Forms for Submission

Below are form(s) separated by title that you are able to use/submit when completing training or other actions. Forms will be added when needed. Please use appropriate form.

Current forms –

1. Training Outcome Click me!
2. Confidentiality and HIPAA Privacy Quiz Click me!
3. Measuring Outcomes-Functional and Meaningful Click me!

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Training Outcome Form for Video and Written Materials

Training Outcome Form for Video and Written Materials

Video = Actual time
Journal Articles = 1 hour of training
Books = up to 3 hours of training
All times will be reviewed and certified

If you are human, leave this field blank.

Name *

Your Full Name

Email Address *

Email address to receive your completed training form.

Date *

Date Format 01/01/2000

Select Training Hours completed for stated material (select 1 option only Use other if not shown) *

1 hour

2 hours

3 hours

30 minutes

Other TimeOther Time

Title of Video, Book or Article *

Synopsis of Material *

List three (3) things you learned from the material you reviewed *

List three (3) ways this training will inform your sessions with families *

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Confidentiality and HIPAA Privacy Quiz

Confidentiality and HIPAA Privacy Quiz

If you are human, leave this field blank.

Name *

Your Full Name

Email

Provider Agency:

Date *

Date format 01/01/2000

Use check-box for True or False under each statement. A score of 85% (no more than 3 incorrect answers is needed for a passing score)

1. There is only one law that governs use and release of confidential information in Early Intervention settings. *

True

False

2. HIPAA stands for Health Care is Private and Accountable. *

True

False

3. The Family Education Rights & Privacy Act is sometimes referred to as the "Buckley Amendment".

True

False

4. The HIPAA Privacy Rule was created to give an individual access to and control over their own personal medical information. *

True

False

5. Wherever the laws governing Early Intervention Services are more stringent, they supersede HIPAA. *

True

False

6. HIPAA provides for protections of personally identifable information only when individually identifiable health information is transmitted electronically. *

True

False

7. It is okay to disclose Protected Health Information to a CYF worker investigating abuse of a child without getting consent from the family. *

True

False

8. If a family requests amendment of their child's record, the agency is only required to store that amendment in the case record for one year. *

True

False

9. Early Intervention staff needs the family's permission to report suspected or actual child abuse to the appropriate authority. *

True

False

10. A general medical release of information is sufficient to release specific HIV information. *

True

False

11. Parents should not expect to gain access to their child's report until they get discharged from the program. *

True

False

12. As long as you use a quiet voice when discussing client information with another professional, it is okay if another co-worker overhears the conversation. *

True

False

13. An agency that provided services to a child must keep that child's record on file permanently. *

True

False

14. Records of instructional, supervisory & administrative personnel which are in the sole possession of the maker and not revealed or accessible to any other person are still considered part of the Education record. *

True

False

15. If the parties to the discussion have a shared professional interest such as IFSP team members, there is no problem with confidentiality. *

True

False

16. A teacher who keeps her case files in her desk drawer and locks her door when she leaves is complying with confidentiality regulations governing security and access to confidential records. *

True

False

17. It's ok to throw a used CD-Rom into the trash can that has client information stored on it. *

True

False

18. Once a visitor has signed in at the front desk, it is not necessary to escort them during their visit. *

True

False

19. If the parents of a child in an EI program are divorced, the agency only needs to disclose the child's case record to one of the parents. *

True

False

Score: __________

Signature of Agency Representative and Date: _______________________________________________________

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Measuring Outcomes

Measuring Outcomes

If you are human, leave this field blank.

Name

Your Full Name

Email

Provider Agency:

Date

Date Format 01/01/2000

1) Select the following criteria according to the ECTA Center that are used to determine if Outcomes are functional, SELECT "ALL" THAT APPLY:

(a) The Outcome integrates developmental domains and is discipline-free.

(b) The Outcome is written in technical language that is easily understood by other interventionist.

(c) The Outcome uses active words rather than passive words.

(d) The Outcome is necessary and functional for the child's and family's life.

2) What is ONE of the three key pieces of information that need to be used when developing IFSP Outcomes:

(a) Start with what you feel are the priorities about the child's learning/development and/or family's needs.

(b) Start with parents'/caregivers' priorities about the child's learning/development and/or family's needs.

(c) Consider first your opinions about how the family should change their routines/activities before asking the family what's working and what's challenging.

(d) Use only the test scores to determine the Outcomes, do not consider what has been learned during the evaluation and assessment.

3) What questions should be asked when determining a progress measurement, SELECT "ALL" THAT APPLY:

(a) What?

(b) When?

(c) How?

(d) Who?

4) What are the TWO types of data that can be collected? 1. 2.

6) List at least FOUR of the possible Data Collection Tools discussed in the training: 1. 2. 3. 4.

5) What should an interventionist do when the measurement listed on the IFSP no longer is relevant and requires updating?

(a) Nothing

(b) Contact the SC to discuss that the measurement is not longer relevant and provide the updated measurement to the SC to make the changes on the IFSP.

(c) Change the measurement and begin measuring using the updated measurement, update the SC at the annual which is in six months.

(d) Notify the family only of the change in measurement.

7) In Chester County, Interventionist complete/submit their quarterly progress reports using the __________ software?

(a) Excel

(b) Formatta

(c) Word

(d) None

8) When are the 3, 6, 9 months quarterly progress reports due to the assigned SC (completed and signed off by the agency reviewer)?

(a) The actual date the quarterly report is due to be completed.

(b) Two months in advance to my agency

(c) When I'm able to get it done.

(d) Two-Weeks prior to the quarterly due date.

9) All team members MAY report overall progress on any of the IFSP outcomes.

True

False

Score: __________

Signature of Agency Representative and Date: _____________________________