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REASON FOR NOTICE The ESIT is required to provide you with prior written notice within a reasonable time before conducting evaluation and assessment activities. It is required that you give informed, written consent for these activities through your signature below. The purpose of evaluation and assessment is to obtain information about your child; provide your family with additional information about your child’s development; identify the unique strengths and needs of your child and services that may be appropriate to meet those needs; determine whether your child remains eligible for the ESIT program; and if your child remains eligible, with your agreement and participation, develop or modify a written Individualized Family Service Plan (IFSP). This is your statement of that notice.

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ESIT Notice and Consent for Evaluation/Assessment

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ACTION PROPOSED An evaluation and (or) assessment will be conducted by at least two qualified individuals from different disciplines (or one qualified professional from two disciplines)  by qualified personnel to determine a child's initial or continuing IDEA Part C eligibility for the ESIT Program in accordance with ESIT program policies and procedures. Your participation as a member of the evaluation team is strongly encouraged. You know your child best and can provide important information about your child. The evaluation and assessment is a comprehensive view of how your child is doing in the areas of cognitive, gross motor, fine motor, communication, social-emotional, and adaptive development, as well as vision and hearing. The results indicate how your child is doing in all of these areas and if your child continues to be eligible for ESIT services.

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DESCRIPTION The evaluation proposed will include multiple procedures, including administration of an evaluation instrument, taking the child’s history, interviewing the parent(s), gathering information from other family members, caregivers, medical or other professionals and reviewing medical, educational or other records. The proposed assessment procedures will determine your child’s unique strengths and needs and appropriate early intervention services. Assessment will include: a review of evaluation results; personal observations of the child, identification of the child’s needs in each developmental area through the use of formal and informal assessment procedures. ESIT providers will talk with you about the methods they will use for this evaluation and assessment. The evaluation and assessment will be provided at no cost to you. The results are kept in your child's early intervention record. No information about the evaluation/assessment will be shared with anyone or any agency outside of the ESIT program unless you provide written consent to do so. The IFSP team will determine whether or not your child continues to be eligible for ESIT services and will provide prior written notice, including your right to dispute the eligibility determination.

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PURPOSE: To provide prior written notice to the parent(s)/caregiver(s) when an initial or ongoing evaluation/assessment is being proposed and to obtain parental
consent to conduct the evaluation/assessment being proposed.

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Is the form easy to read/fill out?
Are logos accurate?
Dates included?

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Virginia Consent Form example (combined)

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Virginia Consent Form example (combined)

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https://infantva.org/documents/forms/3152eEI_130701.pdf