Sync template from atomicqms-style deployment
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Forms/Assessment-Tools/.gitkeep
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Forms/Assessment-Tools/.gitkeep
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# ADOS-2 Administration Fidelity Checklist
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| Form ID | FRM-ADOS-001 | Revision | 1.0 |
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|---------|--------------|----------|-----|
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---
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## Section 1: Assessment Information
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| Field | Entry |
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|-------|-------|
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| Child Name | |
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| Date of Birth | |
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| Chronological Age | |
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| Assessment Date | |
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| Examiner Name | |
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| Observer Name (if applicable) | |
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| Medical Record Number | |
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## Section 2: Module Selection
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### Module Selected
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- [ ] Toddler Module (12-30 months)
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- [ ] Module 1 (31+ months, minimal expressive language)
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- [ ] Module 2 (any age, phrase speech)
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- [ ] Module 3 (fluent speech, child/adolescent)
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- [ ] Module 4 (fluent speech, older adolescent/adult)
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### Module Selection Criteria Met
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- [ ] Age appropriate
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- [ ] Expressive language level appropriate
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- [ ] Module selection documented in report
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### Justification for Module Selection
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## Section 3: Pre-Assessment Preparation
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### Materials and Setup
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- [ ] All required materials prepared and available
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- [ ] Testing room appropriate (minimal distractions)
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- [ ] Video recording equipment functional (if recording)
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- [ ] Scoring forms and manual available
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- [ ] Toys/materials in good condition
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- [ ] Backup materials available
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### Examiner Preparation
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- [ ] Reviewed child's background information
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- [ ] Reviewed previous assessments (if available)
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- [ ] Confirmed module selection
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- [ ] Prepared parent/caregiver for observation
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- [ ] Scheduled adequate time (45-60 minutes typical)
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## Section 4: Administration Fidelity
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### General Administration Principles
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| Item | Met | Notes |
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|------|-----|-------|
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| Rapport established with child | ☐ Yes ☐ No ☐ N/A | |
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| Standardized procedures followed | ☐ Yes ☐ No ☐ N/A | |
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| Flexibility applied appropriately | ☐ Yes ☐ No ☐ N/A | |
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| Presses administered correctly | ☐ Yes ☐ No ☐ N/A | |
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| Natural, playful interaction maintained | ☐ Yes ☐ No ☐ N/A | |
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| Appropriate pacing maintained | ☐ Yes ☐ No ☐ N/A | |
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| Child engaged throughout | ☐ Yes ☐ No ☐ N/A | |
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### Activity-Specific Fidelity
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#### Activities Administered (check all that apply)
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**Toddler Module:**
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- [ ] Free Play
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- [ ] Response to Name
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- [ ] Response to Joint Attention
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- [ ] Bubble Play
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- [ ] Anticipation of a Social Routine
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- [ ] Responsive Social Smile
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- [ ] Anticipation of a Social Routine with Objects
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- [ ] Functional Play
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- [ ] Birthday Party
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- [ ] Snack
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**Module 1:**
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- [ ] Free Play
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- [ ] Response to Name
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- [ ] Response to Joint Attention
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- [ ] Bubble Play
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- [ ] Anticipation of a Routine with Objects
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- [ ] Responsive Social Smile
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- [ ] Functional and Symbolic Imitation
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- [ ] Birthday Party
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- [ ] Snack
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**Module 2:**
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- [ ] Free Play
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- [ ] Response to Name Called
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- [ ] Birthday Party
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- [ ] Snack
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- [ ] Bubble Play
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- [ ] Construction Task
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- [ ] Make-Believe Play
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- [ ] Joint Interactive Play
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- [ ] Description of a Picture
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- [ ] Telling a Story from a Book
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- [ ] Conversation and Reporting
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**Module 3:**
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- [ ] Construction Task
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- [ ] Make-Believe Play
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- [ ] Joint Interactive Play
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- [ ] Demonstration Task
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- [ ] Description of a Picture
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- [ ] Telling a Story from a Book
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- [ ] Cartoons
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- [ ] Conversation and Reporting
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- [ ] Break (if needed)
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- [ ] Creating a Story
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- [ ] Social Difficulties and Annoyance
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- [ ] Emotions
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- [ ] Friends and Relationships
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- [ ] Loneliness
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**Module 4:**
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- [ ] Construction Task (if appropriate)
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- [ ] Current Work or School
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- [ ] Description of a Picture
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- [ ] Telling a Story from a Book
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- [ ] Cartoons
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- [ ] Break
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- [ ] Demonstration Task
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- [ ] Creating a Story
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- [ ] Social Difficulties and Annoyance
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- [ ] Emotions
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- [ ] Friends, Relationships, and Marriage
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- [ ] Loneliness
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### Standardization Issues
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**Were there any deviations from standardized administration?**
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- [ ] No deviations
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- [ ] Minor deviations (describe):
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- [ ] Major deviations affecting validity (describe):
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**Deviations Description:**
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### Child Factors Affecting Administration
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- [ ] Attention difficulties
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- [ ] Behavioral challenges
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- [ ] Fatigue
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- [ ] Illness
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- [ ] Anxiety/shyness
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- [ ] Language barriers
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- [ ] Sensory sensitivities
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- [ ] Other: _______________
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**Impact on Assessment:**
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## Section 5: Scoring Fidelity
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### Real-Time Scoring
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- [ ] Codes recorded during administration
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- [ ] Behavioral notes documented
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- [ ] Unclear items flagged for review
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### Post-Administration Scoring
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- [ ] All items scored within 24 hours
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- [ ] Video review conducted (if recorded)
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- [ ] Scoring manual consulted for unclear items
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- [ ] All required items completed
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### Algorithm and Classification
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- [ ] Algorithm scores calculated correctly
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- [ ] Social Affect (SA) total calculated
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- [ ] Restricted/Repetitive Behavior (RRB) total calculated
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- [ ] Overall Total calculated
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- [ ] Comparison score determined (if applicable)
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- [ ] Classification range determined
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### Classification Result
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- [ ] Autism
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- [ ] Autism Spectrum
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- [ ] Non-Spectrum
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**Overall Total:** _____
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**Comparison Score (if applicable):** _____
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## Section 6: Integration with Other Data
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### ADOS-2 Results Considered Alongside
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- [ ] ADI-R (Autism Diagnostic Interview-Revised)
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- [ ] Developmental history
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- [ ] Cognitive assessment
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- [ ] Adaptive behavior assessment
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- [ ] Language evaluation
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- [ ] Parent/caregiver report measures
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- [ ] Teacher/school observations
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- [ ] DSM-5-TR diagnostic criteria
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### Clinical Judgment Applied
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- [ ] ADOS-2 results interpreted in context
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- [ ] Limitations of ADOS-2 acknowledged
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- [ ] Best estimate clinical diagnosis made
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## Section 7: Quality Assurance
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### Examiner Qualifications
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- [ ] Research-reliable training completed (or equivalent)
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- [ ] Module-specific training completed
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- [ ] Adequate supervised experience
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- [ ] Annual competency check completed
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### Inter-Rater Reliability (if applicable)
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- [ ] Second scorer reviewed video
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- [ ] Agreement calculated
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- [ ] Agreement ≥80% achieved
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**Agreement Percentage:** _____%
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### Supervision/Consultation
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- [ ] Case reviewed with supervisor (if trainee)
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- [ ] Consultation obtained for complex case
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- [ ] Scoring reviewed with experienced colleague
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## Section 8: Documentation
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### Required Documentation Complete
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- [ ] ADOS-2 protocol form completed
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- [ ] Algorithm and classification documented
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- [ ] Behavioral observations recorded
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- [ ] Integration with other data documented
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- [ ] Diagnostic impression documented
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- [ ] Recommendations documented
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### Video Recording (if applicable)
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- [ ] Consent for recording obtained
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- [ ] Video quality adequate for review
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- [ ] Video stored securely per HIPAA
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- [ ] Video retention per policy
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## Section 9: Issues and Concerns
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### Administration Issues Encountered
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### Validity Concerns
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- [ ] No concerns - results considered valid
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- [ ] Minor concerns (specify):
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- [ ] Major concerns affecting validity (specify):
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### Follow-Up Needed
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- [ ] No follow-up needed
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- [ ] Repeat assessment recommended
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- [ ] Additional assessment needed
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- [ ] Consultation recommended
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## Section 10: Competency Verification
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*(To be completed by supervisor or reviewer)*
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### Fidelity Rating
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- [ ] Excellent - All procedures followed correctly
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- [ ] Adequate - Minor deviations, results valid
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- [ ] Inadequate - Significant issues, retraining needed
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### Reviewer Comments
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### Reviewer Signature | | Date | |
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---
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## Section 11: Examiner Self-Reflection
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### Self-Assessment of Administration
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### Areas for Improvement
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### Training Needs Identified
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## Section 12: Signatures
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| Examiner Signature | | Date | |
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|-------------------|---|------|---|
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| Supervisor Review (if applicable) | | Date | |
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---
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*Form FRM-ADOS-001 Rev 1.0*
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**Note:** This checklist is intended to support standardized ADOS-2 administration and quality assurance. It does not replace the official ADOS-2 manual or required training. Examiners must complete research-reliable training or equivalent before administering the ADOS-2 independently.
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0
Forms/Case-Management/.gitkeep
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0
Forms/Case-Management/.gitkeep
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66
Forms/FRM-001-Document-Change-Request.md
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66
Forms/FRM-001-Document-Change-Request.md
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# Document Change Request Form
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| Form ID | FRM-001 | Revision | 1.0 |
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|---------|---------|----------|-----|
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---
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## Section 1: Request Information
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| Field | Entry |
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|-------|-------|
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| Request Date | |
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| Requested By | |
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| Department | |
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## Section 2: Document Information
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| Field | Entry |
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|-------|-------|
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| Document Number | |
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| Document Title | |
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| Current Revision | |
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## Section 3: Change Description
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### Type of Change
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- [ ] New Document
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- [ ] Revision to Existing Document
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- [ ] Document Obsolescence
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### Description of Change
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*(Describe the proposed change in detail)*
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### Reason for Change
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*(Explain why this change is needed)*
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## Section 4: Impact Assessment
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### Affected Areas
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- [ ] Training Required
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- [ ] Other Documents Affected
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- [ ] Process Changes Required
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- [ ] Assessment Protocol Impact
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- [ ] Clinical Competency Impact
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### List Affected Documents
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## Section 5: Approvals
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| Role | Name | Signature | Date |
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|------|------|-----------|------|
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| Requester | | | |
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| Document Owner | | | |
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| Clinical Director (if clinical) | | | |
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| Quality Assurance | | | |
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---
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*Form FRM-001 Rev 1.0*
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157
Forms/FRM-003-CAPA-Form.md
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Forms/FRM-003-CAPA-Form.md
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# Corrective and Preventive Action (CAPA) Form
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| Form ID | FRM-003 | Revision | 1.0 |
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|---------|---------|----------|-----|
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---
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## Section 1: CAPA Identification
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| Field | Entry |
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|-------|-------|
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| CAPA Number | |
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| Date Initiated | |
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| Initiated By | |
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| Department | |
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| CAPA Owner | |
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## Section 2: Problem Description
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### Source of CAPA
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- [ ] Internal Audit
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- [ ] External Audit
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- [ ] Management Review
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- [ ] Clinical Incident
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- [ ] Family Complaint
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- [ ] Assessment Protocol Deviation
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- [ ] Documentation Error
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- [ ] Staff Observation
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- [ ] Other: _______________
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### Severity Level
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- [ ] Critical (affects patient safety or diagnostic accuracy)
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- [ ] Major (significant quality impact)
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- [ ] Minor (limited impact)
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### Description of Nonconformity or Issue
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*(Provide detailed description including what happened, when, where, and who was involved)*
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### Affected Processes/Areas
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- [ ] Diagnostic Evaluations
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- [ ] Screening Programs
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- [ ] School Liaison
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- [ ] Documentation
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- [ ] Assessment Administration
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- [ ] Clinical Protocols
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- [ ] Training/Competency
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- [ ] Other: _______________
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## Section 3: Immediate Action (if applicable)
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### Immediate Containment Actions Taken
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*(Actions to prevent immediate recurrence or mitigate impact)*
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||||
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|
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## Section 4: Root Cause Analysis
|
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### Investigation Method
|
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- [ ] 5 Whys
|
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- [ ] Fishbone Diagram
|
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- [ ] Timeline Analysis
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- [ ] Other: _______________
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|
||||
### Root Cause Findings
|
||||
*(Document the fundamental cause of the problem)*
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|
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### Contributing Factors
|
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- [ ] Training inadequacy
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- [ ] Protocol unclear
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- [ ] Communication breakdown
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- [ ] Assessment tool issue
|
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- [ ] Workload/scheduling
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- [ ] Documentation system
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- [ ] Equipment/materials
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- [ ] Other: _______________
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## Section 5: Corrective/Preventive Actions
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### Action Plan
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| Action # | Description | Responsible Person | Target Date | Status |
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|----------|-------------|-------------------|-------------|--------|
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| 1 | | | | |
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| 2 | | | | |
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| 3 | | | | |
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| 4 | | | | |
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### Type of Action
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- [ ] Corrective (address detected issue)
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- [ ] Preventive (prevent potential issue)
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||||
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### Affected Documents/Procedures
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*(List SOPs, protocols, or forms that need updating)*
|
||||
|
||||
|
||||
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||||
|
||||
### Training Required
|
||||
- [ ] Yes
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- [ ] No
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||||
|
||||
If yes, describe:
|
||||
|
||||
|
||||
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||||
## Section 6: Implementation
|
||||
|
||||
### Implementation Notes
|
||||
*(Document actions taken)*
|
||||
|
||||
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||||
|
||||
|
||||
### Implementation Date | |
|
||||
### Implemented By | |
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||||
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||||
## Section 7: Effectiveness Check
|
||||
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||||
### Verification Method
|
||||
- [ ] Follow-up audit
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||||
- [ ] Metric monitoring
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||||
- [ ] Process observation
|
||||
- [ ] Record review
|
||||
- [ ] Other: _______________
|
||||
|
||||
### Verification Period
|
||||
- Start Date: _______________
|
||||
- End Date: _______________
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||||
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||||
### Effectiveness Results
|
||||
*(Describe results of monitoring - has the issue been resolved?)*
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||||
|
||||
|
||||
|
||||
|
||||
### Effectiveness Verified By | |
|
||||
### Verification Date | |
|
||||
|
||||
## Section 8: CAPA Closure
|
||||
|
||||
- [ ] All actions completed
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||||
- [ ] Effectiveness demonstrated
|
||||
- [ ] Records complete
|
||||
|
||||
### Closed By | |
|
||||
### Closure Date | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-003 Rev 1.0*
|
||||
156
Forms/FRM-004-Training-Record.md
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156
Forms/FRM-004-Training-Record.md
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# Training Record Form
|
||||
|
||||
| Form ID | FRM-004 | Revision | 1.0 |
|
||||
|---------|---------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Section 1: Employee Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Employee Name | |
|
||||
| Employee ID | |
|
||||
| Position/Title | |
|
||||
| Department | |
|
||||
| Hire Date | |
|
||||
|
||||
## Section 2: Training Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Training Topic/Course Title | |
|
||||
| Training Date | |
|
||||
| Training Duration (hours) | |
|
||||
| Training Type | ☐ Classroom ☐ Online ☐ On-the-job ☐ Self-study ☐ Conference |
|
||||
| Trainer/Instructor Name | |
|
||||
| Training Provider | |
|
||||
|
||||
## Section 3: Training Category
|
||||
|
||||
- [ ] New Employee Onboarding
|
||||
- [ ] QMS/Quality Policy
|
||||
- [ ] Regulatory Compliance (HIPAA, IDEA, etc.)
|
||||
- [ ] Assessment Tool Training
|
||||
- [ ] Clinical Protocol
|
||||
- [ ] Safety and Emergency Procedures
|
||||
- [ ] Software/Systems Training
|
||||
- [ ] Professional Development
|
||||
- [ ] Continuing Education
|
||||
- [ ] Annual Refresher
|
||||
- [ ] Other: _______________
|
||||
|
||||
## Section 4: Assessment Tool Specific Training (if applicable)
|
||||
|
||||
### Assessment Tool
|
||||
- [ ] ADOS-2 (specify modules): _______________
|
||||
- [ ] ADI-R
|
||||
- [ ] Bayley-4
|
||||
- [ ] WISC-V
|
||||
- [ ] Stanford-Binet 5
|
||||
- [ ] Vineland-3
|
||||
- [ ] ASQ-3
|
||||
- [ ] M-CHAT-R/F
|
||||
- [ ] WIAT-4
|
||||
- [ ] Conners Rating Scales
|
||||
- [ ] Other: _______________
|
||||
|
||||
### Training Level
|
||||
- [ ] Initial training
|
||||
- [ ] Research-reliable certification
|
||||
- [ ] Refresher training
|
||||
- [ ] Inter-rater reliability check
|
||||
|
||||
### Certification/Reliability Status
|
||||
- [ ] Certified
|
||||
- [ ] Reliability achieved (specify %): _______________
|
||||
- [ ] Certification expiration date: _______________
|
||||
|
||||
## Section 5: Training Objectives
|
||||
|
||||
*(List key learning objectives or competencies covered)*
|
||||
|
||||
1.
|
||||
2.
|
||||
3.
|
||||
|
||||
## Section 6: Assessment of Learning
|
||||
|
||||
### Assessment Method
|
||||
- [ ] Written test (score: _______%)
|
||||
- [ ] Practical demonstration
|
||||
- [ ] Case review
|
||||
- [ ] Direct observation
|
||||
- [ ] Simulation/role-play
|
||||
- [ ] Attendance only
|
||||
- [ ] Other: _______________
|
||||
|
||||
### Assessment Result
|
||||
- [ ] Competent (passed)
|
||||
- [ ] Not yet competent (requires retraining)
|
||||
|
||||
### Comments
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 7: Competency Documentation
|
||||
|
||||
### Initial Competency Verified
|
||||
- [ ] Yes
|
||||
- [ ] No
|
||||
- [ ] N/A
|
||||
|
||||
### Competency Verification Method
|
||||
- [ ] Observation by supervisor
|
||||
- [ ] Case audit
|
||||
- [ ] Fidelity checklist
|
||||
- [ ] Inter-rater reliability
|
||||
- [ ] Other: _______________
|
||||
|
||||
### Competency Verified By | |
|
||||
### Verification Date | |
|
||||
|
||||
## Section 8: Training Effectiveness
|
||||
|
||||
*(To be completed 30-90 days post-training)*
|
||||
|
||||
### Effectiveness Evaluation
|
||||
- [ ] Employee applying skills correctly
|
||||
- [ ] Additional support needed
|
||||
- [ ] Retraining required
|
||||
|
||||
### Evaluated By | |
|
||||
### Evaluation Date | |
|
||||
### Comments | |
|
||||
|
||||
## Section 9: Continuing Education (if applicable)
|
||||
|
||||
| CE Credits | |
|
||||
|------------|---|
|
||||
| Licensing Board | |
|
||||
| License Number | |
|
||||
|
||||
## Section 10: Signatures
|
||||
|
||||
| Employee Signature | | Date | |
|
||||
|-------------------|---|------|---|
|
||||
| Trainer Signature | | Date | |
|
||||
| Supervisor Signature | | Date | |
|
||||
|
||||
---
|
||||
|
||||
## Training History Summary
|
||||
|
||||
*(Use this section to track ongoing training - attach additional pages as needed)*
|
||||
|
||||
| Date | Training Topic | Hours | Trainer | Assessment Result |
|
||||
|------|---------------|-------|---------|-------------------|
|
||||
| | | | | |
|
||||
| | | | | |
|
||||
| | | | | |
|
||||
| | | | | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-004 Rev 1.0*
|
||||
154
Forms/FRM-006-Audit-Checklist.md
Normal file
154
Forms/FRM-006-Audit-Checklist.md
Normal file
@@ -0,0 +1,154 @@
|
||||
# Internal Audit Checklist
|
||||
|
||||
| Form ID | FRM-006 | Revision | 1.0 |
|
||||
|---------|---------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Section 1: Audit Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Audit Date | |
|
||||
| Auditor Name(s) | |
|
||||
| Auditee (Department/Area) | |
|
||||
| Audit Scope | |
|
||||
| Audit Criteria (SOPs, Standards) | |
|
||||
|
||||
## Section 2: Audit Criteria and Findings
|
||||
|
||||
### Instructions
|
||||
- **C** = Conformity (requirement met)
|
||||
- **NC** = Nonconformity (requirement not met)
|
||||
- **OBS** = Observation (potential issue or improvement opportunity)
|
||||
- **N/A** = Not Applicable
|
||||
|
||||
---
|
||||
|
||||
## Section 3: Document Control (SOP-001)
|
||||
|
||||
| Requirement | Status | Evidence Reviewed | Findings/Comments |
|
||||
|-------------|--------|-------------------|-------------------|
|
||||
| Documents have proper identification (ID, rev, date) | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Current versions are available and accessible | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Obsolete documents are removed from use | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Revision history is maintained | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Document reviews conducted per schedule | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
|
||||
## Section 4: Training and Competency (SOP-003)
|
||||
|
||||
| Requirement | Status | Evidence Reviewed | Findings/Comments |
|
||||
|-------------|--------|-------------------|-------------------|
|
||||
| Training records maintained for all staff | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| New employee onboarding completed | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Competency assessments documented | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Assessment tool certifications current | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Annual training requirements met | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Inter-rater reliability checks conducted | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
|
||||
## Section 5: Clinical Assessment Procedures
|
||||
|
||||
| Requirement | Status | Evidence Reviewed | Findings/Comments |
|
||||
|-------------|--------|-------------------|-------------------|
|
||||
| Assessment protocols followed correctly | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Standardized administration maintained | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Scoring accuracy verified | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| DSM-5-TR criteria applied appropriately | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Assessment materials properly maintained | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| ADOS-2/ADI-R fidelity maintained (if applicable) | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
|
||||
## Section 6: Documentation and Records
|
||||
|
||||
| Requirement | Status | Evidence Reviewed | Findings/Comments |
|
||||
|-------------|--------|-------------------|-------------------|
|
||||
| Clinical records complete and accurate | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Informed consent documented | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Reports completed within timeframes | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Required elements included in reports | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Records stored securely (HIPAA) | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
|
||||
## Section 7: Screening Programs (if applicable)
|
||||
|
||||
| Requirement | Status | Evidence Reviewed | Findings/Comments |
|
||||
|-------------|--------|-------------------|-------------------|
|
||||
| Screening tools administered correctly | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Follow-up protocols followed | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Parent communication documented | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Referral pathways established | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
|
||||
## Section 8: School Liaison (if applicable)
|
||||
|
||||
| Requirement | Status | Evidence Reviewed | Findings/Comments |
|
||||
|-------------|--------|-------------------|-------------------|
|
||||
| IEP documentation complete | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| 504 plans properly documented | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| IDEA requirements met | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| School communication timely | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
|
||||
## Section 9: CAPA Process (SOP-002)
|
||||
|
||||
| Requirement | Status | Evidence Reviewed | Findings/Comments |
|
||||
|-------------|--------|-------------------|-------------------|
|
||||
| Nonconformities documented | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Root cause analysis performed | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Corrective actions implemented | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Effectiveness verified | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| CAPA records maintained | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
|
||||
## Section 10: Safety and Incidents
|
||||
|
||||
| Requirement | Status | Evidence Reviewed | Findings/Comments |
|
||||
|-------------|--------|-------------------|-------------------|
|
||||
| Safety procedures followed | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Incidents documented and investigated | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
| Staff aware of emergency procedures | ☐C ☐NC ☐OBS ☐N/A | | |
|
||||
|
||||
## Section 11: Summary of Findings
|
||||
|
||||
### Conformities (Positive Findings)
|
||||
|
||||
|
||||
|
||||
|
||||
### Nonconformities
|
||||
|
||||
| NC # | Type | Description | Objective Evidence |
|
||||
|------|------|-------------|-------------------|
|
||||
| | ☐Major ☐Minor | | |
|
||||
| | ☐Major ☐Minor | | |
|
||||
| | ☐Major ☐Minor | | |
|
||||
|
||||
### Observations/Opportunities for Improvement
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 12: Audit Conclusion
|
||||
|
||||
### Overall Assessment
|
||||
- [ ] Satisfactory - minor or no issues identified
|
||||
- [ ] Needs improvement - nonconformities require corrective action
|
||||
- [ ] Unsatisfactory - major nonconformities requiring immediate action
|
||||
|
||||
### Recommended Follow-Up Actions
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 13: Closing Meeting
|
||||
|
||||
| Attendees | |
|
||||
|-----------|---|
|
||||
| Date | |
|
||||
| Audit findings presented | ☐ Yes |
|
||||
| Questions addressed | ☐ Yes |
|
||||
|
||||
## Section 14: Signatures
|
||||
|
||||
| Auditor Signature | | Date | |
|
||||
|------------------|---|------|---|
|
||||
| Auditee Signature | | Date | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-006 Rev 1.0*
|
||||
0
Forms/School-Reports/.gitkeep
Normal file
0
Forms/School-Reports/.gitkeep
Normal file
393
Forms/School-Reports/FRM-SCH-001-IEP-Documentation-Form.md
Normal file
393
Forms/School-Reports/FRM-SCH-001-IEP-Documentation-Form.md
Normal file
@@ -0,0 +1,393 @@
|
||||
# IEP Documentation and Liaison Form
|
||||
|
||||
| Form ID | FRM-SCH-001 | Revision | 1.0 |
|
||||
|---------|-------------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Section 1: Student Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Student Name | |
|
||||
| Date of Birth | |
|
||||
| Current Age/Grade | |
|
||||
| School District | |
|
||||
| School Building | |
|
||||
| Medical Record Number | |
|
||||
|
||||
## Section 2: Parent/Guardian Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Parent/Guardian 1 Name | |
|
||||
| Phone | |
|
||||
| Email | |
|
||||
| Parent/Guardian 2 Name | |
|
||||
| Phone | |
|
||||
| Email | |
|
||||
|
||||
## Section 3: IEP Meeting Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| IEP Meeting Type | ☐ Initial ☐ Annual ☐ Triennial ☐ Amendment ☐ Other: _____ |
|
||||
| Meeting Date | |
|
||||
| Meeting Location | |
|
||||
| Our Practice Participation | ☐ In-person ☐ Virtual ☐ By phone ☐ Written input only |
|
||||
| Practice Representative | |
|
||||
|
||||
### IEP Team Members Present
|
||||
|
||||
| Role | Name | Present |
|
||||
|------|------|---------|
|
||||
| Parent/Guardian | | ☐ |
|
||||
| Special Education Teacher | | ☐ |
|
||||
| General Education Teacher | | ☐ |
|
||||
| School Administrator/LEA Rep | | ☐ |
|
||||
| School Psychologist | | ☐ |
|
||||
| Speech-Language Pathologist | | ☐ |
|
||||
| Occupational Therapist | | ☐ |
|
||||
| Physical Therapist | | ☐ |
|
||||
| Developmental Pediatrician | | ☐ |
|
||||
| Student (age-appropriate) | | ☐ |
|
||||
| Other: _____________ | | ☐ |
|
||||
|
||||
## Section 4: Eligibility Determination
|
||||
|
||||
### IDEA Eligibility Category (Primary)
|
||||
- [ ] Autism
|
||||
- [ ] Developmental Delay (ages 3-9)
|
||||
- [ ] Emotional Disturbance
|
||||
- [ ] Intellectual Disability
|
||||
- [ ] Multiple Disabilities
|
||||
- [ ] Other Health Impairment
|
||||
- [ ] Specific Learning Disability
|
||||
- [ ] Speech or Language Impairment
|
||||
- [ ] Other: _______________
|
||||
|
||||
### Additional Eligibility Categories (if applicable)
|
||||
|
||||
|
||||
|
||||
|
||||
### Evaluation Data Reviewed
|
||||
- [ ] Cognitive assessment
|
||||
- [ ] Autism diagnostic evaluation (ADOS-2, ADI-R)
|
||||
- [ ] Academic achievement testing
|
||||
- [ ] Speech-language evaluation
|
||||
- [ ] Occupational therapy evaluation
|
||||
- [ ] Physical therapy evaluation
|
||||
- [ ] Behavioral assessment
|
||||
- [ ] Medical information
|
||||
- [ ] Classroom observations
|
||||
- [ ] Parent input
|
||||
- [ ] Other: _______________
|
||||
|
||||
## Section 5: Present Levels of Performance
|
||||
|
||||
### Academic Performance Summary
|
||||
*(Strengths and areas of need)*
|
||||
|
||||
|
||||
|
||||
|
||||
### Functional Performance Summary
|
||||
*(Daily living skills, social-emotional, behavior, communication)*
|
||||
|
||||
|
||||
|
||||
|
||||
### How Disability Affects Educational Progress
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 6: IEP Goals and Objectives
|
||||
|
||||
### Goal #1
|
||||
**Area:** _______________
|
||||
|
||||
**Goal Statement:**
|
||||
|
||||
|
||||
|
||||
|
||||
**Measurable Objectives:**
|
||||
1.
|
||||
2.
|
||||
3.
|
||||
|
||||
**Progress Monitoring Method:**
|
||||
|
||||
**Progress Reporting Schedule:**
|
||||
|
||||
---
|
||||
|
||||
### Goal #2
|
||||
**Area:** _______________
|
||||
|
||||
**Goal Statement:**
|
||||
|
||||
|
||||
|
||||
|
||||
**Measurable Objectives:**
|
||||
1.
|
||||
2.
|
||||
3.
|
||||
|
||||
**Progress Monitoring Method:**
|
||||
|
||||
**Progress Reporting Schedule:**
|
||||
|
||||
---
|
||||
|
||||
*(Attach additional goals as needed)*
|
||||
|
||||
## Section 7: Special Education Services
|
||||
|
||||
| Service | Provider | Frequency | Duration | Location | Start Date |
|
||||
|---------|----------|-----------|----------|----------|------------|
|
||||
| | | | | | |
|
||||
| | | | | | |
|
||||
|
||||
### Service Delivery Models
|
||||
- [ ] Co-teaching/Push-in
|
||||
- [ ] Pull-out (resource room)
|
||||
- [ ] Self-contained classroom
|
||||
- [ ] Related services in general education
|
||||
- [ ] Community-based instruction
|
||||
- [ ] Other: _______________
|
||||
|
||||
## Section 8: Related Services
|
||||
|
||||
| Service | Provider | Frequency | Duration | Location | Start Date |
|
||||
|---------|----------|-----------|----------|----------|------------|
|
||||
| Speech-Language Therapy | | | | | |
|
||||
| Occupational Therapy | | | | | |
|
||||
| Physical Therapy | | | | | |
|
||||
| Counseling | | | | | |
|
||||
| Behavioral Support | | | | | |
|
||||
| Social Work Services | | | | | |
|
||||
| Assistive Technology | | | | | |
|
||||
| Other: ____________ | | | | | |
|
||||
|
||||
## Section 9: Accommodations and Modifications
|
||||
|
||||
### Instructional Accommodations
|
||||
- [ ] Extended time
|
||||
- [ ] Reduced distractions
|
||||
- [ ] Preferential seating
|
||||
- [ ] Visual supports/schedules
|
||||
- [ ] Chunking of assignments
|
||||
- [ ] Repeated/simplified directions
|
||||
- [ ] Use of assistive technology
|
||||
- [ ] Sensory breaks
|
||||
- [ ] Other: _______________
|
||||
|
||||
### Testing Accommodations
|
||||
- [ ] Extended time (specify: _____%)
|
||||
- [ ] Breaks during testing
|
||||
- [ ] Small group or separate setting
|
||||
- [ ] Read-aloud
|
||||
- [ ] Scribe
|
||||
- [ ] Use of calculator
|
||||
- [ ] Simplified language
|
||||
- [ ] Assistive technology
|
||||
- [ ] Other: _______________
|
||||
|
||||
### Modifications to Curriculum
|
||||
- [ ] Modified assignments
|
||||
- [ ] Alternate assessments
|
||||
- [ ] Reduced workload
|
||||
- [ ] Simplified content
|
||||
- [ ] Other: _______________
|
||||
|
||||
## Section 10: Behavioral Intervention Plan (BIP)
|
||||
|
||||
### BIP Status
|
||||
- [ ] BIP in place
|
||||
- [ ] BIP not required
|
||||
- [ ] FBA (Functional Behavioral Assessment) needed
|
||||
|
||||
### Target Behaviors (if BIP in place)
|
||||
|
||||
|
||||
|
||||
|
||||
### Behavioral Supports and Interventions
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 11: Participation in General Education
|
||||
|
||||
### Percentage of Day in General Education
|
||||
- [ ] 80% or more (inclusive)
|
||||
- [ ] 40-79%
|
||||
- [ ] Less than 40%
|
||||
- [ ] Separate setting
|
||||
|
||||
### Justification for Removal from General Education (if applicable)
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 12: Transition Planning (for students age 14+)
|
||||
|
||||
### Post-Secondary Goals
|
||||
**Education/Training:**
|
||||
|
||||
|
||||
|
||||
|
||||
**Employment:**
|
||||
|
||||
|
||||
|
||||
|
||||
**Independent Living:**
|
||||
|
||||
|
||||
|
||||
|
||||
### Transition Services Needed
|
||||
- [ ] Instruction
|
||||
- [ ] Related services
|
||||
- [ ] Community experiences
|
||||
- [ ] Employment and post-school objectives
|
||||
- [ ] Daily living skills (if appropriate)
|
||||
- [ ] Functional vocational evaluation
|
||||
|
||||
### Transition Service Providers
|
||||
|
||||
| Service | Provider/Agency | Contact |
|
||||
|---------|----------------|---------|
|
||||
| | | |
|
||||
|
||||
## Section 13: Extended School Year (ESY) Services
|
||||
|
||||
### ESY Determination
|
||||
- [ ] ESY services recommended
|
||||
- [ ] ESY services not needed
|
||||
|
||||
### ESY Services (if applicable)
|
||||
|
||||
| Service | Frequency | Duration |
|
||||
|---------|-----------|----------|
|
||||
| | | |
|
||||
|
||||
### Justification for ESY
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 14: Assessment Participation
|
||||
|
||||
### State/District Assessments
|
||||
- [ ] Regular assessment without accommodations
|
||||
- [ ] Regular assessment with accommodations
|
||||
- [ ] Alternate assessment
|
||||
|
||||
### Alternate Assessment Justification (if applicable)
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 15: Medical/Clinical Recommendations from Our Practice
|
||||
|
||||
### Key Clinical Findings Relevant to Education
|
||||
|
||||
|
||||
|
||||
|
||||
### Recommendations for School-Based Supports
|
||||
1.
|
||||
2.
|
||||
3.
|
||||
|
||||
### Suggested Accommodations Based on Diagnosis
|
||||
|
||||
|
||||
|
||||
|
||||
### Coordination with Medical/Therapeutic Services
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 16: Parent Concerns and Input
|
||||
|
||||
### Parent-Stated Priorities for IEP
|
||||
|
||||
|
||||
|
||||
|
||||
### Parent Concerns
|
||||
|
||||
|
||||
|
||||
|
||||
### Parent Agreement with IEP
|
||||
- [ ] Parent agrees with IEP
|
||||
- [ ] Parent has concerns (documented above)
|
||||
- [ ] Parent does not consent to IEP
|
||||
- [ ] Parent requests mediation/due process
|
||||
|
||||
## Section 17: Follow-Up and Coordination
|
||||
|
||||
### Our Practice Follow-Up Actions
|
||||
|
||||
| Action | Responsible | Target Date | Status |
|
||||
|--------|-------------|-------------|--------|
|
||||
| | | | |
|
||||
| | | | |
|
||||
|
||||
### Next IEP Review Date
|
||||
| Annual Review Due | |
|
||||
|-------------------|---|
|
||||
| Triennial Evaluation Due | |
|
||||
|
||||
### Coordination Notes
|
||||
*(Communication with school, therapy coordination, etc.)*
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 18: Documentation and Records
|
||||
|
||||
### Records Provided to School
|
||||
- [ ] Diagnostic evaluation report
|
||||
- [ ] Cognitive assessment report
|
||||
- [ ] Medical documentation
|
||||
- [ ] Treatment recommendations
|
||||
- [ ] Progress notes
|
||||
- [ ] Other: _______________
|
||||
|
||||
### Records Received from School
|
||||
- [ ] Current IEP
|
||||
- [ ] Progress reports
|
||||
- [ ] Teacher observations
|
||||
- [ ] School-based evaluation reports
|
||||
- [ ] Other: _______________
|
||||
|
||||
## Section 19: Signatures and Approvals
|
||||
|
||||
| Completed By | | Date | |
|
||||
|--------------|---|------|---|
|
||||
| Reviewed By (Provider) | | Date | |
|
||||
|
||||
---
|
||||
|
||||
## Section 20: Communication Log
|
||||
|
||||
| Date | Contact Person | Topic | Method | Notes |
|
||||
|------|---------------|-------|--------|-------|
|
||||
| | | | ☐ Phone ☐ Email ☐ Meeting ☐ Letter | |
|
||||
| | | | ☐ Phone ☐ Email ☐ Meeting ☐ Letter | |
|
||||
| | | | ☐ Phone ☐ Email ☐ Meeting ☐ Letter | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-SCH-001 Rev 1.0*
|
||||
0
Forms/Screening-Results/.gitkeep
Normal file
0
Forms/Screening-Results/.gitkeep
Normal file
@@ -0,0 +1,212 @@
|
||||
# Developmental Screening Summary Form
|
||||
|
||||
| Form ID | FRM-SCR-001 | Revision | 1.0 |
|
||||
|---------|-------------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Section 1: Child Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Child Name | |
|
||||
| Date of Birth | |
|
||||
| Age at Screening | |
|
||||
| Medical Record Number | |
|
||||
| Screening Date | |
|
||||
| Screened By | |
|
||||
|
||||
## Section 2: Parent/Guardian Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Parent/Guardian Name | |
|
||||
| Relationship to Child | |
|
||||
| Contact Phone | |
|
||||
| Email | |
|
||||
|
||||
## Section 3: Screening Tool(s) Administered
|
||||
|
||||
### Primary Screening Tool
|
||||
- [ ] ASQ-3 (Ages & Stages Questionnaires, 3rd Edition)
|
||||
- [ ] M-CHAT-R/F (Modified Checklist for Autism in Toddlers, Revised with Follow-Up)
|
||||
- [ ] PEDS (Parents' Evaluation of Developmental Status)
|
||||
- [ ] SWYC (Survey of Wellbeing of Young Children)
|
||||
- [ ] BRIGANCE Early Childhood Screens
|
||||
- [ ] Other: _______________
|
||||
|
||||
### Screening Tool Version/Age Range
|
||||
| Tool | Version | Age Range |
|
||||
|------|---------|-----------|
|
||||
| | | |
|
||||
|
||||
## Section 4: ASQ-3 Results (if applicable)
|
||||
|
||||
| Domain | Raw Score | Cutoff Score | Status |
|
||||
|--------|-----------|--------------|--------|
|
||||
| Communication | | | ☐ Above ☐ Monitoring ☐ Referral |
|
||||
| Gross Motor | | | ☐ Above ☐ Monitoring ☐ Referral |
|
||||
| Fine Motor | | | ☐ Above ☐ Monitoring ☐ Referral |
|
||||
| Problem Solving | | | ☐ Above ☐ Monitoring ☐ Referral |
|
||||
| Personal-Social | | | ☐ Above ☐ Monitoring ☐ Referral |
|
||||
|
||||
### Overall Concerns Section Results
|
||||
- [ ] No concerns indicated
|
||||
- [ ] Concerns noted: _______________
|
||||
|
||||
## Section 5: M-CHAT-R/F Results (if applicable)
|
||||
|
||||
### M-CHAT-R Initial Screening
|
||||
- Total Risk Items: _____ / 20
|
||||
- Critical Items: _____ / 6
|
||||
|
||||
### Initial Risk Level
|
||||
- [ ] Low Risk (0-2 total)
|
||||
- [ ] Medium Risk (3-7 total)
|
||||
- [ ] High Risk (8-20 total)
|
||||
|
||||
### Follow-Up Interview Conducted
|
||||
- [ ] Yes
|
||||
- [ ] No (not indicated)
|
||||
- [ ] Declined by family
|
||||
|
||||
### Follow-Up Results (if conducted)
|
||||
- Final Score after Follow-Up: _____
|
||||
- [ ] Passed screening
|
||||
- [ ] Failed screening - referral recommended
|
||||
|
||||
## Section 6: PEDS Results (if applicable)
|
||||
|
||||
### Concerns Identified
|
||||
- [ ] No concerns
|
||||
- [ ] Predictive concerns (Path A)
|
||||
- [ ] Non-predictive concerns (Path B)
|
||||
- [ ] Low concerns (Path C)
|
||||
- [ ] No concerns but parent comment/question (Path D)
|
||||
- [ ] No concerns, no questions (Path E)
|
||||
|
||||
### Recommended Path
|
||||
- [ ] Path A: Refer for diagnostic assessment
|
||||
- [ ] Path B: Screen further with developmental screening tool
|
||||
- [ ] Path C: Age-appropriate anticipatory guidance
|
||||
- [ ] Path D: Address specific question/concern
|
||||
- [ ] Path E: Continue routine surveillance
|
||||
|
||||
## Section 7: Developmental Domains Assessed
|
||||
|
||||
| Domain | Status | Notes |
|
||||
|--------|--------|-------|
|
||||
| Expressive Language | ☐ Typical ☐ Concern ☐ Delay | |
|
||||
| Receptive Language | ☐ Typical ☐ Concern ☐ Delay | |
|
||||
| Gross Motor | ☐ Typical ☐ Concern ☐ Delay | |
|
||||
| Fine Motor | ☐ Typical ☐ Concern ☐ Delay | |
|
||||
| Social-Emotional | ☐ Typical ☐ Concern ☐ Delay | |
|
||||
| Cognitive | ☐ Typical ☐ Concern ☐ Delay | |
|
||||
| Adaptive/Self-Help | ☐ Typical ☐ Concern ☐ Delay | |
|
||||
|
||||
## Section 8: Red Flags Observed
|
||||
|
||||
### Autism-Specific Red Flags
|
||||
- [ ] Limited eye contact
|
||||
- [ ] No response to name
|
||||
- [ ] Limited or no pointing
|
||||
- [ ] Limited social smiling
|
||||
- [ ] Unusual sensory interests
|
||||
- [ ] Repetitive behaviors
|
||||
- [ ] Other: _______________
|
||||
|
||||
### General Developmental Red Flags
|
||||
- [ ] Loss of previously acquired skills
|
||||
- [ ] Significant delay in milestones
|
||||
- [ ] Concerns about hearing or vision
|
||||
- [ ] Asymmetric movements
|
||||
- [ ] Parental intuition of concern
|
||||
- [ ] Other: _______________
|
||||
|
||||
## Section 9: Risk Factors
|
||||
|
||||
- [ ] Prematurity (<37 weeks gestation: _____ weeks)
|
||||
- [ ] Low birth weight (<2500g: _____ g)
|
||||
- [ ] NICU admission
|
||||
- [ ] Family history of developmental disorders
|
||||
- [ ] Environmental risk factors (poverty, exposure)
|
||||
- [ ] Medical conditions affecting development
|
||||
- [ ] Other: _______________
|
||||
|
||||
## Section 10: Overall Screening Result
|
||||
|
||||
### Summary Result
|
||||
- [ ] Passed - Development appears typical
|
||||
- [ ] Monitoring - Some concerns, rescreening recommended
|
||||
- [ ] Failed - Referral for comprehensive evaluation recommended
|
||||
|
||||
### Domains of Concern (if any)
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 11: Recommendations and Referrals
|
||||
|
||||
### Immediate Actions
|
||||
- [ ] Routine developmental surveillance at next well-child visit
|
||||
- [ ] Rescreening in _____ months
|
||||
- [ ] Referral for comprehensive developmental evaluation
|
||||
- [ ] Referral to Early Intervention (Part C Birth-to-Three)
|
||||
- [ ] Referral to Preschool Special Education (Part B)
|
||||
- [ ] Referral to specific services:
|
||||
- [ ] Speech-Language Therapy
|
||||
- [ ] Occupational Therapy
|
||||
- [ ] Physical Therapy
|
||||
- [ ] Audiology
|
||||
- [ ] Ophthalmology
|
||||
- [ ] Other: _______________
|
||||
|
||||
### Referrals Made
|
||||
|
||||
| Service/Provider | Referral Date | Contact Information |
|
||||
|-----------------|---------------|---------------------|
|
||||
| | | |
|
||||
| | | |
|
||||
|
||||
### Parent Education Provided
|
||||
- [ ] Age-appropriate developmental milestones discussed
|
||||
- [ ] Activities to promote development reviewed
|
||||
- [ ] Resources provided (handouts, websites, community programs)
|
||||
- [ ] Follow-up plan explained
|
||||
|
||||
## Section 12: Parent Communication
|
||||
|
||||
### Discussion with Parent/Guardian
|
||||
- Screening results explained: ☐ Yes
|
||||
- Questions answered: ☐ Yes
|
||||
- Recommendations discussed: ☐ Yes
|
||||
- Written summary provided: ☐ Yes
|
||||
|
||||
### Parent Response
|
||||
- [ ] Agrees with recommendations
|
||||
- [ ] Has questions (documented below)
|
||||
- [ ] Declines recommendations
|
||||
- [ ] Requests additional information
|
||||
|
||||
### Notes
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 13: Follow-Up Plan
|
||||
|
||||
| Follow-Up Action | Responsible Person | Target Date |
|
||||
|------------------|-------------------|-------------|
|
||||
| | | |
|
||||
| | | |
|
||||
|
||||
## Section 14: Signatures
|
||||
|
||||
| Screener Signature | | Date | |
|
||||
|-------------------|---|------|---|
|
||||
| Reviewed By (Provider) | | Date | |
|
||||
| Parent Acknowledgment | | Date | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-SCR-001 Rev 1.0*
|
||||
Reference in New Lab Ticket
Block a user