NYCEARLY INTERVENTION PROGRAM CLOSUREFORM
Child’s Name: / DOB:EI #:
Effective Data of Closure:// / Date of Submission://
Prepared bySC/DM/RO:_
(circleone)Name / SC ID #:
Telephone #: / Fax #:
[ ] Case is being closed in Early Intervention (complete section I)
[ ] Case is being closed in Developmental Monitoring(completesection II)
I. EarlyIntervention ClosureDISPOSITION [Check onlyone]
AnyStage:Transition:
[ ]C: Can't locate family[ ]D: Transition to CPSE
[ ]G: Familymoved out of NYC[ ]L:Aged out, not eligible for CPSE/ no referral
[ ]H: Familymoved out of state[ ]M: Aged out, not eligible for CPSE/ referred to other
[ ]I: Child diedprograms
Before IFSP:[ ]N: Aged out, unknown eligibility for CPSE: Process
[ ]E: Evaluation foundchild ineligibleincomplete or Parent refused
[]K: Refused - contact family in 2 months
[ ]Z: Duplicate child insystem
During/ AfterIFSP:
[ ]A: Delay condition resolved
[]B: Family refused EI services
Parent’s Signature:Date: / /
[ ] Parent is unavailable for signature.
Note: If the parent is unavailable forsignature, attachthe SC notes, certified letter (if applicable) andcertified label (if applicable) documenting unsuccessful contactattempts andparent availability issues.
Parent’s signature is not necessary in cases of child death. For more information refer to theClosure Policy.
Parentwas informed of Developmental Monitoring Services option
[ ] J: Transferred to Developmental MonitoringUnit. Risk Factor:__7
[ ] Parent objects to referral to Developmental Monitoring
Note: ServiceCoordinatormust send acopy of thisClosure Formto all service providers including
Transportation and Respite Provider(s)when applicable.
II. Developmental Monitoring Closure
DISPOSITION [Check onlyone]
[]A: Risk Condition Resolved[ ]G:Family moved out of NYC [ ]B: FamilyRefused / Two missed mailings []H:Family moved out of state
[ ]C: Can't locate family[ ]I: Child died
[]D: Transferred to / Active in E.I. [ ]F:> 3 Years Old
[ ]K: Duplicate
COMMENTS:
Parent Signature:Date: / / [ ] Parent was unavailablefor signature. Explain above.
III. EarlyIntervention Official Designee/ Developmental Monitoring Specialist Approval
Reviewed byEIOD/ DM Specialist:Date:/__/_
EIP Data Entry:Date:_//
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INSTRUCTIONSFOR COMPLETION CLOSUREFORM
TheClosureForm may be completed bythe Initial (ISC) orOngoing Service Coordinator (OSC), EIOD/RO staff, or Developmental Monitoring Specialist under thecircumstances described below (SeeAppendix A).
Theindividual completing the formwill:
1. Complete the identifyinginformation.
2. Write the Effective Date of Closure and theDate ofSubmission,(dates do not have to be the same)
•Provider agencies cannot bill for services or service coordination after the Effective Date of Closure.
•The closuredate should allow for any necessaryactivityon the case, such asPrior Written Notice, to have been completed.
3. Circle the correct designation (SC/DM/RO) and print his/her name.
4. If the SC is completing this form, the SC ID number must be specified.
5. Write telephone and faxnumbers.
6. Check to indicate if the case is beingclosed in EarlyIntervention (EI) orDevelopmental Monitoring(DM).
Whenthe Closure Formis completedand submitted byanyof the parties listed, the appropriate staff in the RO or
DMUnit will review the formand sign and date at the bottom.
DataEntry staff will signand date the formto indicate that the information has been entered into KIDS.
Initial andOngoing Service Coordinators:
•Complete Section I of theClosure Form when anyof the conditions listed in the box titled “Disposition”
occurs(seeCrosswalk of Instances ofClosure andDisposition Codes).
NOTE:This form should notbe completed if achild will be leaving oneEI Providerand continue to receive any services through another EIprovider withinthe five boroughs ofNewYork City.
•Keep a completed copyof theClosureForm in the child’sservice coordination case record.
•Send copies to the following: EIOD (or appropriateEI Regional Office Director); the evaluation site (if prior to the IFSPmeeting); and all service provider agencies, including respite and transportation providers,if authorized.
oIf the parentis unavailable for signature, attach the SC notes, certified letter (if applicable) and certified label (if applicable) documenting unsuccessful contact attempts and parent availability issues.For more information refer to the Closure Policy.
oParent signature is NOTnecessaryincases of child death
•If a child is found not eligible for EI services, the SC should discuss referral to DMwith the parents.
.oIf parent agrees with referral to DM, check box“J”indicating the DM referral.
Regional Office Staff:
•Complete Section I of theClosure Form:
-Upon theconclusion of the evaluation process when the child is determined to be not eligible for EI, the familydid not agree with the findingsor did not sign the form, and a Prior Written NoticeForm was
sent.
-After a child has beenre-evaluated, found no longer eligible for EI services, and aPrior WrittenNotice
Formwassent.
•Keep a completed copyof theClosureForm in the child’s municipal case record.
•Send copies to the following: ISC/ OSC, all service provider agencies, and Data Operations for entry into
KIDS.
Developmental Monitoring Staff:
•Complete Section II of theClosure Form when any of the conditions listed under“Disposition” occurs.
•Keep a completed copyof theClosureForm in the child’s municipal case record.
•Send a copy of the formto Data Operations for entryintoKIDS.
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AppendixA:ClosureCodesandDefinitionofCategoriesClosureCode / Definitionof Category
A-Delay
condition resolved / Thecondition for which the child was receiving EI services has been
resolvedand the child no longer requires services.
B-Family
Refused / Withdrawal by parent (or guardian)after the child has been evaluated.
C-Can’t locate
family / Attempts to reach the parent were unsuccessful. Category includes
childrenat any stage in the EI process, and for whompersonnel have been unable to contact or locate after repeated, documented attempts.
D-Transition
toCPSE / Childrenwho have been determined tobe eligible for servicesby the
Committee on Preschool Special Education.
E-Evaluated
foundnot eligible / Childrenwho have been evaluated and determined to be not eligible
forEI services
G-Family
movedout of
NYC / Thefamily moved out of NYC, but remains within NYS.
H-Family
movedout of state / Thefamily moved out of NYS.
I:Child Died / Caseis closed due to child’s death.
K-Refused
Contactin 2 months / Parentswithdraw fromEIP before the Initial IFSP meeting occurs. The
evaluationprocess may or may not have been initiated or completed.
L-Age out,
noteligible for CPSE/ no referral / Childrenwho have been determined tobe not eligible for services by
theCPSE and age out of EI with no referrals to other programs.
M-Age out,
noteligible for CPSE/ referred to other programs / Childrenwho have been determined tobe not eligible for services by
theCPSE and age out of EI with referrals to other programs such as: preschool learning center, Headstart,child care center, health and nutrition services.
N-Age out, unknown
eligibility for CPSE/ process incomplete or parentrefused / Childrenwho have aged out of EI and for whomeligibility for services by the CPSE is unknown or the process is incomplete. Also include
childrenfor whomparents did not consent to transition planning or to referral to CPSE.
Z-Duplicate / Childis already active in KIDS with another ID number
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