Using Curriculum-Based Assessments for Accountability
Online Version of the Basic Information Form
Directions: Please complete the Basic Information Form for EACH child for whom you have a completed AEPS® Child Observation Data Recording Form. You can complete the Basic Information Form on paper or online. You can also Complete the Child Observation Recording Form on paper or online. Be sure you have signed caregiver/parent consent for each child.
AEPS Information
Child's name/ID Number
City
State AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KY KS LA MA ME MD MI MN MO MS MT NE ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Approximate date the AEPS® was completed
Name and role of primary person who completed the AEPS®
Degree of primary person (check the highest degree received)
High School Diploma Associate's Degree Bachelor's Degree Master's Degree Doctorate Degree
High School Diploma
Associate's Degree
Bachelor's Degree
Master's Degree
Doctorate Degree
Type of training the primary person had regarding the AEPS® (check all that apply)
Self Taught (read the manual etc.) Informally, from a colleague (watching, talking to others) From undergraduate or graduate training program Through a workshop but not by an AEPS® trainer Through a 1 day workshop with an expert AEPS® trainer Through several workshops with an expert AEPS® trainer Other
Self Taught (read the manual etc.)
Informally, from a colleague (watching, talking to others)
From undergraduate or graduate training program
Through a workshop but not by an AEPS® trainer
Through a 1 day workshop with an expert AEPS® trainer
Through several workshops with an expert AEPS® trainer
Other
Approximate number of AEPSs® the primary person has completed to date (select one)
Less than five Between 5 and 20 Between 21 and 50 Over 50
Less than five
Between 5 and 20
Between 21 and 50
Over 50
Approximate amount of time the primary person has been using (administering, scoring, and interpreting) the AEPS® (select one)
Less than a month One month to six months One year Between one and three years Over three years
Less than a month
One month to six months
One year
Between one and three years
Over three years
AEPS® Level completed/submitted for child (check one):
Birth to Three – Level I Three to Six – Level II
Birth to Three – Level I
Three to Six – Level II
You may access this child’s data online
OR
I have included/mailed the child’s completed AEPS® Child Observation Data Recording Form
Child Information
Child’s Birthday
Child’s Sex (check one) Male Female
Child’s Developmental Status (check one)
No history or indication of developmental delay or problem
NOTE: A screening instrument must have been completed within 3 months of administration of the AEPS®. Please insert the name of the screener that was administered within 3 months of the AEPS® and verify that the results indicated the child’s development was in line with typical development.
Name of screener
Check if the screener was completed w/in 3 months of the AEPS®
Suspected developmental delay or disability (at-risk)
Identified delay or disability (has an IFSP/IEP in place)
Child’s Ethnicity (check one)
Hispanic/Latino Black Native American Other Asian White Hawaiian Pacific Islander Biracial Don’t know
Hispanic/Latino Black Native American Other
Asian White Hawaiian
Pacific Islander Biracial Don’t know
Does child receive special education or related services? Yes No
If yes, what type of services does he/she receive?
Family Information
Primary Caregiver (check one) Mother Father Guardian Grandparent Other
Less than high school High school Associate’s degree
4-year college or above Don’t know
Comments (optional)
