Nickname:
Center:
Classroom Transitioning From:
Classroom Transitioning To:
Child Transition Information
Referral / £Case Management Status / Monitor / £
*Review Family Goals
Forms to be completed as part of transition plan and submitted to ERSEA office:
□Head Start Application at 2.5 yo □HS Eligibility/Income Documentation at 2.5 yo
□Child Family History Form at 3 yo □Nutrition Screening Form at 3 yo
Health Plans / Health Alerts / Notify Health/Nutrition Manager of planned transition date: / £
Training date for new staff: / Must be completed prior to transition
Nutrition Accommodation Plan / Notify Health/Nutrition Manager of planned transition date: / £
Date reviewed by new staff: / Must be completed prior to transition
Eating Habits
Diapering / Pottying
Nap Routines
Disabilities
Notify Disabilities/Mental Health Manager of planned transition date: £
· ESI-P, ASQ-SE, Vision and Hearing to be completed within 2 weeks of transition from EHS to HS.
· Review status of referrals in process, as applicable.
· Review status of services receiving, frequency and Provider, as applicable:
Classroom Modifications/Accommodations Currently In Use (equipment should go with child):
Education
HS Child Development Assessment to be completed by: / (Site name / Classroom team)
Child Care
Fears
Likes/Dislikes
This Section for
Infant Staff Only / Swing / Exersaucer / Pacifier
Child Goals
1
2
3
4
Transition Schedule
Week 1 / Week 2
Monday
Tuesday
Wednesday
Thursday
Friday
Signatures
We have reviewed the child file together and developed a transition plan for the child and family.
Name: / Date:
(Current Teacher)
Name: / Date:
(Receiving Teacher)
Name: / Date:
(Current FSC)
Name: / Date:
(Receiving FSC)
Name: / Date:
(Parent / Guardian Signature)
M:\Direct Services\Direct Service Forms\Child Transition Information.doc Revised: 08/15/13