Application for Entering the Early Intervention Specialist Registry (Must be submitted within 30 days of hiring as EIS)

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1 Application for Entering the Early Intervention Specialist Registry (Must be submitted within 30 days of hiring as EIS) Please type or print in black ink! PERSONAL INFORMATION Name: Social Security Number XXX-XX- * Last 4 digits only Date of Birth / / ECI EMPLOYMENT Current Position Employment Date: Length of employment: ECI Program: Program Code: Program Phone: Fax: Employee Position Title: Administrative Supervisor s Name: Supervisor Phone: Does the supervisor meet the qualifications outlined in TAC, Title 40, Part 2, Chapter 108, Subchapter C? OTHER ECI EMPLOYMENT Dates of Employment: Position Title: Program Name: Phone: Address: Supervisor s Name: Phone: OTHER ECI EMPLOYMENT (Additional sheets may be attached) Dates of Employment: Position Title: Program Name: Phone: Address: Supervisor s Name: Phone:

2 EDUCATIONAL BACKGROUND DEGREE (Requirement Minimum: Bachelors Degree with at least 18 hours of college coursework that relates to early childhood intervention. Three of the 18 hours must be in early childhood development or early childhood special education.) Full Name of Institution Degree Completed (i.e. Bachelors, BS, MS) Major Years Attended If the degree is from an institution outside of the United States, documentation must be provided that verifies that the degree is comparable to a degree from a U.S. Institution). DEGREE STATUS (Is the degree from a university located in the United States with specialization in one of the areas listed below?) Circle the correct response below: Yes Degree Title: Adaptive Physical Education (with or without teacher certification) Child Development Child Life Communication Disorders Early Childhood (with or without teacher certification) Family Studies Health Psychology Social Work Sociology Special Education (with or without teacher certification) Rehabilitation Counseling or Rehabilitation Services * These areas of study may have different titles in some universities. If there is a question about whether an area of study is equivalent to one of the above, contact the ECI State Office at Transcript contains 3 hours of college credit in early childhood development or early childhood special education. Course name: No List the 18 hours of early childhood intervention related coursework on the next page.

3 Course Title: Number of Hours Credit: TOTAL NUMBER OF CREDIT HOURS RELATED TO EARLY INTERVENTION: PERSONAL VERIFICATION I confirm that all information provided in this application for entering the EIS Registry is accurate and complete. I further verify that I intend to complete the EIS credentialing activities. I understand that my record in the EIS Registry is subject to the Public Information Act. Signature: Date: PROGRAM VERIFICATION I verify that the person completing this application is employed as an EIS Professional by the ECI program listed. Copies of all corresponding documentation including: course work records or transcripts, in service training records, job description, and performance evaluations will be on record in his/her personnel file. (Please do not send those documents to the ECI office.) Administrative Supervisor s Signature: Date: ECI Program Director s Signature: Date: Submit to: EIS Registry ECI State Office 4900 North Lamar Austin, TX Note: If you do not receive information of your application with four (4) weeks of submitting it, call the ECI State to verify it was received. Retain a copy of your application in your personnel file or records.

4 Code of Ethics for Early Intervention Specialists Preamble The Early Intervention Specialist Code of Ethics offers guidelines for responsible behavior and provides a guide for decision making and conduct when ethical issues arise during the course of providing early intervention services. It does not provide a set of rules that prescribe how Early Intervention Specialists (EIS) should act in all situations. Ethical decision making is a process. There are many instances in early childhood intervention where simple answers are not available to resolve complex ethical issues. Expectations and Core Values of the Early Intervention Specialist Responsibility to families and colleagues Early Intervention Specialists believe in responsive and interactive relationships with families, teams and communities. Early Intervention Specialists, through a team approach, empower families to support their child s development to reach his/her fullest potential. Early Intervention Specialists commit to providing high quality services for every family by being prepared for and engaged at every visit. Early Intervention Specialists commit to teams by recognizing themselves as professionals. Early Intervention Specialists strive through their appearance and through their interactions with families, community partners, and colleagues, to promote a positive and professional image of their discipline, their program, and ECI. As professionals, Early Intervention Specialists take responsibility for determining their own professional development needs and keeping current with emerging research and intervention techniques in the early childhood intervention field. Early Intervention Specialists commit to communities by increasing community awareness of early intervention and of their discipline. Early Intervention Specialists advocate for children with developmental delays and special needs by providing education and awareness to families and community partners. Flexibility Early Intervention Specialists value differences, view differences as strengths, and appreciate others for their own unique qualities. Early Intervention Specialists respect individual and cultural differences, families choices for interventions and parenting styles. Early Intervention Specialists provide culturally and linguistically appropriate services for each family. Honesty and Integrity Early Intervention Specialists recommend services based upon the child and/or family s individual needs. Early Intervention Specialists shall treat colleagues, other professionals and families with respect, fairness, and discretion.

5 Early Intervention Specialists commit to families and colleagues by developing relationships based on mutual trust and respect. Early Intervention Specialist Code of Ethics 1. EISs must know and comply with both their program s policies and the Department of Assistive and Rehabilitative Services (DARS) Division for Early Childhood Intervention Services Policy. 2. EISs must operate only within the boundaries provided by their education, training and credentials. 3. EISs must take measures to avoid imposing or inflicting harm. 4. EISs must truthfully represent their services, professional credentials and qualifications. EISs must inform families of the scope and limitations of their credential. 5. EISs must strive to maintain and improve their professional knowledge, skills, and abilities. 6. EISs must maintain the confidentiality of families served by the ECI Program in accordance with DARS-Division for Early Childhood Intervention Services Policy. 7. EISs must establish professional boundaries and avoid establishing dual relationships or conflicts of interest with families. Any prior relationships with a family member must be reported to the EIS s supervisor immediately. 8. Sexual or intimate relationships are prohibited between the EIS and family members of children enrolled in the ECI Program that employs the EIS for three years after the child exits the ECI program. 9. Financial relationships between the EIS and family members of children enrolled in the ECI Program that employs the EIS are prohibited until the child exits ECI. 10. EISs must not exploit their position of trust and influence with a family by benefiting from relationships established as an EIS. 11. EISs must not provide direct service while impaired; including impairments due to the use of medication, illicit drugs or alcohol. 12. EISs must not falsify documentation. 13. EISs must not refuse to provide services for which they are credentialed solely on the basis of a child s and/or family s, gender, race, socioeconomic status, ethnicity, color, religion, national origin, disability, sexual orientation, or political affiliation. 14. EISs must make reasonable efforts to ensure that families receive appropriate services when they are unavailable or anticipate that they will no longer be employed with the ECI Program. 15. EISs have a professional obligation to report unethical behavior demonstrated by other colleagues throughout the ECI system to their program director and to the appropriate board or state agency. By signing below, I agree to abide by the Early Intervention Specialist Code of Ethics: Signature: Date: Print Name:

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