Children's Integrated Services (CIS) Reimbursable Early Childhood Education and Afterschool Consultation and Education (C&E) Report

Children's Integrated Services (CIS) Reimbursable Early Childhood Education and Afterschool Consultation and Education (C&E) Report

Please begin submitting CIS Reimbursable C&E Reports after at least three sessions of at least 45-minutes each. Reports are due monthly, within 30 days of the end of the reporting month. New reports should be completed if there is a change in the regulated program’s primary concerns, lead program staff and/or director or CIS Primary Service Coordinator, or in the CIS Primary Service Coordinator's evidence-informed practices or evidence-based model. Please bring any questions about this reporting form to the CIS State Team.
Fiscal Agent name: *
Regulated program (early childhood education or afterschool) name:*
Regulated program type:*
Regulated program's License number:*
Regulated program's CIS referral date:*

MonthDayYear
Date
Date of regulated program director's written consent to initiate CIS C&E as a One Plan (or equivalent) service:*

MonthDayYear
Date
CIS Primary Service Coordinator’s first and last name: *
The CIS Primary Service Coordinator is the point person for all regional CIS Reimbursable Early Childhood Education C&E efforts related to this regulated program during this time period.
CIS Primary Service Coordinator’s email address:*
Is this a Head Start Program?*

YesNo
What is the regulated program's current STARS Level?*
Is this a Specialized Child Care Program?*

YesNo
Please review primary concerns periodically. Provide a brief description of this regulated program’s primary concern(s): *
Regulated program’s primary contact first and last name*
The primary contact is a person involved in the CIS Reimbursable C&E. This could be the regulated program's director or other designated staff member.
Email address for regulated program's primary contact:*
Please select the evidence-informed practice(s) or evidence-based model(s) that primarily guides this CIS Reimbursable C&E:*

Assessment Process
Please describe the pre-assessment process for this CIS Reimbursable C&E:*
Please describe the planned post-assessment process for this CIS Reimbursable C&E:*
If this is the initial report for a regulated program (following a new referral or significant changes in primary concerns, lead program staff, CIS Primary Service Coordinator, and/or CIS' evidence-informed practices or evidence-based model), please upload their pre-assessment results:

Cancelof
Has the program exited CIS Reimbursable C&E? Significant changes (e.g., in the regulated program’s primary concerns, lead program staff and/or director or CIS Primary Service Coordinator, or in the CIS' evidence-informed practices or evidence-based model) are counted as a “withdrawn” exit (with notice and without all goals met).*

YesNo
Did the regulated program exit due to "Lost to Follow-up?":

YesNo
Please upload the program's post-assessment results along with any notes and interpretation:

Cancelof
For regulated programs that exited due to Lost to Follow-up, please upload a progress report regarding area(s) of concern/goals and including any notes and interpretation.

Cancelof
Has the CIS Primary Service Coordinator delivered C&E services with this regulated program for 6 or more consecutive months without changes in the program's primary concern(s), the program's lead staff/director, CIS' Primary Service Coordinator, or CIS' evidence-informed practices or evidence-based model?*

YesNo
Please upload interim assessment results for regulated programs receiving at least 6 months of CIS Reimbursable C&E.

Cancelof
Do you have another program to report on?*

YesNo

Additional Programs

Program #2
Regulated (early childhood education or afterschool) program name:*
Regulated program type:*
Regulated program's BFIS Provider ID number:*
Regulated program CIS referral date:*

MonthDayYear
Date
CIS Primary Service Coordinator’s first and last name: *
The CIS Primary Service Coordinator is the point person for all regional CIS Reimbursable C&E efforts related to this regulated program during this time period.
CIS Primary Service Coordinator's email address:*
Is this a Head Start Program?*

YesNo
What is the program's current STARS Level?*
Is this a Specialized Child Care Program?*

YesNo
Please review primary concerns periodically. Provide a brief description of this regulated program’s primary concern(s): *
Regulated program’s primary contact first and last name*
The primary contact is a person involved in the CIS Reimbursable C&E. This could be the Program Director or other designated program staff member.
Email address for program's primary contact:*
Please select the evidence-informed practice(s) or evidence-based model(s) that primarily guides this Reimbursable C&E:*

Program #2 Assessment Process
Please describe the pre-assessment process for this CIS Reimbursable C&E:*
Please describe the planned post-assessment process for this CIS Reimbursable C&E:*
If this is the initial report for a regulated program (following a new referral or significant changes in primary concerns, lead program staff, CIS Primary Service Coordinator, and/or CIS' evidence-informed practices or evidence-based model), please upload their pre-assessment results:

Cancelof
Has the program exited CIS Reimbursable C&E? Significant changes (e.g., in the regulated program’s primary concerns, lead program staff and/or director or CIS Primary Service Coordinator, or in the CIS' evidence-informed practices or evidence-based model) are counted as a “withdrawn” exit (with notice and without all goals met).*

YesNo
Did the regulated program exit due to "Lost to Follow-up?":

YesNo
Please upload the program's post-assessment results along with any notes and interpretation:

Cancelof
For regulated programs that exited due to Lost to Follow-up, please upload a progress report regarding area(s) of concern/goals and including any notes and interpretation.

Cancelof
Has the CIS Primary Service Coordinator delivered C&E services with this regulated program for 6 or more consecutive months without changes in the program's primary concern(s), the program's lead staff/director, CIS' Primary Service Coordinator, or CIS' evidence-informed practices or evidence-based model?*

YesNo
Please upload interim assessment results for regulated programs receiving at least 6 months of CIS Reimbursable C&E.

Cancelof

Do you have another program to report on?*

YesNo
Additional Programs

Program #3
Regulated (early childhood education or afterschool) program name:*
Regulated program type:*
Regulated program's BFIS Provider ID number:*
Regulated program CIS referral date:*

MonthDayYear
Date
CIS Primary Service Coordinator’s first and last name: *
The CIS Primary Service Coordinator is the point person for all regional CIS Reimbursable C&E efforts related to this regulated program during this time period.
CIS Primary Service Coordinator's email address:*
Is this a Head Start Program?*

YesNo
What is the program's current STARS Level?*
Is this a Specialized Child Care Program?*

YesNo
Please review primary concerns periodically. Provide a brief description of this regulated program’s primary concern(s): *
Regulated program’s primary contact first and last name*
The primary contact is a person involved in the CIS Reimbursable C&E. This could be the Program Director or other designated program staff member.
Email address for program's primary contact:*
Please select the evidence-informed practice(s) or evidence-based model(s) that primarily guides this Reimbursable C&E:*
Please provide the other evidence-informed practice or evidence-based model that primarily guides your practice:

Program #3 Assessment Process
Please describe the pre-assessment process for this CIS Reimbursable C&E:*
Please describe the planned post-assessment process for this CIS Reimbursable C&E:*
If this is the initial report for a regulated program (following a new referral or significant changes in primary concerns, lead program staff, CIS Primary Service Coordinator, and/or CIS' evidence-informed practices or evidence-based model), please upload their pre-assessment results:

Cancelof
Has the program exited CIS Reimbursable C&E? Significant changes (e.g., in the regulated program’s primary concerns, lead program staff and/or director or CIS Primary Service Coordinator, or in the CIS' evidence-informed practices or evidence-based model) are counted as a “withdrawn” exit (with notice and without all goals met).*

YesNo
Did the regulated program exit due to "Lost to Follow-up?":

YesNo
Please upload the program's post-assessment results along with any notes and interpretation:

Cancelof
For regulated programs that exited due to Lost to Follow-up, please upload a progress report regarding area(s) of concern/goals and including any notes and interpretation.

Cancelof
Has the CIS Primary Service Coordinator delivered C&E services with this regulated program for 6 or more consecutive months without changes in the program's primary concern(s), the program's lead staff/director, CIS' Primary Service Coordinator, or CIS' evidence-informed practices or evidence-based model?*

YesNo
Please upload interim assessment results for regulated programs receiving at least 6 months of CIS Reimbursable C&E.

Cancelof

I certify that the information contained in this report for Reimbursable Early Childhood Education and Afterschool Consultation and Education is true and correct.
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Children's Integrated Services (CIS) Reimbursable Early Childhood Education and Afterschool Consultation and Education (C&E) Report

Dates of Service

Assessment Process

Additional Programs

Program #2 Dates of Service

Program #2 Assessment Process

Additional Programs

Program #3 Dates of Service

Program #3 Assessment Process