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` TABLE 3

REPORT ON INFANTS AND TODDLERS EXITING PART C 1 **2013**
- **2014** 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 50.3 hours per State response, including time for reviewing 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. 108.446 Section 618). Send comments regarding the burden estimate or any

other aspect of this collecti on 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 Num ber 1820
- 0557. Note: Please do not return the completed Report on Infants and Toddlers Exiting Part C form to this address. **All States must submit these data via the IDEA Part C Exiting survey**  **in the EDFacts online survey tool, EMAPS.**  Instructions Autho rization: 20 U.S.C. 14 18 (a)(1)(C) and (a)(3) Due Date: November **5 ,**  **2014** Sampling Allowed: No General Instructions 1. Report the number of infants and toddlers with disabilities who , during the 12
- month reporting period, either no longer receiv ed servi ces under Part C prior to age three or reached age three , and for each child, report by race/ethnicity, gender, and reason that services are no longer received
. 2. States should report counts for a 12
- month reporting period. The State can determine the 12
- m onth reporting period of data collection. This 12
- month window (reporting period) should be the same for each annual report of these data. States must indicate on the form the specific 12
- month period the State used for reporting. If the State needs to revise the dates for its 12
- month reporting period, it should notify OSEP in advance of any change in the State
- identified reporting period. 3. Include on the form any child who was under age three and had an active individualized f amily s ervice p lan (IFSP ) in place at some point during the reporting period and at the end of

**1** Note that in addition to capturing infants and toddlers exiting the Part C program, this form also requires reporting on those children with disabilities who may continue to receive services under Part C under 20 U.S.C. 1435(c).Page 2 of 5 the reporting period either was no longer receiving services under Part C or had reached his or her third birthday
. 4. The infants and toddlers with disabiliti e s represented on this form must be an unduplicated count; no child should be counted more than once during the 12
- month reporting period . If a child is identified as no longer receiving services under Part C more than once during the reporting period, report the reason that service s are no longer being received based on the last time the child exited (i.e., report the child in the category that corresponds to the most recent reason for no longer receiving services under Part C )
. 5. Do NOT report a child as exiting Part C if:
 the child had turned age three at the start of the reporting period ; 2 or
 services were temporarily interrupted and subsequently resumed before the end of the reporting period; or
 the child was under age three at the end of the reporting period and had an active IFSP, even if services were intermittently stopped during the reporting period. 6. If your State serves infants and toddlers who are at risk of having substantial delays if early intervention services are not provided as specified under 20 U.S.C. 1432(5)(B)(i ) , include these children in the table counts if they were no longer receiving service under Part C or reached age three during the reporting period. 7. All reported totals must equal the sum of the subsequent rows or columns. 8. For each reason that a child is no longer receiving services under Part C , the total number of children reported by

race/ethnicity

in Section A must equal the total number of children reported for that exit reason by gender in Section B. 9. STATES SHOULD NOT PROVIDE PERCENTAGES IN SE CTIONS A AND B. THESE WILL BE CALCULATED BY EDFACTS ONLINE SURVEY TOOL, EMAPS. 10. In providing data for this collection, the State is to submit complete and unsuppressed data. Specific Row (Reason for No Longer Receiving Services ) Instructions Using the c ategories below, report each infant or toddler with a disability, as defined in 20 U.S.C. 1432(5) , who reached age three or were no longer receiving services under Part C within this 12
- month reporting period according to the most recent reason for no long er receiving services
. There are three major groupings of reasons: Program C ompletion (category 1), Exit at A ge T hree (categories 2 through 6), and Not R eceiving S ervices (categories 7 through 10). The categories within each of these groupings are def ined below.

2 These children should have been counted in the previous reporting period under “Exit at Age Three”.Page 3 of 5

A. Program Completion 1. No longer eligible for Part C prior to reaching age three

. Include all children who within this 12
- month reporting period, have exited Part C before age three because they are no longer eligible under IDEA, Part C. B. Exit at Age Three 2. Part B eligible, exiting Part C . Include all children determined to be eligible for Part B during the reporting period and who exited (or will soon exit) Part C. This includes children who receive Part B services in conjunction with Head Start. 3. Part B eligible, continuing in Part C . Include all children determined to be eligible for Part B, and whose parents were offered and consented to have their child remain in Part C under 20 USC 1432(5)(B)(ii) and 14 35(c **)**
. The Part B eligible, continuing in Part C category may ONLY be used by a state whose application for IDEA Part C funds includes a policy under which parents of children with disabilities who were eligible for services under IDEA Section 619 and previously received service s under Part C may continue to receive early

intervention services under Part C beyond age three . States that do not offer this option under 20 USC 1432(5)(B)(ii) and 1435(c) may NOT report children in this category . 4. Not eligible for Part B, exit with referrals to other programs . Include all children who reached age three, were evaluated and determined not eligible for Part B, and were referred to other programs, which may include preschool learning centers, Head Start (but not receiving Part B serv ices), and child care centers, and/or were referred for other services, which may

include health and nutrition services, such as WIC. 5. Not eligible for Part B, exit with no referrals . Include all children who reached age three, were evaluated and deter

mined not eligible for Part B, but were not referred to other programs. 6. Part B eligibility

not determined . Include all children who reached their third birthday and their Part B eligibility was not determined during this reporting period . This cate gory includes children who were referred for Part B evaluation, but for whom the eligibility determination has not yet been made or reported or children for whom parents did not consent to transition planning. Include in this category any child who reached age three, and who has not been reported in categories 2
- 5 above. C. Not Receiving Services 7. Deceased . Include all children who died before their third birthday, even if their death occurred at the age of exit. Include only children who died during the reporting period. 8. Moved out of State . Include all children who moved out of state before their third birthday . Include only

children who moved during the reporting period. Do not report a child who moved within State (i.e., from one program to a nother) if services are known to be continuing.Page 4 of 5

9. Withdrawal by

parent (or guardian)
. Include all children under the age of three whose parents declined all services (including service coordination services) after an IFSP was in place , or declined to consent to Part C services on the IFSP and provided written or verbal indication of withdrawal from Part C services. 10. Attempts to contact the parent and/or child were unsuccessful . Include all children, under the age of three , who had an active IFSP, and for whom Part C personnel have been unable to provide early

intervention services either due to lack of response from the parent or family , or inability

to contact or locate the family or child after repeated, documented attempts. Include in this cate gory any child who w as no longer receiving services under Part C before reaching age three , and who has not been reported in categories 7
- 9 above. Specific Column Instructions for Section A: Race/Ethnicity STATES MUST REPORT THE RACE/ETHNICITY OF THE CHI LD, NOT THE FAMILY. FOR EACH OF THE RACE/ETHNICITY CATEGORIES, REPORT AN UNDUPLICATED COUNT OF CHILDREN EXITING. 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 **2013 -**  **14** Exiting data. States s hould report all children with disabilities according to the seven categories l isted below. The following definitions of the seven categories for aggregate report of race/ethnicity have been adapted from definitions appearing in the new guidance
.Page 5 of 5

Hispanic/Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, o r 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, Cam bodia, 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 origins 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. ( Does not include persons of Hispanic/Latino ethnic ity .) 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 origins in two or more of the five race categorie s 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 reported in only one of the race/ethnicity categories, above. Specific Column Instructions for Section B: Gender 1. Report the (unduplicated) number of children with an active IFSP in place at some point during the reporting period and at the end of the reporting period either was no longer receiving services under Part C or had reached his or her third birthday , according to the child’s gender and reason for no longer receiving services. 2. The total numbers of children reported in Section B should equal the total numbers of children reported in Section A by

re ason for no longer receiving servic es.U.S. DEPARTMENT OF EDUCATION TABLE 3 PAGE 1 OF 4 OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES REPORT ON INFANTS AND TODDLERS EXITING PART C PROGRAMS OMB NO.: 1820 - 0557 OFFICE OF SPECIAL EDUCATION P ROGRAMS **2013 -** **2014** FORM EXPIRES: xx /xx /xxxx STATE:____________________________

SECTION A
12 - Month Reporting Period (From MM/Y Y to MM/YY) to

REASON FOR EXIT TOTAL HISPANIC/ LATINO AMERICAN

INDIAN OR ALASKA NATIVE ASIAN BLACK OR AFRICAN A MERICAN NATIVE

HAW AIIAN OR OTHER PACIFIC ISLANDER WH ITE TW O OR MORE RACES TOTAL NUMBER OF INFANTS AND TODDLERS EXITING BY

RACE/ETHNICITY (ROW S 1 - 10) PROGRAM COMPLETION **1.** NO LONGER ELIGIBLE FOR PART C PRIOR TO REACHING AGE THREE EXIT AT AGE THREE 2. PART B ELIGIBLE, EXITING PART C 3. PART B ELIGIBLE, CONTINUING IN PART C 4. NOT ELIGIBLE FOR PART B, EXIT W ITH REFERRALS TO OTHER PROGRAMS 5. NOT ELIGIBLE FOR PART B, EXIT W ITH NO REFERRALS 6. PART B ELIGIBILITY NOT DETERMINED NOT RECEIVING SERVICES 7. DECEASED 8. MOVED OUT OF STATE 9. WI THDRAW AL BY PARENT (OR GUARDIAN) 10

. ATTEMPTS TO CONTACT UNSUCCESSFULU.S. DEPARTMENT OF EDUCATIO N TABLE 3 (CONTINUED) PAGE 2 OF 4 OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES REPORT ON INFANTS AND TODDLERS EXITING PART C PROGRAMS OMB NO.: 1820 - 0557 OFFICE OF SPECIAL EDUCATION PROGRAMS **2013 -** **2014** FORM EXPIRES: xx /xx /xxxx

SEC TION A : PERCENT *

REASON FOR EXIT TOTAL HISPANIC/ LATINO AMERICAN

INDIAN OR ALASKA NATIVE ASIAN BLACK OR AFRICAN AMERICAN NATIVE

HAW AIIAN OR OTHER PACIFIC ISLANDER WH ITE TW O OR MORE RACES
PERCENT* EXITING BY RACE/ETHNICITY (ROW S 1 - 10) 100% P ROGRAM COMPLETION 1. NO LONGER ELIGIBLE FOR PART C PRIOR TO REACHING AGE THREE 100% EXIT AT AGE THREE 2. PART B ELIGIBLE, EXITING PART C 100% 3. PART B ELIGIBLE, CONTINUING IN PART C 100% 4. NOT ELIGIBLE FOR PART B , EXIT W ITH REFERRALS TO OTHER PROGRAMS 100% 5. NOT ELIGIBLE FOR PART B, EXIT W ITH NO REFERRALS 100% 6. PART B ELIGIBILITY NOT DETERMINED 100% NOT RECEIVING SERVICES 7. DECEASED 100% 8. MOVED OUT OF STATE 100% 9. WI THDRAW AL BY PARENT (OR GUARDIAN) 100% 10. ATTEMPTS TO CONTACT UNSUCCESSFUL 100%
* STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION, AS THEY WILL BE CALCUL ATED AFTER THE COUNTS ARE SUBMITTED .

.. U.S. DEPARTMENT OF EDUCATION TABLE 3 (CONTINUED) PAGE 3 OF 4 OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES REPORT ON INFANTS AND TODDLERS EXITING PART C PROGRAMS OMB NO.: 1820 - 0557 OFFICE OF SPECIAL EDUCATION PROGRAMS **2013 -** **2014** FORM EXPIRES: xx /xx /xxxx STATE:____________________________ SECTION B REASON FOR EXIT TOTAL MALE FEMALE TOTAL NUMBER OF INFANTS AND TODDLERS EXITING BY

GENDER (ROW S 1 - 10) PROGRAM COMPLETION **1.** NO LONGER ELIGIBLE FOR PART C PRIOR TO REACHING AGE THREE EXIT AT AGE THREE 2. PART B ELIGIBLE, EXITING PART C 3. PART B ELIGIBLE, CONTINUING IN PART C 4. NOT ELIGIBLE FOR PART B, EXIT W ITH REFERRALS TO OTHER PROGRAMS 5. NOT ELIGIBLE FOR PART B, EXIT W ITH NO REFERRALS 6. PART B ELIGIBILITY NOT DETERMINED NOT RECEIVING SERVICES 7. DECEASED 8. MOVED OUT OF STATE 9. WI THDRAW AL BY PARENT (OR GUARDIAN) 10. ATTEMPTS TO CONTACT UNSUCCESSFULU.S. DEPARTMENT OF EDUCATION TABLE 3 (CONTINUED) PAGE 4 OF 4 OFFICE OF SPECIA L EDUCATION AND REHABILITATIVE SERVICES REPORT ON INFANTS AND TODDLERS EXITING PART C PROGRAMS OMB NO.: 1820 - 0557 OFFICE OF SPECIAL EDUCATION PROGRAMS **2013 -** **2014** FORM EXPIRES: xx /xx /xxxx

SECTION B: PERCENT *
REASON FOR EXIT TOTAL MALE FE MALE PERCENT* EXITING BY GENDER (ROW S 1 - 10) 100% PROGRAM COMPLETION 1. NO LONGER ELIGIBLE FOR PART C PRIOR TO REACHING AGE THREE 100%
EXIT AT AGE THREE 2. PART B ELIGIBLE, EXITING PART C 100% 3. PART B ELIGIBLE, CONTINUING IN P ART C 100% 4. NOT ELIGIBLE FOR PART B, EXIT W ITH REFERRALS TO OTHER PROGRAMS 100%
5. NOT ELIGIBLE FOR PART B, EXIT W ITH NO REFERRALS 100% 6. PART B ELIGIBILITY NOT DETERMINED 100% NOT RECEIVING SERVICES 7. DECEASED 100% 8. MOVED OUT O F STATE 100% 9. WI THDRAW AL BY PARENT (OR GUARDIAN) 100% 10. ATTEMPTS TO CONTACT UNSUCCESSFUL 100% * STATES SHOULD NOT PROVIDE PERCENTAGES IN THIS SECTION, AS THEY WILL BE CALCUL ATED AFTER THE COUNTS ARE SUBMITTED .