Application for Approval of Individual Evaluators, Service Providers and Service Coordinators

Instructions

Introduction

The process described below is for completion of the application for approval of early intervention evaluators, service providers and service coordinators for the statewide Early Intervention Program under Title II-A of Article 25 of the Public Health Law. The following references may be of assistance when completing the application:

Submit one completed Application with original signatures to:

New York State Department of Health
Bureau of Early Intervention
Empire State Plaza
Corning Tower, Room 287
Albany, New York 12237-0660

An applicant must submit an application with all schedules and assurances completed and with all required signatures and notarizations to be considered for approval. This application form is to be used by individuals seeking approval as early intervention service providers and/or supplemental evaluators and/or service coordinators. Staff within the NYSDOH Bureau of Early Intervention will review the application for completeness. If the application is incomplete, the application and all attachments will be returned to the applicant with a letter stating what additional information is required for approval. The application must be notarized again prior to resubmission. When an application is determined to be complete, it will be reviewed. The applicant will receive notification of approval or disapproval upon completion of the review process.

Schedule 1 – General Information

  1. Applicant Identification – Enter name, address, social security number, telephone number, and fax number (if available), in the appropriate space. If you will be delivering services at a location other than the address initially listed, provide the address and phone number of the site or sites.
  2. Personal Qualifying Information – Complete all the information in this section. If your license, registration, or certification was ever suspended or revoked, describe the circumstances, the corrective actions taken for reinstatement, and date of reinstatement. Attach additional sheets to the application, if necessary. A copy of your current certification or registration must be included with the application form. Failure to do so will automatically render the application incomplete, and it will be returned.
  3. In-service/Continuing Education – Indicate any educational program(s) (not part of your degree program) focusing on early intervention for infants and toddlers and their families, which you have attended during the previous three years. Include the name or title of the program, as well as a brief statement as to topics covered and dates of attendance. Attach additional sheets of paper, if necessary.
  4. Employment History – Specify employment history (including ages of children to whom you provided services and specific employment dates) for the past five years. You must have a minimum of two years of experience providing services to infants and toddlers with, or at risk of, developmental delay or disability. Attach additional sheets, if necessary. (A copy of a current resume is sufficient, if it lists specific experience with infants and toddlers.)
  5. Record of Legal Actions – Except for minor traffic violations, describe any criminal or other charges of which you have been convicted or which are pending. "Other charges" may refer to charges of a criminal or civil nature, malpractice, child abuse or maltreatment. Attach additional sheets, if necessary.

Schedule 2 – Service Provision

  1. Indicate the service(s) you are seeking approval for including (for definitions see next page):
    1. Supplemental Evaluation Services
    2. Service Coordination
    3. Service Provision – Indicate from the service models (a through e) all those for which you are seeking approval. If you will provide any services in a site operated by you, you must attach emergency evacuation procedures, and health and safety policies for each site. Health and safety policies must address infection control, management of infectious diseases, sanitation, and reporting of suspected child abuse or neglect.
  2. Indicate in what language(s) you can provide services, other than English.

Schedule 3 – Service Catchment Area

Indicate all counties for which you are seeking approval to provide early intervention services. If those counties are not in proximity to your geographic address, please explain how you will be able to provide services over this extensive area.

Schedule 4 – Qualified Personnel

Indicate your availability in full-time equivalents (FTE) to provide evaluations, service coordination and early intervention services. Calculate the FTE by dividing the total number of hours per week you are available to provide early intervention services by 40 (e.g., 40 hrs=1.0 FTE; 20 hrs=. 5 FTE, etc.). Only those hours during which you are available to provide services to infants and toddlers ages birth to three years of ages with disabilities and their families should be used to calculate the FTE. The total FTE on this schedule cannot exceed 40 hours a week or 1.0 FTE.

Schedule 5 – Assurances

To receive approval, you must provide assurances that you will comply with all applicable state and federal regulations ("A" through "H"), and that the information contained in the application is correct. Signatures must be original and the application must be notarized.

Definitions

Caregiver

Caregiver refers to the individual responsible for the care of this child such as parent, family day care provider, or baby sitter.

Natural Environments

Natural environments refer to settings that are natural or normal for the child's peers who have no disability. These settings include the home; a relative's home when care is delivered by the relative; a childcare setting; or any other community setting in which children without disabilities participate.

Qualified Personnel

Qualified personnel refers to those individuals who have appropriate licensure, certification or registration in the discipline they are providing services, and are approved to deliver services to eligible children, to the extent authorized by their licensure, certification, or registration. The following may be qualified personnel providing services under the Early Intervention Program:

  1. audiologists
  2. licensed practical nurses, registered nurses and nurse practitioners
  3. optometrists with proven competency as low vision specialists
  4. occupational therapists
  5. orientation and mobility specialists
  6. physical therapists
  7. physicians
  8. psychologists
  9. registered dietitians
  10. social workers
  11. special education teachers
  12. speech and language pathologists
  13. teachers of the blind and partially sighted
  14. teachers of the deaf and hearing impaired
  15. teachers of speech and hearing handicapped

Service Coordination

Assistance and services provided by a service coordinator to enable an eligible child and the child's family to receive the services that are authorized to be provided under the Early Intervention Program.

Supplemental Evaluations

Supplemental evaluations refer to physician and non-physician supplemental evaluations.
Supplemental physician evaluation refers to an evaluation by a licensed physician for the purpose of providing specific medical information regarding physical or mental conditions that may impact on the growth and development of the child. If the supplemental evaluation requires a specialist, e.g., child neurologist, developmental pediatrician, orthopedist, psychiatrist, etc., the physician must be board certified. If board certification is not applicable in that specialty, the physician must show evidence of advanced training in the specialty.

Supplemental non-physician evaluation refers to an additional evaluation for the purpose of providing supplemental information regarding a specific area of delay in the child's development. Information obtained from this evaluation provides direction as to the specific early intervention services that may be required for the child. Supplemental non-physician evaluations may only be conducted by the following qualified personnel: special educators, audiologists, physical therapists, occupational therapists, registered nurses, nurse practitioners, registered dieticians, psychologists, social workers, and speech-language pathologists.

Models Of Early Intervention Service Delivery

  1. Home and community based individual/collateral visits
    Home and community based individual/collateral visits refers to the provision by appropriate qualified personnel of early intervention services to the child and/or parent or other designated caregiver at the child's home or any other natural environment in which children under three years of age are typically found (including day care centers and family day care homes).
  2. Facility-based individual/collateral visits
    Facility-based individual/collateral visits refers to the provision by appropriate qualified personnel of early intervention services to the child and/or parent or other designated caregiver at an approved early intervention provider's site.
  3. Parent/child groups
    Parent child groups refers to a group comprised of parents or caregivers, children and a minimum of one appropriate qualified provider of early intervention services at an early intervention provider's site or a community based setting (e.g., day care center, family day care, community center).
  4. Group developmental intervention
    Group developmental intervention refers to the provision of early intervention services by appropriate qualified personnel to a group of eligible children at an approved early intervention provider's site or in a community based setting (e.g., day care center, family day care, community center). This group may also include children without disabilities.
  5. Family/caregiver support group
    Family/caregiver support group refers to the provision of early intervention services to a group of parents, caregivers (foster parents, day care staff, etc.) and/or siblings of eligible children for the purpose of:
    1. enhancing their capacity to care for and/or enhance the development of the eligible child;
    2. providing support, education and guidance to such individuals relative to the child's unique developmental needs.

Inquiries concerning the application can be directed to the New York State Department of Health, Bureau of Early Intervention at (518) 473-7016.