Free 51312.FH11 - Indiana

REASON FOR DELAY OF IFSP
State Form 51312 (R3 / 3-05) / BCD 0089

Name of county Name of child Date of referral (month, day, year) Date IFSP held (month, day, year) Reason for delay: (check all that apply)

Cluster number Date of birth (month, day, year) Due date of IFSP (month, day, year) Number of days from referral to IFSP

Family Intake / SPOE PT Doctor
Give a detailed explanation for delay: (add pages if necessary)

OT

ST

DT

OTHER (specify type):

Signature of intake coordinator Signature of family member

Date (month, day, year) Date (month, day, year)

This form is to be placed in every file that has gone over the 45 day time limit. Federal Regulations requiring the 45 day timeline: 303.321(e) Timelines for public agencies to act on referrals. (2) Within 45 days after it receives a referral, the public agency shall: (i) Complete the evaluation and assessment activities in 303.322; and (ii) Hold an IFSP meeting, in accordance with 303.342 303.342(a) Meeting to develop initial IFSP timelines. For a child who has been evaluated for the first time and determined to be eligible, a meeting to develop the initial IFSP must be conducted within the 45 day time period in 303.321(e).