New Jersey Early Intervention System
NEW JERSEY EARLY INTERVENTION SYSTEM
INITIAL EVALUATION/ASSESSMENT SUMMARY
|Child’s First Name |Child’s Last Name |MI |Child’s SPOE Id # |
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|Child’s Date of Birth |Evaluation Date |Chronological Age |County of Residence |
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|Evaluation/Assessment Location |Start Time |End Time |
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|Evaluation/Assessment Tools in addition to Parent Report and Clinical Observation |
| Battelle Developmental Inventory 2 |Evaluator: |
|(BDI-2) Required Instrument |Agency: |
| Discipline Specific Assessment Instruments |Specify: |
| |Specify: |
| |Specify: |
| Other Instruments/Records |Specify: |
| |Specify: |
| |Specify: |
|Reason for Referral/Family Concerns (Developmental, Medical, Health, Behavior, Vision, Hearing) |
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|DEVELOPMENTAL EVALUATION/ASSESSMENT SUMMARY |
|COGNITIVE |Ability to learn, play productively, and solve problems |
|Mastered Skills: |
|Emerging Skills: |
|Developmental Learning Skills Targeted for Next 6 Months: |
|Clinical Comments: |
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|GROSS MOTOR |Ability to engage in large muscle movements (sitting, crawling, walking) |
|Mastered Skills |
|Emerging Skills |
|Developmental Learning Skills Targeted for Next 6 Months |
|Clinical Comments |
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|FINE MOTOR |Eye/hand coordination and ability to use hands. |
|Mastered Skills: |
|Emerging Skills: |
|Developmental Learning Skills Targeted for Next 6 Months: |
|Clinical Comments: |
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|COMMUNICATION |Ability to understand and use language. |
|Mastered Skills: |
|Emerging Skills: |
|Developmental Learning Skills Targeted for Next 6 Months: |
|Clinical Comments: |
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|ADAPTIVE/SELF-HELP |Ability to do things for him/herself. (feeding, dressing, sensory information) |
|Mastered Skills: |
|Emerging Skills: |
|Developmental Learning Skills Targeted for Next 6 Months: |
|Clinical Comments : |
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|SOCIAL EMOTIONAL |Interactions with adults, children, & their environment; use of toys; transitioning between activities. |
|Mastered Skills: |
|Emerging Skills: |
|Developmental Learning Skills Targeted for Next 6 Months: |
|Clinical Comments: |
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|VISION & HEARING |Ability to use vision and hearing. |
|Vision Screening/Evaluation | Medical/Vision Specialist Date of Screening/Evaluation |
| |NJEIS TET |
|Vision Screening/Evaluation Results/Concerns: |
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|Hearing Screening/Evaluation | By Medical/Hearing Specialist Date of Screening/Evaluation |
| |NJEIS TET |
|Hearing Screening/Evaluation Results/Concerns: |
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|Initial BDI-2 Evaluation Information |
|Developmental Domain |Domain Score |Z Score |Raw Score (RS) |
| |(100 is average) |(0.0 is average) | |
|Adaptive | | | |
|Personal/Social | | | |
|Communication | | | |
|Gross Motor | | | |
|Fine Motor | | | |
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|Cognitive | | | |
|EVALUATION TEAM PARTICIPANTS |
|Name (Print) |Title/Discipline |Agency |Minutes |Signature |
| |Parent/Guardian |N/A | | |
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|PARENT/GUARDIAN FEEDBACK |
|Did this evaluation/assessment attend to the concerns you have about | Yes No |
|your child’s development? |If no, why not? |
| | |
|Do you think that the evaluation/assessment provided a good picture of| Yes No |
|your child’s skills? |If no, why not? |
|Has the evaluation/assessment raised any additional concerns or | Yes No |
|questions about your child’s development? |If yes, please describe: |
|NEXT STEPS |
|Family Next Steps: Family support services, community resources and | |
|obtaining medical records as needed. | |
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