SAMPLE COS B Narrative Violet
[Pages:5]Child's Name Violet Brown
Evaluation Summary
Age 25 months
ID#__________ Date ___/___/___
Where was the evaluation conducted? The evaluation was conducted at home.
Who was present? Violets mom and dad, Shannon and Mark and the early intervention team were present.
Was the child's behavior and participation typical? surprising? Please explain. Violet was very slow to warm to a valuators and needed to be very close to her mother throughout the evaluation. She did warm up at the at the end and participated in most of the tasks presented to her. Mom and dad reported that this was pretty typical for her around unfamiliar people.
Evaluation Team: Pat Maris/Educator Rachel Wheaton/Speech Therapist
Shannon and Mark Smith, parents
Name/Role
Name/Role
Name/Role
Methods / Procedures Used For Evaluation/Assessment: Check all that apply: ? Standardized tool Bayley ? Checklist
? Review of medical record ? Interview ? Observation. Please list other methods and procedures on the lines below:
_____Battelle_______________________ _____________________________ __________________________________
? Eligible: This child meets the eligibility criteria for early intervention services.
Check 1OR 2
1. Single Established Condition (Specify)
Primary Diagnosis:______________________________________________________ ICD-10 Code: ___________
Secondary Diagnosis:____________________________________________________ ICD-10 Code: ___________
2. Significant Developmental Delay (Select Eligibility Category a, b, or c )
Primary Diagnosis:______ Delayed Milestones_______________________________ICD-10 Code: _R62.0_____
a) A delay of 2 standard deviations in at least one of the following area(s)
Cognitive Gross Motor Fine Motor Skills Expressive Communication
Receptive Communication Social Emotional Adaptive Skills
b) A delay of 1.5 standard deviations in at least two of the following area(s)
Cognitive Gross Motor Fine Motor Skills Expressive Communication
Receptive Communication Social Emotional Adaptive Skills
c) There is a significant impact on child/family functioning in the following area(s)
Cognitive Gross Motor Fine Motor Skills Expressive Communication Receptive Communication
Social Emotional Adaptive Skills Vision Hearing Health
Family Circumstance
Not Eligible: This child does not meet the eligibility criteria for EI services (Summarize on Form B). Reminder: Provide procedural safeguards and document on Services Rendered Form. Family declined Early Intervention services
Scores: Indicate Standard Score (SS) (This is the same as Composite Score) Results: Indicate if 2 SD or 1.5 SD, WNL (Within Normal Limits) or SIF (Significant Impact on Functioning). If result is less than 1.5 SD, indicate ................
................
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