Heading Description Points Earned Points Possible Basic Information Provide pseudonym of childs name. Give date of birth and date of screening. State the childs chronological age at the date of testing. If the child is less than 2 years old, please report the childs age in months and days. If the child is 2 years or older, please report the childs age in years and months. Include pseudonyms of the parent(s) or guardian(s) completing the screening and the name of the individual completing the report (you). 5 Reason for Referral and Screening History Indicate the reason the child was referred for screening. If you completed the screening for this course, in order to practice giving a developmental screener, please state this explicitly. If you completed the screening with a child whose parents and/or teacher had developmental concerns, please state the details of those concerns. Note any previous developmental screening results. May include hearing, vision, general developmental, or autism screening results. 2 Background Information Describe the childs family constellation, including parent(s), guardian(s), siblings, and extended family. Note activities that the child and his or her family enjoy doing at home and in the community. 3 Screening Tool and Administration Provide the full name of the developmental screening tool, the version (edition and date of publication), and the purpose of the tool. Describe the familys involvement in the assessment process (., did more than one caregiver answer questions, did they try the skills with the child first, who recorded the responses on the tool, did they ask any questions about or discuss particular items). 5 Screening Results Provide a table of the screening results with columns for the cutoff, total score, and score interpretation. Also include a narrative description of the screening results by domain. Note the score received for each domain and what it means for each domain. Each domains narrative description should include specific examples of skills in each domain that the child was capable of completing and those that he or she is not yet doing based on his or her performance on the screener. The last paragraph should describe the childs overall development, using quantitative information about whether or not the child scored above the cutoff as well as qualitative information from the parent or guardians comments to open-ended questions. This paragraph should conclude with a description of what next steps are required at this time (., screening at next scheduled screening interval at the childs well-child check up, screening in 2 months, immediate referral, no further assessment at this time) and how you shared these results with the family. 10 Recommend-ations Provide at least 1 original bulleted recommendation per domain for activities that the childs parents or guardians could do with the child to address areas in which he or she is not yet performing skills and/or skills that are expected in the next stage of development. Activities should be developmentally appropriate and easy for parents to embed into typical routines (., going for a walk, dinnertime). 10 Reflection Provide a paragraph about your experience administering the screening tool. What did you like about the process? What did you dislike? What did you learn about screening? 10 Overall Organization Screening tool completed thoroughly and attached to written report and consent form. Includes writing and drawing samples as appropriate for the age interval. Screening tool matched the chronological age of the child. Written report organized with headings. Few spelling and grammatical errors. Avoids use of subjective language indicating personal judgment of child and/or family, whether positive or negative. Provides a signature line and signs/dates the bottom of the report.
