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IFSP Checklist

Complete this form using your observations of the meeting via videotape and the IFSP document or for review of the IFSP document only .

Summary Page

(November 2004 Revision)

|Child’s Name:      |Person Reviewing:      |

|ChildLink #:       |IFSP Development Date:       |

|Birth date:      |Type of IFSP:      |

|QI Review Date:       |Length of Videotape:      ____minutes |

| |Record Review Only: Yes No |

|IFSP TEAM |

|Name |Discipline |Agency |

|      |Parent |NA |

|      |Service Coordinator |ChildLink |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

|Background Summary Information for the Checklist |

|Family Resources & Strengths Summary (page 1) |

|      |

| |

| |

|Family Concerns Summary (page 1) |

|      |

| |

| |

|Family Priorities Summary (page 1) |

|      |

| |

| |

|IFSP Outcomes (page 9 +): Total # of outcomes = __     ____. |

|      |

| |

| |

|General Summary of Child’s Present Abilities, Strengths, and Needs and Progress (if Annual IFSP) (pages 3-6 or other resources): |

|      |

| |

| |

|IFSP Services (page 10) |

|      |

| |

|IFSP Section |Total # of items per |Total # of Compliance |Total # of Non |Total # of Can’t Tell/ per |

| |section |per section |Compliance per section |section |

|Family/Child Information (IFSP pp 1-2) |      |      |      |      |

|Current Performance (IFSP pg. 1-4) |      |      |      |      |

|Big Picture/Recommendations (IFSP pp 7-8) |      |      |      |      |

|Intervention Plan(s) (IFSP pp 9+) |      |      |      |      |

|Transition Plan (IFSP pg. 12) |      |      |      |      |

|General Considerations |      |      |      |      |

|Total |      |      |      |      |

IFSP VideoTape Overview

|Videotape Overview (General Rating of What Was Seen/Heard on the Videotape): Assign a rating for those items that you were able to see & hear on the |

|videotape. Not Observed on the Tape means that there was no opportunity for a particular indicator to be observed. For example, if there was no discussion |

|at all about priorities and concerns, then items related to priorities and concerns would be marked as Not Observed. If, for example, only developmental |

|priorities and concerns were discussed, then the category of activities and routines would be rated as 1 because the opportunity for this discussion was |

|present but the discussion did not occur. Technical problems means that whatever was occurring could not be seen or heard. |

| |1= no; not done well; 3 = partly; |Not Observed on the|Technical Problems|

| |done a little bit but not well |Tape | |

| |enough; 5 = yes; done very well) | | |

|How the purpose of the IFSP meeting was explained to the family. |      |      |      |

|      |

|How the facilitator explained the role of each team member. |      |      |      |

|      |

|How each team member facilitated family participation so that the family was |      |      |      |

|able to fully discuss their priorities and concerns. | | | |

|      |

|How each team member facilitated a discussion of priorities and concerns beyond |      |      |      |

|those related to the child’s development or behavior. | | | |

|      |

|How each team member facilitated a discussion of family priorities and concerns |      |      |      |

|related to their child’s participation in everyday activities and routines. | | | |

|      |

|How the facilitator or other team members confirmed their understanding of the |      |      |      |

|family’s priorities and concerns. | | | |

|      |

|How a comprehensive description of the family’s activities and routines was |      |      |      |

|obtained. | | | |

|      |

|How each team member facilitated family identification of desired outcomes. |      |      |      |

|      |

|The extent to which desired outcomes reflected the child’s successful |      |      |      |

|participation in current activities and routines. | | | |

|      |

|The extent to which desired outcomes reflected the child’s participation in NEW |      |      |      |

|activities and routines. | | | |

|      |

|The extent to which there is a match between family priorities and concerns and |      |      |      |

|outcome statements. | | | |

|      |

|How a discussion of possible strategies (methods) for addressing each outcome |      |      |      |

|was held; this discussion was of strategies – ways of addressing each outcome – | | | |

|and not of possible services. | | | |

|      |

|The ways in which the family received complete and unbiased information about |      |      |      |

|possible strategies; suggested strategies were presented and did not just | | | |

|reflect the opinion of what is best in the opinion of one or more of the | | | |

|professional team members. | | | |

|      |

|The ways in which family members were encouraged to contribute information about|      |      |      |

|strategies. | | | |

|      |

|The ways in which services were decided and matched with desired strategies; |      |      |      |

|suggested disciplines were those that could best provide the desired strategies.| | | |

|      |

|How family members were encouraged to ask questions. |      |      |      |

|      |

|How participants used language that was non-judgmental, non-jargon, and |      |      |      |

|understandable. | | | |

|      |

|How team members were successful in engaging the family as active participants |      |      |      |

|in the meeting. | | | |

|      |

|TOTAL # ITEMS SCORED IN EACH COLUMN |      |      |      |

|TOTAL SCORE |      | | |

Additional Comments:

     

|What Needs to Be Done to Enhance the Quality of Future IFSP Meetings? |

|# |Activity |Who will do this? |By when? |Date Completed |

| |      |      |      |      |

|1 | | | | |

| |      |      |      |      |

| | | | | |

|2 | | | | |

| |      |      |      |      |

| | | | | |

|3 | | | | |

| |      |      |      |      |

| | | | | |

|4 | | | | |

| |      |      |      |      |

| | | | | |

|5 | | | | |

Which ONE activity will be completed as part of the self-study? ___     ________

IFSP Checklist

Analysis of MDE/IFSP Document

Complete this section using the IFSP document that was written at the meeting. You will make judgments about compliance. Compliance means that the written IFSP reflects the requirements for the IFSP as written in Part C of IDEA, Act 212, the PA Early Intervention regulations, the state compliance review document, etc.

|Out of |In comp |Can’t |Family Assessment (Page 1) |Comments |

|compliance | |Tell | | |

|None |Some | | | | |

|      |      |      |      |Concerns: Reflects concerns the family has about their child’s |      |

| | | | |participation in routines, and day to day activities. | |

|      |      |      |      |Family’s priorities: Specifies the family’s most important needs and/or |      |

| | | | |goals for the child | |

|Out of |In comp |Can’t |All About Me (Page 2) |Comments |

|compliance | |Tell | | |

|None |Some | | | | |

|      |      |      |      |What activities do I like to do at home and in the community? Identifies|      |

| | | | |activities and routines for both home and community settings as well as | |

| | | | |what the child likes to do; includes a list of natural environments that | |

| | | | |the child currently engages in and those the child would engage in if the| |

| | | | |child did not have developmental delay or disability. | |

|      |      |      |      |How do I play with children, adults, and toys? Describes child’s |      |

| | | | |interests, play skills and preferences | |

|      |      |      |      |What does my family want me to be able to do? Contains a description of |      |

| | | | |the family’s desires for what they would like the child to be able to do;| |

| | | | |provides a rationale for developmental skills the family would like to | |

| | | | |work on (e.g., I would like my child to walk in order to play with the | |

| | | | |child next door); is not restricted to developmental skills but includes | |

| | | | |descriptions of settings, activities, and routines in which the family | |

| | | | |would like the child to participate. | |

|Out of |In comp |Can’t |Child’s Present Abilities, Strengths, & Unique Needs (Pages 3-6) |Comments |

|compliance | |Tell | | |

|None |Some | | | | |

|      |      |      |      |Vision & Hearing Status: Describes the child’s current status in vision |      |

| | | | |and hearing including the dates and the names of the individuals who | |

| | | | |completed the most recent hearing and vision screenings/assessments. | |

| | | | |Present Level of Development Areas: Identifies child’s current abilities | |

| | | | |and strengths including parent report of the child’s abilities. For | |

| | | | |annual IFSP reviews, this section contains a description of progress made| |

| | | | |and outcomes reached; includes the date of the most recent evaluation, | |

| | | | |the child’s age at the evaluation point, the type of evaluation, name of | |

| | | | |instrument, the name of the person(s)/agency(ies) who was responsible for| |

| | | | |the evaluation, and a summary of results. | |

|      |      |      |      |Present Level of Development/Communication: |      |

|      |      |      |      |Present Level of Development/Social-Emotional: |      |

|      |      |      |      |Present Level of Development/Physical: |      |

|      |      |      |      |Present Level of Development/Adaptive: |      |

|      |      |      |      |Other Information: Identifies other information not covered in previous |      |

| | | | |sections including the need for AT services and devices, cultural | |

| | | | |preferences that need to be considered, etc. | |

|Out of |In comp |Can’t |The Big Picture (Page 7) |Comments |

|compliance | |Tell | | |

|None |Some | | | | |

|      |      |      |      |Impact on Daily Experiences & Routines: Identifies how the concerns |      |

| | | | |impact on the child’s learning or interfere with participation in | |

| | | | |activities and routines. | |

|      |      |      |      |What makes learning easier: Lists 1) identified strengths and 2) |      |

| | | | |strategies that make daily activities and routines easier for the child &| |

| | | | |caregiver. | |

|Out of |In comp |Can’t |Recommendations (Page 8) |Comments |

|compliance | |Tell | | |

|None |Some | | | | |

|      |      |      |      |Statement of Eligibility (or continuing eligibility for annual IFSP): |      |

| | | | |One box is checked that best describes eligibility. | |

|Out of |In comp |Can’t |Intervention Plan (Page 9) – |Comments |

|compliance | |Tell |OUTCOME # 1 | |

|None |Some |All | | | |

|      |      |      |      |What is happening now? Describes child’s/family’s current abilities |      |

| | | | |related to the outcome and the child’s routines and activities | |

|      |      |      |      |Objective: Delineates smaller steps child/family does to reach the |      |

| | | | |outcome; may also include steps needed to attain outcome | |

|      |      |      |      |Location: Specifies natural environment in which objectives can be |      |

| | | | |addressed: includes a statement about the reason services are to be | |

| | | | |delivered in that natural environment. | |

|      |      |      |      |Community Resource: Identifies potential resources obtained from the |      |

| | | | |families routines that may support the child’s/family’s attainment of | |

| | | | |objective | |

|      |      |      |      |EI Service: Lists all EI services used to address objectives and methods |      |

| | | | |for attaining objectives | |

|      |      |      |      |By Whom: Contains the names of persons or types of disciplines to be |      |

| | | | |used to attain the objective | |

|      |      |      |      |Method: Describes general ways to work on objectives – the strategies |      |

| | | | |that will be used to help the child/family achieve the stated objective. | |

|      |      |      |      |How we, as a family, will be able to work on…Identifies how the methods |      |

| | | | |and objectives will be incorporated into the family’s everyday activities| |

| | | | |and routines. | |

|      |      |      |      |How will we, as a team, measure…Describes specific ways the team will |      |

| | | | |determine process being made towards that outcome (i.e., observation, | |

| | | | |ongoing assessment, quarterly report, etc.) Identifies reviews of | |

| | | | |progress during quarterly review meetings. | |

|      |      |      |      |Our team will be satisfied we are finished with this outcome when: |      |

| | | | |Indicates how the team will know when the outcome has been achieved | |

|      |      |      |      |Completed during IFSP Review: For IFSP reviews, indicates family rating |      |

| | | | |on the team’s work toward child outcomes | |

|      |      |      |      |*Explain why EI cannot be achieved satisfactorily in a natural |      |

| | | | |environment: Justifies why service cannot happen in a natural | |

| | | | |environment; details plan to transition services to the natural | |

| | | | |environment by the next review. | |

| | | | | | |

|Out of |In comp |Can’t |Intervention Plan (Page 9 +) – |Comments |

|compliance | |Tell |OUTCOME # 2 | |

|None |Some |All | | | |

|      |      |      |      |What is happening now? Describes child’s/family’s current abilities |      |

| | | | |related to the outcome and the child’s routines and activities | |

|      |      |      |      |Objective: Delineates smaller steps child/family does to reach the |      |

| | | | |outcome; may also include steps needed to attain outcome | |

|      |      |      |      |Location: Specifies natural environment in which objectives can be |      |

| | | | |addressed: includes a statement about the reason services are to be | |

| | | | |delivered in that natural environment. | |

|      |      |      |      |Community Resource: Identifies potential resources obtained from the |      |

| | | | |families routines that may support the child’s/family’s attainment of | |

| | | | |objective | |

|      |      |      |      |EI Service: Lists all EI services used to address objectives and methods |      |

| | | | |for attaining objectives | |

|      |      |      |      |By Whom: Contains the names of persons or types of disciplines to be |      |

| | | | |used to attain the objective | |

|      |      |      |      |Method: Describes general ways to work on objectives – the strategies |      |

| | | | |that will be used to help the child/family achieve the stated objective. | |

|      |      |      |      |How we, as a family, will be able to work on…Identifies how the methods |      |

| | | | |and objectives will be incorporated into the family’s everyday activities| |

| | | | |and routines. | |

|      |      |      |      |How will we, as a team, measure…Describes specific ways the team will |      |

| | | | |determine process being made towards that outcome (i.e., observation, | |

| | | | |ongoing assessment, quarterly report, etc.) Identifies reviews of | |

| | | | |progress during quarterly review meetings. | |

|      |      |      |      |Our team will be satisfied we are finished with this outcome when: |      |

| | | | |Indicates how the team will know when the outcome has been achieved | |

|      |      |      |      |Completed during IFSP Review: For IFSP reviews, indicates family rating |      |

| | | | |on the team’s work toward child outcomes | |

|      |      |      |      |*Explain why EI cannot be achieved satisfactorily in a natural |      |

| | | | |environment: Justifies why service cannot happen in a natural | |

| | | | |environment; details plan to transition services to the natural | |

| | | | |environment by the next review. | |

|Out of |In comp |Can’t |Intervention Plan (Page 9) – |Comments |

|compliance | |Tell |OUTCOME # 3 | |

| | | |If a child has more than 3 outcomes, create additional charts on which to| |

| | | |evaluate the additional outcomes. | |

|None |Some |All | | | |

|      |      |      |      |What is happening now? Describes child’s/family’s current abilities |      |

| | | | |related to the outcome and the child’s routines and activities | |

|      |      |      |      |Objective: Delineates smaller steps child/family does to reach the |      |

| | | | |outcome; may also include steps needed to attain outcome | |

|      |      |      |      |Location: Specifies natural environment in which objectives can be |      |

| | | | |addressed: includes a statement about the reason services are to be | |

| | | | |delivered in that natural environment. | |

|      |      |      |      |Community Resource: Identifies potential resources obtained from the |      |

| | | | |families routines that may support the child’s/family’s attainment of | |

| | | | |objective | |

|      |      |      |      |EI Service: Lists all EI services used to address objectives and methods |      |

| | | | |for attaining objectives | |

|      |      |      |      |By Whom: Contains the names of persons or types of disciplines to be |      |

| | | | |used to attain the objective | |

|      |      |      |      |Method: Describes general ways to work on objectives – the strategies |      |

| | | | |that will be used to help the child/family achieve the stated objective. | |

|      |      |      |      |How we, as a family, will be able to work on…Identifies how the methods |      |

| | | | |and objectives will be incorporated into the family’s everyday activities| |

| | | | |and routines. | |

|      |      |      |      |How will we, as a team, measure…Describes specific ways the team will |      |

| | | | |determine process being made towards that outcome (i.e., observation, | |

| | | | |ongoing assessment, quarterly report, etc.) Identifies reviews of | |

| | | | |progress during quarterly review meetings. | |

|      |      |      |      |Our team will be satisfied we are finished with this outcome when: |      |

| | | | |Indicates how the team will know when the outcome has been achieved | |

|      |      |      |      |Completed during IFSP Review: For IFSP reviews, indicates family rating |      |

| | | | |on the team’s work toward child outcomes | |

|      |      |      |      |*Explain why EI cannot be achieved satisfactorily in a natural |      |

| | | | |environment: Justifies why service cannot happen in a natural | |

| | | | |environment; details plan to transition services to the natural | |

| | | | |environment by the next review. | |

|Out of |In comp |Can’t |Service Page (Page 10) |Comments |

|compliance | |Tell | | |

|None |Some | | | | |

|Out of |In comp |Can’t |Non Early Intervention Services (Page 10) |Comments |

|compliance | |Tell | | |

|None |Some | | | | |

|      |      |      |      |Contact Person & Phone – Lists person contacted from above identified |      |

| | | | |resources and their telephone numbers. | |

|Out of |In comp |Can’t |Transition Plan & Family Contact Information (page 11) |Comments |

|compliance | |Tell | | |

|None |Some | | | | |

|Out of |In comp |Can’t |General Considerations |Comments |

|compliance | |Tell | | |

|None |Some | | | | |

|      |      |      |      |The approach used on the IFSP is strengths based rather than deficit |      |

| | | | |based | |

|      |      |      |      |All items on every page are completed |      |

|      |      |      |      |All items on every page are written positively |      |

|      |      |      |      |Items on the IFSP reflect content gathered from a variety of sources. |      |

| | | | |Initial IFSPs address (a) referral reasons, (b) Child and Family Reports,| |

| | | | |(c) previous discussions and (d) child observations. Annual IFSPs | |

| | | | |contain information gathered from observations, discussions, progress | |

| | | | |reports and contact sheets | |

|      |      |      |      |Completed items on the IFSP are descriptive and illustrate child and |      |

| | | | |family situations | |

|      |      |      |      |Active voice and action verbs are used whenever possible |      |

|      |      |      |      |Document is legible for all pages of the NCR forms |      |

|      |      |      |      |Few grammatical errors exist |      |

|      |      |      |      |Creative use of therapists as consultants and service intervals utilized |      |

| | | | |to achieve outcomes | |

Additional Comments:

     

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