Early Head Start Brown Folder Checklist
Early Head Start Brown Folder Checklist
Early Head Start Brown Folder Checklist
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<strong>Early</strong> <strong>Head</strong> <strong>Start</strong> <strong>Brown</strong> <strong>Folder</strong> <strong>Checklist</strong>Child'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)Pregnant Client Rollover: Yes NoIntake Form [Parent Signature 1305.5 (b)]Declaration FormEnrollment Information<strong>Head</strong> <strong>Start</strong> Eligibility Verification 1305.4(e)Recruitment 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)
<strong>Early</strong> <strong>Head</strong> <strong>Start</strong> <strong>Brown</strong> <strong>Folder</strong> <strong>Checklist</strong>FLAP 4: Health InformationWell Baby Checks 1304.20 (a)(1)(ii) Dates:Height: 1304.23(a)(1) Results:Weight:1304.23 (a)(1) Results:Subjective Vision Results: <strong>Checklist</strong> Used? Yes no 1304.20 (b)(1)Subjective Hearing Results: <strong>Checklist</strong> Used? Yes no 1304.20 (b)(1)FOC (under 24 months)Results: Date:Oral Health Screening 1304.20 (a)(1)(ii)Dr.'s Signature & date: (note: Not Stamped) 1304.20 (a)(1)(ii)Consent for Lead and/or Hematocrit Testing Completed with test results.(Lead Results >10 require follow-up required at 12 mos and 24 mos)Lead Questionnaire 1304.20 (a)(1) Results:Lead Test results 1304.20 (a)(1) Results:(Hgb < 11 or Hct < 34 require follow-up) Results: required at 6 mos, 12 mos an 24 mosHematocrit/Hemoglobin 1304.23 (a)(1) Results:T.B. Questionnaire 1304.20 (a)(1)(ii)Immunization (Child Plus Printout) 1304.20 (a)(1)Immunizations (copy of orginal document)ImmTrac Immunization record (If applicable)Immunization Letter (if applicable) 1304.20 (a)(1)(I) Date:Dental Exam 1304.20 (a)(1)(ii)(beginning at 6 months)Dr. Signature/date: (note: Not stamped-signed) 1304.20 (a)(1)(ii)Copy of Medicaid, CHIP, Private Insurance, Other 1304.20 (c )(5)Copy of Medicaid at Enrollment
<strong>Early</strong> <strong>Head</strong> <strong>Start</strong> <strong>Brown</strong> <strong>Folder</strong> <strong>Checklist</strong>FLAP 5: Parent Consent FormsMedical/Dental Emergency Consent/History Form 1304.20 (e)(2)Health History Part 2 (If applicable)Parent Consent For Services 1304.20 (e)Consent for Release and To Request Confidential Information 1304.20 (e)(2)(Move above form to flap 4 when blookwork results are documented on form)Consent for Lead and/or Hematocrit Testing using a Finger stick MethodAuthorization for Medication (if applicable) 1304.22 (c )(1-6)Notification of Health Services (if applicable) 1304.20 (e)(2)Consent for Medical/Dental Follow-up (if applicable) 1304.20 (e)(2)Health Management Plan (if applicable) 1304.20 (a)(iii)(iv)
<strong>Early</strong> <strong>Head</strong> <strong>Start</strong> <strong>Brown</strong> <strong>Folder</strong> <strong>Checklist</strong>FLAP 8: Home Base ONLYNotice of Teacher Home Visit (Home Base) 1306.33 (b)<strong>Early</strong> <strong>Head</strong> <strong>Start</strong> Home Based CalendarLesson Plan (Home Base) 1304.40 (e)(1) (and handout)Received a copy of Parent 's Guide for the Home Base Program Option
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