Attachment G - Early Intervention Records Abstraction Form

ATTACHMENT G

Early Intervention Records Abstraction Form

Early Intervention Records Abstraction Form

The Natural History of Spina Bifida in Children Pilot Project

EARLY INTERVENTION RECORD DATA ABSTRACTION FORM

Participant ID number: _______________ Date information retrieved: (mm-dd-yyyy)

Person retrieving information:

EARLY INTERVENTION SERVICES (Birth-3 years).

Record what type of early intervention services the child received (e.g., Babies Can’t Wait)

1. What date did the child start receiving early intervention services?

____________________________ (mm/dd/yyyy)

2. What date did the child stop receiving early intervention services?

____________________________ (mm/dd/yyyy)

3. What was the reason the child stopped receiving BCW services?

 Age (i.e., too old)

 Completed the duration of services recommended

 Parents/caregiver decided to stop using services

 Other, specify

 Information not available

4. Did the child transfer to a program for early intervention services for children

older than 3 years of age (e.g., Head Start)?

 Yes

 No SKIP 5

 Other, specify

 Information not available

5. To what type of a program did the child transfer?

 Head Start

 Private childcare

 Private preschool

 Home

 Public preschool

 Even Start

 Other, specify

 Information not available

TYPE, FREQUENCY, AND DURATION OF BCW SERVICES

6. What type/s of BCW services did the child receive?

Check all that apply

A  Assistive technology devices and/or services

B  Audiology services

C  Family training, counseling, and home visits

D  Health services

E  Medical services only for diagnostic or evaluation purposes

F  Occupational therapy

G  Physical therapy

H  Psychological services

I  Service coordination services

J  Social work services

K  Special instruction

L  Speech-language pathology

M  Transportation and related costs

N  Other, specify

O  Information not available skip item 7

7.

Collect information for each service that was received (start/end date, frequency, intensity, and the location where the services were performed.

Type of service (mark letter from item 6)	Start-End Date (At what date did the service start and end?)	Frequency (How often did the child receive this type of service?)	Intensity (How long was each session?)	Location (Where was the service provided?)
	Start:_____________ End: _____________
	Start:_____________ End: _____________
	Start:_____________ End: _____________
	Start:_____________ End: _____________
	Start:_____________ End: _____________
	Start:_____________ End: _____________
	Start:_____________ End: _____________

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