APPENDICES FORMS Word Documents EI 5031 ATD Request EI ...
APPENDICES FORMS Word Documents EI 5031 ATD Request EI ...
APPENDICES FORMS Word Documents EI 5031 ATD Request EI ...
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THOMAS R. SUOZZI<br />
COUNTY EXECUTIVE<br />
Child’s Name:<br />
NASSAU COUNTY<br />
DEPARTMENT OF HEALTH<br />
OFFICE OF CHILDREN WITH SPECIAL NEEDS<br />
Early Intervention Program<br />
Preschool Special Education Program<br />
Physically Handicapped Children’s Program<br />
60 Charles Lindbergh Blvd., Suite 100<br />
Uniondale, NY 11553-3683<br />
ABBY J. GREENBERG, M.D.<br />
ACTING COMMISSIONER<br />
BOARD OF HEALTH<br />
Norma J. Henriksen Chair<br />
Diana Coleman Vice-Chair<br />
Ellen J. Braunstein, M.D.<br />
Donna Kass<br />
NOTIFICATION TO DEPARTMENT OF HEALTH<br />
EARLY INTERVENTION PROGRAM<br />
OF ELIGIBILITY DETERMINATION FOR TRANSITIONING <strong>EI</strong> CHILD<br />
Child’s Date of Birth: / / CPSE Meeting Date: / /<br />
Select One Below:<br />
The above named child has been determined by the CPSE:<br />
[ ] Eligible for CPSE services<br />
Or<br />
[ ] Not Eligible for CPSE services<br />
/ /<br />
Parent Signature Date<br />
/ /<br />
CPSE Chair/acting Signature Date<br />
FAX THIS FORM DIRECTLY TO THE NASSAU COUNTY DEPARTMENT OF HEALTH<br />
AT 516-227-8662 IMMEDIATELY FOLLOWING THE INITIAL CPSE<br />
OR<br />
PRESENT TO NASSAU COUNTY EARLY INTERVENTION SERVICE COORDINATOR.<br />
<strong>EI</strong> 5235.L 2/07
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