### 1 of 6 TABLE 1 REPORT OF CHILDREN RECEIVING EARLY INTERVENTION SERVICES IN ACCORDANCE WITH PART C Specific State
- Designated Date Between October 1 and December 1 of **2014 1** 

Paperwork Burden Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average **4 2**  hours per State response, including time for revi ewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit (P.L. 108.44 6 Section 618) . Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave ., SW, Washington, DC 20202
- 4536 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1820
- 0557. Note: Please do not return the completed Report on Children Receiving Early Intervention Services in Accordance with Part C form to this address. **All States must submit these data via the IDEA Part C Child Count and Setting survey**  **in the ED**  **Facts online survey tool, EMAPS.**  Instructions Authorization: 20 U.S.C. 14 18 (a)(1)(B), (a)(2), and (a)(3) and 1435(c)(3) Due Date: **April 1 , 201**  **5** Sampling Al lowed: No General Instructions 1. Report the number of eligible children receiving early intervention services according to an active individualized family service plan (IFSP ) in place on the count date in Sections A, B, and C
. **2** This must be an unduplicated count within each State ; each child is counted once and only once within the State
. 2. The count date for Sections A, B, and C is a state
- designated date between October 1, **2014** and December 1, **2014** (inclusive), and that date should remain consistent e ach year . 3

1 **This collection also includes cumulative numbers of infants and toddlers receiving early intervention services during the mos t recent 12**  **- month period for which data are available.**  **2** Include children for whom the only early intervention services on the IFSP for which parental consent was provided are service coordination services or services provided to the family, such as counseling, family training, and home visits. 3 OSEP recognizes that, rather than referencing a numerical date (such as November 1) for taking its Child Count each year, some States may have identified a specific day of the week in a given month each year (such as the last Friday of each October). In addition, som e States may be unable to reference the same Child Count date if, in a given year, that date falls on a weekend. Therefore, it is acceptable for the actual date of the Child Count in any given year to slide within six (6) days of the State
- established reference date without generating any error flags upon submission to the Federal data system.Page 2 of 6

**3. Report the cumulative number of infants and toddlers with disabilities, ages birth**  **through 2, who received early intervention services (as defined below) during the most recent 12**  **- month period for which data are available**  **in Sections D and E .**  4. All reported totals must equal the sum of the subsequent rows or columns. Report zeroes (0) where there are no children to report in a data cell. 5. Include children in your State who are:
a. Under age three and either (i) E xperiencing developmental dela ys as defined by

the State under 20 U.S.C. 1432(5)(A)(i) and 1435 (a)(1) ; or (ii) D iagnosed with a physical or mental condition which has a high probability of resulting in developmental delay under IDEA Section 632(5)(A)(i)
. Include these children in sections A, B, C, and D. b. Under age three and at risk of having substantial delays if early intervention services are not provided , if your state has elected under 20 U.S.C. 1432(5)(B)(i) to serve such children. Include these children in sections A, B, and C, but not D.
c. Age three and older if your state has elected under 20 U.S.C. 1432(5)(B)(ii) and 1435(c) to provide parents the choice of, and the child’s parent has consented to the ir child, continuing to receive Part C services (in lieu of FAPE) under 20 U.S. C. 1435(c)
. Include these children in sections A, B, and C, but not D. d. R eceiving early

intervention services regardless of whether federal IDEA Part C funds , IDEA Part B funds, or other funds are used to provide these services
. 4 Early intervention servic es are developmental services that : (i) are provided in conformity with an IFSP; (ii) are provided under public supervision (i.e., Federal, State, or local funds are used in connection with the provision of services). This includes children receiving services thro ugh a program funded by public monies as well as children receiving services from a private provider, but whose services are supervised or paid for by

a public agency ; (iii) are provided at no cost except where Federal or State law provides for a system of pay

me nts by families, including a schedule of sliding fees; (iv) are designed to meet the developmental needs of an infant or toddler with a disability (as defined in 20 U.S.C. 1432(5)) ; (v) meet the standards of the State and the requirements of IDEA ; and

**4** Include children for whom the only early intervention services on the IFSP for which parental consent was provided are servic e coordination services or services provided to the family, such as counseling, family training, and home visits. Include all children for whom Part C personnel have been unable to provide early intervention services due to child or family circumstances, lack of response from the parent or family, or inability to contact or locate the family or child after repeated, documented attempts.Page 3 of 6 (vi) are provided, to the maximum extent appropriate, in natural environments. More detailed information about the definition of early intervention services can be found in 20 U.S.C. 1432(4) and in 34 CFR § § 303. 13 and 303. 16
. 6. Do NOT include on this form children age 3 o r older (for example, who are receiving FAPE using Part C funds under 20 U.S.C. 1438(3) ) unless your state has elected under 20 U.S.C. 1432(5)(B)(ii) and 1435(c) to provide parents the choice of, and the child’s parent has consented to their child, continu ing to receive Part C services under 20 U.S.C. 1435(c)
. 7. STATES SHOULD NOT PROVIDE PERCENTAGES IN SECTIONS A OR B, AS THEY WILL BE CALCULATED AFTER THE COUNTS ARE SUBMITTED. 8. In providing data for this collection, the State is to submit complete and unsuppressed data. Instructions for Section A: Age and Race/Ethnicity 1. Enter the count date (a date between October 1, **2014** and December 1, **2014** , inclusive). 2. Report the (unduplicated) number of children receiving early intervention services according to an active IFSP in place on the count date, according to the child’s age and race/ethnicity
. This count should include: a. In Section A.1, all infants and toddlers with disabilities as defined in 20 U.S.C. 1432(5)(A) and (B)(i) , ages birth through 2; and b. In Section A.2, any

children with disabilities as defined in 20 U.S.C. 1432(5)(B)(ii) , ages 3 or older, who are continuing to receive early intervention services under 20 U.S.C. 1432(5)(B)(ii) and 1435(c)
. If your state does not offer parents the choice of continuing to receive Part C services under 20 U.S.C. 1432(5)(B)(ii) and 1435(c) , leave this section blank. 3. Report children in the appropriate category according to their age on the count date. See instructions below for reporting race/ethnicity
. 4. Report children less than 1 year of age in the “birth to 1” cell. 5. States must provide data for each discrete age and age grouping (birth through age 2 and, if appropriate, age 3 or older). 6. States that have discrete age data available must base this report on these actual data. States that do not have data for each discrete age are required to report actual data for the age groupings for birth through age 2 and, if appropriate, age 3 or older.Page 4 of 6

Instructions for Section B: Gender 1. Report the (unduplicated) number of children receiving early intervention services according to an active IFSP in place on the count date, according to the child’s gender
. This count should include:
a. In Section B.1, all infants and toddlers with disabilities as defined in 20 U.S.C. 1432(5)(A) and (B)(i) , ages birth through 2; and b. In Section B.2, any

children with disabilities as defined in 20 U.S.C. 1432(5)(B)(ii), ages 3 or older, who are continuing to receive early intervention services under 20 U.S.C. 1432(5)(B)(ii) and 1435(c)
. If your state does not offer parents the choice of continuing Part C services under 20 U.S.C. 1432(5)(B)(ii) and 1435(c), leave this section blank. 2. The total number of children reported in Section B.1 should equal the total number of children reported in Section A.1. The total number of children reported in Section B.2 should equal the total number of children reported in Section A.2. Instructions for Section C: At Risk (TO BE COMPLETED ONLY BY STATES THAT SERVE AT
- RISK INFANTS AND TODDLERS) 1. Repo rt the (unduplicated) number of infants and toddlers, ages birth through 2, who were determined under 20 U.S.C. 1432(5)(B)(i) to be at risk of experiencing substantial developmental delays if early intervention services were not provided and who have an ac tive IFSP in place on the count date. These infants and toddlers should also be reported in Sections A.1 and B.1. 2. Report at
- risk children according to their age (birth to 1, 1 to 2, or 2 to 3) on the count date. See instructions below for reporting race/ethnicity
. **Instructions for Section D: Cumulative Count by Race/ Ethnicity**  1. Enter the start and end dates of the most recent 12
- month period for which the cumulative count of infants and toddlers, ages birth through 2, who receiv ed early intervention se rvices are available. For example, if data on the total number of infants and toddlers served during the period from July

1, **2013** , through June 30, **2014** , are available, report this count and the corresponding dates in this Section. 2. Report the cumulative number of infants and toddlers with disabilities , ages birth through 2, who received early

intervention services (as defined above) during the most recent 12
- month period for which data are available **, according to the child’s race/ ethnicity**  **.** See instructi ons below for reporting race/ethnicity
. 3. Do NOT include children ages 3 or older in this count.Page 5 of 6

**Instructions for Section E: Cumulative Count by Gender 1.**  **Report the cumulative number of infants and toddlers with disabilities, ages birth through 2, who re**  **ceived early intervention services (as defined above) during the most recent 12**  **- month period**  **for which data are available, according to the child’s**  **gender .**  **2. The total number of children reported in Section E should equal the total number of**  **children repo rted in Section D.**  Race/Ethnicity

Instructions (Sections A, C, **and D** ) STATES MUST REPORT THE RACE/ETHNICITY OF THE CHILD, NOT THE FAMILY. FOR EACH OF THE RACE/ETHNICITY CATEGORIES, REPORT AN UNDUPLICATED COUNT OF ALL CHILDREN SERVED UNDER IDEA, PART C. In October 2007, the Department of Education published its Final Guidance on Maintaining, Collecting and Reporting Racial and Ethnic Data to the U.S. Department of Education in the Federal Register (Vol. 72, No. 202, available at http://www.gpoaccess.gov/nara/index.html ), referred to in these instructions as the new guidance . The procedures for collecting, aggregating, and reporting race and ethnicity, as described in the new guidance , must be implemented **for** the report of the **2014** Child Count data. The following definitions of the seven categories for aggregate report of race/ethnicity have been adapted from definitions appearing in the new guidance **.**Page 6 of 6

Hispanic/Latino A person of Cuban, Mex ican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Refers to Hispanic and/or Latino. American Indian or Alaska Native A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community

attachment. ( Does not include persons of Hispanic/Latino ethnicity .) Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. This includes, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. ( Does not include persons of Hispanic/Latino ethnicity .) Black or African American A person having origin s in any of the Black racial groups of Africa. ( Does not include persons of Hispanic/Latino ethnicity .) Native Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. ( Do es not include persons of Hispanic/Latino ethnicity .) White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. ( Does not include persons of Hispanic/Latino ethnicity .) Two or more races A person having o rigins in two or more of the five race categories listed immediately

above. ( Does not include persons of Hispanic/Latino ethnicity .) Total The unduplicated total across the seven (7) race/ethnicity designations. Note that each child should be reporte d in only one of the race/ethnicity categories, above.ORIGINAL SUBMISSION/REVISION (Circle one) CURRENT DATE:



### ________ U.S. DEPARTMENT OF EDUCATION TABLE 1 PAGE 1 OF 5 OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES REPORT OF CHILDREN RECEIVING OMB NO.: 1820
- 0557 OFFICE OF SPECIAL EDUCATION PROGRAMS E ARLY INTERVENTION SERVICES IN ACCORDANCE W ITH PART C FORM EXPIRES: xx /xx /xxxx STATE:____________________________ CHILD COUNT **2014** SECTION A
COUNT DATE: MONTH DAY YEAR
A.1. A GE AND RACE/ETHNICITY OF INFANTS AND TODDLERS, AGES BIRTH THROUGH 2 Total birth to 1 1 to 2 2 to 3 Percent* TOTAL (ROW S 1
- 7) 100% 1. HISPANIC/LATINO 2. AMERICAN INDIAN OR ALASKA NATIVE 3. ASIAN 4. BLACK OR AFRICAN AMERICAN 5. NATIVE HAW AIIAN OR OTHER PACIFIC ISLANDER 6. WH ITE 7. TW O OR MORE RACES PERCENT * 100%
A.2. AGE AND RACE/ETHNICITY OF CHILDREN, AGES 3 OR OLDER Total 3 to 4 4 to 5 5 or older Percent* TOTAL (ROW S 1
- 7) 100% 1. HISPANIC/LATINO 2. AMERICAN INDIAN OR ALASKA NATIVE 3. ASIAN 4. BLACK OR AFRICAN AMERICAN 5. NATIVE HAW AIIAN OR OTHER PACIFIC ISLANDER 6. WH ITE 7. TW O OR MORE RACES PERCENT * 100%

* STATES SHOULD NOT PROV ID E PERCENTAGES IN THIS SECTION. THESE WILL BE CALCUL ATED BY EMAPS
.ORIGINAL SUBMISSION/REVISION (Circle one) CURRENT DATE:



### ________ U.S. DEPARTMENT OF EDUCATION TABLE 1 (CONTINUED) PAGE 2 OF 5 OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES REPORT OF CHILDREN RECEIVING OMB NO.: 1820
- 0557 OFFICE OF SPECI AL EDUCATION PROGRAMS EARLY INTERVENTION SERVICES IN ACCORDANCE W ITH PART C FORM EXPIRES: xx /xx /xxxx CHILD COUNT **2014** STATE:____________________________
SECTION B B.1. GENDER OF INFANTS AND TODDLERS, AGES BIRTH THROUGH 2, RECEIVING EARLY INT ERVENTION SERVICES

Total Percent* TOTAL BIRTH THROUGH 2 100% 1. MALE 2. FEMALE

B.2. GENDER OF CHILDREN, AGES 3 OR OLDER, RECEIVING EARLY INTERVENTION SERVICES Total Percent* TOTAL 3 OR OLDER 100% 1. MALE 2. FEMALE * STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION. THESE WILL BE CALCUL ATED BY EMAPS
.ORIGINAL SUBMISSION/REVISION (Circle one) CURRENT DATE:



### ________ U.S. DEPARTMENT OF EDUCATION TABLE 1 (CONTINUED) PAGE 3 OF 5 OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES REPORT OF CHILDREN RECEIVING OMB NO.: 1 820
- 0557 OFFICE OF SPECIAL EDUCATION PROGRAMS EARLY INTERVENTION SERVICES IN ACCORDANCE W ITH PART C FORM EXPIRES: xx /xx /xxxx CHILD COUNT **2014** STATE:____________________________ SECTION C (TO BE COMPLETED ONLY BY STATES THAT SERVE AT
- RISK INFANT S AND TODDLERS)

AT - RISK INFANTS AND TODDLERS, AGES BIRTH THROUGH 2 (THESE INFANTS AND TODDLERS SHOULD BE INCLUDED IN COUNTS FOR SECTIONS A.1 AND B.1)
AGE AS OF CHILD COUNT DATE
Total birth to 1 1 to 2 2 to 3 TOTAL (ROW S 1
- 7) 1. HI SPANIC/LATINO 2. AMERICAN INDIAN OR ALASKA NATIVE 3. ASIAN 4. BLACK OR AFRICAN AMERICAN 5. NATIVE HAW AIIAN OR OTHER PACIFIC ISLANDER 6. WH ITE 7. TW O OR MORE RACESORIGINAL SUBMISSION/REVISION (Circle one) CURRENT DATE:



### ________ U.S. DEPARTMENT OF EDUCATION TABLE 1 (CONTINUED) PAGE 4 OF 5 OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES REPORT OF CHILDREN RECEIVING OMB NO.: 1820
- 0557 OFFICE OF SPECIAL EDUCATION PROGRAMS EARLY INTERVENTION SERVICES IN ACCORDANCE W ITH PART C FORM EXPIRES: xx /xx /xxxx CHILD COUNT **2 014**  STATE:____________________________
**SECTION D**

**CUMULATIVE NUMBER OF INFANTS AND TODDLERS WHO RECEIVED EARLY INTERVENTION SERVICES**

**FROM _____/_____/_____ TO _____/_____/_____ (SPECIFY EXACT DATES)**

**D .**  **CUMULATIVE COUNT OF INFANTS AND TODDLERS, AG ES BIRTH THROUGH 2, BY**  **RACE/ETHNICITY Total**  **Percent*** **TOTA L (ROWS 1**  **- 7)**  **100% 1.**  **HISPANIC/LATINO 2.**  **AMERICAN INDIAN OR ALASKA NATIVE 3.**  **ASIAN 4.**  **BLACK OR AFRICAN AMERICAN 5.**  **NAT IVE HAWAIIAN OR OTHER PACIFIC ISLANDER**  **6. WHI**  **TE 7.**  **TWO OR MORE RACES**
*** STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION. THESE WILL BE CALCULATED BY EMAPS.** ORIGINAL SUBMISSION/REVISION (Circle one) CURRENT DATE:



### ________ U.S. DEPARTMENT OF EDUCATION TABLE 1 (CONTINUED) PAGE 5 OF 5 OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES REP ORT OF CHILDREN RECEIVING OMB NO.: 1820
- 0557 OFFICE OF SPECIAL EDUCATION PROGRAMS EARLY INTERVENTION SERVICES IN ACCORDANCE W ITH PART C FORM EXPIRES: xx/xx /xxxx CHILD COUNT **2014** STATE:____________________________
**SECTION E**
**E. CUMULATIVE CO UNT OF INFANTS AND TODDLERS, AGES BIRTH THROUGH 2, RECEIVING EARLY**  **INTERVENTION SERVICES BY GENDER**

**Total Percent** * **TOTAL BIRTH THROUGH 2 100%**  **1. MALE 2. FEMALE** 

*** STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION. THESE WILL BE CALC ULATED BY**  **EMAPS.**