Form BIE-XXXX (To be as BIE-XXXX (To be as Part B IDEIA Tribal Count Data Requirements

OMB 1076-XXXX Expires: MM/DD/YYYY

Form BIE-XXXX

IDEIA Tribal Count Data Requirements

Part B (Children Aged 3 through 5 years)

INSTRUCTIONS

Instructions to Education Line Officers: Each Education Line Officer must send the forms to the appropriate Tribe/tribal organization Early Childhood Coordinator for early intervention/early childhood special education services. It is suggested that you also send a copy to the Tribal leader (do not send to official only). A copy of the form may be obtained from the Bureau of Indian Education website, www.bie.edu/home. This form is due to the Bureau of Indian Education, Albuquerque Service Center, Division of Performance & Accountability by January 28, 2011. Completed forms may be submitted to the Early Childhood Programs office by fax (505) 563-5281. Please call (505) 563-5245 for questions regarding the completion or submission of the forms.

Instructions to Tribal Representatives: A form may be obtained from the Educational Line Officer or online at the Bureau of Indian Education website, www.bie.edu/home. The count date is December 1, 2010, with a due date of January 28, 2011. This count will be utilized to determine funding for the period July 1, 2011 – June 30, 2012. Completed forms are to be submitted to the Education Line Officer before January 28, 2011.

Table 1: Count Indian children aged 3 through 5 years of age who are not enrolled in a private, public or BIA funded school and who reside on the reservation. This is an unduplicated count by categories of disability. Count by age and disability, the total number of Indian children with disabilities residing on the reservation. Of the total by age and disability, count the number the tribe is serving according to an Individualized Education Program (IEP).

Certification – Signed by an authorized tribal official (who is not the Tribal Education Office Director)

Assurance – Signed by an authorized tribal official (who is not the Tribal Education Office Director)

NOTE: Federal requirements state that NO further monies or benefits may be paid out under this program unless this report is completed and filed as required by 20 U.S.C. 1484 (b)(3).

Paperwork Reduction Act Statement: This information is collected to satisfy a statutory mandate established by the Individuals with Disabilities Education Improvement Act, 25 U.S.C. §§ 1400 et seq.. The information is supplied by respondents to receive a benefit. It is not confidential because it is displayed in an aggregate format. It is estimated that responding to the request will take an average of 20 hours to complete. This includes the amount of time it takes to review instructions, gather and maintain the data needed, and complete the form. In compliance with the Paperwork Reduction Act of 1995, as amended, this collection has been reviewed by the Office of Management and Budget and assigned a number and expiration date. The number and expiration date are at the top right corner of the form. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless there is a valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Bureau of Indian Education, U.S. Department of the Interior, 1849 C Street., NW, MS-4141, Washington, D.C. 20240. Note: Comments, names, addresses, phone numbers, e-mail addresses, or other personal identifying information of commenters may be made publicly available at any time. While commenters can ask to withhold personal identifying information from public review, the Department cannot guarantee that it will be able to do so.

Definitions

1. At-risk Infant or toddler – An individual under 3 years of age who would be at risk of experiencing a substantial developmental delay if early intervention services were not provided to the individual.” 20 U.S.C. § 1432(1).

2. Child find – On-going activities designed to facilitate, locate and identify Indian children residing on the reservation who are aged from birth to age two (0-2) and from age three to age five (3-5) and who may be in need of early intervention and early childhood special education services.

3. Deaf-Blindness – Concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational needs that they cannot be accommodated in special education programs solely for children with deafness or children with blindness. 34 CFR § 300.7 (c) (2)

4. Developmental delay - Defined by the state and “as measured by appropriate diagnostic instruments and procedures, in 1 or more of the areas of cognitive development, physical development, communication development, social or emotional development, or adaptive development.” 20 U.S.C. §1432(5)(A)(i).

5. Early Intervention Services – Developmental services that-

   1. Are provided under public supervision:

   2. Are provided at no cost except where Federal or State law provides for a system of payments by families, including a schedule of sliding fees;

   3. Are designed to meet the developmental needs of an infant or toddler with a disability, as identified by the individualized family service plan team, in any 1 or more of the following areas-

      1. physical development;

      2. cognitive development;

      3. communication development;

      4. social or emotional development; or

      5. adaptive development;

   4. Meet the standards of the State in which the services are provided, including the requirements of this subchapter;

   5. Include-

      1. Family training, counseling, and home visits;

      2. Special instruction;

      3. Speech-language pathology and audiology services, and sign language and cued lanague services;

      4. Occupational therapy;

      5. Physical therapy;

      6. Psychological services;

      7. Service coordination services;

      8. Medical services only for diagnostic or evaluation purposes;

      9. Early identification, screening, and assessment services;

      10. Health services necessary to enable the infant or toddler to benefit from the other early intervention services;

      11. Social work services;

      12. Vision services;

      13. Assistive technology devices and assistive technology services; and

      14. Transportation and related costs that are necessary to enable an infant or toddler and the infant’s or toddler’s family to receive another service described in this paragraph;

   6. Are provided by qualified personnel, including-

      1. Special educators;

      2. Speech-language pathologists and audiologists;

      3. Occupational therapists;

      4. Physical therapists;

      5. Psychologists;

      6. Social workers;

      7. Nurses;

      8. Registered dietitians;

      9. Family therapists;

      10. Vision specialists, including ophthalmologists and optometrists;

      11. Orientation and mobility specialists; and

      12. Pediatricians and other physicians;

   7. To the maximum extent appropriate, are provided in natural environments, including the home, and community settings in which children without disabilities participate; and

   8. Are provided in conformity with an individualized family service plan adopted in accordance with section 1436 of this title. 20 U.S.C. §1432(4).

6. Infant or Toddler with a disability – (A) An individual under 3 years of age who needs early intervention services because the individual –

1. Is experiencing development delays, as measured by appropriate diagnostic instruments and procedures in one or more of the areas of cognitive development, physical development, communication development, social or emotional development, and adaptive development; or

2. Has a diagnosed physical or mental condition that has a high probability of resulting in developmental delay; and

(B) may also include, at a State’s discretion –

i. at-risk infants and toddlers;

ii. Children with disabilities who are eligible for services under section 1419 of this title and who previously received services under this subchapter until such children enter, or are eligible under State law to enter, kindergarten or elementary school, as appropriate, provided that any programs under this subchapter service such children shall include-

1. An educational component that promotes school readiness and incorporates pre-literacy, language, and numeracy skills; and

2. A written notification to parents of their rights and responsibilities in determining whether their child will continue to receive services under this subchapter or participate in preschool programs under section 1419 of this title.” 20 U.S.C. §1432(5).

7. Individualized Education Plan (IEP) – A written plan developed by a multidisciplinary team for a child with a disability that is reviewed, and revised accordingly.

8. Individualized Family Service Plan (IFSP) – A written plan for providing early intervention services to an eligible child and the child’s family.

9. Public Awareness Activities – Those activities which the tribal early intervention program utilizes to get the word out to the community and referral sources about the program.

10. Parent Training – Training provided parents to support the care and education of their child(ren).

11. Related service – Transportation, corrective and supportive services ( i.e., speech, physical and occupational therapy, recreating, social work, counseling, medical services).

12. Screening – A quick and basic appraisal of how the child is doing. The screening helps to determine service needs and can be done by most people who work with children from birth to age three.

13. Served – A term utilized in determining the level of services provided by a tribe that includes direct related service activities for an established disability. ‘Served’ should be determined by actual one to one contact with a child or family.

14. State Lead Agency – The agency identified by each state that is responsible for providing Early Intervention and Identification services for all children within the state. (IDEA, Part C)

15. Transition at age – The IFSP or IEP should address the transition of a child from early intervention services to preschool, preschool to kindergarten or to other services. The focus of transition planning focuses on parent training support, and procedures to prepare the child and family for changes in services delivery, including steps to help the child and family adjust and function in the new setting.

PART B

TABLE 1

DECEMBER 1, 2010

TRIBE: Contact Name:

SECTION B – Number of Indian Children ages 3-5 Identified as Disabled and the Number of Disabled 3-5 year olds with an IEP receiving Services from the Tribe:

AGE AS OF DEC. 1, 2010	Age 3		Age 4		Age 5		Age 3-5 Totals
DISABILITY	Total Disabled**	Disabled Served***	Total Disabled**	Disabled Served***	Total Disabled**	Disabled Served***	Total Disabled**	Disabled Served***
Intellectual Disability
Hearing Impairments
Speech/Language Impairments
Visual Impairments
Emotional Disturbance
Orthopedic Impairment
Other Health Impairments
Specific Learning Disabilities
Deaf-Blindness
Multiple Disabilities
Autism
Traumatic Brain Injury
Developmental Delay*
TOTAL: (sum of all of the above)

* The state in which the child lives must have defined and established eligibility criteria for developmental delay in order to use this category for reporting.

** Total Number of Disabled Indian Children by Age residing on reservation.

*** Total Number of Disabled Indian Children by Age residing on reservation served by the Tribe.

PART B

TRIBAL CERTIFICATION

I, the authorizing Tribal official for the _____________________________, certify this data represents an accurate and unduplicated count

(Tribe or Tribal Organization)

of Indian children ages 3-5 with disabilities contacted and receiving special education and related services on December 1, 2010 from the tribe

according to an Individualized Education Program (IEP).

Tribal Official’s Name & Title (type or print) Signature Date

TRIBAL ASSURANCE

_________________________________assures that it has provided the state lead agency in the State(s) in which Indian children

(Tribe or Tribal Organization)

reside, the child find information (including the names and dates of birth and parent contact information) for children with disabilities

aged 3 through 5 who are included in its December 1, 2010, Child Count data to meet the child find coordination and child count

responsibilities in 20 U.S.C. 1411(h)(4).

_______________________________________ ____________ _______________________________________ _____________________

Tribal Official’s Name & Title (type or print) Signature Date

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