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 # |

|      |      |      |      |

|Child’s Date of Birth |Evaluation Date |Chronological Age       |County of Residence |

|      |      | |      |

|Evaluation/Assessment Location |Start Time |End Time |

|      |      |      |

|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:       |

| |

|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       |

| |

|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:       |

| |

|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 | | | |

| | |      |      |

|Cognitive |      |      |      |

|EVALUATION TEAM PARTICIPANTS |

|Name (Print) |Title/Discipline |Agency |Minutes |Signature |

|      |Parent/Guardian |N/A | | |

|      |      |      | | |

|      |      |      | | |

|      |      |      | | |

|      |      |      | | |

|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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