rights; b)        resources,      participation in      frequency,       the developmental     initiation of or   prior to initiation     Service
effectively communicate their children’s needs;      priorities and   everyday routines     duration and         needs of their        change in        of or change in      Coordinator
  and c) help their children learn and develop.        concerns?        and activities?      intensity?              child?            services?           services?           Initials
                Child's Name                        YES       NO        YES       NO       YES       NO         YES       NO        YES       NO        YES         NO
    1
    2
    3
    4
    5
    6
    7
    8
    9
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  15
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  17
  18
  19
  20
  21
  22
  23
  24
  25




FFY 2010                                                                                                                                                                     Name of EIP:
                                                                       Summary Form for Self Report




                                                          divided by sample         Equals compliance
        1. Number of IFSPs that contain a family      0                       0                         #DIV/0!
         directed assessment that includes the                 size of:                     of:
      family's resources priorities and concerns:
        a.Number of IFSPs that contain a family
         directed assessment that includes the            divided by sample         Equals compliance
                                                      0                       0                         #DIV/0!
       parent's perception of the child's abilities            size of:                     of:
                      and needs:
      2. Number of IFSPs with documentation of
     services necessary to meet the needs of the          divided by sample         Equals compliance
                                                      0                       0                         #DIV/0!
         child and family, including frequency,                size of:                     of:
                 duration and intensity:
     a.Number of IFSPs that include services and
      supports identified in the IFSP designed to
                                                          divided by sample         Equals compliance
         enhance the capacity of the family in        0                       0                         #DIV/0!
                                                               size of:                     of:
       meeting the developmental needs of their
                         child:

             3.Number of IFSPs that contain
     documentation that the contents of the IFSP
                                                          divided by sample         Equals compliance
     have been fully explained to the parents and     0                       0                         #DIV/0!
                                                               size of:                     of:
      that Prior Written Notice was given prior to
           initiation of or change in services:


            4. Number of IFSPs that contain
                                                          divided by sample         Equals compliance
      documentation that consent was received         0                       0                         #DIV/0!
                                                               size of:                     of:
      prior to initiation of or change in services:




FFY 2010                                                                                                          Name of EIP:
           Summary Form for Self Report




FFY 2010                                  Name of EIP:
             Indicator 8 - Transition Summary
                                                                                             a. Does the IFSP
Children and families receive timely transition planning to
                                                                                              have transition
 support their child's transition out of early intervention
                                                                                            steps and services
  services to preschool or other appropriate community
                                                                                               documented?
        settings. (For use with APR Indicator 8).

                                                                                Date
                                                               Date of       referred to
                           Child's Name                        Birth            AzEIP         YES
    1
    2
    3
    4
    5
    6
    7
    8
    9
   10
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   12
   13
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   15
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   21
   22
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   25
        A. Number of children and families who have documentation on the IFSP of
                                                                                               0
        transition steps.

        B. Number of children and families with documentation of notification to the LEA
                                                                                               0
        (AZ transition planning form Part 1):

        C. Number of children and families whose transition meeting was held between 2.6-
                                                                                               0
        2.9 years.
 a. Does the IFSP         b. Is there                   c. Is there documentation    c1. If no, has
  have transition   documentation in the Parent Opted- of a transition conference   the Transition
steps and services       child's file of      Out      that occurred between 2.6-     Conference
   documented?     notification to the PEA?                         2.9?              been held?




           NO       YES         NO           Y or N      YES            NO           YES      NO




        divided by sample
                                 0                     Equals compliance of:
        size of:

        divided by sample
                                 0                     Equals compliance of:
        size of:

        divided by sample
                                 0                     Equals compliance of:
        size of:
Was the delay due to   Name of      Service
 exceptional family     School    Coordinator
   cirumstances?       District     Initials




    YES          NO




   #DIV/0!


   #DIV/0!



   #DIV/0!

				
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