APPENDICES FORMS Word Documents EI 5031 ATD Request EI ...

Nassau County Department of Health 

EARLY INTERVENTION PROGRAM Page 1 

2007 Best Practice Manual Appendix 

EI 5031 ATD Request 

EI 5035 Evaluation Packet 

APPENDICES 

FORMS 

Word Documents 

EI 5077 6 Month Provider Progress Report 

EI 5078 3 Month Provider Progress Report 

EI 5092 Consent Withheld 

EI 5093 IFSP Review Request/Amendment 

EI 5129 Justification for Assistive Technical Device (ATD) 

EI 5167 Health Status Information Form for MD 

EI 5170 Individual Family Service Plan (IFSP) 

EI 5170.8 IFSP Review 6, 18, 30 Months 

EI 5171 Family Assessment 

EI 5177 Provider Daily Notes/Attendance Sheet 

EI 5192 ABA – Service Coordinator Guidelines for PDD & Autism 

EI 5194 ABA Team Meeting Notes 

EI 5195 ABA Team Meeting Attendance Sheet 

EI 5201 Notification of Non Delivery of Authorized Services 

EI 5202 Parent Referral Letter 

EI 5216 Bilingual Evaluation Justification 

EI 5216.S Bilingual Evaluation Justification (Spanish) 

EI 5224L Transition Notice – Parent Consent 

EI 5229.A Community Setting – IFSP Amendment 

EI 5231 Home Language Survey 

EI 5235L CPSE Notification to DOH of Eligibility Determination of Transition Child 

EI 5241 Timeline of CPSE Process – Parent Check List 

EI 5243 Memo to CPSE with Recent Progress Notes 

EI 5255 ABA Team Meeting Suggestions and Questions


EARLY INTERVENTION PROGRAM Page 2 

2007 Best Practice Manual Appendix 

EI 5267A Recommend Childhood & Adolescent Immunization Schedule of US 2005 for 

Best Practice 

EI 5267B Recommend Childhood & Adolescent Immunization Schedule of US 2005 for 

Best Practice 

EI 5283 ABA Transition Plan – Preschool/IFSP Amendment 

EI 5284 ABA Team Member Progress Report 

EI 5285 ABA Team Leader 3 Month Progress Report 

EI 5287 ABA Team Leader 6 Month Progress Report 

EI 5294 School District Request for EIP Progress Notes 

Transition Table 

EI 5091.ex ABA Service Plan Schedule 2 

Excel Spread Sheets 

EI 5229.Cex ABA Initiation – Interaction Statement Data Sheet 

EI 5229.Dex ABA Community Track Log 

EI 5230.ex ABA Chart (Sessions & Hours) 

EI 5253.ex NC EIP Inclusion Progress 

NYSDOH Early Intervention Website 

http://www.health.state.ny.us/community/infants_children/early_intervention/index.htm 

February 4, 2000 ABA Memo 

March 31, 2006 Memo – Co Treatments 

February 1, 1999 NYS Memorandum - ATD 

March 15, 2000 Memo TSHH Re-issued Dec. 2000

Nassau County Department of Health Assistive Technology 

Early Intervention Program Request & Authorization 

Preschool Special Education Program 

INSTRUCTIONS FOR ASSISTIVE TECHNOLOGY REQUEST 

1. Therapist/Evaluator to complete Section I and/or II and III. 

2. A separate form must be completed for each requested device and/or service. 

3. For custom devices attach a written cost estimate. 

4. Attach the Amendment/Justification Form. 

5. Attach a prescription for each requested device. 

6. All devices will be reimbursed at the current Medicaid rates. 

INCOMPLETE FORMS will NOT be considered for review and will be returned to therapist/evaluator. 

Only original forms will be accepted. NO FAXES or copies. 

Medicaid #: __ 

Child/s Name: E.I.O.D.: 

Address: Address: Nassau County Department of Health 

60 Charles Lindbergh Blvd, Suite 100 

Telephone: DOB: Uniondale, NY 11553-3683 

Parent/Guardian Name: Telephone: 516-227- Date: 

SECTION I - REQUESTED DEVICE 

Description: Vendor Name: 

CPT Code: Cost: 

Address: 

Telephone: 

SECTION II - REQUESTED SERVICES 

Description: Provider Name: 

Address: 

CPT Code: Cost: Telephone: 

SECTION III - REQUESTED BY 

Name: Title: Date: 

Agency Name: 

Agency Address: 

Signature: Telephone: 

NASSAU COUNTY DEPARTMENT OF HEALTH AUTHORIZATION 

[ ] Authorized on: [ ] Denied on: 

Signature: Title: 

KIDS Authorization # Check Date: 

Voucher #: Verified By: 

Check #: Batch #: 

EI 5031 5/06


Early Intervention Program 

EVALUATION SUMMARY 

Eligibility Determination 

(Page 1 of 3) 

Evaluating Agency Child 

Name: Name: 

Address: Date of Birth: 

Core Eval. Completed on: / / 

Telephone: Suppl’mt Evals completed on: / / 

�Family Assessment Offered & Refused Area of Suspected Delay:_________________________________ 

�Family Assessment Completed & Attached 

Physician Non-physician Non-physician Supplemental 

�Bilingual �Multiple Disciplinary �Supplemental �Supplemental �To determine Eligibility 

Designated Contact Person: (Individual to Name IFSP Date 

Represent Evaluation Team at IFSP meeting) Phone # / / 

Discipline(s) Involved in Evaluation 

Audiologist Pediatrician Social Worker 

Nurse Physical Therapist Special Educator 

Nurse Practitioner Psychologist Speech/Lang. Pathologist 

Nutritionist Other Physician Other: 

Occupational Therapist Physician Assistant 

COMPLETE THE SECTION BELOW FOR CORE EVALUATION & 

SUPPLEMENTAL DETERMINATION OF ELIGIBILITY 

Evaluation Summary Diagnosed Condition ICD-9 Code 

Functional Area Developmental 

Status (1) 

Method (2) (1) 

Adaptive (2) 

Cognitive (3) 

Communication Eligibility Determination 

Social/Emotional Eligible Not Eligible 

Physical 

(1) DEVELOPMENTAL CODES 

A No Delay 

B 2.0+ SD below mean (sufficient alone for eligibility) 

C 1.5+ SD below mean (similar delay in another functional area need to establish eligibility) 

D 12 Month or more delay (sufficient alone for eligibility) 

F 33% or more delay (sufficient alone for eligibility) 

G 25% or more delay (similar delay in another functional area needed to establish eligibility) 

H Suspect (use with screenings only) 

I Slight delay (not sufficient for eligibility) 

Eligibility Determination Completed by: 

EI 5035.1 8/06 Name Title 

(2) METHOD 

T– Standardized 

Test 

P– Clinical 

Opinion



Evaluating Organization: Child’s Name: 


Evaluation Team 

(Page 2 of 3) 

List all individuals involved in the evaluation; indicate if individual participated in Family Assessment, 

Core Evaluation or a Supplemental Evaluation. 

Name: Instrument(s) used: 

Profession: 

Date Evaluated: / / � Family Assessment 


Profession: 

Date Evaluated: / / � Core Eval. � Supplemental Eval. 


Profession: 



Profession: 



Profession: 



Profession: 



Profession: 



Profession: 


EI 5035.2 8/06



Child’s Name: 

Evaluation: Summary Narrative 

Include the following: (use additional pages as necessary) 


Evaluation Team 

(Page 3of 3) 

1. description of the assessment process & condition 

2. the child’s responses 

3. the family’s belief of whether the child’s response was optimal 

4. an explanation of the scores & measures reported 

5. statement of eligibility 

*Attach a copy of the Health Status Report completed by the primary care provider 

and incorporate any information provided by physician into summary narrative. 

Date Evaluation was discussed with family: / / 

Evaluation Report sent by (provider name) 

To family on / / . 

Narrative Completed by: 

EI 5035.3 8/06 

Name Title Date

NASSAU COUNTY DEPARTMENT OF HEALTH 

EARLY INTERVENTION PROGRAM 

60 Charles Lindbergh Blvd., Suite 100 

Uniondale, NY 11553-3683 

(Please Type) 6 MONTH PROGRESS REPORT 

Date of Report _____/_____/_____ DOH/SC/EIOD: 

PLEASE CHECK IFSP PERIOD 

[ ]6 Mo [ ]12 Mo [ ]18 Mo [ ]24 Mo [ ]30 Mo [ ]36 Mo [ ]Discharge 

Child’s Name:_________________________________ Therapist: ______________________________________________ 

D.O.B.: ____/____/____ Age:_____ Adjusted Age: _____ License #: ______________________________________________ 

IFSP Period:____/____/____ to ____/_____ /_____ Discipline/Service: ______________________________________________ 

Frequency/Duration:______________________________ Agency: ________________________________________________ 

Key: C = Clinician cancelled FV = Family vacation H = Holiday I = IFSP meeting M = Make-up N = No one home 

P = Parent cancelled PV = Provider vacation S = Child sick/hospitalized X = Treatment session 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

1. Progress Summary (includes): 

a) Strategies and treatment used to address current IFSP goals – (Note if they have been attained, are emerging or not yet 

reached.) - 

b) When & how do you communicate with team members & how often 

c) Formal assessments of child’s current level of functioning; (include test results) - 

EI 5077.A 06/06 Over

2. Therapeutic Plan: 

a) Outcomes/long term goals - 

b) Measures of success/short term objectives – report on data and programming. 

3. Family/Caregiver Plan: 

a) Specific suggestions/recommendations for family/caregiver to facilitate attainment of goals - 

b) Describe family/caregiver involvement – 

(If applicable) 

Date of discharge: _____/_____/_____ 

Therapist Signature Date: / / 

Signature & Title Date: / / 

(Person Reviewing Report) 

EI 5077.B 06/06





3 MONTH PROGRESS REPORT 

(Please Type) 

Only Original Forms will be Accepted Date of Report: 

EIOD: 

Child’s Name Date of Birth: CA: AA: 

IFSP Period: FREQ/DURATION: 

Provider/(Agency Name) & Discipline: 

Name/Title of Person Completing Report: License #: 

Signature of Person Completing Report: 

Check as appropriate: ( )3 Mo. ( )9 Mo. ( )15 Mo. ( )21 Mo. ( )27 Mo. ( )33 Mo. ( )39 Mo ( )Discharge 



1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

PROGRESS TO DATE (What is specific to your sessions, include behavioral observations and interaction with family.) 

Signature and title of person reviewing report _____________________________________________________________ 

EI 5078 9/06

THOMAS R. SUOZZI 

COUNTY EXECUTIVE 

Nassau County 

DEPARTMENT OF HEALTH 

OFFICE OF CHILDREN WITH SPECIAL NEEDS 



Physically Handicapped Children’s Program 



CONSENT WITHHELD 

ABBY J. GREENBERG, M.D. 

ACTING COMMISSIONER 

BOARD OF HEALTH 

Norma J. Henriksen Chair 

Diana Coleman Vice-Chair 

Ellen J. Braunstein, M.D. 

Donna Kass 

[ ] I do not agree with certain aspects of the IFSP developed on _________________________ 

[ ] I believe my child should also receive: 

____________________________________________________________________ 

____________________________________________________________________ 

____________________________________________________________________ 

[ ] I do not want my child to receive: 

____________________________________________________________________ 

____________________________________________________________________ 

____________________________________________________________________ 

[ ] Other unresolved concerns: 

____________________________________________________________________ 

____________________________________________________________________ 

____________________________________________________________________ 

[ ] I do not accept the IFSP developed on __________________________. 

I understand that I have due process rights that are described in the New York State Department of 

Health handbook, “Your Family Rights.” They have also been explained to me by my Service 

Coordinator. 

Parent/Guardian Signature:______________________________________Date________________ 


NASSAU COUNTY DEPARTMENT OF HEALTH EARLY INTERVENTION PROGRAM 

IFSP REVIEW REQUEST/AMENDMENT 

Child's Name Child's DOB / / 

Name of EIOD Request Date / / 

Request submitted by Discipline/Title/Agency 

�Parent �Provider �Other 

Reason(s) for change in services or need for Supplemental Evaluation: 

Signatures: Therapist Parent Date: / / 

(DOH Use Only) Department of Health, in conjunction with family, therapist(s), Ongoing Service Coordinator agree upon: 

� Supplemental Evaluation Authorized EIOD Signature Date: / /____ � 

Current IFSP will not be amended at this time 

� Community programs and resources discussed with family 

� New outcome(s), strategy(s):__________________________________________________________________________________________ 

� Amended Services:_________________________________________________________________________________________________ 

� Changes will begin in two weeks � Changes will begin at new IFSP period 

� Transportation: � Not Applicable � Parent � Bus/Reason_______________________________________________________ 

� Reason why services are not provided in natural environment________________________________________________________________ 

Parent/Legal Guardian Signature Date _ / _ /_____ 

Early Intervention Official Signature Date _ / _ /_____ 

Once signed, this page becomes part of the IFSP. 

EI 5093. NCR 7/05 Distribution: DOH EIP: White Provider: Yellow Parent: Pink DOH EIP: Gold

NASSAU COUNTY DEPARTMENT OF HEALTH EARLY INTERVENTION PROGRAM 

IFSP AMENDMENT 

ATD REQUEST/JUSTIFICATION 

Complete and attach this justification to the signed ATD Request form generated by the Department of Health Service Coordinator. 

Child’s Name: Child’s DOB: / / 

Insurance coverage (Medicaid, private, CHP): 

Name of DOH Service Coordinator: Request Date: / / 

Request submitted by: Discipline: 

1. Child’s medical diagnosis: 

2. What equipment is presently in the home? 

3 Please explain how family has previewed equipment (except for orthotics). Include your attempts at borrowing the equipment from 

the TRAID Center (378-5089) or vendor and/or adapting present toys, furniture, e.g., highchair. 

4. How long do you anticipate child will use equipment? 

5. Reason(s) for request: Justification summary must include purpose of equipment and how the ATD will enable child to achieve IFSP 

outcomes: 

Signature of Therapist: Date: / / 

Signature of Parent: Date: / / 

Signature of EIOD: Date: / / 

EI 5129 06/04 Distribution: White - DOH EIP Yellow – Provider Pink – Parent Gold – ATD Committee

HEALTH STATUS REPORT 

In compliance with the New York State Early Intervention Regulations Section 69-4.8(4)(I)(a), a physical examination is required 

as part of the initial multidisciplinary evaluation including a routine vision & hearing screening. 

Child’s Name ________________________________________ SEX: F M Date of Birth _____/_____/______ 

Birth Weight: _________________________ Place of Birth: ________________________________________ 

Significant Family Medical/Social History (Explain) 

Vision______________________ Hearing_______________________ 

TB _________Chronic Illnesses_______________________________ 

Social Concerns: ___________________________________________ 

Exposure to Violence: _______________________________________ 

High Risk Birth/Complications: _________________________________ 

IMMUNIZATION HISTORY 

DATE IMMUNIZATION GIVEN 

___________________________________________________________ 

________________1st________2nd_______3rd_______4th______5 th __ 

HEP B_____________________________________________________ 

DTP_______________________________________________________ 

HIB________________________________________________________ 

POLIO_____________________________________________________ 

MMR______________________________________________________ 

VARICELLA 

PNUMOCOCCAL____________________________________________ 

INFLUENZA_________________________________________________ 

HEPATITIS A_____________________________________________________ 



� None 

ALLERGIES 

� Food__________________________________________________ 

� Medicine_______________________________________________ 

� Other__________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

___________________________________________________________ 

_____________________LEAD TEST HISTORY______________________ 

________________DATE_____________________RESULT_________ 

ONE YEAR_________________________________________________ 

TWO YEARS________________________________________________ 

OTHER 

Complete Physical Examination 

Date of Examination: / / 

Nassau County Department of Health Early Intervention Program. 

EI 5167.A 08/06 

Height: __________ Weight: ___________Percentile: _______________ 

Head Circumference: ___________ B / P : _______/___________ 

Nutritional Concerns:__________________________________________ 

___________________________________________________________ 

Current Medications:__________________________________________ 

___________________________________________________________ 

DEVELOPMENTAL OBSERVATIONS – Please complete for each age level by placing a check in each area. Indicate 

any action or follow-up necessary. 

BY 6 MONTHS: BY 12 MONTHS: BY 18 MONTHS: BY 2 YEARS: BY 3 YEARS: 

____Imitates vocalizing 

EI 5167.A 8/02 

____Turns to voice 

____Stands alone 2 secs. 

____Bangs two blocks 

____Imitates household 

chores (sweeping) 

____Kicks ball forward 

____Combines 2 words 

____Holds 2-3 sentence 

conversation 

____Rolls over ____Says “Mama/Dada” ____Says 4 words besides ____Strangers understand ____Names 4 animal 

____Reaches (ea. Hand) specifically “Mama/Dada” half child’s speech pictures 

____Cuddles ____Responds to “no” ____Points to one body part ____Points to 6 named body ____Knows 2 animal 

PARENTAL ____Plays patty CONSENT cake or waves TO “show OBTAIN/RELEASE me your nose” parts (nose, INFORMATION 

eyes…) actions -flies, meows? 

____AVOIDS EYE “bye-bye” ____Drinks from a cup ____Names 1 animal picture ____Understands what to 

CONTACT ____Scribbles ____Takes off clothing do when tired, cold 

____AVOIDS EYE CONTACT (other than hat) or hungry (1 of 3) 

____AVOIDS EYE CONTACT ____Imitates vertical line 

Child’s Name ___________________________________ ____CONCERN THAT CHILD Date PERSISTENT: of Birth _________________ 

CAN’T HEAR ____TOE WALKING ____ROCKING ____Washes & dries hands 

I,______________________________, give my consent to have my child’s records ____ECHOLALIA released to 

Name of Parent/Guardian ____TUNES (Please OUT Print) 

____HEADBANGING (repeating what was 

just said) 

____HANDFLAPPING

PARENTAL CONSENT TO OBTAIN/RELEASE INFORMATION 

Child’s Name: Date of Birth: / / 

I, , give my consent to have my child’s records released to 

Name of Parent/Guardian (Please Print) 

Nassau County Department of Health Early Intervention Program. 

Signature of Parent/Guardian Date 

PHYSICIAN RECOMMENDATIONS & REFERRALS 

Please indicate which of the medical specialty 

areas this child has visited or been referred: 

Referred Date Visited 

Developmental 

Pediatrician _______ __________ 

Visual/ 

Opthamologist _______ __________ 

ENT/Hearing _______ __________ 

Neurologist _______ __________ 

Cardiologist _______ __________ 

Orthopedist/ 

Physiatrist _______ __________ 

Neo-Natal Spec. _______ __________ 

Gastro-Intestinal _______ __________ 

Genetic Testing _______ __________ 

Audiological _______ __________ 

Physical Thpy. _______ __________ 

Occupational Thpy: _____ __________ 

Speech Thpy. _______ __________ 

EI 5167.B 08/06 

CLINICAL IMPRESSIONS & RECOMMENDATIONS 

Indicate all chronic conditions and/or findings needing 

follow-up: 

1. ______________________________________ 

2. _______________________________________ 

DIAGNOSIS & ICD 9 CODE: 

__________________________________________ 

__________________________________________ 

This child is being referred because he/she is 

suspected of having a disability, which includes a 

developmental delay and/or a diagnosed physical or 

mental condition that has a high probability of resulting 

in developmental delay. 

Physician Signature 

Print Name__________________________________ 

Address_____________________________________ 

___________________________________________ 

Phone No.___________________________________ 

License No.__________________________________ 

_____

NASSAU COUNTY EARLY INTERVENTION PROGRAM IFSP REVIEW PLAN: [ ]6 Months [ ]18 Months [ ]30 Months 

Child’s Name__________________________________________________Childs DOB______/______/____________Date______/______/______ 

Outcomes Achieved/Current Level of Functioning: 

Ongoing/New Concerns/New Outcomes: 

Measures of Success: 

Strategies (Include assistive tech. devices, supplemental evaluations, specific changes in services, etc.): 

� IFSP Transition Guidelines reviewed with family. Last Date of EI Eligibility / / 

List changes in day care, insurance, work #, pediatrician, service coordination, transportation and/or reasons why services are not provided in natural environment: 

� Transportation: � Not Applicable � Parent � Bus/Reason 

IFSP Review Participants: 

I have reviewed the IFSP with my coordinator, and agree with the above IFSP Review Plan. 

Parent/Legal Guardian Signature ______/______/______ 

EIOD Signature__________________________________________________________________________________________________ ______/______/______ 

EI 5170.8 NCR 5/06 Distribution: White: EIP Yellow: Provider Pink: Parent/Guardian




FAMILY ASSESSMENT 

Child’s Name____________________________________________ Date of Birth______/______/______ 

1. Why did you refer your child to Early Intervention? 

2a. If you need help, who can you ask? 

2b. What do you need help with in providing for your child? (For example, health insurance or a pediatrician.) 

3a. What areas of your child’s development concern you? 

3b. What are your immediate priorities in obtaining help for your child? 

4. What would you like your child to achieve through the Early Intervention Program? 

Completed by______________________________________________ Date______/______/______ 

(Signature and Title) 


Page ____ of ____ NASSAU COUNTY EARLY INTERVENTION PROGRAM 


(Please print legibly-use black ink) 

DAILY NOTES/ATTENDANCE SHEET 

DOH EIOD: Ongoing Service Coordinator: 

Child’s Name: Date of Birth: / / Age: 

IFSP Period: / / to / / Service:_____ _____ _____ _____ 

Type Location Frequency Duration 

# Authorized Sessions: Authorization #: ICD-9 Code: 

Provider/Agency Name: Provider: 

Name Professional Title 

[Key] C= Clinician cancelled FV= Family Vacation H= Holiday I= IFSP meeting M= Make-up N= No one home 

P= Parent cancelled PV= Provider Vacation S= Child sick/hospitalized X= Treatment session 

DATE: / / [ ] IN:____OUT:____ *Parent/Caregiver Signature:_________________ SESSION #:___ 

Desired Outcome/Goals: 

Makeup for: ___________ 

Session Content: CPT CODES: 

Provider Signature/License Initials: 



Makeup for: ___________ 





Makeup for: __________ 





Makeup for: __________ 



Recommendations for support, education, and guidance for parents: (Complete every 4 sessions) 

_______________________________________________________________________________________________________________________ 

________________________________________________________________________________________________________________________ 

________________________________________________________________________________________________________________________ 

I certify that all the information listed above is correct to the best of my knowledge. 

EI 5177.A 4/07 Provider Signature/License Initials:

Page ____ of ____ Child’s Name: 



Makeup for: __________ 





Makeup for: __________ 





Makeup for: __________ 





Makeup for: __________ 


*Confirms provider’s attendance 


Recommendations for support, education, and guidance for parents: (Complete every 4 sessions) 

________________________________________________________________________________________________________________________ 

________________________________________________________________________________________________________________________ 

________________________________________________________________________________________________________________________ 

SPECIFIC CONTACT AND COMMENTS BETWEEN TEAM MEMBERS, DOH, AND OTHERS (Doctors, etc.) 

DATE CODES NOTES 

Codes: TC: Telephone Contact AV: Agency Visit HV: Home Visit IFSP: Indiv Fam Svc Plan 

TM: Team Meeting CN: Communications Notebook TC: Teacher/Therapist Consult 

I certify that all the information listed above is correct to the best of my knowledge. 

EI 5177.B 4/07 Providers signature/License Initials:__________________________



Nassau County 













Konna Kass 

SERVICE COORDINATION GUIDELINES FOR PROVIDING APPLIED BEHAVIORAL 

ANALYSIS (ABA) FOR CHILDREN DIAGNOSED WITH PDD OR AUTISM 

1. Child must have a documented diagnosis by a qualified professional before intensive services can be 

authorized. Based on the practice acts of N.Y.S., licensed psychologists and physicians are the only 

individuals qualified to diagnose PDD/Autism. An original written report completed by the qualified 

professional must be forwarded to Quality Assurance for review & data entry of diagnosis. 

2. Once diagnosis is confirmed, parent should be given the N.Y.S. Clinical Practice Guidelines. This 

should be done prior to the IFSP meeting. 

3. Only children with a PDD/Autism diagnosis may receive ABA more than once per day & have monthly 

team meetings with all therapists involved. 

4. See your supervisor before discussing any ABA plan with parent/caregiver or provider. 

It is also important to discuss ongoing service coordination with your supervisor. 

5. The Team Leader will be identified and authorized for an extended visit for the monthly team meetings. 

All other therapists who attend the monthly meetings are authorized for a basic visit (under their 

discipline). The Team Leader may be authorized for an extended visit each week under family training. 

6. Prior to a meeting, all progress reports & review requests must be reviewed with a Supervisor. 

Supervisors are expected to attend meetings on all ABA cases. 

7. At the IFSP parents/caregivers must be given a copy of Nassau County Department of Health Guideline 

for Intensive Behavior Services. Parental signature with date is required (Form EI5191) and is to be 

attached to IFSP. All services must be included in the IFSP on the outcome page under strategies. 

8. Once provision of services have been arranged, the child’s weekly schedule must be provided by the 

Lead ABA teacher to the Coordinator prior to authorization of services. Data entry will be done by 

Quality Assurance once schedule is submitted. Any change will necessitate a new service plan 

schedule to be submitted. 

Φ Φ Φ Φ Φ 

EI 5192 02/07 

(Based on N.Y.S. Autism, P.D.D. Clinical Practice Guidelines.)



ABA TEAM MEETING ATTENDANCE SHEET 

Having participated in this team meeting, I agree to implement the goals, programs and behavior plans as discussed. 

Child:_________________________________________________________ Date:______/______/______ Time:_____________ 


NAME (Print) AGENCY SIGNATURE & TITLE



NASSAU COUNTY 





NOTIFICATION OF NON-DELIVERY OF AUTHORIZED SERVICES 







Donna Kass 

The purpose of this form is to provide written information to the Nassau County Early Intervention Official Designee (EIOD) after 

telephone contact when the services contained in the IFSP are not being delivered in the manner authorized. 

This form is to be used by: 

1. an independent contracted service provider or a service provider working for an agency. Either provider MUST notify the 

Ongoing Service Coordinator as soon as: 

• the child has missed five (5) consecutive sessions; or 

• there has been difficulty in delivering the services in the authorized manner. 

-OR- 

2. the contracted Ongoing Service Coordinator to notify the Nassau County Early Intervention Official Designee as soon as: 

• the child has missed five (5) consecutive sessions; 

• there has been difficulty in delivering the services in the authorized manner; or 

• they anticipate or experience an inability to deliver services contained as written in the child’s IFSP. This notice should be 

forwarded within ten (10) days of the authorized start date of the service. 

TO: (Check the appropriate box) Date: ________/________/________ 

[ ] _________________________________________ [ ] _________________________________________ 

Name of Early Intervention Official Designee Name of Ongoing Service Coordinator 

FROM: (Check the appropriate box and complete the required information) 

[ ] _________________________________________ [ ] _________________________________________ 

Service Provider Ongoing Service Coordinator 

___________________________________________________________________________________________________ 

Address 

(________)________________________________ (________)____________________________________ 

Phone Number Fax Number 

RE: Child’s Name: DOB: / / 

Check Reason(s) for Contact to EIOD: SERVICE TYPE:_________________________ AUTH. #:__________________________ 

RE: Child’s Name:_________________________________________________________ DOB:_________/_________/_________ 

[ ]Difficulty delivering services as authorized in the child’s IFSP. Auth. Start:_____/_____/_____ Auth. End:_____/_____/______ 

[ ]Inability to deliver services contained in the IFSP. Auth. Start:_____/_____/_____ Auth. End:_____/_____/______ 

[ ]Five (5) consecutive authorized services missed: 

Dates of Missed Sessions Reason(s) for Missed Sessions 

1. _____/_____/_____ _______________________________________________________________________ 

2. _____/_____/_____ _______________________________________________________________________ 

3. _____/_____/_____ _______________________________________________________________________ 

4. _____/_____/_____ _______________________________________________________________________ 

5. _____/_____/_____ _______________________________________________________________________ 

AFTER THE PHONE CALL TO THE EIOD NAMED ON THE CHILD’S INDIVIDUALIZED FAMILY SERVICE PLAN, 

PLEASE DIRECT THIS NOTIFICATION OF NON-DELIVERY OF AUTHORIZED SERVICES BY FAX (516) 227-8662 


PARENT REFERRAL LETTER TO THE 

COMMITTEE ON PRESCHOOL SPECIAL EDUCATION (CPSE)* 

TO: CPSE Chairperson: 

School District: 

School District Address: 

FROM: Parent Name(s): 


Child’s Birthdate: 

Family Address: 

Family Telephone: 

Cell Phone: 

Work/Alternate: 

Date / / 

Dear : (CPSE Chairperson) 

I am writing to refer my child, , to the CPSE for an 

evaluation and possible services. I am concerned that: 

I understand that my school district will explain the evaluation process to me and that I will be 

provided with a list of evaluators to choose from. 

My child is presently receiving Early Intervention services. My EI Service Coordinator is 

and can be reached at (516) 227- /fax# (516) 227-2662. 

I look forward to hearing from you so that I can begin the evaluation process. 

Sincerely, 

(Parent Signature) 

*This letter does not replace the Consent to Evaluate form from the School District. 

EI5202 9/06 

.

Child’s Name 



Nassau County 




BILINGUAL EVALUATION JUSTIFICATION 





Diane Coleman Vice-Chair 


Donna Kass 

The enclosed evaluation(s) is considered to be bilingual due to the following: (Check where appropriate) 

The [ ]MDE / [ ]Supplemental Evaluation(s) was performed in ____________________________________ 

(Second Language) 

Evaluation(s) / Discipline(s) (1)__________________________ (2)___________________________ 

Name/Title of Evaluator(s) (1)__________________________ (2)___________________________ 

OR 

An interpreter* was present during the [ ]MDE / [ ] Supplemental Evaluation(s) to assist a monolingual 

evaluator and the family with the evaluation process. 

Name of Interpreter________________________________________________________ 

AND 

The [ ]written / [ ]oral summary of this evaluation was provided to the family in the dominant language or 

other mode of communication of the parent. 

To the extent feasible and with the parent’s preference, consent and confidentiality requirements, the 

written/oral summary of the evaluation must be provided in the dominant language or other mode of 

communication of the parent. 

[ ] Parent requested English Summary Narrative [ ] Parent requested non-English Summary Narrative 

________________________________________________________ _____/_____/_____ 

Parent Signature to the Above Choice Date 

If written summary not feasible, please explain: 

* An interpreter interprets the spoken word either from one language to another, or to another mode such as sign 

language. Family members should not be used as interpreters unless absolutely unavoidable. Additionally, siblings 

should not be asked to take on the role of explaining a sibling’s disability to his/her parent. 

__________________________________ _____________________________ _____/_____/_____ 

Signature/Title of Person Attesting to the Above Agency (if applicable) of Person Attesting Date 

EI 5216 2/07 White: Evaluator Yellow: DOH EIP Pink: Parent



Departamento de Salud 

DEL CODADO DE NASSAU 

OFICINA DE NIÑOS CON NECESIDADES ESPECIALES 

Programa de Intervención Temprana 

Información del Seguro De Salud 



JUSTIFICACIÓN DE EVALUACIÓN BILINGUE 





Diane Coleman Vice-Chair 


Donna Kass 

Nombre del Niño________________________________________________________________ 

La evaluación incluida(s) es considerada a ser bilingüe por lo siguiente: (Marque donde apropiado) 

El [ ] MDE / [ ] Evaluación(es) Suplementario fue realizado en _________________________ 

(Segundo Lenguaje) 

Evaluación(es) / Disciplinas(s) (1) __________________ (2) _________________ 

Nombre/Titulo de Evaluador(es) (1) __________________ (2) _________________ 

SI NO 

Un interprete* estuvo durante el [ ] MDE / [ ] Evaluación(es) Suplementario para asistir al 

evaluador monoligual y la familia con el proceso de evaluación. 

Nombre del Interpretador___________________________________________________ 

Y 

El sumario [ ] escrito / [ ] oral de esta evaluación fue dado a la familia en el leguaje dominante o 

otro modo de comunicación de los padres. 

Al punto posible y con la preferencia de los padres, consentimiento y confidencialidad requisada, el 

sumario escrito/oral de la evaluación debe ser dado en el lenguaje dominante u otro modo de 

comunicación de los padres. 

[ ] Padres solicitan Sumario Narrativo en Ingles [ ] Padres solicitan Sumario Narrativo no-Ingles 

_____________________________________________ ____/____/____ 

Signatura del padre a lo elegido arriba fecha 

Si el sumario escrito no es posible, favor de explicar: 

*Un interprete interpreta la palabra hablada de un lenguaje a otro, o ha a otro modo como lenguaje por 

senas. La familia no debe ser usada como interpretes a menos que sea absolutamente inevitable. 

Adicionalmente, hermanos no deben ser pedidos al papel de explicarles la discapacidad de su hermano 

a sus padres. 

____________________________________ __________________________ ____/____/____ 

Signatura/Titulo de Persona declarando arriba Agencia (si aplicable) de persona declarando fecha 

EI 5216.S 02/07 Distribution: White: Parent/guardian Yellow: EIP



Nassau County 








EARLY INTERVENTION TRANSITION NOTICE-PARENT CONSENT 

TO: EIOD: EIOD PHONE: 516-227- 

Early Intervention Official DATE: / / 



School District 

CHILD’S NAME: DOB: / / 

CHILD’S ADDRESS: 

CHILD’S PHONE: 

I understand that as of my child’s third birthday my child will no longer be eligible for Early Intervention 

services unless a Committee for Preschool Education (CPSE) evaluation and meeting was held and he/she 

has been found eligible for services under Section 4410 of the Education Law. 

In order to initiate the transition process to determine continued eligibility my child must be referred to my local 

school district CPSE. The choices below are only for transition information. Please choose from option I, II or option III. 

I. [ ] CPSE Transition Process already initiated. 







Donna Kass 

II. [ ] I give consent to the Nassau County Early Intervention Program to notify my local CPSE and 

release/obtain pertinent information. I wish to begin the transition process. 

(Therefore choose A or B) 

A. [ ] I do not request a transition planning conference but I want to begin the transition 

process for my child to the CPSE of my school district. Foregoing the planning 

conference will in no way interfere with receiving a timely evaluation to determine 

eligibility for CPSE services. 

B. [ ] I request a transition planning conference with my Ongoing Service Coordinator and a 

CPSE representative from my school district to explain the CPSE process and CPSE 

services. This meeting will be arranged by the Early Intervention Official Designee and 

will be held at least 90 days before my child is first eligible for services under 

CPSE. The purpose of this meeting will decide the need for a referral to CPSE. 

Eligibility will not be determined at this conference. OR 

III. [ ] I do not request the Nassau County Early Intervention Program to notify my local school district 

CPSE to begin the transition process for my child. I understand my child will no longer be 

eligible to receive Early Intervention services after his/her third (3 rd ) birthday if eligibility has not 

already been determined by my school district CPSE. 

Date / / 

Parent/Surrogate/Guardian Signature 

EI 5224.1 02/07 Date Mailed to School District / /

(Team Leader to complete Part I first) 

Nassau County Early Intervention Program 

Plan to Generalize Skills in Community Setting/IFSP Amendment 

Part I 

Child’s Name: Date of birth: _____/_____/_____ 

1. How long has child been receiving ABA? 

2. What abilities is the child demonstrating that have prompted consideration for attending a 

community pre-school? 

3. Describe the child’s social skills: 

a) Eye contact 

b) Play skills 

c) Attending skills 

d) Ability to transition from one activity to the next 

4. Communication skills 

a) Child’s ability to express needs 

b) Child’s ability to follow verbal directives 

c) Describe alternative communication methods in place to enable child to communicate ie: visual 

aides 

5. Behavioral & Safety Concerns 

6. Feeding Issues 

7. What other social interactions has the child had, both in & out of the home? 

______________________________________ _____/_____/_____ 

ABA Team Leader’s Signature Date over ⇐ 

EI 5229.A 10/03

Part II 

OSC/EIOD_______________________________________________ Request Date_____/_____/_____ 

(To be completed by pre-school teacher after reviewing Part I) 

There will be an observation of child at school. 

1. Size of class, age range, student-teacher ratio, how many children, how many staff 

members? 

2. Daily routine/schedule 

3. How is transition from one activity to the next accomplished? 

4. Are all directions verbal, i.e. – any visual prompts? 

5. Do you have the ability to modify, if necessary, the classroom environment to suit the 

needs of this child? If yes, please explain. 

_______________________________________ _____/_____/_____ 

Pre-School Director Signature Date 

______________________________________ _____/_____/_____ 

Parent Signature Date 

(DOH use only) 

[ ] Approved Numbers of Hours Per Week_________ From:____/_____/_____ To:_____/_____/_____ 

[ ] Denied OSC/EIOD Signature________________________________________ Date:_____/_____/_____ 




Nassau County 








HOME LANGUAGE SURVEY 







Donna Kass 

1. What is your relationship to the child: Check one: � Mother � Father � Guardian 

2. What language did your child learn when he/she first began to talk? 

3. What language(s) does your family speak in your home? 

4. What language(s) does the mother speak to her child? 

5. What language(s) does the father speak to his child? 

6. What language does the caretaker speak to the child? How often? 

7. What language(s) does the child seem to respond to most readily? 

8. What language does your child speak to his/her brothers and sisters most of the time? 

9. Was the child born outside the continental United States? 

10. How long has child been exposed to English? 

If less than 3 months, suggest 3 month wait. 

11. Did the child spend time in a: � Foster Home � Orphanage 





NASSAU COUNTY 














Donna Kass 

NOTIFICATION TO DEPARTMENT OF HEALTH 


OF ELIGIBILITY DETERMINATION FOR TRANSITIONING EI CHILD 

Child’s Date of Birth: / / CPSE Meeting Date: / / 

Select One Below: 

The above named child has been determined by the CPSE: 

[ ] Eligible for CPSE services 

Or 

[ ] Not Eligible for CPSE services 

/ / 


/ / 

CPSE Chair/acting Signature Date 

FAX THIS FORM DIRECTLY TO THE NASSAU COUNTY DEPARTMENT OF HEALTH 

AT 516-227-8662 IMMEDIATELY FOLLOWING THE INITIAL CPSE 

OR 

PRESENT TO NASSAU COUNTY EARLY INTERVENTION SERVICE COORDINATOR. 

EI 5235.L 2/07


TIMELINE OF COMMITTEE ON PRESCHOOL SPECIAL 

EDUCATION (CPSE) TRANSITION PROCESS 

PARENT CHECKLIST 

REGISTER AT SCHOOL DISTRICT, SIGN CONSENT AND CHOOSE AN EVALUATION 

SITE 

HEAR FROM MY EVALUATION SITE AND HAVE EVALUATIONS SCHEDULED 

EVALUATIONS PERFORMED AT EVALUATION SITE, HOME, CHILD CARE OR 

CHILD’S PRESCHOOL 

RECEIVE EVALUATION REPORTS WITH RECOMMENDATIONS 

EVALUATION SITE REVIEWS REPORT WITH ME 

RECEIVE NOTICE OF CPSE MEETING FROM MY SCHOOL DISTRICT 

CALL AND TELL SERVICE COORDINATOR WHEN MEETING IS 

ATTEND CPSE MEETING WHERE DETERMINATION OF ELIGIBILITY AND SERVICES 

ARE MADE. 

IF MY CHILD IS APPROVED FOR RELATED AND/OR SEIT SERVICES: 

• I RECEIVE A LIST OF THERAPY PROVIDERS AT CPSE MEETING 

• SUBSEQUENTLY SELECT A PROVIDER OF SERVICES 

• SCHEDULE THERAPY 

• INFORM DISTRICT OF PROVIDER 

OR 

IF MY CHILD IS APPROVED FOR A CENTER-BASED PROGRAM, THE SCHOOL 

DISTRICT WILL ASSIST ME IN FINDING A PLACEMENT 

• IEP SENT TO CENTER-BASED PROGRAM BY DISTRICT 

RECEIVE COPY OF MY CHILD’S IEP AND GOALS FROM MY SCHOOL DISTRICT



DATE: / / 

TO: CPSE Chairperson 

NASSAU COUNTY 








FROM: Early Intervention Program 

RE: Progress Notes 







Donna Kass 

CHILD: CHILD DOB: / / 

With parental consent we have enclosed the most recent Early Intervention Progress Reports for 

the above named child. 

These reports are being sent to aid in planning for this child’s transition to the CPSE. 

In accordance with the Federal Educational Rights and Privacy Acts (FERPA) these records are 

confidential and may not be released to persons other than those authorized. 

Early Intervention Official Designee 

516-227- 

EI5243 3/07

Team Member: 

Question/Suggestion: 

Positive Outcome: 

Team Member: 



Team Member: 



Parent: 



EI5255 4/05 

Nassau County 





TEAM MEETING SUGGESTIONS AND QUESTIONS

Recommended Childhood and Adolescent Immunization Schedule – United States, 2005 

TABLE. Catch-up immunization schedule for children and adolescents who start late or who are >1 month behind, 

by vaccine and dosage interval – United States, 2005 

Vaccine Minimum 

Catch-up schedule for children aged 4 months-6 years 

Minimum Interval between doses 

Age for ____________________________ _____________________________ ____________ 

Dose 1 

Dose 1 to dose 2 

Dose 2 to dose 3 

Dose 3 o does 4 

DTaP¹ 6 wks 4 wks 4 wks 6 mos 

IPV² 6 wks 4 wks 4 wks 4 wks² 

HepB³ Birth 4 wks 8 wks (and 16 wks after first dose) 

MMR⁴ 12 mos 4 weeks⁴ 

Varicella 12 mos 

Hib⁵ 6 wks 4 wks: if first dose administered 

at age

Vaccine 

Hepatitis B 

Diphtheria, 

Tetanus, pertussis 

Haemophilus 

Influenzae type b 

Polio 

Measles, mumps, 

rubella 

Chicken pox 

Pneumococcal 

disease 

Influenza 

Hepatitis A 

Birth 

* 

RECOMMENDED CHILDHOOD AND ADOLESCENT IMMUNIZATION 

1 

Month 

√ 

Tetanus 

2 

Months 

√ 

√ 

√ 

√ 

√ 

only 

4 

Months 

√ 

√ 

√ 

6 

Months 

√ 

√ 

12 

Months 

√ 

√ 

√ 

√ 

15 

Months 

SOURCE: DEPARTMENT OF HEALTH AND HUMAN SERVICES; CENTERS FOR DISEASE CONTROL AND PREVENTION 

√ 

√ 

√ 

√ 

√ 

√ 

18 

Months 

24 

Months 

Yearly for 

For 

4-6 11-12 

Years Years 

√ √ 

√ 

√ 

At-risk 

At-risk 

populations 

populations 

13-18 

Years

(Team Leader to complete Part I first) 

Part I 

Nassau County Early Intervention Program 

Pre-School Transition Plan/IFSP Amendment for ABA 

Child’s Name: Date of birth: _____/_____/_____ 

1. How long has child been receiving ABA? 

2. What abilities is the child demonstrating that have prompted consideration for attending a 

community pre-school? 

3. Describe the child’s social skills 

a) Eye contact 

b) Play skills 

c) Attending skills 

d) Ability to transition from one activity to the next 

4. Communication skills 

a) Child’s ability to express needs 

b) Child’s ability to follow verbal directives 

c) Describe alternative communication methods in place to enable child to communicate ie: visual 

aides 

5. Behavioral & Safety Concerns 

6. Feeding Issues 

7. What other social interactions has the child had, both in & out of the home? 

______________________________________ _____/_____/_____ 

ABA Team Leader’s Signature Date over ⇐ 


Part II 

OSC/EIOD_________________________________ Request Date_____/_____/_____ 

(To be completed by pre-school teacher after reviewing Part I) 

There will be an observation of child at school. 

1. Size of class, age range, student-teacher ratio, how many children, how many staff 

members? 

2. Daily routine/schedule 

3. How is transition from one activity to the next accomplished? 

4. Are all directions verbal, ie – any visual prompts? 

5. Do you have the ability to modify, if necessary, the classroom environment to suit the 

needs of this child? If yes, please explain. 

_______________________________________ _____/_____/_____ 

Pre-School Director Signature Date 

______________________________________ _____/_____/_____ 


(DOH use only) 

[ ] Approved Numbers of Hours Per Week_________ From:____/_____/_____ To:_____/_____/_____ 

[ ] Denied OSC/EIOD Signature________________________________________ Date:_____/_____/_____ 






APPLIED BEHAVIORAL ANALYSIS 

TEAM MEMBER PROGRESS REPORT 



[ ]3 Mo [ ]6 Mo [ ]9 Mo [ ]12 Mo [ ]15 Mo [ ]18 Mo [ ]21 Mo 

[ ]24 Mo [ ]27Mo [ ]30 Mo [ ]33 Mo [ ]36 Mo [ ]39 Mo [ ]Discharge 

(Please Type) 





Name/Title of Person Completing Report: License #: 

Signature of Person Completing Report: [ ]Team Leader 



1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

PROGRESS TO DATE (What is specific to your sessions, include behavioral observations and interaction with family.) 

Signature and title of person reviewing report _____________________________________________________________ 







TEAM LEADER PROGRESS REPORT 

FAMILY TRAINING 



[ ]3 Mo [ ]6 Mo [ ]9 Mo [ ]12 Mo [ ]15 Mo [ ]18 Mo [ ]21 Mo 

[ ]24 Mo [ ]27Mo [ ]30 Mo [ ]33 Mo [ ]36 Mo [ ]39 Mo [ ]Discharge 

(Please Type) 





Team Leader Name/Title: License # 

Team Leader Signature: 


P = Parent cancelled PV = Provider vacation S = Child sick/hospitalized FT = Family Training X = Treatment session 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

Family/Caregiver Plan: 

a. Specific suggestions/recommendations for family/caregiver to facilitate attainment of goals: 

b. Describe family/caregiver involvement: 

(If applicable) Date of Discharge: / / 

Signature & Title: Date: / / 

(Person Reviewing Report) 







TEAM LEADER 6 MONTH PROGRESS REPORT 

(Please Type) 

Date of Report _____/_____/_____ 



[ ]6 Mo [ ]12 Mo [ ]18 Mo [ ]24 Mo [ ]30 Mo [ ]36 Mo [ ]Discharge 

Child’s Name:_________________________________ Team Leader: ______________________________________________ 

D.O.B.: ____/____/____ Age:_____ Adjusted Age: _____ License #: _______________________________________________ 

IFSP Period:____/____/____ to ____/_____ /_____ Discipline/Service: _______________________________________________ 

Frequency/Duration:______________________________ Agency: ________________________________________________ 



1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 

Month/Year: 

1. Progress Summary (includes): 

a) Describe teaching methodaies used to address current IFSP goals – (Note if they have been attained, are emerging or 

not yet reached.): 

b) When & how do you communicate with team members & how often – include interaction w/related service providers: 


Team Leader Name: 


TEAM LEADER 6 MONTH PROGRESS REPORT 



c) Formal assessments of child’s current level of functioning (include test results): 

2) Therapeutic Plan: 

a) Outcomes/long term goals: 

b) Measures of success/short term objectives – report on data and programming: 

(If applicable) 

Date of Discharge: / / 

Team Leader’s Signature: Date: / / 

Signature & Title: Date: / / 

Person Reviewing Report 




School District: 

Chairperson: 

Mailing Address: 

Town, Zip Code: 

Nassau County 














Donna Kass 

SCHOOL DISTRICT REQUEST FOR EI PROGRESS REPORTS 

In order to assist transition planning please forward the following child’s most recent Progress 

Reports to the above address. * 

Child’s Name Date of Birth 

If you have any questions please call: 

/ / 

/ / 

/ / 

/ / 

(Name of Contact Person) (Phone Number) 

*Progress Reports will be released by the Department of Health only if the Department has already 

obtained written parental consent. 


THOMAS R. SUOZZI ABBY J. GREENBERG, M.D. 

COUNTY EXECUTIVE ACTING COMMISSIONER 

NASSAU COUNTY 





TRANSITION TABLE 

Transition Dates for Infants and Toddlers Moving Into Preschool Services 

Child Born First Eligible for 

Preschool (4410) 

Services 

First Eligible for 

Evaluation Process 

Written Notice to CPSE 

Due By 

Last Eligibility Date 

for Early 

Intervention 

Services * 

Jan 1 – June 30, 2003 Jan 2, 2006 Sep 1, 2005 Aug 31, 2006 

July 1- Aug 31, 2003 July 1, 2006 Mar 1, 2006 Aug 31, 2006 

Sep 1 – Dec 31, 2003 July 1, 2006 Mar 1, 2006 Dec 31, 2006 


July 1 – Aug 31, 2004 July 1, 2007 Mar 1, 2007 Aug 31, 2007 

Sept 1 – Dec 31, 2004 July 1, 2007 Mar 1, 2007 Dec 31, 2007 




Jan 1 - June 30, 2006 Jan 2, 2009 Sep. 1, 2008 Aug. 31, 2009 

July 1 - Aug 31, 2006 July 1, 2009 Mar 1, 2009 Aug 31, 2009 

Sept 1 - Dec 31, 2006 July 1, 2009 Mar 1, 2009 Dec 31, 2009 




*A child’s eligibility for EIP ends on the day before his/her third birthday unless the 

child has been determined eligible for CPSE services at a CPSE meeting and an 

IEP has been developed. 3/07

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