North Dakota Early Intervention

Case Review Form

 

Instructions:   Please complete every item as indicated unless the specific instructions allow you to skip the item

If items are left uncompleted, you will be prompted to complete the item and will not be able to submit the form until the required data has been entered. 

Complete entering each case review in one session as you will not be able to complete part of the form, save it and return to finish the form later. However,  if you want a copy of the data you have entered, you may print the form (use landscape orientation)  at any time before you click on the submit button.

Demographic Data:

1.  ASSIST Client ID:  
2.  Person(s) Submitting Case Review:  
3.  Child's Chronological Age Years:                  Months:                 
4.  Region:
5.Interventionist/Professional Title:  
6.  Case Manager:  
7.  Type of IFSP: (Check All That Apply)   Initial IFSP      Annual IFSP      Periodic Review      2 yr. 7 mo. Transition  

 2 yr. 9 mo.Transition      Medical Services        Low Incidence Condition   

Other (Please describe):

 

I.  Child's Current Level (Present Level of Performance) *Abilities & Strengths ( Indicator #9A)

1. (Indicator # 7A) Initial evaluation was completed and documented in Lotus Notes/ ASSIST within 45 days:    Yes    No

2.  Initial Referral Date (mm/dd/yy):                 

3.  (Indicator # 7B) Initial IFSP developed within 45 days:    Yes    No 

4.  IFSP Dates:  Start Date of IFSP (mm/dd/yy)    End date of IFSP (mm/dd/yy):  

5.  IFSP participants included: (check all that apply) 

  Parent

  Service Coordinator

  Person(s) providing direct service

 Person(s) directly involved in conducting evaluations/assessments

Other:

If  participant absent, how was information obtained? (Check all that apply.)

  Chart Review/written report

  Telephone Conference

Other:

 

6.  (Indicator #9A) List name of ALL individuals who completed an evaluation (even if they did not attend the IFSP meeting.)

Evaluator's Name and Title:       Check if individual attended IFSP meeting 

Evaluator's Name and Title:      Check if individual attended IFSP meeting 

Evaluator's Name and Title:      Check if individual attended IFSP meeting

Evaluator's Name and Title:      Check if individual attended IFSP meeting

 

7.  (Indicator #9A) Were two or more disciplines involved in assessment.   Yes    No
8.  (Indicator #9A) Review of pertinent records (health and medical) included.   Yes

No

9.  (Indicator #9A)
   
Present level information based on objective criteria: in each    developmental area.   
  Yes

No

 

10.  (Indicator #9A) Developmental Areas Included in Present Level of Performance  (Check All That Apply)

 Yes

No (a) Gross Motor  Yes No (f) Hearing

 Yes

No (b) Fine Motor   Yes No (g) Communication

 Yes

No (c) Vision   Yes No (h) Social/Emotional

 Yes

No (d) Cognitive   Yes No (i) Adaptive

 Yes

No (e) Early Literacy  Yes No (j) Other:   

 

11.  Tools Utilized:  Check all that apply.  (Two tools are required for compliance.)
  Bayley-R Developmental Assessment of Young Children (DAYC)
Early Learning Accomplishment Profile Preschool Language Scale (ELAP) Hawaii Early Learning Profile (HELP)
Preschool Language Scale-4 Mullen Scale
Peabody Developmental Motor Scales II (PDMSII) Receptive Expressive Emergent Language Scale  (REEL-3)
Rossetti Infant Toddler Checklist Sensori Motor Checklist
Vision Screening for Young Children Other:
Comments:
 

A. Child’s status (including strengths and challenges) is described for each required developmental area (physical development including vision, hearing and health status, cognitive development, communication development, social or emotional development, and adaptive development, early literacy) in the context of everyday routines and activities.

  Unacceptable (1)

Minimally Acceptable (2)

Practice  Standard (3) (Meets the intent of IDEA)

Best Practice (4)

The child’s current status is summarized in terms of one or more of the following:

  1. Test scores
  2. Child’s deficits
  3. Vague child strengths without describing  developmental status as it relates to everyday routines and activities; or
  4. All developmental areas are not included
Child’s current status in each required developmental area is described functionally, including strengths and needs; however, additional clarification is required (see comments). Child’s current status in each required developmental area is described functionally, including strengths and needs. The child’s current status in each required developmental area is described functionally, including strengths and needs relevant to challenges and what is working well in everyday routines and activities.
Comments:

B.  Child’s interests, motivators, fears, and dislikes are related to participation in everyday routines. (Indicator #9A)

  Unacceptable

Minimally Acceptable

Practice  Standard (3) (Meets the intent of IDEA)

Best Practice

The status of current abilities does not include information about people, places and things that are motivators, interests, fears, and dislikes.

The status of current abilities includes a description of:

1.  People, places, and things that motivate, engage, and bring enjoyment to the child, and

2.  Child's fears and dislikes; however, additional clarification is required (see comments).

Complete report of the status of current abilities includes a description of the following:

1.  People, places, and things that motivate, engage, and bring enjoyment to the child, and

2.  Child's fears and dislikes.

The status of current abilities includes sufficient information on people, places, and things that interest and motivate the child to participate in everyday routines and activities.       AND

There is information on how the child’s fears or dislikes impact successful participation.

Comments: 

  II.  Summary of Family Concerns, Priorities, and Resources (Indicator #9A)

A. With the concurrence of the family, information is included on the people who are important to the child and family and the family’s concerns and resources. This information is connected to the family’s everyday routines and activities.

  Unacceptable

Minimally Acceptable

Practice Standard (Meets the intent of IDEA)

Best Practice

The IFSP contains no information on family concerns, priorities, or resources,        AND      There is no documentation that the family declined to provide information on concerns, priorities, and resources          OR     The IFSP contains information about family routines and activities but no specific information on all of the following:

  1. Important people 

  2. Concerns

  3. Resources

With family concurrence, information is described on all of the following; however, additional clarification is required (see comments):

  1. Family concerns
  2. Important people for the family
  3. General resources
  4. Specific resources related to families capacity to enhance child’s development    BUT

This information is not connected to what is working well and the challenges in the family’s everyday routines and activities.

OR    The family declined to provide information and documentation is present; however, additional clarification is required (see comments).

With family concurrence, information is described on all of the following:

  1. Family concerns
  2. Important people for the family
  3. General resources
  4. Specific resources related to families capacity to enhance child’s development

BUT

This information is not connected to what is working well and the challenges in the family’s everyday routines and activities.

 

With family concurrence, information is described on all of the following:
  1. Family concerns

  2. Important people for the family AND

  3. General specific resources included

 AND   The information is connected to what is working well and the challenges within typical routines and activities.

Comments:  
 

B. With family concurrence, there is clear information on family priorities and how they link to family concerns, strengths, and interests. (Indicator #9A)

  Unacceptable

  Minimally Acceptable

Practice Standard (Meets the intent of IDEA)

Best Practice

There is no information provided about family priorities.       AND     There is no documentation that the family declined to share this information.

With family concurrence, family priorities are described; however, additional clarification is required (see comments).        OR      The family declined to provide information and documentation was present; however, additional clarification is required (see comments).

With family concurrence, family priorities are described     OR      The family declined to provide information and documentation was present.

 

With family concurrence, information on family priorities is present along with how the priorities are linked to the family concerns, strengths, and interests.

Comments:  

(Indicator #9A)

1.   Includes interview:    Yes    No

2.   Priorities are ranked in numerical rank order by the family:    Yes    No

3.  Completed within 45 days for initial IFSP and prior to reviews and:     Yes    No

4.  Identifies supports and services when necessary:     Yes    No (This information is found in the service details on the Case Plan.)

 

Comments:  

 

III.  Family and Child Centered Outcomes  (Indicator #9A)

A.  Child and family outcomes correlate with family priorities and concerns relative to the child’s development.

  Unacceptable

Minimally Acceptable

Practice Standard (Meets the intent of IDEA)

Best Practice

Child and family outcomes seem to be based on provider priorities

(e.g., there is not a clear connection with the concerns and priorities expressed by the family.)        AND/OR      No family outcomes are included related to specific family needs and concerns 

Child and family (when identified by team) outcomes are based on family concerns and priorities; however, additional clarification is required (see comments).

 (e.g. There are unclear connections between information in the summary of family concerns, priorities, and resources to enhance the development of their child and the family and child outcomes.)

Child and family (when identified by team) outcomes are clearly based on family concerns and priorities

 (e.g. Connections between information in the summary of family concerns, priorities, and resources to enhance the development of their child and the family and child outcomes are outlined.)

Child and family (when identified by team) outcomes are clearly based on family concerns and priorities

 (e.g.  Family concerns, priorities are central to the family and child outcomes and  resources to enhance the development of their child are identified/secured based on the priorities of the family/child.

Comments: 
 

B.  Child outcomes are functional, measurable (including criteria, procedures, and timelines,) and related to participation in everyday routines.  (Indicator #9A)

  Unacceptable

Minimally Acceptable

Practice  Standard (Meets the intent of IDEA)

Best Practice

Child outcomes are written:

  1. As services to be provided, and/or
  2. In discipline-specific therapeutic language, and/or
  3. In vague terms, rather than written as functional and measurable

Child outcomes are:

  1. Functional, and
  2. Measurable (outcome indicates end result and why; criteria indicates how we know outcome is met, however, additional clarification is required (see comments).
  

Child outcomes are:

  1. Functional, and
  2. Measurable (outcome indicates end result and why; criteria indicates how we know outcome is met)
     

Child outcomes are all of the following:

  1. Functional
  2. Measurable (including criteria, procedures, and timelines)
Related to participation in everyday routines and activities
Comments:
 

C.  Child outcomes are developmentally appropriate and can realistically be achieved in the given review period.       (Indicator #9A)

  Unacceptable

Minimally Acceptable

Practice  Standard (Meets the intent of IDEA)

Best Practice

Child outcomes:

  1. Have little or no relationship to the information on the child’s current functioning, and/or
  2. Are not likely to be achieved given the review period

 

Child outcomes:

  1. Are consistent and relevant with information on child’s current functioning, and
  2. Can realistically be achieved in the agreed upon review period; however, additional clarification is required (see comments).

Child outcomes:

  1. Are consistent and relevant with information on child’s current functioning, and
  2. Can realistically be achieved in the agreed upon review period

 

Child outcomes:

  1. Are consistent and relevant with information on child’s current functioning,
  2. Can realistically be achieved in the agreed upon review period, and
  3. Are reflective of the child's interests.
Comments: 
(Indicator #9A) 1.  Includes outcomes/strategies on pre-literacy and language.    Yes    No

 

IV. Family and Child Centered Outcomes: Intervention Strategies and Activities (Indicator #9A)

 

A.  Early intervention strategies and activities support the child’s and family’s everyday routines and activities and build family capacity (confidence and abilities).

  Unacceptable

Minimally Acceptable

Practice  Standard (Meets the intent of IDEA)

Best Practice

Strategies and activities reflect only what the professional will do with the  child, and only include specialized places and equipment.

Strategies and activities reflect that the early intervention personnel are supporting the family/caregivers to implement intervention strategies, which take place in the home and community settings; however, additional clarification is required (see comments).

Strategies and activities reflect that the early intervention personnel are supporting the family/caregivers to implement intervention strategies, which take place in the home and community settings. Strategies and activities reflect that the family and/or caregiver(s) implement strategies in the context of everyday routines and activities of interest with professionals providing direct services and/or consultation and coaching for family/caregiver learning and problem-solving.
Comments: 
 

B. Early intervention strategies and activities are written in family-friendly language, are individualized to the family, address the child and family’s specific needs and concerns, and build on child and family strengths.

  Unacceptable

Minimally Acceptable

Practice  Standard (Meets the intent of IDEA)

Best Practice

Strategies and activities:

  1. Are written in professional jargon, and/or
  2. Seem so general that they could appear on any IFSP

Strategies and activities are:

  1. Written in commonly understood language, and
  2. Individualized to address the child and family’s specific needs and concerns; however, additional clarification is required (see comments).

Strategies and activities are:

  1. Written in commonly understood language, and
  2. Individualized to address the child and family’s specific needs and concerns
Strategies and activities are all of the following:
  1. Written in easy to understand language
  2. Individualized to specific needs and concerns of the child and family
  3. Build on child and family strengths
Comments: 
 

C. Early intervention strategies and activities are linked to the child’s functional skills and are connected to the identified outcomes.

  Unacceptable

Minimally Acceptable

Practice  Standard (Meets the intent of IDEA)

Best Practice

Strategies and activities are disjointed and not connected to the outcomes (e.g., they could be implemented in isolation without achieving the outcome).

AND/OR  Strategies and activities do not link with the child’s functional skills.

Strategies and activities are connected to the outcome and reflect the child’s functional skills; however, additional clarification is required (see comments).

Strategies and activities are connected to the outcome and reflect the child’s functional skills.

Strategies and activities are connected to the outcome and reflect the child’s functional skills, interests and priorities.
Comments: 

 

V.  Early Intervention Resources, Supports, and Services (Indicator #9A)

 

A.  Frequency, intensity, and method of specific early intervention services relate to child and family outcomes and the family’s/caregiver’s capacity and need for support and problem solving of challenges.

  Unacceptable

Minimally Acceptable

Practice  Standard (Meets the intent of IDEA)

Best Practice

Specific child and family services are not listed.        OR         Frequency, intensity, and method are not included for each specific service.      OR      Frequency , intensity, and method for each specific service is documented, but information and/or number of service providers involved indicate that:

  1. A clinical model of direct therapy will be implemented, and/or

  2. Family capacity will most likely not be enhanced, and/or

  3. Families are likely to feel overwhelmed or burdened

Frequency, intensity, and method of specific early intervention services appear to be related to child and family outcomes and the family’s/caregiver’s capacity and need for support and problem solving of challenges. However, additional clarification is required (see comments).

Specific child and family services are listed and seem reasonable given:

  1. The developmental status of the child
  2. The family’s concerns, priorities, and resources
  3. The IFSP outcomes   

AND       Frequency, intensity, and method are specified for each service and seem reasonable and fit into the family’s daily routines and priorities given all of the following:

  1. The  developmental status of the child

  2. The family’s concerns, priorities, and resources

  3. The IFSP outcomes

 

Specific child and family services are listed and seem reasonable given all of the following:

  1. The developmental status of the child

  2. The family’s concerns, priorities, and resources

  3. The IFSP outcomes

AND   Frequency, intensity, and method are specified for each service and seem reasonable and fit into the family’s daily routines and priorities given all of the following:

  1. The developmental status of the child

  2. The family’s concerns, priorities, and resources

  3. The IFSP outcomes

AND      There is evidence in the strategies of building family capacity through consulting across disciplines (or environments where concerns are being addressed by a single provider) and coaching with the family.

Comments: 
Early Intervention Services:  (Indicator #9A)
1.  The majority of early intervention services were delivered in the home or community    Yes      No
2.  Location of  services identified   Yes    No
3.  Type of services identified  (Individual/Group)   Yes      No
4.  Funding sources of services identified  Yes      No
5.  Dates and duration of services documented  Yes     No
6.  Parents rights are documented  Yes       No
7.  Frequency of EI and consultations services documented  Yes       No
Comments:

 

VI.  Assistive Technology (Indicator #9A)

 

A.  Assistive technology services and supports are provided when needed to achieve identified outcomes and support the child’s participation in family routines and community settings.         Check if Assistive Technology Is Not Needed  and Skip This Item.

  Unacceptable

Minimally Acceptable

Practice  Standard (Meets the intent of IDEA)

Best Practice

Assistive technology is not clearly related to the identified outcome.

Assistive technology is clearly necessary to achieve IFSP outcomes based on all of the following information:

  1. The child’s developmental status
  2. IFSP outcomes
  3. Strategies and activities

However, additional clarification is required (see comments).

Assistive technology is clearly necessary to achieve IFSP outcomes based on all of the following information:

  1. The child’s developmental status
  2. IFSP outcomes
  3. Strategies and activities

 

  1. Assistive technology:

  2. Is clearly necessary to achieve IFSP outcomes, and
  3. Enable the child to participate in everyday routines and activities based on all of the following information:

-The child’s developmental status

-IFSP outcomes

-Strategies and activities

Comments: 

B. Assistive technology devices are chosen with careful consideration of the child’s needs and the appropriate method(s) to achieve the outcome.          Check if Assistive Technology device Is not reqiored and skip these items.

Unacceptable

Minimally Acceptable

Practice  Standard (Meets the intent of IDEA)

Best Practice

Strategies and activities are disjointed and not connected to the outcomes (e.g., they could be implemented in isolation without achieving the outcome).  AND/OR        Strategies and activities do not link with the child’s functional skills.

Specialized assistive technology equipment is authorized even when there is no documentation that it is necessary in the IFSP; and typically available equipment/materials could be used/adapted to meet the child’s needs.  However, additional clarification is required (see comments).

Specialized assistive technology equipment is authorized even when there is no documentation that it is necessary in the IFSP; and typically available equipment/materials could be used/adapted to meet the child’s needs.

 

Specialized assistive technology equipment is included in the IFSP:
  1. When necessary to meet outcomes, and
  2. When typically available equipment/materials cannot be used/adapted to meet the child's needs.
List Assistive Technology:
Comments: 

VII. Natural Environments Justification (Indicator #9A)

 A.  Adequate information and evidence is provided to support the rationale that a child’s needs and outcomes cannot be achieved in natural settings.

  Unacceptable

Minimally Acceptable

Practice Standard 

(Meets the intent of IDEA)

Best Practice

The IFSP identifies one or more services that are not in a natural environment for the child and family.    AND     There is no justification or the justification is not based on the needs of the child, but appears to be for:
  1. Administrative convenience, and/or
  2. Fiscal reasons, and/or
  3. Personnel limitations, and/or
  4. Parent/therapist preferences

The child is receiving most services in natural environments.      AND    When a service is provided in a setting that is not a natural environment, a justification is included in the IFSP that is based on the needs of the child, justifying that the setting is necessary to achieve the outcome.

 However, additional clarification is required (see comments).

The child is receiving most services in natural environments.    AND    When a service is provided in a setting that is not a natural environment, a justification is included in the IFSP that is based on the needs of the child, justifying that the setting is necessary to achieve the outcome.

 

All services are provided in natural environments.       OR       The child is receiving most services in natural environments      AND     When a service is provided in a setting that is not a natural environment, a justification is included in the IFSP that is based on the needs of the child, justifying that the setting is necessary to achieve the outcome.           AND         For each service justified there is a plan to transition interventions into natural settings.

Comments: 

VIII. Transition (Indicator #8A)

  Click on this option button if the child will be less than age 2 at the end date of the IFSP and skip to "Transition Planning" below.     
 A . The IFSP includes documentation that transition issues are identified and discussed and steps are included to prepare the family for choices/options at different transition points.

  Unacceptable

Minimally Acceptable

Practice  Standard (Meets the intent of IDEA)

Best Practice

No information is noted in the IFSP, even about the required age three (3) transition items on the Transition Checklist.

The required transition discussion items in the Transition Checklist and transition issue(s) specific to the child and/or family needs and interests are identified (as appropriate) in the IFSP.       AND

The steps that support the transition to either Part B preschool services or other services that may be available as appropriate to the child are also described including all of the following:

  1. Specific places
  2. Programs
  3. Dates
  4. People who will need to be involved in the transition process.

 However, additional clarification is required (see comments).

The required transition discussion items in the Transition Checklist and transition issue(s) specific to the child and/or family needs and interests are identified (as appropriate) in the IFSP.      AND    The steps that support the transition to either Part B preschool services or other services that may be available as appropriate to the child are also described including all of the following:

  1. Specific places
  2. Programs
  3. Dates
  4. People who will need to be involved in the transition process.

 

 

The required transition discussion items in the Transition Checklist and transition issue(s) specific to the child and/or family needs and interests are identified (as appropriate) in the IFSP.     AND     The steps that support the transition to either Part B preschool services or other services that may be available as appropriate to the child are also described including all of the following:

  1. Specific places
  2. Programs
  3. Dates
  4. People who will need to be involved in the transition process are identified with contact information and implementation schedules. 
Comments:
 
Transition Planning:  If the child will be less than age 2 at the end date of the IFSP, click on the N/A option button.
1. (Indicator #8B)  Was notification of LEA completed for potentially eligible children by 2 years of age.    Yes No N/A
2.  Transition outcome or activity that addresses the child, family and receiving agency is included in IFSP by the time the child is age 2.    Yes No N/A
3.  Prior notice for the 2 year, 7 month transition planning meeting has been completed.    Yes No N/A
By the child's age 2 yr, 7 months:
4.  The 2.7  transition assessment planning meeting was completed.    Yes No N/A
By the child's age 2 yr, 9 months:
5.  Prior notice of meeting has been completed.    Yes No N/A
6.  (Indicator #8C)  Transition conference occurred for children potentially eligible for Part B:  By the child's age 2 yr, 9 months (the following may occur up to 9 months prior to age 3 but must occur at least 90 days prior to 3rd birthday.):     Yes No N/A
7.  Determination of DD eligibility has been made.    Yes No N/A
8.  Determination of Part B eligibility has been made.    Yes No N/A
9.  Transition plan within IFSP/IEP    OR     if not eligible, a plan for community services and supports is established.    Yes No N/A
10. (Indicator #8A) Did the child exit Part C with appropriate transition steps and services?                                          Answer "Yes" if all of the above 9 questions have been answered with a "YES."    Yes No N/A
Comments: 

 

IX. IFSP Review (Indicator #9A)

Click on this option button to indicate that this case review is of an initial IFSP and do not complete this section.
 A.  SIX MONTH & PERIODIC REVIEW:  Child/family response to strategies and progress toward achieving child and family outcomes is documented and necessary changes are made in the IFSP.

  Unacceptable

Minimally Acceptable

Practice  Standard (Meets the intent of IDEA)

Best Practice

There is inadequate information on how well strategies are working for child/family and if child/family outcomes are being achieved.     OR       Information provided is focuses on provider activities (e.g. What is being done to the child).       AND/OR   Changes in IFSP are not justified by progress or there are not changes that appear necessary based on progress.

 

For all outcomes, information describes how well strategies are working toward achieving outcomes.     AND     For child outcomes, there is information on:

  1. Progress toward meeting the outcomes, and
  2. Current developmental status including child behavior and skills.   

AND     Information is adequate for reviewers to determine if modifications and revisions are appropriate.      However, additional clarification is required (see comments).

For all outcomes, information describes how well strategies are working toward achieving outcomes.          AND          For child outcomes, there is information on:

  1. Progress toward meeting the outcomes, and
  2. Current developmental status including child behavior and skills.

AND        Information is adequate for reviewers to determine if modifications and revisions are appropriate.

For all outcomes, information describes how well strategies are working toward achieving outcomes.         AND         For child outcomes, there is information on all of the following:

  1. Progress toward meeting the outcomes, and
  2. Current developmental status including child behavior and skills
  3. Discussion of child behavior and skills in everyday routines and activities

AND       Information is adequate for reviewers to determine if modifications and revisions are appropriate.

Comments: 

 

Completed Within IFSP (Indicator #9A)
1.  Date and team members documented in ASSIST    Yes    No
2.  How team members participated included in IFSP    Yes   No
3.  Documentation of prior notice    Yes   No
4.  Review Dates:
Comments:
Compliance Reviewer

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