Infant & Toddler
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| |Family |
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| |Address |
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| |City, State, Zip |
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| |Child’s Name |
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| |DOB |
|Enter Local tiny-k Program specific info here | |
|Reason for Notice |Consent" means that: (1) You have been fully informed of all information about the |
|The Infant-Toddler Program is required to obtain your permission before |activity(ies) for which consent is sought in your native language (unless clearly |
|conducting screening activities. Further, it is required that you give |not feasible to do so) or other mode of communication; (2) that you understand and |
|informed, written consent for these activities through your signature below. |agree in writing to the carrying out of the activity(ies) for which consent is |
|The purpose of screening is to determine if your child requires a |sought; (3) the consent describes the activity(ies); and (4) the granting of your |
|multidisciplinary evaluation/assessment to determine eligibility for early |consent is voluntary and may be revoked in writing at any time. |
|intervention services. | |
Action Proposed
The Screening involves taking a brief look at the developmental areas of cognition, gross motor, fine motor, communication, social-emotional, adaptive, health including vision, and hearing. The screening results will be used to determine if your child needs to complete the multidisciplinary evaluation process to determine eligibility for early intervention services. The results of the screening are kept in your child's early intervention record. This information will remain confidential.
Description
How the screening is performed will vary based on the needs of your child. It will include review of available medical/developmental records, parent interview, child observation, and administration of formal and informal screening tools. Screening team members will talk with you about these methods.
Timelines
The screening, multidisciplinary team evaluation, assessment and development of an Individualized Family Service Plan (IFSP) must be completed within 45 calendar days from the date your child was referred to the early intervention program. If your family needs additional time beyond the 45 days, it is important that you tell your Family Service Coordinator.
Parent(s)/Guardian Acknowledgment and Statement of Consent
I acknowledge being provided a copy of the Child and Family Rights and the Kansas ITS Complaints Process – Kansas Infant Toddler Services. This information has been explained to me and I understand it. As discussed in this information, I have the right to contact the Kansas Department of Health and Environment at 785.296.6135 or 1.800.332.6262 and make an informal complaint, formal written complaint, request mediation and/or an impartial due process hearing should I disagree with the above proposed or refused action(s). For more information, I may also consult the Kansas Infant Toddler Services website at
I do I do not: give my informed consent for the activities described above.
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Parent/Guardian Signature Date
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Parent/Guardian Signature Date
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