Personal Touch EIP

Progress Note Checklist

NYC Early Intervention Program Provider Progress Note PAGE 1
Encircled type of progress report Y N
(Circle One) 3 , 6, 9, 12 month
If report is not typed, handwriting is legible Y N

Y N Child’s name, correct spelling: (followed last name, first name) Y N

Y N IFSP Period, correct time frame ____ NOT per quarter

Y N DOB: ______ Y N EI ID #: _______

Y N Provider Agency Name: ______________ Y N Provider ID #: __________

Y N Name of Interventionist: ______ FULL name and title

Y N Discipline: ____ (OT, PT, ST, SI, SW)
Y N Service Type: ____ (OT, PT, ST, SI, SW, or FT~Family Training) -- No other answers

Y N Authorization Frequency? _____________ Y N Service Start Date: ______________

(should indicate if it’s weekly or monthly) (regular service start date should NOT be
the same as FT start date; these two dates
should be different)
Y N Completed section under gaps in service delivery
Y N If there was a gap, inclusive dates were noted.
Y N If there was a gap, reason was noted.
MUST BE COMPLETED. State None if N/A. If there are any gaps in service delivery, (ie 3 or more consecutively scheduled
visits), describe length and reason for gap in service delivery. ___________________

Y N Filled Out IFSP Outcomes Y N Checked Rate Progress in this time period

IFSP OUTCOME(S): _____________________ RATE PROGRESS IN THIS TIME PERIOD

______________________________________ No Little Moderate Great Deal Outcome
______________________________________ Progress Progress Progress Progress Achieved

Y N Filled out section about how they worked with family to help child reach outcome
How did you work with the family to help the child to reach this outcome? ________________________________________
__________________________________________________________________________________________________
Provider Progress Note PAGE 2
Y N Section 1 filled out.

Y N For 3rd and 9th month, need current developmental level of functioning in age or age range (in months)
Y N For 6th and 12th month, need percentage of delay.
Y N Stated how progress was determined (clinical opinion, dev.checklist, criterion-referenced instrument)

Y N Section 2 filled out. – should not be left blank

Y N Section 3 filled out. – should not be left blank
Y N Section 4: Recommendations – should not be left blank; should state continuation at the current mandate
and any new suggested goals
Y N EI form submitted or letter of justification was written regarding any change in frequency, location, etc.

Y N Signature of interventionist
Y N Date filled out; should be when the clinician submitted the report
(CANNOT BE BACKDATED or DATED in ADVANCE)
Y N License No. (Note: Only Special Educators are allowed NOT to write their license number)

Signature of interventionist completing report: ____________________ Date: ___________

License No. ______________ (If certified interventionist, do not indicate certificate number).