Sample Self Assessment Report

Self Assessment Guidance and Report TemplateRevised 200913. How many transition files did you review?14. Of the transition files reviewed, how many of the IFSPs include a written transitionplan?14a. If compliance is not at 100%, for children still participating in the Birth to 3Program, when will transition steps be added to the IFSP?15. What is your practice for assuring that all children between 2 years, 3 months of ageand three years old have LEA Notification sent thru PPS?15a. Of the transition files reviewed, how many children had documented LEAnotification?15b. If compliance is not at 100%, for children still participating in the Birth to 3Program, when will LEA Notification be sent?15c. For the same time period, how does this sample compare to PPS data (useIndicator 8 report)16. Of the transition files reviewed, how many had Transition Planning Conferences thatoccurred at least 90 days before the 3 rd birthday?16a. How does this sample compare to PPS data (use Indicator 8 report)?16b. Provide the documented reasons for each transition file reviewed in whichthe Transition Planning Conference was not within the 90 days or more before the3 rd birthday?16c. If compliance is not at 100%, for children still participating in the Birth to 3Program, when will the TPC occur?17. Number of transition files that had exit child outcome data completeda.) by exit date_____b.) entered into PPS by exit date______,18. If referred to LEA, how and when were exit outcomes shared with LEA?REFLECT: What is working well with your transition process and how might youenhance it?How does your practice utilize the team process (including families and the LEA staff) todetermine relevant evidence and decision-tree decision making when determining exitchild outcome ratings?

Self Assessment Guidance and Report TemplateRevised 2009State of Wisconsin Outcome #7: The State Lead Agency effectivelysupports and supervises the implementation of the early interventionsystem.SPP Indicator 9. General supervision system identifies and corrects noncompliance assoon as possible but in no case later than one year from identification Target 100%19. Explain what your county B-3 program did to resolve any Findings of Non-Compliance during the past year (if applicable).20. How is the county administration involved in supporting and supervising B-3 staffand provider agencies?21. How does the county publicly report information about their indicator data to thecommunity?Reflection on the Process:22. What did you learn about your programs ability to meet DHS 90 requirements fromthe file review checklist process (strengths and opportunities for enhancement)?23. How will your B-3 program implement quality improvements based on SelfAssessment findings?24. What technical assistance do you need from RESource/State?

Self Assessment Guidance and Report TemplateRevised 2009Additional Information for ‘on-site’ year (complete or be prepared toprovide this information at on-site)State of Wisconsin Outcome #4: Families receive early interventionservices from trained and qualified providers.What is the caseload for Service Coordinators based on FTE?Within the past year, what specific activities/professional development did staff andcontracted providers receive to meet the required 5 hours of B-3 training?How does your county assure that families are being supported by qualified staff?How does your county address recruitment and retention of staff?State of Wisconsin Outcome #6: Adequate state, federal and privatefunds are available for early intervention servicesAdministrator Questions: Who is involved in fiscal discussions including budgeting / contracting? How much will be spent on administration of Birth to 3 Program for the currentyear? (Administrative costs include personnel costs for supervision or clericalsupport prorated based on percent of time spent on Birth to 3 activities. Overheadcosts charged to Birth to 3 would be included here.) What percent are administrative costs of your total B-3 budget? What do you do to monitor expenditures and revenues of contracted providers? How do you use this information to make budgets and contracts? Who is billing targeted case management, MA, and insurance? How is this revenue offsetting B-3 expenses? How much was collected in the last calendar year from TCM? From MA? FromInsurance? From Enhanced Rate? How has the county made use of the enhanced rate to offset Birth to 3 expenses? If therapy providers are directly receiving the enhanced rate reimbursement how isthe county compensated? What changes have you made in recent years to improve your fiscal status?Please attach a copy of your contract(s) and/or addendums with yourproviders.Please plan to share your chart of current frequency of services from each ofthe current files reviewed.Please complete the Child Fidelity Checklist regarding Child Outcomes.Reworked November 4, 2009