***Restricted***

PART A

SECTION 1
(i) Child’s Surname: Forename(s):
DOB: School Reception Start Date:
SECTION 2
Name of Pre-school setting: URN/PVI Setting code:
District:
Form completed by: Designation:
Number of hours attended: Number of hours per week of ADN funding received:
End date of current funding: Date of EY Forum review:
(Please ensure completed application is received by the Business Support Team in the appropriate district office at least 10 working days before the Early Years Forum meeting. Incomplete forms will be returned)
SECTION 3 External agencies currently involved:
Educational Psychologist Behaviour Support Early Years Area SENCO
Hearing or Visual Impairment Autism Outreach Team Paediatrician Speech and
Language Therapist Physiotherapist Occupational Therapist Social Care
Physical Disability Support Service LST Child and Family Engagement Worker
CAMHS Midlands Psychology
Any other agency (please specify)
Any other relevant information (changes in circumstances, any other factors which may impact on the child’s learning, development and progress? e.g. attendance, illness, changes in family or setting circumstances)

PART B

How have you used the additional funding?

What targeted support has the child received during the ADN funded period? Please give details of specific interventions/targets
(e.g. speech & language targets) / Number of children / How often and how long / What progress has the child made again this target?
Total hours supported per week, 1:1
Total hours supported per week, small group
Total hours supported per week, whole group

PART C

Child’s Progress

What progress has been made in the targeted areas? Please give specific details.

PART D

Overall effectiveness of additional support

5 / 4 / 3 / 2 / 1
Better than expected / Good / Adequate / Some / Limited

Reasons for overall score

Proposed use of further ADN Resources

Please indicate below how additional resources would be used.

Funding is up to a maximum of 15 hours/week, unless eligible for 30 hours.

Targets to be development and supported.
(Please give as much detail as possible.) / 1 : 1 / small group/
whole group / Number of hours per week / Number of weeks if short-term need
Total hours
Warning Note:
ADN funding awarded is subject to scrutiny and monitoring at any time.
If awarded funding is not being used to support the individual pupil for whom it was given as agreed, then funding will be withdrawn retrospectively and with immediate effect.

PART E

Criteria

Funding levels are based on Staffordshire’s graduated response, including the criteria. Please indicate which criteria and level of need best fits this child:

Additional needs / Complex needs / Severe needs
Two-year-old criteria
Three-year-old criteria
Visual Impairment criteria
Hearing Impairment criteria

If the child’s needs have changed since the last application please attach a new annotated criteria.

PART F

Checklist of Evidence

Please attach these

IEPs/evidence of support in targeted areas

Development journal summary sheet (or similar summary of skills)

Personal Education Plan if pupil is Looked After

Setting SENCo:

Signature:

Name (please print clearly)

Date

Please send forms to the appropriate district office. Forms needs to be received at least 10 working days before the forum to be considered at the first available forum.

1

September 2017

Stafford and South Staffs:

Business Support Team

The Kingston Centre

Fairway

Stafford

ST16 3TW

Lichfield and Cannock:

Business Support Team

The Old Library

Bird Street

Lichfield

WS13 6PN

Newcastle and Moorlands:

Business support Team

Seabridge Centre

Ashway,

off Seabridge Lane,

Newcastle,

ST5 3UB

East Staffs and Tamworth:

Business Support Team

Burton Education Centre
Grange Street
Burton-on-Trent

DE14 2ER

1

September 2017