ACYF
Administration on Children, Youth and Families |
U.S. DEPARTMENT
OF HEALTH AND HUMAN SERVICES
Administration for Children and Families |
| 1. Log No. ACYF-IM-HS-95-03 |
2. Issuance Date: 01/19/95 |
| 3. Originating Office: Head Start Bureau |
| 4. Key Word: Performance Standards Record-Keeping |
INFORMATION MEMORANDUM
TO: Head Start Grantees and Delegate Agencies
SUBJECT: Head Start Performance Standards Record-Keeping Requirements
LEGAL AND RELATED REFERENCES: The Head Start Act, as amended,, 42 U.S.C. 9831 et seq.; 45 CFR Parts 1303, 1304, 1305, 1306 and 1308
SUMMARY: The purpose of this Program Instruction is to further explain to all grantees and delegate agencies the record-keeping requirements set forth in the revised Head Start Program Performance Standards.
BACKGROUND: The Head Start Performance Standards which were published as a final rule on November 5, 1996 (61 FR 57186-57227) include the following language (at S1304.51(g) regarding record-keeping systems:
1304.51(g) Record-keeping systems,
Grantee and delegate agencies must establish and maintain efficient and effective record-keeping systems to provide accurate and timely information regarding children, families, and staff and to ensure confidentiality of this information.
These record-keeping requirements are further explained in this program instruction. Specifically, this program instruction addresses four types of records: 1) child and family records; 2) child records; 3) family records and 4) program records. These systems were previously addressed in the Head Start Performance Standards. They are covered by the Paperwork Reduction Act. Accordingly, we are providing the following details concerning our expectations for grantee and delegate agency record-keeping.
INSTRUCTIONS:
Grantees and delegate agencies shall keep the following records in implementing the Head Start Program Performance Standards:
A. Child and family records.
(1) Grantee and delegate agencies must inform parents of the nature of the child and family data to be collected and the uses to which the data will be put and provide assurances that the uses will be restricted to the stated purposes.
(2) Grantee and delegate agencies must establish and maintain a written policy regarding the confidentiality of and access to the records of staff, volunteers, families, and children, which meets State and local laws.
(3) At the parents' request, all or portions of each child's and family's records shall be copied or summarized and provided to the parent or to another person designated by the parent. If given to a third party, the transaction must be documented with the signature of the parent.
(4) To help ensure the continuity of services and support, grantee and delegate agencies must ensure that, if written parental consent is received, child and family records are transferred from one Early Head Start or Head Start program to another, or to and from other child placements or schools, in a timely and efficient manner.
B. Child records.
Grantees and delegate agencies must establish and maintain records on individual children, containing:
(1) Records of each child's attendance;
(2) Records of each child's developmental progress, including:
(i) Summaries of findings from the child's developmental assessment and records of any subsequent referrals;
(ii) Specific evidence of the child's educational and developmental progress; and
(iii) Plans to meet the special education or related service needs of children with disabilities, in accordance with the requirements of 45 CFR Part 1308 and Part H of the Individuals with Disabilities Education Act.
(3) Health records for each child including:
(i) The Medical and developmental history, including immunization status and assessment results:
(ii) Up-to-date information about medical, dental, and mental health referrals, treatment and follow-up;
(iii) Records of illnesses and accidental injuries occurring during program hours, including documentation that the child's parents or legal guardians were notified immediately of injuries or illnesses;
(iv) Information about each child's food tolerances and preferences and developmental changes in each child's feeding and nutrition and, for each infant and toddler, daily records of feeding amounts, types, and schedules, and new foods introduced;
(v) Emergency contacts for health care providers and parents, signed parent consent forms for medical treatment during health emergencies, physicians' medication, and sources of payment for health services; and
(vi) Signed parent consent forms for releases of family or child information, child participation in special activities, child transportation arrangements, and any other special parental instructions for each child.
C. Family records.
Grantee and delegate agencies must establish and maintain records on individual families, which contain:
(1) Recruitment, enrollment, and attendance data, including enrollment forms and income documentation;
(2) Family Partnership Agreements and ongoing documentation of progress toward meeting family goals, including information about the services provided to or arranged for families, service referrals, and follow-up reports;
(3) Reports on home visits and staff-parent conferences; and
(4) Documentation of all contacts with the child's family related to poor or irregular attendance, in accordance with the requirements of 45 CPR 1305.8 on attendance.
D. Program records.
Grantees and delegate agencies must establish and maintain essential program records that include, at a minimum:
(1) Personnel files for each staff member and consultant containing information related to, as appropriate: hiring, qualifications and licenses, background checks, criminal record checks, health examinations, salary increases and promotions, professional development and training received, performance agreements and reviews, and adverse actions;
(2) Files for volunteers containing information related to volunteer health examinations, criminal record checks (if required by State or local law), references, and signed statements denying histories of child abuse or neglect;
(3) Food service and menu records that document the types and numbers of meals and snacks served daily (with separate recordings for children and adults), compliance with food safety and sanitation laws, and any other information deemed necessary for the effective provision of nutrition services;
4) Facilities and equipment records that contain valid licenses or registrations, as required by Federal, State, or local law; and current copies of applicable facilities and equipment inspection, maintenance, and repair reports; and
5) Fiscal records and records of the insurance coverage as required by 45 CFR 1301.11 on insurance and bonding.
IMPLEMENTATION:
This program Instruction is effective when the revised Program Performance Standards take effect on January 1, 1998.
Please be advised that record-keeping will be one of the requirements monitored during on-site program reviews.
INQUIRIES:
Regional Administrators, Regions I-X
American Indian and Migrant Programs Branch
Administration for Children and Families
/S/
James A. Harrell
Acting commissioner
INSTRUCTIONS FOR COMPLETING THE CHILD HEALTH RECORD INTRODUCTION
The Child Health Record consists of the following forms:
Form 1: General Information
Forms 2A and 2B: Health History
Form 3: Screenings, Physical Examination/Assessment
Form 4: Immunizations
Form 5: Dental Health
Form 6: Nutrition
Form 7 and 8: Growth Charts
Form 9: Psychological and Social Development
Form 10: Staff Observations of Health and Behavior
These forms, when completed, present a comprehensive picture of the child's health. You may find it convenient to make multiple copies of some of the forms. Suggestions are made here as to the number of copies that may be useful.
The first entries in a child's record are made during the initial intake interview with the parent or guardian. Questions to be asked during the interview are on the General Information, Health History, Immunizations, Dental Health, and Nutrition forms. After asking those questions, the interviewer puts these forms, together with the remaining forms that make up the Child Health Record, in the child's folder. As the year goes on, the record is updated. At the end of the year, copies of selected forms can be given to the parent or guardian as a permanent record of the child's health.
If the intake interviewer in your program is not familiar with the health component, be sure he or she is familiar with the forms and with which questions should be followed up during the interview. A person familiar with health should then review the record to identify any problems which should be drawn to the attention of a health professional.
INSTRUCTIONS FOR COMPLETING THE FORMS
FORM 1: GENERAL INFORMATION
Form I contains child and family data and emergency information. The whole form is to be completed by a Head Start staff person during the intake interview with the parent/guardian, except for item 14 which can be filled in from Items 18,123, and 24 on Form 2A of the Health History after the interview.
We suggest that you make three copies of Form 1: one each for your file, for the Social Services Coordinator and for the classroom teacher, so that he/she will have emergency information easily available. (If you do send a copy to the teacher, block out the sections related to Source of Reimbursement or Services and Household Information, since they may contain confidential information.)
Item 9. Source of Reimbursement or Services: EPSDT is the Early and Periodic Screening Diagnosis and Treatment component of the federally funded, state-administered Medicaid (Title XIX) program. It is designed to provide for the detection and treatment of health problems of Medicaid-eligible children and youth (birth to age 21). The program has different names in different states (e.g., Child Health Assurance Program in New York; Medi-check in Illinois; Project Health in Michigan; Child Health Disability Prevention program in California). In some states, only children in families receiving public assistance payments are eligible, while in others both the medically indigent and certain other groups of low-income or young people are eligible. Be sure to coordinate with your social services coordinator in determining a family's eligibility to assure that the family is asked for eligibility information only once.
In addition, review eligibility requirements for Medicaid/EPSDT, and assist families as appropriate in receiving Medicaid certification.
Federal, State or Local Agencies are those sources of services such as Crippled Children's Services, health departments, neighborhood health centers, and children and youth programs.
Other (3rd Party) indicates health insurance.
FORMS 2A and 2B: HEALTH HISTORY
The Health History assists staff in identifying and assessing children's past and present health problems in order to plan for their present and future health needs. It provides information necessary for Head Start staff (i.e., teachers, social workers, cooks, etc.) in planning their work with the children and their families. Through the intake interview, the stage is set for parent education and parent involvement in preventive health care.
These questions can tell us about a parent's understanding of preventive health services. By asking relevant questions and listening to the answers, we can begin to understand the health needs of the child and family. In addition, since Head Start is for families, this is a good chance to show your interest in the other members of the family as well as in the Head Start child.
Form 2A is for recording answers to questions about the mother's pregnancy and the child's birth history, hospitalizations and illnesses, health problems, and allergies. This section is to be completed during the parent/guardian intake interview by a Head Start staff person, preferably one knowledgeable in health. After the interview, the Health Coordinator or a staff person with health training summarizes in the Relevant Information section of Form 3 any points a health care provider should review during the physical examination/assessment. Keep the original copy of the form and photocopy it when you need to send the information to health professionals or others, needing access to the information.
Form 2A is designed so that "yes" answers are flags to possible health problems. Ask the parent/guardian to give details on any questions answered "yes" and be sure that the Health Coordinator or a person with training in health reviews each child's health history.
Form 2B has questions about the child's physical, psychological, and social development. These should be asked early in the program year, after the child has been enrolled, so that the parents can answer frankly without being afraid that their child won't be accepted if they give a "wrong" answer. You may want to do this after the first interview, during a home visit, for example.
FORM 2A: HEALTH HISTORY
Pregnancy/Birth History
1. Did mother have any health problems during this pregnancy or during delivery? Relevant problems to be considered include anemia, taking medications other than vitamins, positive serological blood test results, toxemia (excessive swelling and high blood pressure), bleeding during pregnancy, hemorrhage after pregnancy, forcep delivery, Cesarean section, and unplanned or unwanted pregnancy. Some of these problems may create stress for a woman during pregnancy and affect her reactions to and feelings about the child. This information is helpful to the physician in examining a child who is developmentally slow or has behavioral problems.
2. & 3. Did mother visit physician fewer than two times during pregnancy? Was child born outside of a hospital? Sensitive follow-up to questions on the birth can give clues to the child's health now, as well as to how much the mother knows about preventive health care.
If the mother had no or very little prenatal care and the child was not born in a hospital (and a home delivery was not planned), it may suggest problems with accessibility to providers, poor transportation, lack of understanding of the need for preventive care, or even, perhaps, indifference to the pregnancy.
4. Was child born more than 3 weeks early or late? Difficult deliveries, prolonged labors, and premature or exceptionally late births are important because they all have potential long-term effects on the child's health or development. In addition there is evidence that a strong relationship between mother and child begins to be formed very early and that children who are separated from their mothers after birth (as may happen with a premature infant) may have difficulties in kindling a warm, affectionate relationship later on.
5. What was child's birth weight? Birth weight provides a baseline against which a child's present weight can be compared. Children whose birth weight was 5 1/2 pounds or less or who were born 3 weeks early at a somewhat greater risk for neurological problems than are full-term infants.
6. & 7. Was anything wrong with child at birth? Was anything wrong with child in the nursery? If yes, ask what specifically was wrong? How was the problem treated? How long after delivery was it before the mother was able to feed and hold the baby?
Problems of the newborn may affect the child's future health, particularly the development of the nervous system. In addition, prolonged separation from the mother may cause developmental lags and difficulty for the child in establishing trusting, affectionate relationships later on.
8. Did child or mother stay in hospital for medical reasons longer then usual? If yes, ask why. Specify reasons (medical or psychosocial, such as drugs, emotional problems, inadequate supplies at home to care for infant and do forth).
9. Is mother pregnant now? If she is, ask what prenatal arrangements have been made, or, if the mother has not located a source of prenatal care, schedule a time later to talk about prenatal care if there is not enough time to discuss this during the interview.
Hospitalizations and Illnesses
Answers to questions on hospitalization and illness are important because they give us clues about possible stress and anxiety induced in the child and family and about the child's feelings toward doctors, nurses and hospitals. They may serve as indicators of children who are at high risk for accidents, infections, or illnesses.
10. Has child ever been hospitalized or operated on? If yes, for each hospitalization indicate the child's age, length of stay, reason for admission, and how often parent/guardian visited the child.
11. & 12. Has child ever had a serious accident? Has child ever had a serious illness? If yes, indicate child's age, diagnosis or description of what was wrong and, if an accident, how it happened.
Health Problems
13. Does child have frequent...? If any of the conditions are checked, ask how child dresses (i.e., hats, boots, rain gear) and the type of heat and ventilation system at home. How does mother decide the child should be taken to the doctor? Where is the child usually taken for treatment (private doctor, clinic, emergency room)?
14. through 20. This set of questions anticipates health problems common to three to five year olds. These problems or conditions may still be prevalent and require Head Start involvement. For each of these questions answered "yes," determine if the child is under the care of a doctor, dentist, or other health professional and record that person's name in item 20. Record the name of medication being taken, if known, in item 19.
21. through 23. Has child had ... ? If yes, for each item checked, ask if the child was seen by a doctor, what treatment was prescribed and whether the child required hospitalization. Attach a separate piece of paper if the child has had a number of illnesses.
24. Does child have any allergy problems? If the child is allergic, get information on how severe the reaction is, what medication, if any, is taken when the child has an allergic reaction, and what other measures the parent finds helpful.
NOTE: Enter any information regarding severe allergic reactions and/or emergency steps to take in case of a severe reaction on Forms I and 5 and relay it to the teacher.
25. & 26. These questions are asked to help the program identify any children who should be followed up or who have been diagnosed as having handicaps and may need special services or education. We have not used the word "handicap" however, because some parents may feel hesitant to say that their child has a handicap and because that word might have too limited a meaning to the parent. If the parent is unsure about what the questions mean, you can give examples (child finds it hard to play, parent must make special arrangements to move the child, child is extremely sensitive to temperature changes, etc.) but be sure to say that we want to know about any conditions which interfere with the child's life.
FORM 2B: HEALTH HISTORY (CONTINUED)
Physical, Psychological, and Social Development
These questions can give the staff an understanding of the parents' relationship with the child and can alert the staff to any recent changes a death, divorce, hospitalization, and so forth -- in the child's life. The answers can help the staff plan individual activities based on the child's strengths, needs and, if necessary, to plan referrals. As we said above, this information should be collected early in the program year, but after the child has been accepted into the program so that the parents can answer frankly, without being afraid that their child won't be accepted if they give a "wrong" answer.
NOTE: In some programs, certain developmental questions may be asked by staff other than the health component staff. If so, work with staff in other components to prevent duplication of history-taking and to assign responsibility clearly and appropriately.
27. Can you tell me one or two things your child is interested in or does especially well? This question also lets the parent/guardian know that the program wants to work with the child's strengths and interests and not just with problems. Use short, descriptive phrases to record the parent/guardian's responses, and check them for correctness with the parent/guardian before you write them down.
28. Does your child take a nap? Suddenly falling asleep or sleeping for unusually long periods may be signs of other health problems which need medical assessment, or it may signify that the child is not getting enough sleep at night.
29. Does your child sleep less than 8 hours a day or have trouble sleeping... ?
If yes, what time does the child go to bed, and, if unusually late, why? Does bedtime cause a battle between child and parent? Does the child seem tired and irritable during the day?
30. How does your child tell you he/she has to go to the toilet? Record responses in brief phases. Record the parent's pronunciation of what the child says as well as possible so that the staff will be able to understand when the child wants to use the toilet.
31. Does your child need help in going to the toilet during the day or night, or does your child wet his/her pants? If "yes," has the child ever had bowel and bladder control problems during daytime/ night time? If the child has been trained, is he or she under unusual stress? Does he or she have a cold or infection; a stomach upset? If the problem persists, the child should be referred to a doctor for a medical assessment. Assure the parents that bed-wetting is not abnormal for preschoolers, especially boys, who are slower to develop bowel and bladder control. Ask if parent/guardian knows any reason child is still wetting the bed.
32. through 34. How does your child act... ? After the parent has answered each question, briefly note the answers given. Try not to suggest answers to the parent. If the parent and the child have been very socially isolated, the parent may not be able to respond to the questions. This important information should be noted so that the teaching staff will be prepared to help the child adjust to the very new situation.
35. Does your child worry a lot or is he/she very afraid of anything? Common fears include animals, going to school, going to bed, water, fire, being away from the parent, and so forth. This question helps the staff either plan to help the child get over this fear or to avoid accidentally scaring him or her in the classroom.
36. Children learn to do things at different ages ... If the parent or guardian has not raised other children and has not known many other parents and their children, they may not be able to answer this question and should not be pushed to do so. Remind them that there is no "right" age at which a particular skill is developed and stress that a child may develop differently from the milestones and still be normal.
You may want to share with parents the milestones of normal child development (physical, cognitive and emotional) in order to help them to understand their child's behavior better and therefore work more effectively with them. Try to get an idea from the parent/ guardian about when the child began to do each of the activities. (Give the child's age in years and months, if possible.) If the parent/guardian is not sure or doesn't remember, enter DK for "don't know."
37. & 38. Does your child have any difficulties saying what he/she wants to do or do you have any trouble understanding your child? Children sometimes get cranky... If the parent has trouble understanding the child, try to find out more about the problem. Is the child withdrawn or reluctant to speak, does the parent have trouble understanding the child, and so forth? Record the answers briefly.
39. Have there been any big changes in your child's life in the last six months? Children's behavior and feelings may be affected both by things which are very important to adults (such as the loss of a member of the family or temporary separation from a parent or a person who usually takes care of the child) and those which do not seem so important to adults but are important to the child (such as the loss of a pet). Children may be affected not only by "bad" situations, but also by joyful occurrences which may nevertheless be upsetting to the child (such as a move, an addition to the family, etc.). You might want to list a wide variety of changes to the parent or guardian to give an idea of what kinds of changes are meant.
40. Are you or your family having any problems now that might affect your child? If yes, what problem(s) are there, and how has the parent attempted to manage the problem to date? If the parent does express a concern, be careful to let the parent know that it has been noted and that the program will try to help the parent start to deal with it. It is important to alert the appropriate staff to the concern and to be sure that it is not merely filed away in the record.
41. Is there anything else you would like us to know about your child? This question is open-ended -- don't suggest answers for the parent to pick from. You are more interested in getting a general idea of anything the parent considers important which the interviewer hasn't asked about yet than in getting specific information about the child.
FORM 3: SCREENINGS, PHYSICAL EXAMINATION/ASSESSMENT*
Form 3 enables the program to share information with the health care provider about the child's health history, staff and parent observations, and on the results of any medical screening tests the child has received before seeing the provider. The form is sent to the provider, who uses it to return test results, findings from the physical examination/ assessment, and recommended treatment, if any, to the program. If the child is referred to a specialist for treatment, the form should be sent with the child to give the specialist background information.
We suggest that you make four copies of Form 3: one for the provider's records, and three for the program's records. Two of the program's copies can be sent as needed when the child is referred to a specialist for treatment. The fourth copy can be given to the parents as part of an end-of-the-year summary.
PART I: Relevant Information
This section is to be completed by the Health Coordinator based on information collected during the parent/guardian interview and from parent or teacher observation ' s of the child. Use it to relay any concerns noted by the program to the medical health provider.
Screening Tests
A child may not need to have a particular screening test if he or she has had it in accordance with the Periodicity Schedule. Refer to Transmittal Notice 80.1 to see how often the screening tests should be given and for needed documentation. If a program performs some screening tests itself, it should be sure to relay the results to the health provider on this form.
Before sending the child to the health care provider for a physical examination/assessment, enter the results from any screening tests the child has already had in Part I, Screening Tests. Ask the provider to perform any additional screening tests which the child needs and which the provider has agreed to perform, and to enter the results in Part I, as well as to enter the results of the physical examination/assessment in Part II and to update the immunization record (Form 4).
NOTE: You may find it useful to have specific numerical screening test results on the child's record. For purposes of complying with the Performance Standards, however, the minimum requirement for recording results is as follows:
*Programs may use the EPSDT billing report form instead of or in addition to this form.
- NORMAL - no action needed
- SUSPECT - retest
- ATYPICAL/ABNORMAL - referral or diagnosis needed
If your program tests for sickle cell anemia, make certain that counseling for genetic defects and health education is available for parents of children with positive results.
PART II: Physical Examination/Assessment
It is especially important to encourage the health provider to comment in this section and in the Findings, Treatments, and Recommendations section on any abnormalities detected.
Findings, Treatments, and Recommendations
Entries into this part are to be made by the physical exam provider, any specialists to whom the child is referred for treatment, the Health Coordinator, and any other persons involved in the diagnosis, treatment, and follow-up on the child's medical needs or problems.
FORM 4: IMMUNIZATIONS
Form 4 is used to document information on the child's immunization history. Multiple copies can be made for use, as needed, by the program, the health care provider, other agencies, the school system, and the parents.
The information is gathered by a Head Start staff person during the intake interview. Be sure to remind the parent/guardian before the interview that you will be collecting information on the child's immunizations and that they should bring all immunization records they have for the child.
Item 1. Immunizations
A complete series of immunizations is one which includes the 4-6 year (before school) boosters. Consult ACYF information Memorandum 83-21 for more information on the ages at which children should get each dose.
In order to make this a legal document which the parents can use to prove which immunizations the child has had, be sure to have the doctor or a clinic representative sign in the "Doctor or Clinic" column for each dose given. If the dose was given in the past and the parent/guardian is showing you a record, write in the doctor or clinic and the date the dose was given and sign the statement at the bottom of the page saying that you have seen written documentation that the child has had the doses.
If a parent/guardian tells you that the child has received an immunization but does not have written proof, ask him or her to obtain proof from the doctor or clinic and to bring it to you so the child will not have to repeat immunizations.
Item 2. Exemptions
There are several reasons why a child may not get a particular immunization:
- If he or she has had the disease and is therefore immune to it already, write "Has had disease" on the form and be sure to attach a note from a physician certifying that the child has had that illness.
- If a child is allergic to one of the ingredients making up the immunization write "Allergic to" indicating the particular thing the child is allergic to. Again, attach a physician's note saying what the child is allergic to.
- If the parents refuse to give consent for religious, political, or other reasons, write, "Parent(s) will not consent," and attach a consent form which the parents have signed, indicating that they refuse to give their consent.
In some states, Head Start may require more immunizations, or different immunizations, than the state recommends for preschool children. Be aware of the recommendations in your state and of how they differ from Head Start requirements so that you can explain them to parents and providers who may not be familiar with Head Start policy.
If a child without all the required immunizations is enrolled, be sure to follow up on that child and the family, providing appropriate health education to be sure the parents understand the importance of immunizing their child completely.
NOTE: Remember, all immunizations listed must be documented!
Attach a copy of the documentation to the immunization history and send it to the physician or clinic when the child has a physical examination/assessment or has additional immunizations.
FORM 5: DENTAL HEALTH
Form 5, the dental health record, provides a way to exchange information between the Head Start staff and the dental provider and, at the end of the school year, to provide a dental health status summary to the parents.
We suggest making four copies of Form 5: one copy for the dentist's files; one copy to be returned to the Head Start program after the child's first dental visit, to indicate services needed and, if appropriate, to allow the Head Start program to approve treatment needed; and two copies to be returned to the program after the child's last visit, as a record of services received and an indication of activities the program or the parents can undertake to assure the child's continuing dental health. One of these copies can be given to the parents as a permanent record when the child leaves Head Start and one can be left in the child's Head Start file.
Ask the dentist to complete the Child Oral Health Summary, (item 12) during and/or after the final visit, sign the form, and return a copy of the dental record to the program.
PART I: Head Start-Generated Data
Information entered in this part is provided by Head Start staff before the child goes to the dentist. The information is gathered at the initial interview, with answers to questions 1 and 2 being entered directly on Form 5, and the remaining data coming from other forms as indicated below.
The answer to Question 3-is taken from the General-Information
Sheet (Form 1), Questions 11 and 12.
The answer To Question 4 is taken from the Health History
(Form 2A), Question 20.
The answer to Question 5 is taken from the Health History
(Form 2A), Questions 18 and 19.
The answer to Question 6 is taken from the Health History
(Form 2A) Questions 23 and 24.
The answer to Question 7 is taken from the General Information
Sheet (Form 1), Question 9.
Question 8, Priority Group, deals with the reality that very often all Head Start children cannot be examined immediately to determine their dental needs. The program must therefore decide which children go to the dentist first.
To determine which priority group the child is in, follow these guidelines:
Priority A, Needs Attention Immediately: Children with painful teeth, injured tissues within the mouth, injured facial tissue, bleeding gums, oral infection, oral sores or badly decayed teeth. Make sure these children see the dentist as soon-as possible.
Priority B, Needs Attention Soon: Children with obvious-cavities or with abnormalities in their mouths. Assure that these children are seen by a dentist soon.
Priority C, Needs Routine Care: Children with no gross dental problems but who need dental examination because they have not been examined at any time during the 12 months before they enter the Head Start program. Make certain that examinations are scheduled for these children.
FORM 6: NUTRITION, and FORMS 7 AND 8, GROWTH CHARTS
Form 6 is designed to help you record basic nutrition screening information collected from the parent/guardian during the initial interview from the health provider, and from your own measurements of the child's height and weight. This information includes, besides height and weight measurements, hemoglobin/hematocrit results and an estimate of the kinds and amounts of food the child is eating.
Some of the information asked for is also recorded in other places on the Child Health Record. It is recopied herd so that all the information related to the child's nutrition is available in one place. We suggest you make two copies of the form. If the child is referred, a copy of - this form should be given to the nutritionist or physician to provide a summary of the child's nutritional status. Retain the original for your files.
PART I: Dietary Habits
The questions in this section of the nutrition record are designed to identify children who may be at risk because of unusual eating patterns or other nutritional problems. A Head Start staff person collects the information required during the parent/guardian interview.
1. What foods does your child especially like? This question enables the interview to begin on a positive note and helps the cooks at the centers know what foods the children like.
2-11. These questions help a health provider or nutritionist detect possible situations which affect the child's nutrition. They are designed to identify children whose dietary habits may warrant referral.
If any starred block is checked, check the appropriate square in item 15, "Criteria for Referral or Further Investigation," and bring this to the attention of a qualified nutritionist.
12. About how often does your child eat ... ? This question is used to identify children who may have inadequate, excessive, or inappropriate food intake. Again, if any of the starred numbers are circled, check the first box under "Criteria for Referral" and bring it to the nutritionist's attention.
13. Growth. Enter growth data as directed onto the accompanying Growth Charts Forms 7 and 8. Each time growth measurements are made, place a suitable mark (small circle or an "x") on the appropriate chart at the point where a vertical line through the exact age and a horizontal line through the weight or height would cross. Do the same for the weight for height chart. Remember there are variations between children, and that among ethnic groups there are differences in growth and development.
NOTE: A child who weighs more or less than is typical at a certain age or is shorter than is typical may simply be large or small for that age. On the other hand, the child may have a nutritional problem. When you find a child with measurements in any of the shaded areas, check the appropriate box in question 15, find out more about the child's diet, and/or consult with a nutritionist or physician. Single measurements should be taken and recorded as accurately as possible. It is the child's rate of growth that is most important. If sequential measurements show that a plateau has been maintained in height and weight or that the pattern of growth has changed markedly, further follow-up is needed.
14. Anemia Screen. The results of the laboratory test of the child's blood should be copied from the Form 3, Screenings, Physical Exam/ Assessment. A hemoglobin concentration or a hematocrit determination should be routinely performed. (See Transmittal Notice 80.1.) If a child has a hemoglobin of less than 11 gm. or a hematocrit of less than 34% check the appropriate square in item 15, "Criteria for Referral."
15. Criteria for Referral or Further Investigation. This section summarizes the answers to questions 2 to 14 and the growth charts. Check the appropriate box if a potential problem has been identified, as explained above, and bring the child to the attention of a qualified nutritionist or physician.
FORM 9: PSYCHOLOGICAL AND SOCIAL DEVELOPMENT
NOTE: Forms 9 and 10 are different than forms 1-8, because they are for summarizing information during the year and not for entering information at the beginning of the year.
There are two parts to this form: a General Statement portion for recording observations and progress throughout the year, and a Tracking Record where the accomplishment of the initial developmental screening assessment and the scheduling and completion of any required follow-up activities may be entered. The form enables a Mental Health Coordinator or other health staff person to make sure that children for whom developmental problems have been identified are receiving all appropriate follow-up steps.
We suggest you make two copies of the form, one for your files and one for a mental health or other health professional to whom the child may be referred.
Some of the terms that appear on Form 9 are used in a special way by people who work in the mental health area and by the Medicaid/EPSDT program.
- Screening for Developmental Assessment is the process which separates those children who may have special needs from those who probably do not. Screening can be done by using standardized instruments, behavioral checklists, parent interviews or other information from parents, the physical exam, and/or staff.
- Developmental Assessment is the diagnostic process conducted by a licensed/certified mental health professional -- individually or as part of an inter-disciplinary diagnostic team. It provides a functional diagnosis (and additionally, in the case of a handicapped child, a confidential categorical diagnosis), which is then incorporated into the individualized plan for follow-through.
Part I: General Statement
Enter the indicated information in Part I during the year, as information on the child's development is obtained. When problems are identified, indicate the plan and outcome on a separate page or on the back of Form 9. The information in Part I can be used in writing the end-of-year summary for the parent or guardian.
Part II: Tracking Record
Emphasis in the Tracking Record should be in recording the occurrence and completion of the necessary steps in such a way that a reviewer can readily tell if additional action is required. It need not be used to repeat sensitive information that may appear on evaluation reports or other forms.
Space is provided in which to enter the dates and results of up to three developmental assessments. Enter the results of the first developmental assessment in the first column, and use the additional columns of the Tracking Record if assessments or referrals are repeated at later times during the program year, or if a reassessment is deemed necessary.
- Screening Method or Instrument Used: Enter the name of the particular early identification instrument, behavioral checklist, or other method used for screening for the developmental assessment.
- Staff Review of Screening (date): When the staff has reviewed the screening results, enter the date.
- Result of Staff Review: Check the block corresponding with the decision made during the staff review of screening results for this child. If it is decided that there is "no problem," no further entries need be made on the Tracking Record.
- (Before Referral) ....: If a referral to a mental health professional for emotional or behavioral problems is indicated by the staff review, a physical examination must have been conducted first to identify or to rule out any physical causes such as hearing, dental, nutritional, neurological, hormonal, or other problems (see Performance Standards). Record the dates here as the exam is scheduled, completed, and results are received by Head Start.
- (If Referred) .... : After physical problems are identified or ruled out and a referral for developmental assessment is planned, enter the name of the professional or agency to whom the referral is made and the date of the scheduled appointment on lines a and b. Check the block in line c when the appointment is kept, or enter the date of a rescheduled appointment on line d. Record the date when a report is received by Head Start on line e.
- Individualized Plan for Follow-Through Written (date): A plan of activities must be written to suit the individual needs of each child who requires additional staff and/or professional assistance (see Performance Standards). When this has been done, enter the date.
FORM 10: STAFF OBSERVATIONS OF HEALTH AND BEHAVIOR
The teacher is in an ideal position to observe the child during everyday activities and to notice health habits; physical, psychological, and social development; and reactions to the environment. Ask the teacher to complete Form 10 early in the school year and to update it during the year based on his or her observations of the child in the classroom and at play, noting any important points about the child that the program or a health professional should be aware of. Summarize from the form any information needed by other Head Start Staff or health professionals to whom the child is referred.
In home-based programs, the Home Visitor will complete this form. ...
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