New Jersey Early Intervention System

NEW JERSEY EARLY INTERVENTION SYSTEM

INITIAL EVALUATION/ASSESSMENT SUMMARY

Child’s First Name / Child’s Last Name / MI / Child’s SPOE Id #
Child’s Date of Birth / Evaluation Date / Chronological Age / County of Residence
Evaluation/Assessment Location / Start Time / End Time
Evaluation/Assessment Tools in addition to Parent Report and Clinical Observation
Battelle Developmental Inventory 2
(BDI-2) Required Instrument / Evaluator:
Agency:
Discipline Specific Assessment Instruments / Specify:
Specify:
Specify:
Other Instruments/Records / Specify:
Specify:
Specify:
Reason for Referral/Family Concerns (Developmental, Medical, Health, Behavior, Vision, Hearing)
DEVELOPMENTAL EVALUATION/ASSESSMENT SUMMARY
COGNITIVE / Ability to learn, play productively, and solve problems
Mastered Skills:
Emerging Skills:
Developmental Learning Skills Targeted for Next 6 Months:
Clinical Comments:
GROSS MOTOR / Ability to engage in large muscle movements (sitting, crawling, walking)
Mastered Skills
Emerging Skills
Developmental Learning Skills Targeted for Next 6 Months
Clinical Comments
FINE MOTOR / Eye/hand coordination and ability to use hands.
Mastered Skills:
Emerging Skills:
Developmental Learning Skills Targeted for Next 6 Months:
Clinical Comments:
COMMUNICATION / Ability to understand and use language.
Mastered Skills:
Emerging Skills:
Developmental Learning Skills Targeted for Next 6 Months:
Clinical Comments:
ADAPTIVE/SELF-HELP / Ability to do things for him/herself. (feeding, dressing, sensory information)
Mastered Skills:
Emerging Skills:
Developmental Learning Skills Targeted for Next 6 Months:
Clinical Comments :
SOCIAL EMOTIONAL / Interactions with adults, children, & their environment; use of toys; transitioning between activities.
Mastered Skills:
Emerging Skills:
Developmental Learning Skills Targeted for Next 6 Months:
Clinical Comments:
VISION & HEARING / Ability to use vision and hearing.
Vision Screening/Evaluation / Medical/Vision Specialist Date of Screening/Evaluation
NJEIS TET
Vision Screening/Evaluation Results/Concerns:
Hearing Screening/Evaluation / By Medical/Hearing Specialist Date of Screening/Evaluation
NJEIS TET
Hearing Screening/Evaluation Results/Concerns:
Initial BDI-2 Evaluation Information
Developmental Domain / Domain Score
(100 is average) / Z Score
(0.0 is average) / Raw Score (RS)
Adaptive
Personal/Social
Communication
Gross Motor
Fine Motor
Cognitive
EVALUATION TEAM PARTICIPANTS
Name (Print) / Title/Discipline / Agency / Minutes / Signature
Parent/Guardian / N/A
PARENT/GUARDIAN FEEDBACK
Did this evaluation/assessment attend to the concerns you have about your child’s development? / Yes No
If no, why not?
Do you think that the evaluation/assessment provided a good picture of your child’s skills? / Yes No
If no, why not?
Has the evaluation/assessment raised any additional concerns or questions about your child’s development? / Yes No
If yes, please describe:
NEXT STEPS
Family Next Steps: Family support services, community resources and obtaining medical records as needed.

NJEIS Form-0041July 1, 2012