Head Start Brown Folder Checklist

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)