Title: Section 69-4.8 - Evaluation and Screening of the Child and Assessment of the Child and Family

69-4.8 Evaluation and Screening of the Child and Assessment of the Child and Family

Evaluations and screenings.

(a) To determine eligibility for the Early Intervention Program, a timely screening and/or multidisciplinary evaluation may be conducted to determine if the child has a developmental delay or disability, unless eligibility is established in accordance with subdivision (c) of this section.

(1) The child's parent shall have the opportunity to be present and participate in the performance of a screening, evaluation and, where applicable, assessment, unless the parent's circumstances prevent the parent's presence. If the parent’s circumstances prevent the parent’s presence, the parent shall have the opportunity to designate, in writing, another family member to be present and participate in the performance of the screening, evaluation and, where applicable, assessment.

(2) If the child’s eligibility is established in accordance with subdivision (c) of this section, a multidisciplinary assessment of the child shall, with parental consent, be conducted and a voluntary family-directed assessment shall be offered to the parent in accordance with subdivisions (f) and (g) of this section.

(b) If the child is suspected of having a developmental delay, the evaluator shall, with parental consent, conduct a screening to determine if further evaluation under the Early Intervention Program is appropriate, or conduct a multidisciplinary evaluation to determine the child’s eligibility for the Early Intervention Program.  If the results of the screening demonstrate that further evaluation under the Early Intervention Program is appropriate then the evaluator shall conduct a multidisciplinary evaluation.  If the screening indicates that the child is not suspected of having a disability, the child may still receive a multidisciplinary evaluation to determine eligibility for the program upon parent request.  If the child is determined eligible for the Early Intervention Program, a voluntary family-directed assessment shall be offered to the parent in accordance with subdivision (g) of this section. 

(1) When determining whether to conduct a screening prior to a multidisciplinary evaluation, the evaluator may rely on a recommendation from the Early Intervention Official, a physician, or other qualified personnel. The evaluator may also conduct a screening based upon a request from the parent.

(i) Prior to a screening being conducted, the evaluator shall provide notice to the parent of the intent to conduct a screening. The notice shall inform the parent that parental consent is required to conduct a screening and of the parent’s right to request a multidisciplinary evaluation at any time during the screening process.

(ii) The purpose of a screening, if conducted, is to determine whether the child is suspected of having a disability and requires a multidisciplinary evaluation.

(2) A screening shall not be conducted if the child’s eligibility for the Early Intervention Program is established in accordance with procedures set forth in subdivision (c) of this section.

(3) The screening shall be conducted using appropriate instruments on the list of instruments approved by the department and by personnel qualified to administer those instruments.

(4) Parental consent shall be obtained prior to conducting the screening procedures.

(5) If, at any time during the screening process, the parent requests and consents to a multidisciplinary evaluation, the screening shall conclude and a multidisciplinary evaluation of the child shall be conducted even if the child is not suspected of having a disability.

(6) The evaluator shall explain the results of the screening to the parent and shall fully document the results in writing.

(i) If, based upon the screening, a child is suspected of having a disability, the child shall, with parental consent, receive a multidisciplinary evaluation to be conducted in accordance with the procedures set forth in subdivision (e) of this section.  The evaluator shall discuss implications of the screening for the child’s multidisciplinary evaluation, including composition of the multidisciplinary evaluation team.

(ii) If, based upon the screening, a child is not suspected of having a disability, a multidisciplinary evaluation shall not be provided, unless requested by the parent.  The Early Intervention Official shall provide the parent with written notice of the screening results upon receipt of such results from the evaluator, which shall include information on the parent’s right to request a multidisciplinary evaluation.

(c) If a child has a diagnosed medical condition with a high probability of resulting in a developmental delay, a review of the child’s medical and other records, with parental consent, may be used by the evaluator to establish eligibility for the Early Intervention Program.  If a child’s eligibility is determined in accordance with this subdivision a multidisciplinary assessment of the child shall be conducted. 

(1) If the child’s eligibility is established based on a review of the child’s medical or other records, without a multidisciplinary evaluation, the evaluator shall document in writing the basis for the child’s eligibility, conduct a multidisciplinary assessment of the child and offer a voluntary family-directed assessment in accordance with procedures set forth in subdivision (g) of this section.

(d) Qualified personnel shall use informed clinical opinion when conducting a screening, evaluation and/or assessment of the child.

(1) Informed clinical opinion may be used as one factor to establish the child’s eligibility for the Early Intervention Program even when other instruments do not establish eligibility; provided, however, that the evaluator shall provide written documentation that shall include observations of the child, a detailed summary of the parent interview, and a review of pertinent medical and other records and a description of all procedures used to evaluate the child and reasons why the child meets eligibility criteria set forth in section 69-4.23(a) of this Subpart, in the evaluation report. 

(2) Informed clinical opinion shall not be used to negate the results of evaluation instruments that were used to establish eligibility.

(e) If a multidisciplinary evaluation is conducted pursuant to this section, the evaluators shall obtain informed parental consent to perform the evaluation prior to initiating the evaluation procedures.

(1) The multidisciplinary evaluation team shall include two or more qualified personnel from different disciplines who are trained to utilize appropriate methods and procedures and have sufficient expertise in child development; and at least one of whom shall be a specialist in the area of the child's suspected delay or disability, if known.

(2) The multidisciplinary evaluation of the child shall utilize age-appropriate procedures and instruments on the list of standardized instruments approved by the department, unless written justification is included in the evaluation report for why such instruments are not appropriate or available for the child.  The most recent version of the evaluation instrument must be administered, scored, and reported following all protocols in the examiner’s manual as issued by the test developer.  

(3) The multidisciplinary evaluation shall include the following:

(i) administering the evaluation instrument;

(ii) taking the child’s history, including interviewing the parent about the child’s development and developmental progress;

(iii) identifying the child’s level of functioning in cognitive development, physical development, communication development, social emotional development, and adaptive development;

(iv) gathering information from other sources, such as family members, other caregivers, medical providers, social workers, and educators, as applicable, to understand the full scope of the child’s unique strengths and needs; and

(v) a review of medical, educational, and other records.

(4) The evaluator shall avoid making recommendations regarding frequency and duration of specific services until such time as the family's total priorities, concerns, and resources have been assessed and the plan for services to be included in the IFSP is under discussion.

(f) If a multidisciplinary assessment is conducted pursuant to this section it shall be conducted by qualified personnel and shall include the following:

(1) a review of the results of the child’s medical or other records; including reports of any previous evaluations;

(2) personal observations of the child;

(3) the identification of the child’s needs in the areas of cognitive development, physical development, communication development, social emotional development, and adaptive development;

(i) the assessment of the child's physical development shall include a health assessment including a physical examination, routine vision and hearing screening, and, where appropriate, a neurological assessment, except when:

(a) a physical examination has occurred within a sufficient timeframe, as determined by the child's age and commonly accepted examination schedules, such as those recommended by the American Academy of Pediatrics, and/or New York State Child/Teen Health Plan, and documentation of such examination is available; and

(b) no indications are present which suggest the need for re-examination, such as rapid regression in development.

(4) an assessment of the transportation needs of the child, which shall include parental ability or inability to provide transportation, health and safety concerns, and any parental concerns related to transporting the child.

(g) The evaluator shall offer the parent the opportunity to participate in a voluntary family-directed assessment. The purpose of the assessment shall be to identify the family’s resources, priorities, and concerns and the supports and services necessary to enhance the family’s capacity to meet the developmental needs of the family’s infant or toddler with a disability.  The family-directed assessment shall be conducted by qualified personnel and shall:

(1) be voluntary on the part of each family member participating in the assessment;

(2) be based on information obtained through an assessment tool and an interview with those family members who elect to participate in the assessment; and

(3) include the family’s description of its resources, priorities, and concerns related to enhancing the child’s development.

(i) The screening, evaluation and assessment procedures, including clinical observation, shall be conducted in an environment appropriate to the unique needs of the child and conducive to ensuring accuracy of results, with consideration given to the preferences of the parent.  Such settings may include structured (e.g., clinic or office), unstructured (e.g., play room), and natural settings (e.g., the child's home). 

(h) Results of the child's screening, evaluation and/or, where applicable, assessment, shall be fully shared with the parent following the completion of the screening, evaluation and/or assessment, in a manner understandable to the parent.

(i) The evaluation team shall prepare an evaluation report and written summary, which shall include the results of the multidisciplinary evaluation or assessment of the child as applicable, and the voluntary family-directed assessment if completed. The evaluation team shall submit the summary and report as soon as practicable subsequent to the evaluation or, for children who are determined eligible, no later than 30 days after the evaluation to enable convening of the individual family service plan meeting within 45 days of the date that the Early Intervention Official received the referral. Such summary and report shall be submitted to the following individuals: the parent; Early Intervention Official; initial service coordinator; with parental consent, the child's primary health care provider; and, with parental consent, for those children in the care and custody or custody and guardianship of the local social services commissioner, such commissioner or their designee.

(1) The evaluation report and summary shall: identify the persons performing the evaluation or, where applicable, the assessment of the child and voluntary family-directed assessment; describe the assessment process and conditions; describe the child's response; describe the family's belief about whether the child's response was optimal; identify measures and/or scores that were used; and explain these measures and/or scores.

(2) If the child is found eligible for the Early Intervention Program, the evaluation report and summary shall include a statement of the child's eligibility, including diagnosed condition with a high probability of delay, if any, and/or developmental delay in accordance with section 69-4.23(a) of this Subpart.  Such statement shall describe the child’s developmental status, including objective and qualitative criteria, in sufficient detail to demonstrate how the child meets the eligibility criteria for the program in accordance with criteria set forth in section 69-4.23 of this Subpart.

(3) The parent shall have the opportunity to:

(i) discuss the child’s evaluation report and summary and, where applicable, the voluntary family-directed assessment with the evaluator or evaluators, including any concerns they may have about the evaluation and assessment process;

(ii) receive assistance in understanding these results; and

(iii) address concerns that the evaluation and, where applicable, the assessment considers their concerns and observations about their child and that such documents accurately identify family resources, priorities, and concerns.

(4) To the extent feasible, and within the confidentiality requirements prescribed in section 69-4.17(c) of this Subpart, if the parent prefers and consents to disclosure to an interpreter, the written and oral summary shall be provided in the dominant or native language or other mode of communication of the parent.

(5) A parent who disagrees with the results of an evaluation or assessment may request to obtain an additional evaluation or supplemental evaluation to the extent authorized by federal and state laws or regulation.

(j) If a child is determined ineligible for services, including determinations that additional evaluations or supplemental evaluations are not necessary or appropriate, the parent may request a mediation or a hearing.  However, the parent may not make such a request until all evaluations are complete and a determination of ineligibility has been made.

(k) With parental consent, certain evaluations may be conducted or repeated and reimbursed in accordance with this Subpart, if deemed necessary and appropriate by the Early Intervention Official, either in conjunction with the required annual evaluation of the individualized family service plan, or more frequently under the following conditions:

(1) an observable change in the child's developmental status indicates the need for modification of the individualized family service plan or a change in eligibility status; and

(2) the parent, Early Intervention Official, service coordinator, or provider(s) requests a re-evaluation at the six-month review of the individualized family service plan.

(l) After a child's initial multidisciplinary evaluation, any additional evaluation shall be described in the child's individualized family service plan, including the type of evaluation, projected date for the evaluation, and if known, the evaluator.

(m) Nondiscriminatory procedures shall be employed in all aspects of the evaluation and assessment processes.

(1) Responsiveness to the cultural background of the family shall be a primary consideration in all aspects of the evaluation and assessment processes.

(2) Tests and other evaluation materials and procedures shall be administered in the dominant or native language or other mode of communication of the child, unless it is clearly not feasible to do so.

(3) No single procedure or instrument may be used as the sole criteria or indicator of eligibility.

(n) An evaluation or assessment shall not include a reference to any specific provider of early intervention services.

(o) Costs for multidisciplinary evaluations and assessments shall be reimbursed in accordance with section 69-4.30(c) of this Subpart.