End Session

Head Start Forms

Head Start Child Program File - PY 55

Section 2 - EHS Health Nutrition

2.0 TOC EHS Health and Nutrition (05-2020)

2.1 Immunization Record-Blue Card 1.2019

2.10 Medication Treatment Log (05-2020)

2.11A Authorization to Administer Medication at School (05-2020)

2.11B Individual Health Plan - IHP (05-2020)

2.12 Ouch Report (05-2020)

2.13 Parent Consent for Application of Diaper Rash Crm-Sunscreen (05-2020)

2.2 Health Consent & Acknowledgement Form (05-2020)

2.3 Child's Preadmission Health History (LIC 702) (05-2020)

2.4 Physical Exam Form (05-2020)

2.4A 12M Well Baby CheckUp (05-2020)

2.4A 15M Well Baby CheckUp (05-2020)

2.4A 1M Well Baby CheckUp (05-2020)

2.4A 2M Well Baby CheckUp (05-2020)

2.4A 4M Well Baby CheckUp (05-2020)

2.4A 6M Well Baby CheckUp (05-2020)

2.4A 9M Well Baby CheckUp (05-2020)

2.4B Toddler Physical (05-2020)

2.5 Dental Health Form (05-2020)

2.6A Infant Nutrition-Health Questionnaire (INHQ) (05-2020)

2.6B Toddler Nutrition-Health Questionnaire (TNHQ) (05-2020)

2.7 Supplemental Health Data (05-2020)

2.8A Request for Special Meals-Accommodations Medical Statement (05-2020)

2.8B Request for Special Meals-Accommodations Parent-Guardian (05-2020)

2.9 Medication Intake Form (05-2020)

Authorization to Release Information (05-2020)

Parent Permission for Wellness Exam (05-2020)

Parents Written Refusal of Services (05-2020)

EHS Health & Nutrition Instructions

2.10 Medication Treatment Log Instructions (05-2020)

2.11A Authorization to Administer Medication at School Instructions (05-2020)

2.11B Individual Health Plan - IHP Instructions (05-2020)

2.12 Ouch Report Instructions (05-2020)

2.13 Parent Consent for Diaper Rash-Sunscreen Instructions (05-2020)

2.2 Health Consent and Ackn Intructions (05-2020)

2.3 Child's PreAdmission Health History LIC 702 Instructions (05-2020)

2.4 Physical Exam Form Instructions (05-2020)

2.4A Well-Baby Check-Up Instructions (05-2020)

2.4B Toddler Physical Instructions (05-2020)

2.5 Dental Health Form Instructions (05-2020)

2.6A-B Nutrition Health Questionnaire Instructions (05-2020)

2.7 Supplemental Health Data Instructions (05-2020)

2.8A-B Request for Special Meals-Accommodations Instruction Sheet (05-2020)

2.9 Medication Intake Form Instructions (05-2020)

Authorization to Release Information Instructions (05-2020)

Parent Permission for Wellness Exam Instructions (05-2020)

Parents Written Refusal of Services Instructions (05-2020)

PROMIS-- Individual Child Health Summary Report Instructions (05-2020)

Other content related forms

Health Screenings Fact Sheet (05-2018)

Identifying Health Concerns (05-2019)

LEAD letter from the County - Head Start Lead Screening Letter to Providers

Which Special Meals Form Do I Use

Exposure Notices forms

Chicken Pox (E)

Chicken Pox (S)

Fifth Disease (E)

Fifth Disease (S)

Giardiasis (E)

Giardiasis (S)

Hand-Foot-Mouth Disease (E)

Hand-Foot-Mouth Disease (S)

Head Lice (E)

Head Lice (S)

Hepatitis A (E)

Hepatitis A (S)

Impetigo (E)

Impetigo (S)

MRSA (E)

MRSA (S)

PinkEye (S)

PinkEye(E)

Pinworms (E)

Pinworms (S)

Pneumonia (E)

Pneumonia (S)

Ringworm (S)

Ringworm(E)

Scabies (E)

Scabies (S)

Strepcoccal (E)

Streptococcal (S)

Immunizations forms

CA Immunization Handbook July 2019

Notice of Immunizations Needed ENGLISH

Notice of Immunizations Needed SPANISH

Child Program File Sections - PY 55

CSQI Only Forms
Child File Transfer Forms
Service Packets
Service Packet Checklists
Child File Review Checklists
Progress Notes
Section 0 Cover Sheets
Section 1 Enrollment
Section 2 Health Nutrition
Section 3 Family Partnerships
Section 4 Education
- EHS Education
- HS Education
Section 5 Disabilities
- EHS Disabilities
- HS Disabilities
Section 6 Mental Health
- EHS Mental Health
- HS Mental Health
PY 55 Service Packet 1 - Virtual Services
- EHS Virtual Services
- HS Virtual Services