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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