Hawaii State Department of Health



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|Child’s Name: |      | |

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|Date of Birth: |

|Part C Eligibility: (Check all that apply) | | |

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|Diagnosis |

|Rating: |

|Who provided input prior to the meeting and/or participated in the discussion at the meeting to determine Child Outcomes rating? |

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|Input |Participated | | |

| | |Care Coordinator |

| | |Child Development Specialist |

| | |Family Member/Guardian |

| | | |Family declined to participate |

| | | |Lost contact with family |

| | |Occupational Therapist |

| | |Physical Therapist |

| | |Psychologist |

| | |Public Health Nurse |

| | |Social Worker |

| | |Speech Language Pathologist |

| | |Special Education Teacher |

| | |Teacher |

| | |Other: |      |

| | |Other: |      |

Outcome 1: Positive Social and Emotional Skills (including social relationships)

|How does your child relate to parents or caregivers and other family members? How does your child get along with other children in different situations, like at |

|home, child care, or a family party? How about with other adults? How does your child show different feelings like mad, happy, sad, scared? Does your child know |

|how another person is feeling? |

|To answer the questions below, think about how your child acts in these and similar areas (as shown by assessments and based on observations from people who know |

|your child well): |

|Relating with adults including family members, relatives, friends, strangers; |

|Getting along with other children including brothers and sisters, cousins, friends, strangers; |

|Following rules when in groups or interacting with other people; [Discuss “following rules” only if child is older than 18 months.] |

|Understanding and showing emotions; [Discuss emotions only if child is older than 24 months.] |

|1a. Has your child shown any new skills or behaviors related to this goal since the last rating? |

| Yes | No | N/A (first measurement for this child) |

|1b. Does your child ever function in ways that would be considered age-appropriate with regard to social and emotional skills? |

| No, not yet. | Yes. Refer to the MDE report. |

|Does your child use any immediate foundational skills* upon which | Is your child’s functioning age-appropriate across all or almost all settings and situations? |

|to build age-appropriate functioning across settings and | |

|situations? | |

| No | Yes. Refer to MDE report. | No, not yet. | Yes. Refer to MDE report. |

| |To what extent does your child use immediate|To what extent does your child use |Does anyone have any concerns about your child’s|

| |foundational skills across settings and |age-appropriate skills across settings and |functioning in regards to this goal area? |

| |situations? |situations? | |

| | Sometimes. |

| |Refer to the MDE report. |

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|*Immediate Foundational Skills= the set of skills and behavior that occur developmentally just prior to age-expected functioning |

Outcome 2: Learning and Using Knowledge and Skills

|What has your child learned to do recently? Is your child doing new things? |

|To answer the questions below, think about what your child is doing in these and similar areas (as shown by assessments and based on observations from people who |

|know your child well): |

|Thinking, reasoning, remembering, and solving problems; |

|Understanding symbols; |

|Receptive and expressive communication skills; |

|Understanding the physical and social worlds. |

|2a. Has your child shown any new skills or behaviors related to this goal since the last rating? |

| Yes | No | N/A (first measurement for this child) |

|2b. Does your child ever function in ways that would be considered age-appropriate with regard to learning and using knowledge and skills? |

| No, not yet. | Yes. Refer to MDE report. |

|Does your child use any immediate foundational skills* upon which | Is your child’s functioning age-appropriate across all or almost all settings and situations? |

|to build age-appropriate functioning across settings and | |

|situations? | |

| No | Yes. Refer to MDE report. | No, not yet. | Yes. Refer to MDE report. |

| |To what extent does your child use immediate|To what extent does your child use |Does anyone have any concerns about your child’s|

| |foundational skills across settings and |age-appropriate skills across settings and |functioning in regards to this goal area? |

| |situations? |situations? | |

| | Sometimes. |

| |Refer to the MDE report. |

|Notes: | |

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|*Immediate Foundational Skills= the set of skills and behavior that occur developmentally just prior to age-expected functioning |

Outcome 3: Taking Appropriate Action to Meet Needs

|How does your child get what s/he wants? What does your child do to get something s/he needs? |

|To answer the questions below, think about how your child acts in these and similar areas (as shown by assessments and based on observations from people who know |

|your child well): |

|Taking care of basic needs (like showing hunger, dressing, feeding, toileting, etc.); |

|Contributing to own health and safety (follows rules, assists with hand washing, avoids inedible objects, etc.) [Discuss health & safely only if child is older |

|than 24 months.]; |

|Getting from place to place (mobility) and using tools (such as forks, pencils, strings attached to toys, etc.) |

|3a. Has your child shown any new skills or behaviors related to this goal since the last rating |

| Yes | No | N/A (first measurement for this child) |

|3b. Does your child ever function in ways that would be considered age-appropriate with regard to taking appropriate action to meet his/her needs? |

| No, not yet. | Yes. Refer to MDE report. |

|Does your child use any immediate foundational skills upon which to| Is your child’s functioning age-appropriate across all or almost all settings and situations? |

|build age-appropriate functioning across settings and situations? | |

| No | Yes. Refer to the MDE report. | No, not yet. | Yes. Refer to the MDE report. |

| |To what extent does your child use immediate|To what extent does your child use |Does anyone have any concerns about your child’s|

| |foundational skills* across settings and |age-appropriate skills across settings and |functioning in regards to this goal area? |

| |situations? |situations? | |

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|Notes: | |

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|*Immediate Foundational Skills= the set of skills and behavior that occur developmentally just prior to age-expected functioning |

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State of Hawai‘i

Department of Health

Early Intervention

CHILD OUTCOMES SUMMARY

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