Important Steps
NYC EARLY INTERVENTION PROGRAM CLOSURE FORMChild’s Name:DOB:EI #:Effective Data of Closure://Date of Submission://Prepared by SC/DM/RO:_ (circle one)NameSC ID #:Telephone #:Fax #:[ ] Case is being closed in Early Intervention (complete section I)[ ] Case is being closed in Developmental Monitoring (complete section II)I. Early Intervention ClosureDISPOSITION [Check only one]Any Stage:Transition:[ ]C: Can't locate family[ ]D: Transition to CPSE[ ]G: Family moved out of NYC[ ]L: Aged out, not eligible for CPSE/ no referral[ ]H: Family moved out of state[ ]M: Aged out, not eligible for CPSE/ referred to other[ ]I: Child diedprogramsBefore IFSP:[ ]N: Aged out, unknown eligibility for CPSE: Process[ ]E: Evaluation found child ineligibleincomplete or Parent refused[ ]K: Refused - contact family in 2 months[ ]Z: Duplicate child in systemDuring/ After IFSP:[ ]A: Delay condition resolved[ ]B: Family refused EI servicesParent’s Signature:Date: / / [ ] Parent is unavailable for signature.Note: If the parent is unavailable for signature, attach the SC notes, certified letter (if applicable) and certified label (if applicable) documenting unsuccessful contact attempts and parent availability issues.Parent’s signature is not necessary in cases of child death. For more information refer to the Closure Policy.Parent was informed of Developmental Monitoring Services option[ ] J: Transferred to Developmental Monitoring Unit. Risk Factor:__7 [ ] Parent objects to referral to Developmental MonitoringNote: Service Coordinator must send a copy of this Closure Form to all service providers includingTransportation and Respite Provider(s) when applicable.II. Developmental Monitoring ClosureDISPOSITION [Check only one][ ]A: Risk Condition Resolved[ ]G: Family moved out of NYC [ ]B: Family Refused / Two missed mailings [ ]H: Family moved out of state[ ]C: Can't locate family[ ]I: Child died[ ]D: Transferred to / Active in E.I. [ ]F: > 3 Years Old[ ]K: DuplicateCOMMENTS:Parent Signature:Date: / / [ ] Parent was unavailable for signature. Explain above.III. Early Intervention Official Designee/ Developmental Monitoring Specialist ApprovalReviewed by EIOD/ DM Specialist: Date: /_ _/_ EIP Data Entry:Date: _/ / Closure Form 1/11INSTRUCTIONS FOR COMPLETION CLOSURE FORMThe Closure Form may be completed by the Initial (ISC) or Ongoing Service Coordinator (OSC), EIOD/RO staff, or Developmental Monitoring Specialist under the circumstances described below (See Appendix A).The individual completing the form will:1. Complete the identifying information.2. Write the Effective Date of Closure and the Date of Submission,(dates do not have to be the same)?Provider agencies cannot bill for services or service coordination after the Effective Date of Closure.?The closure date should allow for any necessary activity on the case, such as Prior Written Notice, to have been completed.3. Circle the correct designation (SC/DM/RO) and print his/her name.4. If the SC is completing this form, the SC ID number must be specified.5. Write telephone and fax numbers.6. Check to indicate if the case is being closed in Early Intervention (EI) or Developmental Monitoring (DM).When the Closure Form is completed and submitted by any of the parties listed, the appropriate staff in the RO orDM Unit will review the form and sign and date at the bottom.Data Entry staff will sign and date the form to indicate that the information has been entered into KIDS.Initial and Ongoing Service Coordinators:?Complete Section I of the Closure Form when any of the conditions listed in the box titled “Disposition”occurs (see Crosswalk of Instances of Closure and Disposition Codes).NOTE: This form should not be completed if a child will be leaving one EI Provider and continue to receive any services through another EI provider within the five boroughs of New York City.?Keep a completed copy of the Closure Form in the child’s service coordination case record.?Send copies to the following: EIOD (or appropriate EI Regional Office Director); the evaluation site (if prior to the IFSP meeting); and all service provider agencies, including respite and transportation providers, if authorized.oIf the parent is unavailable for signature, attach the SC notes, certified letter (if applicable) and certified label (if applicable) documenting unsuccessful contact attempts and parent availability issues. For more information refer to the Closure Policy.oParent signature is NOT necessary in cases of child death?If a child is found not eligible for EI services, the SC should discuss referral to DM with the parents..oIf parent agrees with referral to DM, check box “J” indicating the DM referral.Regional Office Staff:?Complete Section I of the Closure Form:-Upon the conclusion of the evaluation process when the child is determined to be not eligible for EI, the family did not agree with the findings or did not sign the form, and a Prior Written Notice Form wassent.-After a child has been re-evaluated, found no longer eligible for EI services, and a Prior Written NoticeForm was sent.?Keep a completed copy of the Closure Form in the child’s municipal case record.?Send copies to the following: ISC/ OSC, all service provider agencies, and Data Operations for entry intoKIDS.Developmental Monitoring Staff:?Complete Section II of the Closure Form when any of the conditions listed under “Disposition” occurs.?Keep a completed copy of the Closure Form in the child’s municipal case record.?Send a copy of the form to Data Operations for entry into KIDS.Closure Form Instructions 1/11Appendix A: Closure Codes and Definition of CategoriesClosure CodeDefinition of CategoryA- Delaycondition resolvedThe condition for which the child was receiving EI services has beenresolved and the child no longer requires services.B- FamilyRefusedWithdrawal by parent (or guardian) after the child has been evaluated.C- Can’t locatefamilyAttempts to reach the parent were unsuccessful. Category includeschildren at any stage in the EI process, and for whom personnel have been unable to contact or locate after repeated, documented attempts.D- Transitionto CPSEChildren who have been determined to be eligible for services by theCommittee on Preschool Special Education.E- Evaluatedfound not eligibleChildren who have been evaluated and determined to be not eligiblefor EI servicesG- Familymoved out ofNYCThe family moved out of NYC, but remains within NYS.H- Familymoved out of stateThe family moved out of NYS.I: Child DiedCase is closed due to child’s death.K- RefusedContact in 2 monthsParents withdraw from EIP before the Initial IFSP meeting occurs. Theevaluation process may or may not have been initiated or completed.L- Age out,not eligible for CPSE/ no referralChildren who have been determined to be not eligible for services bythe CPSE and age out of EI with no referrals to other programs.M- Age out,not eligible for CPSE/ referred to other programsChildren who have been determined to be not eligible for services bythe CPSE and age out of EI with referrals to other programs such as: preschool learning center, Headstart, child care center, health and nutrition services.N- Age out, unknowneligibility for CPSE/ process incomplete or parent refusedChildren who have aged out of EI and for whom eligibility for services by the CPSE is unknown or the process is incomplete. Also includechildren for whom parents did not consent to transition planning or to referral to CPSE.Z- DuplicateChild is already active in KIDS with another ID numberClosure Form Instructions: Appendix A Closure Codes and Definitions of Categories 1/11 ................
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