Health Forms

Form Name Content Area Purpose
45 Day Screening Parent Notice Health To notify parents regarding different types of screening the child will be tested on.
Child Accident Report Form /
Forma Para Reportar Accidentes del Niños
Health Complete when child gets hurt in classroom or playground
Child Health History/
Historia del Desarrollo de Salud del Niño
Health Health form in Enrollment Packet
CHILDPLUS Monitoring Form Health 1/3 Sheet for Tracking Health Services
Consent for Blood Lead Screen Health Form Parent Must Sign to Allow DACHS to performt a Lead Test on Child
Contagious Illness at Head Start Center / Enfermedades Contagiosas a Centro de Head Start Health Informs Parents of a Contagious Illness at a Head Start Center
Daily Safe Environments Health Monitoring Checklist
Daily Sensory Health Check Health Monitoring Checklist
Declination Statement for Health Services/ Declaracion de Declinacion Para services de salud Health Parents complete if children do not have a physical and/or dental exam
Dental Exam- Medical Exam Reminder/ Examen Dentista- examen Fisico Recordatorio Health Letter to parents
Dental Health Form Health To be completed by dentist
Diet Plan for Meals at Child Care Health To be completed by Dr.
EHS-Daily Sensory Health Check Health Monitoring Checklist
EHS&HB Health Screening ENGL-SPAN 2015-16 Health 45 day Screening Form
Follow Up to Dental Exam Form Health To be completed by Dr
Follow Up to Physical Exam Form Health To be completed by Dr.
Health Box Inventory Health Health Supplies provided to the Direct Service Staff at the start of the year
Health Monitoring Tool for Beginning of School Year Health Monitoring form
Health Services Objectives /
Objectivos de Servicos de Salud
Health Goals of the Health content area
Hearing Vision Screening Health 45 day completed mandate screening
Height/ Weight Growth Chart Summary Form Health 45 day form used by FOW’s
Immunization Reminder for Parents Health Reminder for Parents that Child Needs Immunizations
Individual Health Care Plan- IHCP Health Complete this form with parent, FOW, teacher & Specialist
Lead Risk Questionnaire /
Questionario Sobre Los Riesgos del Plomo
Health Form for parents to fill out in Enrollment Packet
Medically Fragile Release (4) Health To be completed by Dr. complete with signature and date
Medication Monitoring Form (3) Health To monitor childs reaction to RX
Monthly First Aid Inventory Health Monitoring form for First Aid Kit supplies. To be filled out monthly and submitted to the Health Specialist for review & replenishing supplies. Can also be submitted when items are needed during the month
Parent/ Guardian Permission to Reveal or Obtain Confidential Information/ Permiso Para Dar u Obtener Informacion Confidencial Health Parent Notice
Parent/ Guardian Written Consent for Medication Administration (2) / Consentimiento to Escrito Para Padres/ Guardianes Para La Administracion de Medicamientos Health Form for parent to give staff permission to administer RX
Parent Notice of Height/ Weight Form/ Noticia Para Padres de Statura y Peso Health Height and Weight to give parents a choice of services
Permission to Release Dental and Physical Exam Form / Consentimiento para Exámenes Dentales y Físicos Health Form for parents to sign in Enrollment Packet
Physical & Dental Questions (Pink 1/2) Health PIA’s ask the parents these questions
Physical Exam Form Health To be completed by Dr.
Physician’s Orders for Prescribed Medicines/Other (1) / Orden para el Médico por Medicinas/Otro(1) Health To be completed by Dr. to administer RX and accompanied by the
Medically Fragile Release(4) with Dr. signature & date”
Reminder and Release Form for Blood Lead Screen Test and Hemoglobin/Hematocrit Test Health Reminder/Release for Blood Lead Screen Test and Hemoglobin/Hematocrit Test
Schedule for Cleaning, Sanitizing, and Disinfecting Health To meet Federal and Licensing Standards
Toilet Training Calendar/ Calendario de Entrenamiento Del Baño Health Assist parent w/toilet training process
Toilet Training Letter to Parents/ Carta Para Padres/ Toilet Training Plan/ Plan de Entrenamiento / Parents Toilet Training Agreement/ Contracto de Entrenamiento Para Los Padres Health Assist parent w/toilet training process