ITCVA Resource Library

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  • Procedural Safeguards Documents

    Procedural Safeguards Forms and Templates

    • Confirmation of IFSP Schedule (1048A) PDF | DOC

    • Confirmation of Scheduled Meetings/Activities (1048) PDF | DOC

    • Declining Early Intervention Services (1050A) PDF | DOC

    • Family Cost Share (FCS) Agreement (1229) PDF | DOC

    • Family Cost Share TEMPORARY Agreement (1229A) PDF | DOC

    • Family Cost Share Appeal (1230) UPDATED 2021-07-09 PDF | DOC

    • Family Cost Share Fee Scale (3143) PDF

    • Notice and Consent to Determine Eligibility (3145) PDF | DOC

    • Notice and Consent for Assessment for Service Planning (3152) PDF | DOC

    • Notice of Action DMAS EI Services (3153) PDF | DOCX

    • Notice to DMAS: Family Declining to Bill Private Insurance (3141) PDF | DOC

    • Parental Prior Notice (1047A) PDF | DOC

  • Activity Notes

    • Intervention Activity Note Option 1 (3144 V1) PDF

    • Intervention Activity Note Option 2 (3144 V2) PDF

    Eligibility Determination

    • Eligibility Determination (3142) PDF | DOC

    ICDF

    • ICDF (Individual Child Data Form) (1137) PDF | DOCX

    IFSP

    • IFSP (Individualized Family Service Plan) (1044) PDF | DOCX

    • IFSP (Individualized Family Service Plan) (TRAC-IT Version 2022-09) | DOCX

    • IFSP Summary Letter (3223A) DOC

    • IFSP Review Summary Letter (3223B) DOC

    Memorandum of Agreement

    • State MOA with Guidance for Local Systems DOCX

    Physician Certification

    • Physician Certification Letter (3146) PDF | DOC

    • Physician Certification w/ Health Indicator Questions (3227) PDF | DOC

    • Physician Communication re: Health Indicator Questions (3228) PDF | DOC

    Referral

    • Acknowledgement to Referral Source (0023) PDF | DOC

    • Referral Form - NON-Physician (3149) PDF | DOC

    • Referral Form - Physician (3094) PDF

    • Referral Form Instructions - Physician (3094A) PDF

    Screening

    • Hearing Screening Form (3022) PDF | DOC

    • Hearing Screening Form Instructions (3022A) PDF

    • Vision Screening Form (3021) PDF | DOC

    • Vision Screening Form Instructions (3021A) PDF

    Service Coordination

    • Initial EI Service Coordination Plan (3226) PDF | DOC

    Surrogate Parents

    • Notice to Biological Adoptive Parent (0013) PDF | DOC

    • Surrogate Parent Identification of Need (3150) PDF | DOC

    • Surrogate Parent Appointment (0021) PDF | DOC

    • Surrogate Parent Termination (0022) PDF | DOC

    Texting

    • Permission for Texting (0011) PDF

  • Please refer to the Quicklinks section on the Child Outcomes & Functional Assessment page of our website. Thank you.

  • Family Outcomes and the Family Survey: Improving Experiences and Outcomes for Families in Early Intervention

    Family Survey 2023

    • Family Survey Flyer 2024 | ENGLISH & SPANISH PDF

    • Family Survey ENGLISH PDF | SPANISH PDF

    • Coaching in Action Checklist PDF

    • Coaching in Action Checklist: Tips & Clarifications PDF

    • Fidelity Assessment FAQs PDF

    • Fidelity Assessment Implementation At-A-Glance PDF

    • Local Coaching Fidelity Assessment Report ANY YEAR

    • Preparing for Fidelity Assessment: A Webinar for Observers and Supervisors LINK

    • Preparing for Fidelity Assessment: A Webinar for Providers LINK

    • Video Recording Guidelines PDF

  • General Monitoring and Supervision

    • Local System Manager (LSM) Handbook PDF UPDATED 2021-10

    • ITOTS Reports for Local System Monitoring PDF

    • Quarterly Data Verification Reports: What? Why? How? PDF

    • Quality Record Review Tool PDF

    Child and Family Outcomes

    • Toolkit for Analysis of Child and Family Outcomes PDF

    • Relationship of Quality Practices to Child and Family Outcome Measurement Results VIRGINIA PDF | NATIONAL PDF

    Compliance Indicators

    • IND 01 (Timely Initiation of Services) - Tracking Timeliness of Service Delivery EXCEL

    • IND 07 (45-Day Timeline) - Tips for Monitoring Compliance PDF

    • IND 08 (Transition) - Tips for Monitoring Compliance PDF

    Fiscal Monitoring and Oversight

    • Data Entry and Notification Requirements for the Medicaid EI Benefit YouTube

    • How to Complete Your Initial Fiscal Form YouTube

    • How to Complete Your Mid-Year and End-of-Year Fiscal Form YouTube

    • How to Complete Your Federal Balance Report PDF

    • How to Make a Budget Revision YouTube

    • How to Complete the Therapy Provider Report YouTube

    Improvement Planning

    • ITCVA Improvement Plan Template DOCX

  • These documents outline steps local system managers, supervisors, and fiscal officers can take to orient themselves to the Infant & Toddler Connection of Virginia's early intervention system and administration.

    • EI Case Management Experience Log (3148-A) PDF | DOC

    • EI Training Record (3148-B1) PDF | DOC UPDATED 2021-07-09

    • EI Training Record Sample (3148-B2) PDF

  • Developed by/for Virginia

    • Public Awareness Order Form PDF

    • What Is Early Intervention? Flyer ENGLISH PDF | SPANISH PDF

    • ITCVA Poster (ENGLISH & SPANISH) PDF

    • Public Awareness Materials Printing Instructions PDF

    • ITCVA Logo PNG

    • Virginia Best Practice Protocol for Hospitals Referring to ITCVA PDF

    • On Your Way - Skill-Building Worksheets for Families and Caregivers PDF

    Other Materials and Resources

    • CDC Developmental Milestones Brochure PDF

    • Local ITC Systems Map PDF

    • HIPAA Security Awareness Training PDF

    • Virginia Interagency Memorandum of Agreement 2013-05 PDF

  • Over the years a number of core EI documents (e.g., procedural safeguards forms, the IFSP, etc.) have been translated into a number of languages. Use the links below to download ZIP files of the documents available in each language.