WV BIRTH TO THREE
Office of Maternal, Child and Family Health
Bureau for Public Health
Department of Health and Human Resources

Instructions: Child Outcome Summary Form

Purpose:  The Child Outcome Summary Form (COSF) is to be used to assist the team, including the family, in evaluating and reporting the child’s individual progress toward important national child outcomes as required by the U.S. Department of Education. 
 
Legal Basis: Individuals with Disabilities Education Improvement Act (IDEA) 
 
Completing the Form: Child Outcome Summary Form  
 
The Interim Service Coordinator and/or Ongoing Service Coordinator is responsible for assuring that the Initial, Annual and Exit COSF is completed for every child on their caseload. In situations where there is no Developmental Specialist on the team when the child exits WV Birth to Three, the Service Coordinator is responsible for completing the Exit COSF following the guidelines below. 

Initial COSF: The Initial COSF is completed during the Initial IFSP meeting.  The Developmental Specialist who completed assessment will facilitate the discussion and completion of the COSF immediately following the determination of eligibility and prior to the development of the IFSP Outcome pages.  The IFSP team is to consider the information gathered as part of the evaluation/assessment process to complete the initial COSF rating.  In the rare circumstance that a Developmental Specialist is not present during the initial IFSP meeting, the Developmental Specialist will gather information from the IFSP team and complete the COSF within 10 days after the meeting.  An Initial COSF rating will not be completed for those children who are 30 months or older at the Initial IFSP meeting. 
 
Annual COSF: The Annual COSF is completed during the Annual IFSP meeting. The Developmental Specialist, who completed assessment for the annual IFSP, will facilitate the discussion and completion of the COSF immediately following the determination of eligibility and prior to the development of the IFSP Outcome pages.  The IFSP team is to consider the information gathered as part of the redetermination of eligibility to complete the annual COSF rating. In the rare circumstance that a Developmental Specialist is not present during the annual IFSP meeting, the Developmental Specialist will gather information from the IFSP team and complete the COSF within 10 days after the meeting. 
 
Exit COSF: Exit from WV Birth to Three can occur for a variety of reasons, such as when the child turns three years of age, or when the family has elected to no longer receive services, or when the child is no longer eligible for, or in need of services.  Hopefully most exits can be planned for and the child/family will receive support for the transition.  Whether the child’s Exit was planned or occurs unexpectedly, a COSF needs to be completed for each child when he/she exits 6 months or more after his/her Initial IFSP.   

Planned Exits 
 
The early intervention team may complete the Exit COSF during natural junctures such as Annual IFSP, IFSP review or 90 Day Transition Planning Conference as long as the child will be exiting at or near that event (within the next 120 days).   
Unplanned Exits  
 
If a child exits within the first six months of the Initial IFSP, the Developmental Specialist will submit a COSF form, indicating that the Exit COSF rating was not completed because the initial IFSP was completed less than six months before the child’s exit. No rating will occur. 
 
If the child exits unexpectedly and the exit is more than 6 months after the child’s Initial IFSP, the Developmental Specialist will be responsible for submitting the Exit COSF, with input from the IFSP team members.  
 
•	If the IFSP team has provided service within the last three months prior to the child’s exit, the Developmental Specialist will complete the EXIT COSF using information gathered from the early intervention team. 

•	If the early intervention team has not provided service within the last three months prior to child’s exit, the Developmental Specialist will submit the COSF form, indicating the Exit COSF rating was not completed due to inability to locate family.  No rating will occur. 

NOTE:  In situations when the team is unable to contact or locate the family, the TA Bulletin, “Inability to Provide IFSP Services,” must be followed and steps documented prior to determining that exit has occurred. Once the team has determined an unplanned exit has occurred, the Exit COSF must be completed within 5 days of Exit.  

Filling in the blanks:  
 
Child’s Identifying Information:

•	Enter child’s name - first (not nickname), middle, and last name  
•	Enter the child’s numerical date of birth (month, day, and year). Check to be sure that the date of birth is accurate.  
•	Enter the date the form is being completed 

COSF Facilitator/Discipline:

•	Enter the name of the individual who is facilitating the completion of the COSF 
•	Enter the discipline of the individual who is facilitating the completion of the COSF 
  
Date of COSF completion:

•	Enter the numerical date the COSF is being completed 
 
Type of COSF completed today: 
 
•	Check the appropriate box indicating if you have completed an □ Initial COSF, not required if the child is 30 months or older, □ Annual COSF, □ Exit COSF or documenting why an Exit COSF has not been completed □ Exit COSF not completed due to inability to locate family, □ Exit COSF not completed, the initial IFSP was completed less than six months ago 
Rating in the Three Outcome areas: 
 
•	1.a, 2.a or 3.a:  Check one box per outcome area which best describes the child’s current level of functioning.   

•	1.b, 2.b or 3.b:  For initial COSF, check □Not Applicable.  For Annual or Exit COSF, check the box that best describes whether or not the child has shown any new skills or behaviors related to the outcome area in the last 12 months:   □Yes  □ No 
 
To Help You Decide on the Rating 
 
	Answers are expected to take into account the child’s functioning across a full range of situations and settings. Therefore, information from many individuals in contact with the child could be considered in deciding on an answer. These may include (but not be limited to): parents and family members, caregivers or child care providers, therapists, service providers, case managers, teachers, and physicians.  
	  
	Many types of information could be considered in selecting an answer. These may include (but are not be limited to): parent and clinical observation, curriculum-based assessments, norm-referenced assessments, service provider notes about performance in different situations, and progress and issues identified in the IFSP.  

	Depending on the assessment, assessments can a useful source of information for reaching a summary rating decision but assessment information should be placed in context with other information available about a child. Many assessments are domain-based and were not designed to provide information about functional behaviors and functioning across a variety of situations. Knowing that a child has or has not mastered assessment items that are related to the outcome provides helpful information but the information should be used in conjunction with what else is known about the child. A high score on a set of items in a domain related to the outcome might not mean the child has achieved the outcome and, conversely, a low score might not mean the child has not achieved it.  

	Answers should reflect the child’s current functioning across the typical setting and situations that make up his/her day.  Answers should convey the child’s typical functioning across typical settings, not his/her capacity to function under ideal circumstances.  
	  
	If assistive technology or special accommodations are available in the child’s everyday environments, then the answer should describe the child’s functioning using those adaptations. However, if technology is only available in some environments or is not available for the child, rate the child’s functioning with whatever assistance is commonly present. Answers are to reflect the child’s actual functioning across a range of settings, not his/her capacity to function under ideal circumstances.  

Documentation Used to Support the Ratings on the COSF: 
 
•	Check the appropriate boxes to document the type of documentation used to support the rating.   
	□ Activity Notes □ Child Observation □ Evaluation/Assessment □ Family Interview 
	□ IFSP □ Medical Record Review □ Transition Summary Update □ Other 

Team Members Participating in Rating of COSF 
 
	This section documents who and how the multi–disciplinary evaluation/IFSP team members participated in the completion of the COSF.  Practitioners who attend the eligibility determination/IFSP meeting face to face will complete the required information and provide signature.  For practitioners who participate via phone, the Service Coordinator will complete required information and print the practitioner’s name. 
 
•	Name:  Enter name 

•	Signature/Credential:  Sign with credential 

•	Date:  Enter numerical date of participation 

•	Role on Team:  Enter role on MDT team; for example, “Service Coordinator”, “Speech Therapist”, “Developmental Specialist” 

•	Method of Contribution:  Enter whether the practitioner participated face to face, on the phone or sent an authorized representative   
 
The Developmental Specialist will send the completed Child Outcome Summary Form to the WV Birth to Three State Office via mail, fax or email at the address on the form.  The Developmental Specialist should keep a copy of the form for their records for quality assurance purposes.