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

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Nassau County Department of Health 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: <strong>EI</strong> 5035.1 8/06 Name Title (2) METHOD T– Standardized Test P– Clinical Opinion
Nassau County Department of Health Early Intervention Program Evaluating Organization: Child’s Name: EVALUATION SUMMARY 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 Name: Instrument(s) used: Profession: Date Evaluated: / / � Core Eval. � Supplemental Eval. Name: Instrument(s) used: Profession: Date Evaluated: / / � Core Eval. � Supplemental Eval. Name: Instrument(s) used: Profession: Date Evaluated: / / � Core Eval. � Supplemental Eval. Name: Instrument(s) used: Profession: Date Evaluated: / / � Core Eval. � Supplemental Eval. Name: Instrument(s) used: Profession: Date Evaluated: / / � Core Eval. � Supplemental Eval. Name: Instrument(s) used: Profession: Date Evaluated: / / � Core Eval. � Supplemental Eval. Name: Instrument(s) used: Profession: Date Evaluated: / / � Core Eval. � Supplemental Eval. <strong>EI</strong> 5035.2 8/06
Page 1 and 2: Nassau County Department of Health
Page 3: Nassau County Department of Health
Page 7 and 8: NASSAU COUNTY DEPARTMENT OF HEALTH
Page 9 and 10: EARLY INTERVENTION PROGRAM NASSAU C
Page 13 and 14: HEALTH STATUS REPORT In compliance
Page 15 and 16: NASSAU COUNTY EARLY INTERVENTION PR
Page 17 and 18: Page ____ of ____ NASSAU COUNTY EAR
Page 19 and 20: THOMAS R. SUOZZI COUNTY EXECUTIVE N
Page 23 and 24: Child’s Name THOMAS R. SUOZZI COU
Page 27 and 28: Part II OSC/EIOD___________________
Page 29 and 30: THOMAS R. SUOZZI COUNTY EXECUTIVE C
Page 31 and 32: THOMAS R. SUOZZI COUNTY EXECUTIVE D
Page 33 and 34: Recommended Childhood and Adolescen
Page 35 and 36: (Team Leader to complete Part I fir
Page 41 and 42: THOMAS R. SUOZZI COUNTY EXECUTIVE S

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