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WV BIRTH TO THREEOffice of Maternal, Child and Family HealthBureau for Public HealthDepartment of Health and Human ResourcesChild Last Name:Child First Name: MI:DOB: ID #:FOLDER: EA REPORTS Date:WV Birth to ThreeEvaluation/Assessment Summary ReportAdd Agency Logo hereSubmitted by:Add Agency Logo if appropriateName:Address:City/State/Zip:Contact Info:Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Click or tap here to enter text.Complete Submitted by:Use Agency address or deleteinformation not addedFor full WV Birth to Three Guidance on Evaluation and Assessment ReportsChild Full Name:Chronological Age:Evaluation Date:First name Middle initial. Last nameClick or tap here to enter text.Date of Birth:Adjusted Age:Click or tap here to enter text.No adjusted age mark N/AClick or tap here to enter text.(if applicable)Parent(s) Name:May include both parents ifmailing address is the sameParent(s) Name:Click or tap here to enter text.Mailing Address:Click or tap here to enter text.Mailing Address:Click or tap here to enter text.Contact Number:Click or tap here to enter text.Contact Number:Click or tap here to enter text.Email Address:Click or tap here to enter text.Email Address:Click or tap here to enter text.Location of Evaluation/Assessment Activities:Click or tap here to enter text.Name and relationship of individuals whoIndividuals Present and Participating (Relationship to Child):participated in assessmentEvaluators:Be sure to include your credentials after your nameList full name of assessment tool, not an abbreviation Tools administered must beAssessment Tool Used:from the WV Birth to Three Assessment Tool List.Purpose: To gather information to determine eligibility for WV Birth to Three and plan for Individualized FamilyService Plan. Initial Annual To provide additional information to the IFSP Team regarding the following area of concern:Enter new area of concern, reason for assessment.WVDHHR/BPH/OMCFH/WVBTT – WVBTT EVALUATION/ASSESSMENT WORD – rev 6-27-22
WV BIRTH TO THREEOffice of Maternal, Child and Family HealthBureau for Public HealthDepartment of Health and Human ResourcesChild Last Name:Child First Name: MI:DOB: ID #:FOLDER: EA REPORTS Date:Parent Reported Priorities and Concerns Regarding Child's DevelopmentSummarize the parent’s priorities and concerns for which they are seeking support. These priorities andconcerns should drive the evaluation/assessment activities. These priorities and concerns may include: 1 –specific concerns such as the child is not yet sitting up,2 – more global concerns such as I am not sure mychild is talking the way he should for his age,3 – concerns upon the diagnosis of the child (i.e., DownSyndrome, or Autism); and/or,4 – a description of how the parents feel WVBTT may help them. ****Please notethat when documenting parent report, it is preferred that we use the parent’s names instead of mom, dad,grandmother etc.Family InformationDocument who is serving in the role of parent (s), what languages are spoken in the home, the informal supportsthat the family relies upon in time of need and the formal support systems that the family is engaged with. Youwill want to capture how the informal and formal supports are working for the family and where there may beneeds for additional linkages to community resources. Identify important family traditions, values and beliefsthat inform the child rearing practices. Document any family risk factors including maternal factors (teenagemother, educational level, mental health issues, developmental disability, substance use disorder), CPSinvolvement, lack of support systems or increased stressors within the family. The identification of specific riskfactors will assist in the determination and eligibility design of appropriate family outcomes and the selection ofappropriate team IFSP team members should the child be found eligible.Developmental HistorySummarize the child’s developmental history as shared by the parent/caregivers. Within this section we learn ifthe child has moved through developmental milestones as would be expected, or was the child developing ontarget and then suddenly there was a change. We begin to understand when the family began to have concernsand what they have tried in the past to support their child’s development.Medical History/Current Health S tatusSumm ar ize medical information reviewed in medical records and shared by the family. Documentation shouldinclude the specific diagnosed medical conditions (established conditions and/or biological risk factors) thatsupport the eligibility decision. Medical diagnosis or conditions should be confirmed in review of referralinformation or supported by written documentation obtained with the family’s written permission from the child’sprimary care physician, medical specialist, or a licensed psychologist. You may also want to include anymedications the child is currently taking as well as immunization status and the physicians currently supportingtheir health care.Vision/Hearing InformationVISION – Has the child’s vision been screened by their primary care physician or a specialty care physician(i.e., optometrist, pediatric ophthalmologist) and what were the results. Share any parent/professional concernsand observations as well.HEARING - Has the child’s hearing been screened by their primary care physician or a specialty carephysician (i.e., audiologist, ENT) and what were the results. Share any parent/professional concerns andobservations as well.WVDHHR/BPH/OMCFH/WVBTT – WVBTT EVALUATION/ASSESSMENT WORD – rev 6-27-22
WV BIRTH TO THREEOffice of Maternal, Child and Family HealthBureau for Public HealthDepartment of Health and Human ResourcesChild Last Name:Child First Name: MI:DOB: ID #:FOLDER: EA REPORTS Date:Observation and Assessment Results Across SettingsProvide a detailed description of the results of assessment tool(s), parent/caregiver interview, and observationsof the child’s functional abilities within the daily activities and routines of the child/ family. This will includeinformation across all settings where the child spends time. Summarize information on how the child learns, whatsorts of activities are likely to engage the child’s attention, how persistent they are at tasks, and where there aredelays and needs for support. Note what objects, materials and toys are available in the home and how theparent(s) interact with and teach the child. This information will assist in the identification of evidence-basedintervention strategies and the selection of appropriate IFSP team members should the child be eligible.Documentation should support the decision as to whether the child is displaying developmental delay or atypicaldevelopmental patterns for the determination of eligibility.Child Development is Impacting Their Participationin the Family's Everyday Routines and Activities in the Following WaysDocument from the family’s perspective, how the child’s delay, medical condition and/or risk factors are impactingthe child’s ability to learn and participate successfully in the daily life of the child and family. Through yourconversations with the family and observations of the child, you will document what is going well and where thereare challenges in specific daily activities and routines of concern such as mealtime, bedtime, going on outings.This information will assist in prioritizing which routines should be the focus of intervention, what the family wouldlike the child to be able to do within the routine and why this is important to the family. Note: Use the Daily FamilyRoutines Form to assist you in gathering information on the child’s strengths and challenges within the daily routines.Summary of Developmental Domains Evaluated and Developmental ScoresEnter domain(s) in which you have completed an evaluation/assessment and/or observation. For example:Motor, Cognition, Communication, Adaptive and/or Social Emotional. If you have not assessed a developmentaldomain, please leave the domain blank. Vision: Please document if a vision assessment was completed by avision specialist. Hearing: Please document if a hearing assessment was completed by a Hearing Specialist.DomainTest UsedADAPTIVEIf you have identifiedthe full name of thetool in the beginning ofthe report, you mayabbreviate here.Score(s)Developmental DelayChoose option by clicking on the downpointing arrow in each section.Enter score(s)obtained throughadministration of (There must be documentation in the body ofthe chosenthe assessment report to support yourtool(s).selections.)COGNITIVEClick or tap here to enter Click or tap here toChoose an item.text.enter text.COMMUNICATIONClick or tap here to enter Click or tap here toChoose an item.text.enter text.MOTORClick or tap here to enter Click or tap here toChoose an item.text.enter text.SOCIALEMOTIONALClick or tap here to enter Click or tap here toChoose an item.text.enter text.WVDHHR/BPH/OMCFH/WVBTT – WVBTT EVALUATION/ASSESSMENT WORD – rev 6-27-22
WV BIRTH TO THREEOffice of Maternal, Child and Family HealthBureau for Public HealthDepartment of Health and Human ResourcesChild Last Name:Child First Name: MI:DOB: ID #:FOLDER: EA REPORTS Date:Established ConditionsEstablished Conditions CategoryChoose category from dropdownList Medical ConditionBased on medical records, enter child’s diagnoses asthey apply to the category.Choose an item.Click or tap here to enter text.Choose an item.Click or tap here to enter text.Choose an item.Click or tap here to enter text.Choose an item.Click or tap here to enter text.At-Risk ConditionsAt-Risk CategoryChoose category from dropdownList Biological and/or Family At-Risk Factorfrom Eligibility PolicyBased on medical records enter the specific childdiagnoses. From conversations with family, enter familyrisk factors as they apply to the category asdocumented in the body of the report.Choose an item.Click or tap here to enter text.Choose an item.Click or tap here to enter text.Choose an item.Click or tap here to enter text.Choose an item.Click or tap here to enter text.Choose an item.Click or tap here to enter text.Recommendations to Enhance Child's ParticipationThe team will meet and review all information to make a final determination regarding eligibility.The Family may begin implementing any or all strategies immediately. The followingrecommendations may be used for IFSP planning and development.Family Routine/ActivityRecommendationsRecommendations should be related to the specific familyroutine or activity that has been identified. It is up to theIdentify a routine or activity where the child isdiscretion of the evaluator to decide which recommendationsneeding support or that is going well and wouldto share. Some recommendations will be easy for a family toprovide a wonderful learning opportunity to support interpret and incorporate into their daily routines while othersstrategies to promote the child’s development.will need the support of a professional to implement to assurethe safety of the child, for example feeding interventions,positioning, positive behavior supports.WVDHHR/BPH/OMCFH/WVBTT – WVBTT EVALUATION/ASSESSMENT WORD – rev 6-27-22
WV BIRTH TO THREEOffice of Maternal, Child and Family HealthBureau for Public HealthDepartment of Health and Human ResourcesClick or tap here to enter text.Child Last Name:Child First Name: MI:DOB: ID #:FOLDER: EA REPORTS Date:Click or tap here to enter text.Other RecommendationsThese are other recommendations you feel may be necessary to plan for and/or implement appropriate earlyintervention services should the child be eligible. Examples: Audiological evaluation Functional behavior assessment to determine cause(s) of challenging behaviors Referral for feeding assessmentThis report has been completed based upon the information gathered from a valid, recognized WVBTTassessment or evaluation tool and additional information has been gathered from the family.My printed name, credentials, signature below will affirm and attest to that fact:Printed Name:Signature:Your name and credentialsContact Phone:A digital/electronic signature is requiredto complete yourevaluation/assessment.Date Completed:Your contact phoneDate report completed – Using adigital signature will include thedate with your signatureDIGITAL/ELECTRONIC SIGNATURE USING MS WORD - to apply your digital/electronic signature to your evaluation/assessmentcompleted in MS Word, you will need to first save your Word document as a PDF document.Once you apply your digital signature it will lock the document to prevent editing by others. USING PDF VERSION - Once you apply your digital/electronic signature it will lock thedocument to prevent editing by others. Please save your document prior to adding the digitalsignature as well as afterward. USING TEAM SIGNATURE PAGEo Each individual team member is required to print their name, contact information, date, andto sign the team signature page digitally or electronically.o It is necessary to complete your information PRIOR to digitally/electronically signingthe document. Once you have entered your information, save the signed document toyour computer so that it is easily recognizable. (i.e. – TEAM EA REPORT for AB201500000.) Forward the document on to the next team member to complete theirinformation. The last team member to sign, should make certain that all team membersare sent the completed signed document AND inform members that the document andsignature page has been uploaded to BTT Online.AFTER COMPLETING YOUR REPORT, do the following: Save your report after it has been signed in a PDF format. This assures your reportcannot be edited by others and for ease of uploading to WVBTT Online. At least 2 days prior to the IFSP meeting, upload your signed report to WVBTT Online tothe Evaluation/Assessment folder. Ask the family how they prefer to receive a copy of the assessment report, secure email orvia postal mail so they may have a copy prior to the Eligibility/IFSP Meeting.At least 2 days prior to the IFSP Meeting, send the parent a copy of the assessment report inthe family’s preferred format.WVDHHR/BPH/OMCFH/WVBTT – WVBTT EVALUATION/ASSESSMENT WORD – rev 6-27-22
Enter new area of concern, reason for assessment. Child Full Name: First name Middle initial. Last name Date of Birth: Click or tap here to enter text. Chronological Age: Click or tap here to enter text. Adjusted Age: No adjusted age mark N/A Evaluation Date: Click or tap here to enter text. Add Agency Logo if appropriate Submitted by:
