Forms

Authorization to release information form in Spanish, developed by Ottawa ISD, undergoing approval by the Michigan Department of Education.

Approved Authorization to Release Information form.

A new Authorization to Share Information Form was created by the Michigan Department of Education along with the departments of Community Health and Human Services. Federal requirements in each agency have increased the need to share information across systems. It was realized that the current Authorization to Share Information Form was not adequate to address the additional data requirements. The departments created and sent the form to the Office of Special Education Programs (OSEP) in Washington, DC. OSEP has approved the form for use in Part C of the Individuals with Disabilities Education Act (IDEA) known in Michigan as Early On. In addition, both the Michigan Department of Community Health and the Michigan Department of Human Services has approved this form; making it FERPA (Family Educational Rights and Privacy Act) and HIPAA (Health Insurance Portability and Accountability Act) compliant.

The Michigan Department of Education is requiring all Early On service areas to use this new Authorization to Share Information Form. This form will go into effect on July 1, 2009.

A new Authorization to Share Information Form was created by the Michigan Department of Education along with the departments of Community Health and Human Services. Federal re ... More[+]

The Early On Authorization to Share Information Form was modified to allow state agencies, as well as local agencies, to be able to participate in sharing information related to Early On. This prototype replaces the previous state prototype dated 9/11/2008. It has been reviewed by experts in the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA), and has been deemed HIPAA and FERPA compliant.

This form may be used by Early On personnel, partner agencies, primary referral sources, and others supporting implementation of Early On. A parent/guardian of a child enrolling in Early On must sign this form to indicate that he/she is either agreeing to or refusing to share personally-identifiable information.

The Early On Authorization to Share Information Form was modified to allow state agencies, as well as local agencies, to be able to participate in sharing information r ... More[+]

Child Outcomes Ratings for the Preemie Survey

Approved Consent to Evaluate form.

Consent for evaluation for eligibility determination, in Spanish, developed by Ottawa ISD, undergoing approval by the Michigan Department of Education.

The Michigan Department of Education approved prototye for the Individualized Family Service Plan and Individualized Education Plan for Early On^® Michigan. Approved after public comment, June, 2008 Updated 06/26/08

The Michigan Department of Education approved prototye for the Individualized Family Service Plan and Individualized Education Plan for Early On^® ... More[+]

Guidelines for completing the state approved IFSP/IEP

This "green form", developed collaboratively by state agencies, may be used for Early On health status. It has places for hearing, vision, diagnoses, and health-related issues.

This "green form", developed collaboratively by state agencies, may be used for Early On health status. It has places for hearing, vision, diagnoses, and health-relate ... More[+]

A checklist for vision and hearing screening that may be used when vision and hearing equipment is not available.