WV Birth to Three Child’s Name: _____________________________________________
Office of Maternal, Child and Family Health
Bureau for Public Health Child’s DOB: ______________________________________________
Department of Health and Human Resources
STATE OFFICE USE - SPOE ID #:
WV BIRTH TO THREE CHILD OUTCOMES SUMMARY FORM
This Child Outcomes Summary Form (COSF) is to be used to assist the team, including the family, in evaluating and reporting the child’s individual progress toward important
national child outcomes as required by the U.S. Department of Education. This rating should reflect the child’s current functioning across settings and activities and take into
consideration modifications and adaptations that have been made to assist the child’s participation. Consult the Child Outcomes Summary Form Instructions for further
clarification on form completion.
COSF Facilitator Discipline
Date of COSF completion:
Month Day Year
Type of COSF completed today: Initial COSF Annual COSF Exit COSF
1. POSITIVE SOCIAL EMOTIONAL SKILLS (INCLUDING SOCIAL RELATIONSHIPS) - Check box that applies
1. A. To what extent does this child show behaviors and skills related to this outcome appropriate for his or her age across a variety of settings and situations?
For example: attachment/separation/autonomy, expressing emotions and feelings, social interactions and play, following rules if older than 18 months.
Completely
The child uses The child uses age
age expected expected behaviors
behaviors and skills and skills but there
in all or almost all are still some
everyday situations significant concerns
- no concerns
Somewhat Emerging Not Yet
The child uses a mix The child The child uses The child The child uses no
of age expected and occasionally uses age immediate occasionally uses immediate foundational
not age expected expected behaviors foundational skills immediate skills across settings
behaviors and skills and skills across most of the time across foundational skills and situations - has
across settings and settings and situations settings and situations across settings and mostly foundational
situations - more not age - not yet age expected situations - more skills similar to a much
expected foundational skills younger child
1. B. Has this child shown any new skill or behaviors related to ‘positive social emotional skills’ in the last 12 months?
YES
NO
Not applicable - Initial IFSP
2. ACQUIRING AND USING KNOWLEDGE AND SKILLS - Check box that applies
2. A. To what extent does this child show behaviors and skills related to this outcome appropriate for his or her age across a variety of settings and situations?
For example: attends, explores, imitates, object permanence, early concepts, expressive language and communication, problem solving.
Completely
The child uses The child uses age
age expected expected behaviors
behaviors and skills and skills but there
in all or almost all are still some
everyday situations significant concerns
- no concerns
Somewhat Emerging Not Yet
The child uses a mix The child The child uses The child The child uses no
of age expected and occasionally uses age immediate occasionally uses immediate foundational
not age expected expected behaviors foundational skills immediate skills across settings
behaviors and skills and skills across most of the time across foundational skills and situations - has
across settings and settings and situations settings and situations across settings and mostly foundational
situations - more not age - not yet age expected situations - more skills similar to a much
expected foundational skills younger child
2. B. Has this child shown any new skill or behaviors related to ‘acquiring and using knowledge’ in the last 12 months? YES NO Not applicable - Initial IFSP
WVDHHR/BPH/OMCFH/WVBTT/WVBTT S:\Birth0-3\FORMS\FORMS APPROVED - Word\COSF\COSF Form REVISION 4.14.17.Docx
