Child’s Name:
Date of Birth: / / / /
Month / Day / Year
Part C Eligibility: (Check all that apply)
Developmental Delay / Biological At Risk
Diagnosis / ICD-10 Code / Diagnosis / ICD-10 Code
Child Outcomes Rating Date: / / / /
Month / Day / Year
Rating: / Initial / Final
Who provided inputprior to the meeting and/or participated in the discussion at the meeting to determine Child Outcomes rating?
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:

EI-7c: Child Outcomes Summary, 09.15.15

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 similarareas (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 to build age-appropriate functioning across settings and situations? / Is your child’s functioning age-appropriate across all or almost all 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 foundational skills across settings and situations? / To what extent does your child use age-appropriate skills across settings and situations? / Does anyone have any concerns about your child’s functioning in regards to this goal area?
Sometimes.
Refer to the MDE report. / Most or all of the time. Refer to the MDE report. / More skills are not age-appropriate than age-appropriate. Refer to the MDE report.
/ Skills are a mix of age-appropriate and not age-appropriate. Refer to the MDE report.
/ Yes. Refer to the MDE report. / No.
Uses skills that are not yet immediate foundational. / Occasional use of immediate foundational skills. / Uses immediate foundational skills most or all of the time across settings and situations. / Occasional use of age-appropriate skills; more behavior that is not-age-appropriate. / Uses a mix of age-appropriate and not age-appropriate behaviors and skills across settings. / Concerns exist, but functioning age-appropriate across all or almost all settings and situations. / Functioning age-appropriate across all or almost all settings and situations.
Notes:
*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 doingin 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 to build age-appropriate functioning across settings and situations? / Is your child’s functioning age-appropriate across all or almost all 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 foundational skills across settings and situations? / To what extent does your child use age-appropriate skills across settings and situations? / Does anyone have any concerns about your child’s functioning in regards to this goal area?
Sometimes.
Refer to the MDE report. / Most or all of the time. Refer to the MDE report. / More skills are not age-appropriate than age-appropriate. Refer to the MDE report.
/ Skills are a mix of age-appropriate and not age-appropriate. Refer to the MDE report.
/ Yes. Refer to the MDE report. / No.
Uses skills that are not yet immediate foundational. / Occasional use of immediate foundational skills. / Uses immediate foundational skills most or all of the time across settings and situations. / Occasional use of age-appropriate skills; more behavior that is not-age-appropriate. / Uses a mix of age-appropriate and not age-appropriate behaviors and skills across settings. / Concerns exist, but functioning age-appropriate across all or almost all settings and situations. / Functioning age-appropriate across all or almost all settings and situations.
Notes:
*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 build age-appropriate functioning across settings and situations? / Is your child’s functioning age-appropriate across all or almost all 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 foundational skills* across settings and situations? / To what extent does your child use age-appropriate skills across settings and situations? / Does anyone have any concerns about your child’s functioning in regards to this goal area?
Sometimes.
Refer to the MDE report. / Most or all of the time. Refer to the MDE report. / More skills are not age-appropriate than age-appropriate. Refer to the MDE report.
/ Skills are a mix of age-appropriate and not age-appropriate. Refer to the MDE report.
/ Yes. Refer to the MDE report. / No.
Uses skills that are not yet immediate foundational. / Occasional use of immediate foundational skills. / Uses immediate foundational skills most or all of the time across settings and situations. / Occasional use of age-appropriate skills; more behavior that is not-age-appropriate. / Uses a mix of age-appropriate and not age-appropriate behaviors and skills across settings. / Concerns exist, but functioning age-appropriate across all or almost all settings and situations. / Functioning age-appropriate across all or almost all settings and situations.
Notes:
*Immediate Foundational Skills= the set of skills and behavior that occur developmentally just prior to age-expected functioning

EI-7c: Child Outcomes Summary, 09.15.15