Infant & Toddler Connection of Virginia Individual Child Data Form Part C 01-02

Infant & Toddler Connection of Virginia – Individual Child Data Form Child’s Full Name: First, M I, Last Name ITOTS Id: ______Local Case Number: ______Street Address:______

City, State Zip______Was Child Evaluated to Determine Eligibility? a t Yes Date Eligibility Determined: ______/ ______/ ______a Child’s SSN: ______- ______- ______D

Result: No Reason:

d Date of Birth: ______/ ______/ ______l

i Eval. – Ineligible Unable to Contact h City/County of Residence: ______Eligible/Declined Services Deceased C

Race Code: _____ Gender: Male Female Eligible/Will Receive Svcs. Declined Eligibility

Service Coordinator: ______Eligible/Chose Other Svcs. Determination

Referral Source Code: ____ Other (list______) Eligible/Unable to Contact

a Eligible/Decline assessment for service planning r Date of Referral: ______/ ______/ ______r Eligible/Ineligible at assessment for service planning e f

e Intake Date: ______/ ______/ ______Exit Date: ______/ ______/ ______

R Race Codes: P = Pacific Islander or Hawaiian Native IFSP Date: ______/ ______/ ______A = Asian N = American Indian/Alaskan Native B = Black/African American W = White/Caucasian Mitigating Circumstances Related to exceeding H = Hispanic/Latino T = Two or more races U = Unknown 45-day Timelines Provider unavailability Referral Source Codes: 6. Hospital 10. Parent/Guardian y t 1. CSB 7. Pediatrician/Family 11. DSS CAPTA i Child ill Temporarily lost contact l i 2. Local School Physician Group/ 12. VISITS

b Family ill Foster/Surrogate Parent i 3. Health Department Practice 13. Another System g Family scheduling preference related issues i 4. DSS (Non-CAPTA) 8. Private Therapy 14. Other l

E Disaster/Severe Weather 5. Private, Non-profit Org. 9. Friend/Neighbor/Relative P

S Primary Service Setting (check only one) Medically Fragile F I

1. Program Designed for Children with Developmental Delays or Disabilities (Does this child meet the definition of medically

fragile as defined in the instructions?) 2. Program Designed for Typically Developing Children

y 3. Home 5. Residential Facility t i Yes No l i 4. Hospital (inpatient) 6. Service Provider Location (center/clinic/hospital) b i 7. Other (list______) g i l Risk factors (check all that apply) E Developmental Delay (check all that apply)

P Cognitive Apgar Score of 0-3 at 5 minutes S Birth Weight - Low (1500 g to <2500 g or 3.25lbs to 5.5 lbs)

F Physical: including fine & gross motor I

Birth Weight - Very Low (<1500 grams or <3.25 lbs.)

Communication

Brain or spinal cord trauma

Social or emotional y Diagnosed genetic disorders t i Adaptive l

i Documented systemic infection, congenital or acquired b (check all that apply) i Atypical Development Environmental – social risk factor: g i l Abnormal or questionable sensory-motor responses Domestic violence E

Behavioral disorders that interfere with acquisition of Lack of adequate shelter P Lack of familial support

S developmental skills F I Identified affective disorders Family history of childhood Blindness Impairment in social interaction and communication Family history of childhood Deafness skills along with restricted and repetitive behaviors Founded child abuse/neglect Diagnosed Disabling Condition (check all that apply) Hyperbilirubinemia requiring exchange transfusion Lack of well-child care Autism Spectrum Disorder Periventricular Lead poisoning Brain or spinal cord trauma, with Leukomalacia Major congenital anomalies (see instructions) abnormal neurologic exam at Seizures with Maternal age 15 or less discharge significant n Maternal conditions during pregnancy such as accidents, o i Cleft Lip and/or Palate encephalopathy t

i phenylketonuria (PKU), maternal diabetes or sickle cell Congenital or acquired hearing loss Severe attachment d Meningitis n Chromosomal abnormalities disorder o Mother HIV Positive

C Effects of toxic exposure including Severe Grade 3 Neonatal Seizures g fetal alcohol syndrome, drug intraventricular n Oxygen Therapy Greater than 28 days i l withdrawal, exposure to chronic hemorrhage with

b Persistent pulmonary hypertension

a maternal use of anticonvulsants, hydrocephalus or

s Preemie – Gestational Age: 28-31 weeks i antineoplastics, and anticoagulants Grade 4

D Preemie – Gestational Age: 32-37 weeks Endocrine Disorders intraventricular d Seizure disorder--excluding recurrent febrile seizures e Failure to thrive hemorrhage s Severe chronic illness o Gestational Age Less Than or Significant central

n Severe parenting risk factor Equal to 28 Weeks nervous system g Mental illness a i Hemoglobinopathies (Sickle Cell) anomaly (e.g. cerebral Intellectual disability D Inborn errors of metabolism palsy) Physical disability Meningomyelocele (spina bifida) Symptomatic Substance Abuse Microcephaly congenital infection Small for gestational age (10th percentile or less) NICU Stay of ≥28 Days Visual disabilities Other (please list______)

DMH 888E 1137 R5/12 Infant & Toddler Connection of Virginia – Individual Child Data Form Page 2 Child’s Name: Entitled Part C Frequency Intensity (Please also note “Other” service setting here) # of Every Times Day/Week/ Minutes Setting Service Times / only During Month/Year (5-360) Provider Local Provider

Entitled Part C Services Service Settings Assistive Technology Psychological Services 1. Program Designed for Children with Developmental Services/Devices Respite Care Delays or Disabilities Audiology Service Coordination 2. Program Designed for Typically Developing Children Counseling Services Sign/Cued Language 3. Home Developmental Services Social Work Services 4. Hospital (inpatient) Health Services Speech/Lang. Pathology 5. Residential Facility Medical Services (diag/eval) Transportation 6. Service Provider Location (center/clinic/hospital) Nursing Services Vision Services 7. Other (Specify other service setting in row above) Nutrition Services Other Entitled Part C Services (Specify Occupational Therapy Above) Physical Therapy Service Provider Codes: 6. Department for the Deaf and 11. Child Care Center and Organization 1. Community Services Board Hard of Hearing 12. Pediatrician/Family Physician 2. Local Education Agency 7. Extension Agency 13. Private Therapy Group/Practice 3. Department of Health 8. Va. School for the Deaf and Blind 14. Other Service Provider (Specify) 4. Department of Social Services 9. Private, Non-profit Organization 5. Department for the Blind and Visually Impaired 10. Hospital ______e

v Third Party Health Coverage i t Active/Inactive Status: Inactive Active (Check all that apply) c a Date Inactive: ______/ ______/ ______Family Fees n I

- Medicaid/FAMISID#: ______e Date Active: ______/ ______/ ______v

i None t

c Date Last IFSP Service Expires: ______/ ______/ ______Insurance ID#: ______A

/ Date Of Closure: ______/ ______/ ______Insurance Policy Name: ______e

g Transition Destination: (select one only) r TRICARE ID#: ______a Another Part C System in Virginia Which: ______h

c Deceased Left Virginia ______s i

D Exit At Age 3 – No Referrals Lost Contact With Family

Missing Exit Data Justification

d Exit with Referrals Other l 1. Exited without sufficient notice i ___ Preschool/Day Care (Specify______) h 2. Unable to Schedule – child ill C ___ Headstart Parent Withdrew ___ Private Therapy 3. Unable to Schedule – family Public School/Part B Eligible scheduling IFSP Complete (Child < 3) Part B Referral, Eligibility Not Yet Determined 4. Unable to Schedule – provider unavailability 5. Other (Specify______) Indicator Assessment Entry Interim 1 Interim 2 Exit Missing Exit Data Assessment Date Yes No Yes No Yes No Justification Positive Social Relationship Using Knowledge & Skills

DMH 888E 1137 R5/12 Takes Action to Meet Needs

DMH 888E 1137 R5/12