ILLINOIS CHILD OUTCOMES SUMMARY FORM
ILLINOIS EARLY CHILDHOOD OUTCOMES SUMMARY FORM Entry Exit Date:
Name: SID: Male Female DOB:
Last First Middle
District: School:
|Persons involved in deciding summary ratings - Role/Title |
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Bottom of Form
Top of Form
|Positive Social Relationships |Acquire and Use Knowledge and Skills |Take Appropriate Action to Meet Own Needs |
| |1 - Not Yet | |1 - Not Yet | |1 - Not Yet |
| |2 - Between Emerging and Not Yet | |2 - Between Emerging and Not Yet | |2 - Between Emerging and Not Yet |
| |3 - Emerging skills | |3 - Emerging skills | |3 - Emerging skills |
| |4 -Between Somewhat and Emerging | |4 -Between Somewhat and Emerging | |4 -Between Somewhat and Emerging |
| |5 - Somewhat | |5 – Somewhat | |5 - Somewhat |
| |6 - Between Somewhat and Completely | |6 - Between Somewhat and Completely | |6 - Between Somewhat and Completely |
| |7 - Completely | |7 – Completely | |7 – Completely |
|Summary of Evidence: |Summary of Evidence: |Summary of Evidence: |
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|Sources of Supporting Evidence – Date |Sources of Supporting Evidence – Date |Sources of Supporting Evidence – Date |
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|special considerations |special considerations |special considerations |
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|Did a Coordinator, LEA Representative or Administrator Participate in the Ratings? | Yes No |
|Did an Early Childhood Teacher Participate in the Ratings? | Yes No |
|Did a Psychologist or Social Worker Participate in the Ratings? | Yes No |
|Did a Speech/ Language Pathologist Participate in the Ratings? | Yes No |
|Did another Related Service Provider (e.g. OT/PT) Participate in the Ratings? | Yes No |
|How was Parent Involved in | |1- Information Received in Team | |2 - Information from Parent | |3 - Did Not Use Information from |
|the Ratings? | |Meeting from Parent | |Incorporated into assessment(s) | |Parent in Ratings Process |
Exit Rating Only
|Made Progress Positive Social Relationships? | Yes No |
|Made Progress Acquire use and Knowledge Skills? | Yes No |
|Made Progress Take Appropriate Action to Meet Own Needs? | Yes No |
|Primary Assessment (Select Only One) |
| |1 - Assessment and Evaluation Programming System | |4 - Creative Curriculum Assessment | |7- Transdisciplinary Play-Based Assessment |
| |(AEPS) | | | |(TPBA) |
| |2 - Carolina Curriculum for Infants and Toddlers /| |5 - Hawaii Early Learning Profile (HELP) | |8 - Work Sampling System |
| |Preschoolers with Special Needs | | | | |
| |3 - High Scope Child Observation Record | |6 - Individual Growth and Development Indicators| |9 – Child has an IEP for Speech Only |
| | | |(IGDI) | | |
Entered into SIS by Date:
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