Free Program Participation System (PPS) - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-21225AI (07/2008)

STATE OF WISCONSIN

PROGRAM PARTICIPATION SYSTEM: B-3 MODULE, DESKCARD
CHILD AND REFERRAL TO BIRTH TO 3 INFORMATION
Language Preference Albanian Arabic Bosn/Croat/Serv Burmese Cambodian Chinese English Farsi French Referral Source CAPTA Referral Child Care Provider County Social Services Agency CYSHCN Regional Center Head Start Provider Hospital or Specialty Clinic Evaluation Type Assistive Technology Audiology Communication Health Medical Child's Characteristics 1 / 2 / 3 Blind / visually impaired Communication delay Deaf Deaf / blind Developmental Disability ­ autism spectrum Reason for Late IFSP Exceptional Family Reason German Greek Hmong Italian Korean Laotian Native American Norwegian Polish Other county staff Other health care provider Parent or relative Physician Public Health Agency School District Russian Somali Spanish Swedish Thai Ukrainian Vietnamese Other

Tribal Health Center or Tribal CYSHCN Tribal School or Tribal Head Start Program Other

SCREENING / EVALUATION
Nursing Nutrition Occupational Therapy Physical Therapy Psychological Developmental Disability ­ brain trauma Developmental Disability ­ cerebral palsy Developmental Disability ­ epilepsy Developmental Disability ­ mental retardation Social Work Special Instruction Vision Other

Developmental Disability ­ other or unknown Hard of Hearing Physical Disability / Mobility Impairment Severe emotional disturbance Severe health impairments

SERVICE PLANNING
System Reason Weather

Assessment - Positive Socio-emotional Skills Ranking; Acquiring and Using Knowledge and Skills Ranking; Taking Appropriate Actions to Meet Needs Ranking (7) Child shows functioning expected for his or her age in all or (3) Child does not yet show functioning expected of a child of almost all everyday situations. Functioning is considered his or her age in any situation. Child's behaviors and skills appropriate for his or her age. include immediate foundational skills upon which to build age(6) Child's functioning generally is considered appropriate for appropriate functioning. his or her age but there are some significant concerns about (2) Child's behaviors and skills include some immediate the child's functioning in this outcome area. foundational skills but these are not displayed very often (5) Child shows functioning expected for his or her age some across settings and situations. of the time and/or in some situations. Child's functioning is a (1) Child does not yet show functioning expected of a child his mix of age-appropriate and not appropriate functioning. or her age in any situation. Child's skills and behaviors also do (4) Child shows some but not much age-appropriate not yet include any immediate foundational skills upon which to functioning. build age-appropriate functioning. Sources of Information Parent Interview Observation Assessment, Evaluation and Programming System (AEPS) Battelle Developmental Inventory, Second Edition (BDI-2) Brigance Inventory of Early Development II Carolina Developmental Profile Creative Curriculum of Developmental Continuum Early Learning Accomplishment Profile (E-LAP) Hawaii Early Learning Profile (HELP) High/Scope Child Observation Record (COR) for Infants and Toddlers High/Scope Preschool Child Observation Record (COR) The New Portage Guide Birth to Six The Work Sampling System, (preschool 3 and 4, 2004) The Ounce Scale Peabody Developmental Scales Preschool Language Scales REEL Rosetti Infant/Toddler Scales Mullen Scale of Early Learning Other--Specify

F-21225AI Page 2

SERVICE PLANNING (Cont'd)
SERVICES Service Type Assistive Technology Audiology Communication Services Family education and counseling Health Services Interpreter Services Primary Location Child Care Center Early Intervention Center Family Child Care Home Hospital Reason for Late Start Exceptional Family Reasons IFSP Team determined that a particular service would appropriately begin on a date beyond the 30-day timeline Additional Assessment - Type Assistive Technology Audiology Communication Health Medical Medical Services Nursing Services Nutrition Services Occupational Therapy Physical Therapy Psychological Services Service Coordination Social Work Special Instruction Transportation Vision Services Other

Other Location that is not a natural environment Other settings designed for typically developing children Outpatient Services Residential

System Reason Weather

Nursing Nutrition Occupational Therapy Physical Therapy Psychological

Social Work Special Instruction Vision Other

TRANSITION / PROGRAM EXIT
Transition Planning Conference ­ Exception Reason Birth to 3 invited the LEA, but they did not attend Birth to 3 program did not start Transition process in a timely manner. Birth to 3 was unable to schedule the Transition Planning Conference with the school district prior to the 90 day timeline Child exited the Birth to 3 Program before the Transition Planning Conference was required. Program Exit - Closing Reason Child is no longer in need of services. Successful completion of the IFSP. Child moved out of the state Child moved within the state Child turned 3, child referred to LEA, LEA did not find child eligible for early childhood special education services and the child was referred to other programs. Child turned 3, child referred to LEA, LEA did not find child eligible for early childhood special education services and the child was not referred to other programs Child turned 3, child referred to LEA, LEA found child eligible for early childhood special education. Child Outcomes: See SERVICE PLANNING ­ Assessment (Page 1) Sources of Information: See SERVICE PLANNING ­ Sources of Information (Page 1) Child was referred to Birth to 3 after 2 years 9 months of age. Family did not consent to a Transition Planning Conference . Family did not provider timely consent for a Transition Planning Conference Family was not available for the scheduled Transition Planning Conference

Child turned 3, child referred to LEA, special education eligibility process was not yet completed. Child turned 3, parents did not consent to LEA referral and/or LEA evaluation. Child turned 3, the Birth to 3 Program not refer the child to the LEA because the child was not believed to be eligible for early childhood special education. Child under 3, the Birth to 3 Program is unable to locate the family or child after repeated, documented attempts. Death of child. Family chose to discontinue services.