Kev Tso Npe Kuaj Me Nyuam Yaus Thaum Ntxov
LUS QHIA PAUB THIAB QHIA UA DAV DAV: Tus me nyuam niam txiv/neeg saib xyuas yuav tsum ua kom tiav phab ib ntawm
daim ntawv tso npe. Phab ob yog rau tsev kawm ntawv neeg haujlwm ua nkaus xwb. Thov sau ua ntawv loj los sis ntaus ntawv
teb rau tshuab hluav taws xob.
Me Nyuam Npe Raws Cai (Npe, Npe Nruab Nrab, Xeem):
Me Nyuam Npe Me Nyuam Yaus los sis Lwm Lub Npe (Npe, Npe Nruab Nrab, Xeem):
Me Nyuam Hnub Yug:
Tub los ntxhais:
Niam Txiv/Neeg Saib Xyuas:
Chaw Nyob:
Tub
Ntxhais
P.O. Box:
Chaw Nyob:
Zos:
Xeev:
Zip:
Niam Txiv/Neeg Saib Xyuas:
Chaw Nyob:
P.O. Box:
Chaw Nyob:
Zos:
Xeev:
Zip:
Haiv neeg/Pawg neeg (xaiv ib qho XWB)
1 - Qhab Asmeslivkas
2 - Esxias los sis Neeg Pov Txwv Pas Xis Fiv
3 - Mev/Latino
4 - Dub, tsis yog Caj Ceg Mev
5 - Dawb, tsis yog Caj Ceg Mev
Thov teb tsoom fwv cov lus nug txog haiv neeg/pawg neeg hauv qab no. Koj muaj cai xaiv tshaj ib qho lus teb nyob rau
Feem B. Xyuas lus qhia tseeb nyob phab ob saum toj seb yuav teb seem no li cas.
*Feem A –Tus me nyuam puas yog Mev/Latino? (Xaiv IB QHO)
TSIS YOG, tsis yog Mev/Latino
YOG, yog Mev/Latino
*Feem B – Koj tus me nyuam yog haiv neeg dab tsi? (xaiv tag nrho cov uas dhos)
Qhab Asmeslivkas/Neeg Yug Alaska
Neeg Yug Has Vais/Neeg Pov Txwv Pas Xis Fiv
Esxias
Dawb
Dub/Asmeslivkas Dub
LUS QHIA TXOG LUS SIV THAWJ HOM/HOM THIB OB
Koj tus me nyuam xub kawm tau hom lus twg?
Askiv
Lwm Hom (sau qhia)
Hais lus hom twg heev tshaj tom koj tsev?
Askiv
Lwm Hom (sau qhia)
Feem ntau koj tus me nyuam hais lus hom twg?
Askiv
Lwm Hom (sau qhia)
LUS QHIA TXOG KEV KUAJ KEV NOJ QAB NYOB ZOO THIAB KEV LOJ HLOB DHAU LOS
Koj tus me nyuam puas tau kuaj kev noj qab nyob zoo thiab kev loj hlob txhij txhua ua ntej yuav kawm ntawv (3-5 xyoos)?
TAU
TSIS TAU
Yog tau, cov hnub tim kuaj:
Chaw Kuaj:
Koj tus me nyuam puas tau raug ntsuam xyuas tso rau kev kawm ntawv tshwj xeeb los sis tau txais kev qhia ntawv tshwj xeeb los
ntawm ib qho Kev Qhia Pab Cuam Tus Kheej (Individual education Program - IEP) los sis Kev Qhia Pab Cuam Tsev Neeg
(Individual Family Education Program - IFSP)?
TAU
TSIS TAU
NIAM TXIV/NEEG SAIB XYUAS LUS QHIA TIAS MUAJ TSEEB
Ntawm no kuv qhia tias cov lus teb saum toj no muaj tseeb thiab txhij txhua raws li kuv paub zoo tshaj plaws.
Niam Txiv/Neeg Saib Xyuas Kos npe
Revised 11/2016
Hnub Tim
Nplooj 1
Registration for Early Childhood Screening - Hmong
Cov lus qhia teb thiab phua lub ntsiab rau cov lus nug txog haiv neeg/pawg neeg nyob rau Feem A thiab Feem B.
Nqe lus nug rau Feem A hais txog haiv neeg, tsis yog pawg neeg. Txawm ho tau xaiv dab tsi nyob rau Feem A los xij, kom tus niam
txiv teb ntxiv rau nqe lus nug nyob rau Feem B hais txog nws pawg neeg uas yog kom kos rau ib lub los sis tshaj ib lub thawv.
Qhab Asmeslivkas los sis Neeg Yug Alaska – Tus neeg uas muaj caj ceg los ntawm ib hom thawj neeg twg los xij ntawm
Asmeslivkas Qaum Teb thiab qab Teb (nrog rau Asmeslivkas Phab nruab Nrab), thiab uas tseem coj tuav kev cai dab qhuas los
sis nyob txuam nrog zej zos
Esxias – Tus neeg uas muaj caj ces los ntawm ib hom thawj neeg twg los xij ntawm Sab hnub Tuaj Phab Deb , Esxias Qab Teb
Phab Hnub Tuaj los sis Suam Av khej Teb uas muaj, xws li, Qhab Meem Teb, Suav Teb, Nyiv Pooj Teb, Korea, Mas Les Xias,
Pakistan, lub Pov Txwv Fis Liv peej, Thaib Teb thiab Nyaj Laj Teb
Dub los sis Asmeslivkas Dub – Tus neeg muaj caj ces los ntawm ib haiv neeg dub twg los xij ntawm Africa.
Neeg Yug HasVais los sis Lwm Tus Neeg Pov Txwv Pas Xis Fiv – Tus neeg muaj caj ces los ntawm ib hom thawj neeg twg
los xij ntawm Has Vais, Guam, Samoa los sis lwm cov Pov Txwv Pas Xis Fiv.
Dawb – Tus neeg muaj caj ces los ntawm thawj hom neeg twg los xij ntawm Yus Lauv (Europe), Ntuj Suam Av Nruab Nrab
(Middle East) los sis As Fiv Kas Qaum Teb (North Africa
TO BE COMPLETED BY SCHOOL DISTRICT PERSONNEL ONLY
Screening District Number and Type:
Screening Date:
Screening District Name:
Child’s Resident District Name:
Resident Screening District Number and Type:
MARSS ID Number:
Check type of screening child received – STATE AID CATEGORY (SAC)
(To be completed by the Early Childhood Screening Coordinator)
___ 41 - Screening by District
___ 44 - Private Provider
___ 42 - Child and Teen Checkups/EPSDT
___ 43 - Head Start
___ 45 - Conscientious Objector, no screening
Check the Primary type of referral following the early childhood health and developmental screening using STATUS END
CODES (SEC). Only one box may be checked. Must have a valid SEC for – STATE AID CATEGORY (SAC) 41. If unsure of
referral status for SAC 42-44, use “no referral” SEC 60. (To be completed by the Early Childhood Screening Coordinator.)
Status End Codes:
___ 60 No referral
___ 64 Referral to early childhood programs*
___ 61 Referral to special education
(*School Readiness, Head Start, Early Childhood Family
Education, family literacy)
___ 62 Referral to health care provider
65 Referral, parent declined
___ 63 Referral to special education AND health care
provider
SCHOOL DISTRICT VERIFICATION OF INFORMATION
I hereby verify that the above information is true and current to the best of my knowledge.
School District Early Childhood Screening Coordinator Signature
Revised 11/2016
Nplooj 2
Date
Registration for Early Childhood Screening - Hmong