Head Start Brown Folder Checklist

Head Start Brown Folder ChecklistChild's Name:FLAP 1: Eligibility and EnrollmentChange of Status 1304.51 (e)(g) (if applicable)Current Year- Enrollment 1305.3 (g)(2)(ii)Family Information/Emergency ContactsFamily Member InformationEnrollment InformationEnrollment contact note 1304.51 (g)Staff and Parent Signatures 1305.5 (b)1st Year-Enrollment (if applicable )Recruitment Application 1305.5 (b) 1304.51 (g)Intake Form [Parent Signature 1305.5 (b)]Declaration FormEnrollment InformationRecruitment contact note 1304.51 (g)Birth Certificate 1305.5 (b)Power of Attorney (if applicable) 1305.5 (b)Court Order/Guardianship (if applicable) 1305.5 (b)Authorization of Care (if applicable) 1305.5 (b)

Head Start Brown Folder ChecklistFLAP 2: Family ServicesFamily Partnership, Family Assessment, Referrals & Follow UpReferral Follow-up Form (if applicable) 1304.40 (b)(2)Follow Up on Family Partnership Plan (2nd Home Visit)Family Goal(s) and Strategy SheetFamily AssessmentFamily Partnership Plan (1st Home Visit) 1304.40 (a)(1)Monthly Contact Notes (4110) & Attendance (2320)May 2013April 2013March 2013February 2013January 2013December 2012November 2012October 2012September 2012

Head Start Brown Folder ChecklistFLAP 3: Mental Health & DisabilitiesTransition Planning Form (If Applicable)Child Plus Contact NotesFollow-up Regarding Referral Services(if applicable) 1304.20(a)(1)(iv)CURRENT ARD/IEP Forms (if applicable) 1304.20 (c )(4) 1308.19 (a)Missed Appointment Letter (if applicable)Plan of Action/Referral Form (if applicable) (134.20 (a)(1)(iii) 1304.24 (a)(3)(iii)Decline of Services by Parent and /or Legal Guardian (if applicable) 1304.20 (e)(5)Consent for Release and/or Obtain Confidential Information(for disability services) 1304.20 (e)(2)Mental Health/Disability Referral Packet (if applicable)Consent for Mental Health Assessment/Services (if applicable)Private Provider Diagnosis Forms (if applicable)Behavior Observation Form (if applicable)ASQ-SE 1304.20 (b)(1) Date:Articulation 1304.20 (b)(1) Date:ECI Paperwork (i.e--IFSP, progress Notes) (if applicable)

Head Start Brown Folder ChecklistFLAP 4: Health InformationPhysical Examination (write in results) 1304.20 (a)(1)(ii) Date:Dr.'s Signature & date: (note: Not Stamped) 1304.20 (a)(1)(ii)Physical Exam Results:(Hgb < 11 or Hct < 34 or if stated by physician require follow-up)Hematocrit/Hemoglobin 1304.23 (a)(1) Results:Height: 1304.23 (a)(1)Results:Weight:1304.23 (a)(1)Results:Blood Pressure 1304.20 (a)(1)(ii)Results:Vision: 1304.20 (b)(1)Results:Strabismus 1304.20 (b)(1)Results:Hearing: 1304.20 (b)(1)Results:Consent for Lead and/or Hematocrit Testing Completed with test results.Lead Questionnaire 1304.20 (a)(1) Results:Lead Test results 1304.20 (a)(1)Results:(Lead Results >10 require physician follow-up)Follow for Lead Test 1304.20 (a)(1) Results:T.B. Questionnaire 1304.20 (a)(1)(ii) Results:T.B. Skin Test (if applicable) 1304.20 (a)(1)(ii) Results:Immunization Record (partner and grantee sites) 1304.20 (a)(1)(ii)ImmTrac Immunization record (If applicable)Immunization (Child Plus printout partner and grantee) 1304.20 (a)(1)Immunization Letter (if applicable) 1304.20 (a)(1)(I)Dental Exam 1304.20 (a)(1)(ii)Date:Follow- Up to Dental Exam 1304.20 (a)(1)(ii) Date:Dental Exam Results:If Failed - Need T.B. Skin TestDr. Signature/date: (note: Not stamped-signed) 1304.20 (a)(1)(ii)Medical and Dental Follow-up Form (if applicable) 1304.20 (e)(2)Add contact notes under respective document (if applicable)Is Medical or Dental Follow Up Required YES NO (circle one)Copy of Medicaid, CHIP, Private Insurance, Other 1304.20 (c )(5)Health Refusal Form (if applicable) 1304.20 (a)(1)(iii)

Head Start Brown Folder ChecklistFLAP T.B. Questionnaire 5: Parent Consent 1304.20 Forms (a)(1)(ii)Medical/Dental Follow-up Needed: Emergency 1304.20 Consent/History (c )(3)(I-ii) Form 1304.20 (e)(2)Health History Part 2 (if applicable)Parent Dr. Signature/date: Consent For (note: Services Not 1304.20 stamped-signed) (e) 1304.20 (a)(1)(ii)Consent Intra-Inter for Agency Release Referral and/or Form To Request (if applicable) Confidential 1304.20 Information (a)(1)(iii) 1304.20 (e)(2)Consent for Lead and/or Hematocrit Testing using a Finger stick Method (Move above form to flap 4 when blookwork results are documented on form)Authorization for Medication (if applicable) 1304.22 (c )(1-6)Notification of Health Services (if applicable) 1304.20 (e)(2)Health Management Plan (if applicable) 1304.20 (a)(iii)(iv)

Head Start Brown Folder ChecklistFLAP 6: Nutritional InformationDiet History for Children 1304.23 (a)(2)Growth Chart (Child Plus Print Out) 1304.23 (a)(1)Height:Weight:BMI %:Nutritional Treatment and Follow up Form (if applicable) 1304.20 (a)(1)(iii)(iv)Contact Note (if applicable) 1304.20 (a)(1)(iii)(iv)Nutrition Education Follow-Up Letter (if applicable) 1304.20 (a)(1)(iii)(iv)Copy of Doctor's Note for Special Diets (if applicable) 1304.20 (a)(1)(iii)(iv)

Head Start Brown Folder ChecklistFLAP 7: Developmental AssessmentsLAP-D Quick Screen 1304.20 (b)(1)Education ICOPA (if applicable)Full LAP-D (If applicable) 1304.20 (b)(1)LAP-3 (parent report) 1304.20 (c)(2)AprilJanuaryOctoberIndividualized Anecdotal Observation Form (1304.21 (c )(2)AprilJanuaryOctoberParent Conference: 1304.21 (a)(2)(iii)Date:Date:Date:Date:Date:Parent Home Visit: 1304.40 (I)(1-3) 1304.40 (I)(4-5)Date:Date:Education Missed Home Visits (if applicable) 1304.40 (I)(1-3)(4-5) 1304.51 (g)Pedestrian and Bus SafetyDate:

Head Start Brown Folder ChecklistFLAP 8: Home Base ONLYNotice of Teacher Home Visit (Home Base) 1306.33 (b)Lesson Plan (Home Base) 1304.40 (e)(1)Received a copy of Parent 's Guide for the Home Base Program Option

Head Start Brown Folder Checklist