CHILD OUTCOMES SUMMARY FORM

Date:   _____/_____/_____        
Mon     Day       Yr

Child Information

Name:   ___________________________________________________

Date of birth:  _____/_____/_____
		 Mon	  Day      Yr	

ID:____________________________________________

Persons involved in deciding the summary ratings:

Name	Role	

		

		

Family information on child functioning (Check all that apply):
___ Received in team meeting 
___ Collected separately 
___ Incorporated into assessment(s)
___ Not included 
        
© 2005 SRI International.  Version:  4-20-06  Permission is granted to reproduce this form for state and local program use.  Identify as “Developed by the Early Childhood Outcomes Center with support from the Office of Special Education Programs, U.S. Department of Education.”  Please contact staff@the-ECO-center.org if you wish to use or adapt the form.   
1.   POSITIVE SOCIAL-EMOTIONAL SKILLS (INCLUDING SOCIAL RELATIONSHIPS)

To answer the questions below, think about the child’s functioning in these and closely related areas (as indicated by assessments and based on observations from individuals in close contact with the child):

•	Relating with adults
•	Relating with other children
•	Following rules related to groups or interacting with others (if older than 18 months)

1a. To what extent does this child show age-appropriate functioning, across a variety of settings and situations, on this outcome?   (Circle one number)

Not Yet		Emerging		Somewhat		Completely	
1	2	3	4	5	6	7	
Supporting evidence for answer to Question 1a 

Source of information	Date	Summary of Relevant Results	

	

	

	

	

	

1b. (If Question 1a has been answered previously):   Has the child shown any new skills or behaviors related to positive social-emotional skills (including positive social relationships) since the last outcomes summary?  (Circle one number) 
Yes	  1	Describe progress:    	
No	2		

2.   ACQUIRING AND USING KNOWLEDGE AND SKILLS

To answer the questions below, think about the child’s functioning in these and closely related areas (as indicated by assessments and based on observations from individuals in close contact with the child):

•	Thinking, reasoning, remembering, and problem solving
•	Understanding symbols
•	Understanding the physical and social worlds

2a. To what extent does this child show age-appropriate functioning, across a variety of settings and situations, on this outcome?   (Circle one number)

Not Yet		Emerging		Somewhat		Completely	
1	2	3	4	5	6	7	

Supporting evidence for answer to Question 2a 

Source of information	Date	Summary of Relevant Results	

	

	

	

	

	

2b. (If Question 2a has been answered previously):   Has the child shown any new skills or behaviors related to acquiring and using knowledge and skills since the last outcomes summary?     (Circle one number) 
Yes	  1	Describe progress:    	
No	2		

3.   TAKING APPROPRIATE ACTION TO MEET NEEDS

To answer the questions below, think about the child’s functioning in these and closely related areas (as indicated by assessments and based on observations from individuals in close contact with the child):
•	Taking care of basic needs (e.g., showing hunger, dressing, feeding, toileting, etc.)
•	Contributing to own health and safety (e.g., follows rules, assists with hand washing, avoids inedible objects) (if older than 24 months)
•	Getting from place to place (mobility) and using tools (e.g., forks, strings attached to objects)

3a. To what extent does this child show age-appropriate functioning, across a variety of settings and situations, on this outcome?   (Circle one number)

Not Yet		Emerging		Somewhat		Completely	
1	2	3	4	5	6	7	
Supporting evidence for answer to Question 3a  

Source of information	Date	Summary of Relevant Results	

	

	

	

	

	
3b. (If Question 3a has been answered previously):   Has the child shown any new skills or behaviors related to taking appropriate action to meet needs since the last outcomes summary?     (Circle one number)
Yes	  1	Describe progress:    	
No	2