Closing Interview Information from Providers for EDT Representative
Cluster B - First Steps of Northeast Indiana

Provider: Please fill out and send back to the ED team representative
Please indicate (circle, or highlight if using on computer) the following next to each question:
2 – Had the skill
1 – Emerging skill
0 – Does not have the skill

Date:

Provider name and discipline:

Child’s name and ID #:

ED Team representative name:

Fine Motor:

2 1 0 Brings hands to midline
2 1 0 Brings objects to midline
2 1 0 Grasps hand size object using ends of thumb, index finer and second fingers
2 1 0 Uses a pincer grasp
2 1 0 Aligns and stacks objects
2 1 0 Rotates wrist to twist off top or turn puzzle piece to fit space
2 1 0 Assemble – top on bottle, or puzzle (simple) together, or pop beads together
2 1 0 Uses either index finger to activate objects
2 1 0 Orients a picture book and turns pages
2 1 0 Copies simple shapes

Gross Motor:

2 1 0 Turns head, moves arms, kicks legs independently
2 1 0 Rolls by turning segmentally from stomach to back to stomach
2 1 0 Creeps forward using alternating legs and arms
2 1 0 Assumes balanced sitting position (not W sitting)
2 1 0 Sits down in and gets out of chair
2 1 0 Walks avoiding obstacles
2 1 0 Stoops and regains balanced standing position without support
2 1 0 Runs avoiding obstacles
2 1 0 Walk up and down stairs independently, with rail, wall or hand held
2 1 0 Jumps forward
2 1 0 Pedals and steer a tricycle
2 1 0 Catches, kicks, throws and rolls a ball (must do all four)
2 1 0 Climbs up and down play equipment

Closing Interview continued

Adaptive:

2 1 0 Uses tongue and lips to take in and swallow solid food and liquids
2 1 0 Bites and chews hard and chewy foods
2 1 0 Drinks from an open cup, holds by self and does not spill
2 1 0 Eats with fork and/or spoon
2 1 0 Transfers food and liquid between containers (not spill or overfill)
2 1 0 Initiates toileting
2 1 0 Washes and dries hands independently
2 1 0 Brushes teeth independently
2 1 0 Undresses independently: must take off all of the following –
Hat, socks, shoes, pants, shirt, and jacket (can be unzipped for them)





Cognitive:

2 1 0 Orients to sights, sounds, touch (must do all three)
2 1 0 Visually follows object and/or person to point of disappearance
2 1 0 Locates object in latter of two successive hiding places
2 1 0 Maintains search for object that is not in its usual location
2 1 0 Correctly activates a mechanical toy
2 1 0 Reproduces part of an interactive game or song to continue activity
2 1 0 Imitates uncommon motor actions
2 1 0 Imitates not commonly used words
2 1 0 Retains objects when new object is obtained
2 1 0 Uses an object to get another ( pushes a stool or toy to stand on to reach another)
2 1 0 Navigates large object around barriers (stroller around furniture)
2 1 0 Solves common problems (gets help, or tries a variety of ways to solve)
2 1 0 Uses imaginary play (not pretend play with objects, but without objects and just makes up situation)
2 1 0 Puts objects into categories
2 1 0 Demonstrates one to one correspondence (gives one to each person)
2 1 0 Demonstrates functional use of reading materials
2 1 0 Demonstrates 6 opposite pairs (i.e. hot/cold, on/off, under/over, up/down, day/night, big/little, in/out)
2 1 0 Repeats simple nursery rhymes






Closing Interview continued

Social Communication:

2 1 0 Turns and looks at speaker
2 1 0 Establishes joint gaze (Make eye contact with them, say look, and look at something without pointing, and see if they follow your gaze)
2 1 0 Engages in two or more babbling or spoken word exchanges
2 1 0 Gains attention, and refers to a person, object or event (should use some gesture if appropriate)
2 1 0 Uses 10 or more consistent word approximations (if uses five, then scores a one)
2 1 0 Locates 20 or more objects, pictures or events without a cue
2 1 0 Follows 2 step directions without a visual cue
2 1 0 Use 50 words – must have all of the following:
3 proper names
15 object names
2 pronouns
5 action words (verbs)
5 descriptive words (adjectives)
if has part of each category, then the whole section only scores a ONE
2 1 0 Uses 2 word phrases
2 1 0 Uses 3 words phrases



Social:

2 1 0 Responds appropriately to familiar adult’s affect (facial expressions, gestures, or tone of voice)
2 1 0 Initiates AND maintains interaction (2 or more exchanges) with adults
2 1 0 Initiates AND maintain communication (2 or more exchanges) with adults
2 1 0 Meets own needs in daily situations (hunger, thirst, fatigue, upset, bathroom)
2 1 0 Participates in social routines
2 1 0 Initiates AND maintains interaction (2 or more exchanges) with peers
2 1 0 Initiates AND maintain communication (2 or more exchanges) with peers



THANK YOU SO MUCH FOR YOUR HELP WITH THIS EXIT INFORMATION!!




2/13/08 NECC approved