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>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
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