DCYF Form 15-054 "Esit Notice and Consent for Evaluation/Assessment" - Washington

What Is DCYF Form 15-054?

This is a legal form that was released by the Washington State Department of Children, Youth, and Families - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the Washington State Department of Children, Youth, and Families;
  • Easy to use and ready to print;
  • Available in Cambodian;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DCYF Form 15-054 by clicking the link below or browse more documents and templates provided by the Washington State Department of Children, Youth, and Families.

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Download DCYF Form 15-054 "Esit Notice and Consent for Evaluation/Assessment" - Washington

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ESIT Notice and Consent for Evaluation/Assessment
PURPOSE: To provide prior written notice to the parent(s) when an evaluation/assessment is being proposed and to obtain parental
consent to conduct the evaluation/assessment being proposed.
CHILD’S NAME
DOB
FAMILY RESOURCES COORDINATOR
REASON FOR NOTICE
The ESIT is required to provide you with prior written notice within a reasonable time before conducting evaluation and assessment
activities. It is required that you give informed, written consent for these activities through your signature below. The purpose of
evaluation and assessment is to obtain information about your child; provide your family with additional information about your child’s
development; identify the unique strengths and needs of your child and services that may be appropriate to meet those needs;
determine whether your child remains eligible for the ESIT program; and if your child remains eligible, with your agreement and
participation, develop or modify a written Individualized Family Service Plan (IFSP). This is your statement of that notice.
"Consent" means that: (1)You have been fully informed of all information relevant to the activity(ies) for which consent is sought
.
in your native language or mode of communication including sign language, Braille, or oral communication as appropriate
(2)
that you understand and agree in writing to the carrying out of the activity(ies) for which consent is sought; (3) the consent
describes the activity(ies)and lists the early intervention records (if any) that will be released and to whom they will be released;
and (4) the granting of your consent is voluntary and may be revoked in writing at any time. . If you revoke consent, it is not
retroactive (it does not apply to an action that occurred before the consent was revoked).
ACTION PROPOSED
An evaluation and assessment will be conducted by at least two qualified individuals from different disciplines (or one qualified
professional from two disciplines) in accordance with ESIT program policies and procedures. Your participation as a member of the
evaluation team is strongly encouraged. You know your child best and can provide important information about your child. The
evaluation and assessment is a comprehensive view of how your child is doing in the areas of cognitive, gross motor, fine motor,
communication, social-emotional, and adaptive development, as well as vision and hearing. The results indicate how your child is
doing in all of these areas and if your child continues to be eligible for ESIT services.
DESCRIPTION
The evaluation proposed will include multiple procedures, including administration of an evaluation instrument, taking the child’s
history, interviewing the parent(s), gathering information from other family members, caregivers, medical or other professionals and
reviewing medical, educational or other records. The proposed assessment procedures will determine your child’s unique strengths
and needs and appropriate early intervention services. Assessment will include: a review of evaluation results; personal
observations of the child, identification of the child’s needs in each developmental area through the use of formal and informal
assessment procedures.
ESIT providers will talk with you about the methods they will use for this evaluation and assessment.
The evaluation and assessment will be provided at no cost to you. The results are kept in your child's early intervention record. No
information about the evaluation/assessment will be shared with anyone or any agency outside of the ESIT program unless you
provide written consent to do so. The IFSP team will determine whether or not your child continues to be eligible for ESIT services
and will provide prior written notice, including your right to dispute the eligibility determination.
ACKNOWLEDGMENT AND STATEMENT OF CONSENT
Parent Initials
I have received a copy of my rights and procedural safeguards under Part C of IDEA (Early Support for
Infants and Toddlers program, Individuals with Disabilities Education Act (IDEA) Part C Procedural
Safeguards [Parent Rights]) with this notice.
These rights and procedural safeguards have been explained to me and I understand them. I understand that my consent is voluntary
and that I can choose, at any time, not to have my child evaluated/assessed even after signing this form. I understand that if I choose
not to consent to this evaluation or assessment, my child will not be evaluated or assessed.
 I do
 I do not give my informed consent for ESIT to carry out the activity(s) described above.
NOTICE OF CONSENT FOR EVALUATION/ ASSESSMENT
DCYF 15-054 (01/2019) INT/2019
ESIT Notice and Consent for Evaluation/Assessment
PURPOSE: To provide prior written notice to the parent(s) when an evaluation/assessment is being proposed and to obtain parental
consent to conduct the evaluation/assessment being proposed.
CHILD’S NAME
DOB
FAMILY RESOURCES COORDINATOR
REASON FOR NOTICE
The ESIT is required to provide you with prior written notice within a reasonable time before conducting evaluation and assessment
activities. It is required that you give informed, written consent for these activities through your signature below. The purpose of
evaluation and assessment is to obtain information about your child; provide your family with additional information about your child’s
development; identify the unique strengths and needs of your child and services that may be appropriate to meet those needs;
determine whether your child remains eligible for the ESIT program; and if your child remains eligible, with your agreement and
participation, develop or modify a written Individualized Family Service Plan (IFSP). This is your statement of that notice.
"Consent" means that: (1)You have been fully informed of all information relevant to the activity(ies) for which consent is sought
.
in your native language or mode of communication including sign language, Braille, or oral communication as appropriate
(2)
that you understand and agree in writing to the carrying out of the activity(ies) for which consent is sought; (3) the consent
describes the activity(ies)and lists the early intervention records (if any) that will be released and to whom they will be released;
and (4) the granting of your consent is voluntary and may be revoked in writing at any time. . If you revoke consent, it is not
retroactive (it does not apply to an action that occurred before the consent was revoked).
ACTION PROPOSED
An evaluation and assessment will be conducted by at least two qualified individuals from different disciplines (or one qualified
professional from two disciplines) in accordance with ESIT program policies and procedures. Your participation as a member of the
evaluation team is strongly encouraged. You know your child best and can provide important information about your child. The
evaluation and assessment is a comprehensive view of how your child is doing in the areas of cognitive, gross motor, fine motor,
communication, social-emotional, and adaptive development, as well as vision and hearing. The results indicate how your child is
doing in all of these areas and if your child continues to be eligible for ESIT services.
DESCRIPTION
The evaluation proposed will include multiple procedures, including administration of an evaluation instrument, taking the child’s
history, interviewing the parent(s), gathering information from other family members, caregivers, medical or other professionals and
reviewing medical, educational or other records. The proposed assessment procedures will determine your child’s unique strengths
and needs and appropriate early intervention services. Assessment will include: a review of evaluation results; personal
observations of the child, identification of the child’s needs in each developmental area through the use of formal and informal
assessment procedures.
ESIT providers will talk with you about the methods they will use for this evaluation and assessment.
The evaluation and assessment will be provided at no cost to you. The results are kept in your child's early intervention record. No
information about the evaluation/assessment will be shared with anyone or any agency outside of the ESIT program unless you
provide written consent to do so. The IFSP team will determine whether or not your child continues to be eligible for ESIT services
and will provide prior written notice, including your right to dispute the eligibility determination.
ACKNOWLEDGMENT AND STATEMENT OF CONSENT
Parent Initials
I have received a copy of my rights and procedural safeguards under Part C of IDEA (Early Support for
Infants and Toddlers program, Individuals with Disabilities Education Act (IDEA) Part C Procedural
Safeguards [Parent Rights]) with this notice.
These rights and procedural safeguards have been explained to me and I understand them. I understand that my consent is voluntary
and that I can choose, at any time, not to have my child evaluated/assessed even after signing this form. I understand that if I choose
not to consent to this evaluation or assessment, my child will not be evaluated or assessed.
 I do
 I do not give my informed consent for ESIT to carry out the activity(s) described above.
NOTICE OF CONSENT FOR EVALUATION/ ASSESSMENT
DCYF 15-054 (01/2019) INT/2019
PRINT PARENT(S) NAME
PARENT(S) SIGNATURE
DATE
RECEIVED BY NAME/TITLE/AGENCY
DATE
Attachment: Early Support for Infants and Toddlers program, Individuals with Disabilities Education Act (IDEA) Part C Procedural
Safeguards [Parent Rights])
Note: Parents are to receive a copy of this form and a signed copy is to be included in the child’s early intervention record.
NOTICE OF CONSENT FOR EVALUATION/ ASSESSMENT
DCYF 15-054 (01/2019) INT/2019
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