New Jersey Early Intervention System
Comprehensive System of Personnel Development
Competency-Based Orientation System

 
Participant Information Sheet
Please complete immediately and submit.
This information is required in order for you to successfully complete your orientation requirements.
Name:  Date: 
Agency for whom you provide services: 
Early Intervention position title for which you are enrolled as a practitioner with Covansys (consult your administrator if you are uncertain):
Audiologist
Behavior Specialist
Child Development Specialist
Child Development Associate
     (Paraprofessional)
Family Therapist
Nurse (RN)
Nutritionist
Occupational Therapist Asst.
     (COTA)(Paraprofessional)
Occupational Therapist
Orientation/Mobility Specialist
Physical Therapist		 Physical Therapist Asst.
     (Paraprofessional)
Physician
Pediatrician
Ophthalmologist
Optometrist
Psychologist
Social Worker
Special Educator
Special Educator-Hearing Impaired
Special Educator-Visually Impaired
Speech Pathologist
Phone, including extension
Email
FAX
Mailing Address
Month and Year of Employment as a NJEIS Practitioner
License/Credential(s) Held