Section One: Enrollment Inspection of Confidential Records Referral Record Change of Status Child Plus Application Form District Enrollment Forms

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1 HEAD START FORMS

2 Section One: Enrollment Inspection of Confidential Records Referral Record Change of Status Child Plus Application Form District Enrollment Forms Notification Letter (optional if prior to school starting) Parent Handbook/Student Handbook Code of Conduct Copy of Birth Certificate Copy of Social Security card Video Surveillance Policy (as needed) Legal Document Log

3 If you have reviewed all this student s Education Folder and do not find the information you are looking for, please ask a staff member.

4 Head Start INSPECTION OF CONFIDENTIAL RECORD NAME TITLE DATE PURPOSE

5 Head Start REFERRAL HEALTH/EDUCATION CHILD S NAME DATE TYPE OF REFERRAL REFERRAL CONTACT FOLLOW UP DATE COMMENTS INITIAL OF REFERRING STAFF

6 Head Start CHANGE OF STATUS Effective Date: Name of Child: Drop Re-enrollment Reason: Center: Teacher: Child withdraws before 10:00 a.m. /use that days date as drop date; Child withdraws after 10:00 a.m. /use the next days date as drop date Transfer Campus: Teacher: Reason: Change of Address: Change of Phone: Change of Employment: Mother Father Name: Place of Employment: Company: Phone: Person to Contact in case of Emergency: Name: Relationship: Phone: Submitted by: Title: Date: Mother or Dad s Signature: Date: 4/06

7 Applicant Information Complete for individuals who are applying to a program. Child s Information Last First Middle Preferred Birthday: SSN Gender: Male Female Place of Birth: Adult Name Child s Relationship Custody? Parental Status: One Two Yes No Number in Family Number in Household Yes No Primary Language At Home Number of Children By age: 0-3 By age: 4-5 Releases Signed? Yes No Date Signed TANF Status: YES NO SSI: YES NO WIC: YES NO Living Address Address/Phone Mailing Address Living Address Line 2 Mailing Address Line 2 City State Zip County City State Zip Phone Type if Primary Phone Number Phone Number Phone Note ( ) ( ) ( ) ( ) Medicaid Eligibility Status: On Medicaid Potentially Eligible Primary Health Coverage Other Health Coverage Health Coverage Not Eligible Medicaid Number Insurance Number Demographics Race (check ALL that apply): Asian Black Hispanic White Native American Pacific Islander Other: Language English if Primary Proficiency Nationality Ethnicity Certification: I certify that this information is true. If any part is false, my participation in this agency s programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours. Mom or Dad s/guardian Signature Date Verifying Staff Member Date Page 1 of 2 Copyright 2004 Management Information Technology USA, Inc. 4/06

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9 Informacion de Aplicante - Applicant Information Complete for individuals who are applying to a program. Información sobre su niño - Child s Information Apellido - Last Primer Nombre - First Segundo Nombre - Middle Nombre preferido - Preferred Fecha de Cumpleaños - Birthday: Número de Seguro Social - SSN Sexo - Gender: M F Ciudad, estado de nacimiento - Place of Birth: Nombre de Adulto Relación al Niño Adult Name Child s Relationship Date Signed Releases Signed? Yes No Es guardián? Custody? Si - Yes No - No Si - Yes No - No Cuántos padres viven en casa? Parental Status: Uno - One Dos - Two Cuántos en la familia? Number in family Cuántos viven en casa? Number in household Idioma que se habla en casa Primary Language At Home Cuántos niños en casa? Number of Children Por edad: 0-3 By age: 0-3 Por edad: 4-5 By age: 4-5 TANF Status: YES NO SSI: YES NO WIC: YES NO Dirección de casa - Living Address Dirección de Casa/ Número de Teléfono - Address/Phone Dirección de correo - Mailing Address Línea adicional para dirección de casa - Living Address Line 2 Línea adicional para dirección de correo - Mailing Address Line 2 Ciudad - City Estado - State Código Postal Zip Condado- County Ciudad - City Estado - State Código Postal Zip Tipo de teléfono Phone Type if Primary Número de Teléfono Phone Number Numero de Teléfono Phone Number Phone Note ( ) ( ) ( ) ( ) Medicaid Eligibility Status: On Medicaid Not Eligible Potentially Eligible Nombre de su seguro de salud - Primary Health Coverage Información sobre seguro de salud - Health Coverage Número de Medicaid - Medicaid Number Nombre de seguro de salud adicional - Other Health Coverage Número de su seguro de salud - Insurance Number Raza (favor de indicar todos lo que pertenecen) Race (check ALL that apply): Asiático - Asian Negro - Black Hispano - Hispanic Anglo - White Indio - Native American Indio de las islas Pacificas - Pacific Islander Otra raza - Other: Información Demográfica - Demographics Idioma - Language Ingles - English si es su idioma primaria if Primary Proficiency Nacionalidad - Nationality Su etnicidad - Ethnicity Certificación: Certifico que esta información es la verdad. Si alguna parte no es la verdad, mi participación en los programas de esta agencia pueden ser terminados y quizás resultará en acción legal. También entiendo que esta información está dada en confianza estricta dentro de esta agencia y tengo acceso de esta información durante las horas de negocio de esta agencia. Padre/Guardian Fecha Verifying Staff Member Date Copyright 2004 Management Information Technology USA, Inc. 4/06

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11 NOTIFICATION LETTER Head Start Center: Address: Telephone: Date: Dear Parent/Guardian, Your HEAD START application for has been screened and the results are indicated by the check mark below: Your child has been approved for the Head Start program. Your child has been approved, but because our classes are presently filled, has been placed on our waiting list. Your child is too young for Head Start, this year. Your family income makes your child ineligible at this time. Your child s name will be considered for enrollment on this basis. If your child is accepted for enrollment at a later time, you will be notified. If your child has been approved, an enrollment time and place have been written in below. ENROLLMENT DATE LOCATION TIME Completion of enrollment will take between 1 and 1 ½ hours. Please bring your Medicaid card and a copy of current physical and dental records, if you have one, and proof of any insurance you may have. Sincerely, Head Start Representative 4/06

12 CARTA DE NOTIFICACION Head Start Escuela: Dirección: Número de Teléfono: Fecha: Estimados Padres/Guardianes, Su aplicación en el programa de HEAD START para ha sido revisada y el resultado está marcado: (Nombre del niño) Su hijo ha sido aprobado para el programa de Head Start. Su hijo ha sido aprobado pero porque nuestras clases ya tienen el límite de niños, hemos puesto el nombre de su niño en una lista de espera. Su hijo está muy joven para el programa de Head Start este año. El salario de su familia hace que su niño sea inelegible horita. Su niño no será considerado por esta razón. Si aceptamos a su hijo en el futuro, le notificaremos. Si hemos aceptado a su niño, la fecha, el tiempo de matriculación y el lugar en donde recibirse está escrito abajo. FECHA DE MATRICULACION HORA LUGAR/ESCUELA Se tomará aproximadamente una hora en matricular a su hijo. Favor de traer su tarjeta de Medicad, si lo tiene, o prueba de seguro. Sinceramente, Representante de Head Start 5/2007

13 OPTIONAL ENROLLMENT FORMS Thank You Letter for Your Interest Video Surveillance Policy

14 Dear Parent/Guardian: Head Start Thank you for your interest in our Head Start Child Development Program. To be considered for the program, we must have reasonable verification of 12 months income for your total family. Examples of this verification could be: A copy of your current income tax (please note this is a federally sponsored program) OR W-2 forms for parents or guardians Income earned in previous 12 months (notarized family statement of gross earnings, 12 months worth of check stubs). Eligibility might be able to be determined with lesser documentation, but that will slow the eligibility process. Also, please understand that we will need to determine your family composition for eligibility, i.e. total in household including children. You will need to bring documentation of any additional non-taxable income you receive: Child Support Social Security Benefits Unemployment Compensation Dividends, Interest Welfare Payments Pensions, Annuities Workers Compensation Alimony Educational Loans/Grants Other necessary documentation to bring is your child s: Birth Certificate Social Security Card Shot Record Food Stamp Letter TANF Documentation Proof of medical and/or dental insurance When you come in to bring the information requested, it will take 15 to 30 minutes to complete the eligibility form. If you have any questions, please feel free to call our office at. Thank you for your cooperation. 5/2007

15 Estimado Padre/Guardián, Head Start Muchas gracias por su interés en el programa de Desarrollo de Niños de Head Start. Para ser considerado en el programa, tenemos que recibir 12 meses de verificación de salario de su familia en total. Ejemplos de verificación pueden ser: Copia de su declaración de impuestos federales, O Formas de W-2 de los padres/guardianes, Los recibos (de 12 meses) de sueldo. Podemos determinar elegibilidad con menos documentación, pero el proceso tomará más tiempo. También, favor de entender que necesitaremos determinar su elegibilidad considerando todas personas en su familia, incluyendo los niños. Necesitará traer documentación de ingresos adicionales que recibe. Por ejemplo: Sostén de niño (resultado de divorcio) Beneficios de Seguro Social Beneficios de desocupación Dividendo, Interés (de dinero) Pagos de ayuda del Estado (para su bienestar) Pensión, anualidad Compensación de trabajo Asistencia (resultado de divorcio) Préstamos educacionales/donaciones Otros documentos de su hijo que son necesario traer: Certificado de nacimiento Tarjeta de seguro social Forma/record de inmunizaciones Carta del estado acerca de poder recibir estampillas para comida TANF un programa del gobierno de Texas para familias en necesidad de ayuda Prueba de seguro médico o dental Cuando usted venga a traer la información requerida, tomará 15 a 30 minutos para completar la forma de elegibilidad. Si usted tiene cualquier pregunta, favor de llamar nuestra oficina. Muchas gracias por su cooperación.

16 Video Surveillance Policy Head Start Dear Parents, This is to notify you of our classroom video surveillance cameras. The purpose of the video cameras is for your child s safety as well as the Head Start center teachers, staff and parents. We take pride in providing the best childcare and learning environment, our preventative measure is to video tape your children in their classrooms. Head Start has posted video surveillance signs in the classrooms and around the Head Start building to inform the general public of the Head Start video cameras. Extreme care is enforced in safeguarding these surveillance tapes against unauthorized use. After reading the above notice, I Head Start classroom. the parent/legal guardian of understand that my children will be under videotape surveillance while in the I understand that the surveillance cameras in the classrooms are there to protect the welfare of my children, and the Head Start staff and teachers. Parent/Guardian Date Site Manager Date 4/04

17 PÓLIZA DE VIGILANCIA DE VIDEO Head Start Estimados Padres, Esta carta es para notificarle de nuestras cámaras de video para vigilancia en los salones de clase. El propósito de las cámaras de video es para la seguridad de su niño así como la seguridad de las maestras de Head Start, los empleados de Head Start, y los padres de los niños. Tomamos mucho orgullo en proveer el mejor cuidado de su niño y ambiente de aprender. Nuestro método preventivo es de tomar video durante el tiempo que los niños están en sus clases. Head Start ha puesto rótulos dentro de y alrededor de la escuela que anuncian al público de las cámaras de video para vigilancia. Tomamos cuidado en la salvaguardia de estos videos contra abuso ilegal. Después de leer esta carta, yo el padre/guardián legal de entiendo que mis niños estarán bajo vigilancia de cámaras de video durante su tiempo en el programa de Head Start. Entiendo que las cámaras de vigilancia en las clases están allí para proteger el bienestar de mis niños y los empleados de Head Start. Padre/Guardián Fecha Empleado de Head Start Fecha

18 INCOME DOCUMENTATION Eligibility Worksheet Individual Systematic Form Committee Systematic Form Signature Page Group Systematic Selection Form

19 ELIGIBILITY Family Size (total # in household) Family s Gross Annual Income (parents only) ITEM $ $ A) Taxable income earned (computed in the following ways) 1) Income earned in previous calendar year (from Federal Income Tax Form) 2) Income earned in previous 12 months (family statement of gross earnings) $ $ (B) Additional non-taxable income 1) Veteran s benefits $ 2) Social Security benefits $ 3) Unemployment compensation $ 4) Dividends, interest $ 5) Welfare payments $ 6) Pensions, annuities $ 7) Workers Compensation $ 8) Alimony $ 9) Child Support $ 10) Educational loans/grants $ C) Total of B $ D) Total of A & B $ E) Deductions (medical & dental expenses and casualty or theft loss in excess of 10% of gross family income) $ F) Total (adjusted gross family income = E minus D) $ MAXIMUM ALLOWABLE INCOME FOR FAMILY SIZE $ ABOVE INCOME $ BELOW INCOME $ I (we) agree to report any and all changes as they occur in my (our) family s income during the period my (our) children are enrolled in the program. I also understand that I am required to furnish written proof of all income information on this form. I hereby affirm that all the information given above is accurate. Date Verifier s Signature Mom or Dad/Guardian s Signature 5/2007

20 File in confidential folder for income Region 9 Head Start Individual Systematic Selection Form Head Start This information is to be used with professional staff only in keeping with FERPA and I.D.E.A. B Confidentiality Requirements and Head Start performance Standards. Revised 4/2007

21 File in ERSEA Binder Region 9 Head Start Committee Systematic Selection Form Signature Page ISD Head Start (a) Approved Over Income Birth Date Child Age as of Sept. 1 Code # # in Family Male/Female Single Parent Home Disabilities Family Income Below Poverty Guideline on Public Assistance Child in Foster Care Non Parent Guardian Family Preservation/Open CPS Case Family is on TANF Family is Homeless Child has Obvious Medical Need Stressors (See Application Checklist) Early Head Start Transfer/ Even Start Child is Non English Speaking Family has 3 or more Children Parent Employment or Training Totals Date of Application 15 20/10/ pts. each /10 Signature of Systematic Selection Date Committee Member Date This information is to be used with professional staff only in keeping with FERPA and I.D.E.A. B confidentiality requirements and Head Start performance Standards. Revised 8/2007

22 File in ERSEA Binder ISD Region 9 Head Start Group Systematic Selection Form Signature Page Head Start (a) Approved Over Income Birth Date Child Age as of Sept. 1 Code # # in Family Male/Female Single Parent Home Disabilities Family Income Below Poverty Guideline on Public Assistance Child in Foster Care Non Parent Guardian Family Preservation/Open CPS Case Family is on TANF Family is Homeless Child has Obvious Medical Need Stressors (See Application Checklist) Early Head Start Transfer/ Even Start Child is Non English Speaking Family has 3 or more Children Parent Employment or Training Totals Date of Application 15 20/10/ pts. each /10 This information is to be used with professional staff only in keeping with FERPA and I.D.E.A. B confidentiality requirements and Head Start performance Standards. Revised 8/2007

23 APPLICATION CHECKLIST

24 Head Start Child s Name: APPLICATION CHECKLIST POINT SYSTEM: Stressors (2 points each) Lack of transportation..family does not have private vehicle Child living with relatives Explain: CPS Intervention investigation Family living with relatives Education level below 12 th grade Teenage Parent (when Head Start child was born - between 13-19) Migrant Family.family has moved several times in the past 12 mos. seasonal/agricultural work Parent Deployed Parent Disability Sibling Disability Pregnancy Recent Relocation.within 6 months Recent Unemployment.within 6 months Working and in school (including GED classes, Vo Tech, College) Other Explain: Disability (5, 10 or 20 points) Suspected ECI (Early Childhood Intervention) or other program for children with disabilities Qualified for special education services Medical (10 points) Child has obvious medical need Transition/Transfers (15 points) Even Start Project Together/Early Head Start Transfer (from another Head Start Program) Other Homeless (20 points) please explain: Non-parent Guardian (100 points) Family Preservation (30 points) Parent Employment or Training (20 points) both or (10 parents) one MUST HAVE: Child s: Birth Certificate Social Security Card Medicaid/Insurance Card Shot Record Parent s: Proof of Income Picture I.D. PLEASE ASK ABOUT THE FOLLOWING: (Check if attached, if not checked, explain status) Physical exam Status: Dental exam Status: Approved Verified by:

25 Section Two: Health Consent for Health Services Emergency Consent and Medical Information Release Form Copy of Health Contact Follow-up Form (as needed) Documentation of Insurance (Medicaid/Chips, etc.) Child Health-Form 2A,6 Head Start Health Services Release of Information Child Health Form 3 - Physical Hearing and Vision for 3 year old Copy of Immunization Record Lead Screening/TB screening Child Health Record Form 5 - Dental Child Plus Growth Charts Head Start Observation Notes In House Referral (as needed) Accident Report (as needed)

26 Head Start Consent for Health Services I, hereby give my consent for the child listed below to receive the screening tests and examinations checked below, and for transport of the child to and from the services as needed. I understand these services are deemed necessary or advisable by the Head Start program and that I will be informed of any results that are not normal. I also understand that is my responsibility to provide Head Start with an up-to-date immunization record and a record of medical and dental examinations performed in the past year. This consent is valid for one year after the signed date. The purpose of this consent has been explained to me. I agree: That in case of emergency or if a parent or guardian cannot be contacted, Head Start may provide first aide or emergency medical care if needed. Yes No Initial below: Developmental Screening Medical Examination Speech Screening Hearing Test Immunizations (if necessary) Mental Health Screening Crisis Counseling Dental Examination Height and Weight Vision Test T.B. Test Brush teeth daily with fluoride toothpaste Lead Screening I understand that this involves a blood sample obtained by a fingerstick or venipuncture if necessary. As a parent/guardian of, I hereby authorize the release of Medicaid/THSTEPS eligibility information and medical records to satisfy Head Start requirements. CHILD S NAME DATE OF BIRTH Signature of Mom or Dad/Guardian Relationship to Child Date I have explained to the purpose of this release and the nature of the tests and examinations that the children enrolled in Head Start receive. Signature of Head Start Staff Date

27 PERMISO PARA RECIBIR SERVICIOS DE SALUD Head Start Yo, doy permiso que mi hijo obtenga los exámenes que he designado en la siguiente parte de esta forma. Además, doy permiso que alguien del programa de Head Start lo transporte para recibir estos servicios. Entiendo que mi hijo necesita estos exámenes y que me avisarán si un examen no resulte en manera normal. También entiendo que es mi responsabilidad proveerle a Head Start con los record corrientes de inmunizaciones de mi hijo y examen hechos por un médico o dentista dentro del año pasado. Esta forma está en efecto por un año desde hoy. Me han explicado el propósito de esta forma. Estoy en acuerdo: Que si hay alguna emergencia en donde no me pueden comunicar por teléfono, el personal de Head Start puede proveer auxilio de emergencia si es necesario. Si No Favor de marcar los servicios que necesita su hijo: Examen de desarrollo Examen de salud mental Examen por un medico Examen por consejero de crisis Examen por un dentista Examen para manera de habla Examen para saber que tan alto está y cuanto pesa mi hijo Examen auditiva Examen de visión Inmunizaciones (si es necesario) Examen para tuberculosis Examen para ver si se cepilla los dientes con pasta de diente que contiene fluoruro Examen que indica si el niño se ha puesto en contacto con plomo. (En años pasados los cuartos en casas eran pintados con pintura que tenía plomo. Este plomo es como veneno si uno se pone en contacto con el.) En este examen se le tiene que obtener sangre por un dedo. Como padre/guardián de, yo doy permiso que el programa/personal de Head Start puedan usar la información de Medicad/THSTEPS y los record médicos de mi hijo. NOMBRE DE NIÑO FECHA DE NACIMIENTO Firma de padre/guardián Parentesco al niño Le he explicado a niños de Head Start. Firma de personal de Head Start Fecha el propósito de esta forma y los servicios de salud que reciben los Fecha

28 Head Start Emergency Consent and Medical Information Release Form Name of Child: Birth Date: Sex: Address: Student Social Security : School: Teacher: In the event that I cannot be reached to make arrangements for medical attention for my child, at the time of an accident or illness while he or she is attending a Head Start program, I grant and authorize a representative of Head Start to grant permission to the medical staff and the Emergency Department staff of the local hospital to perform any medical or surgical treatment and to administer such anesthesia and/or drugs as may be deemed necessary in the diagnosis or treatment of said patient. Furthermore, I hereby authorize release of all medical/dental pertinent information concerning my child to a designated representative of Head Start. We the parent(s)/guardian(s) of the above named child acknowledge it is our responsibility to keep the information in this Emergency Consent form current and correct. We agree to notify Head Start of any changes to phone numbers or changes of physician or changes in name of those who shall be contacted in the event of any emergency. Medications Taken By Child: Child s Allergies: Chronic Diseases: Child s Doctor: Child s Dentist: Signature of Mom or Dad Date Home Phone Work Phone 4/06

29 Permiso Para Divulgar Información de Emergencia y Medico Head Start Nombre del niño: Fecha de nacimiento: Sexo: Su dirección: Número de seguro social (del niño): Nombre de escuela: Nombre de su maestra: Durante el tiempo que mi niño esté bajo el cuidado del programa de Head Start, doy permiso que los empleados de Head Start arreglen que mi niño tenga tratamiento de emergencia si es que no se puedan ponerse en contacto conmigo. Les doy permiso a los empleados de Head Start que autoricen al Departamento de Emergencia que le den a mi hijo anestesia y/o drogas que sean necesarias para el bienestar de mi hijo. Además, doy permiso al personal de Head Start que puedan divulgar información de mi hijo acerca de su salud física o dental a personal de Head Start. Nosotros, los padres/guardianes de este niño reconocemos que es nuestra responsabilidad de asegurar que esta forma tenga la más reciente información acerca de la salud de mi niño y los nombres y números de teléfono de emergencia. Aseguramos decirles a los empleados de Head Start cuando haya cambio de médico y su número de teléfono o los nombres y números de teléfono de la gente a quien se le puede llamar en caso de emergencia. Nombres de las medicinas que toma mi hijo: Alergias que tiene mi hijo: Enfermedades crónicas: El nombre de su doctor: El nombre de su dentista: / Firma de mamá o papá/guardián Fecha: Número de teléfono de casa/trabajo

30 Head Start Health Contact Follow-up Form This is a summary for the child listed below. We hope that it will be of assistance to you. Child s name Date Screening completed Results were normal Yes/No Date of Followup/Treatment Results Hearing Vision Dental Additional Information: Staff Signature/Date File in Health Section and Give copy to Parent 4/06

31 Forma de Continuación De Información de Salud Head Start Esta forma sirve como sumario de examines para el niño cuyo nombre sigue. Esperamos que le ayude. Nombre del niño Examen de oídos Fecha que se cumplió el examen Los resultados son normales Si/No Fecha para continuación de tratamiento Los resultados Examen de visión Examen dental Información adicional: Firma de Personal/Fecha File in Health Section and Give copy to Parent

32 CHILD HEALTH RECORD: FORM 2A, HEALTH HISTORY TO BE COMPLETED BY HEAD START STAFF DURING PARENT/GUARDIAN INTERVIEW. HEAD START CENTER: CHILD S NAME: SEX: BIRTHDATE: PERSON INTERVIEWED: DATE: RELATIONSHIP: NAME OF INTERVIEWER: TITLE: PREGNANCY/BIRTH HISTORY YES NO EXPLAIN YES ANSWERS 1. DID MOTHER HAVE ANY HEALTH PROBLEMS DURING THIS PREGNANCY OR DURING DELIVERY? 2. DID MOTHER VISIT PHYSICIAN FEWER THAN TWO TIMES DURING PREGNANCY? 3. WAS CHILD BORN OUTSIDE OF A HOSPITAL? 4. WAS CHILD BORN MORE THAN 3 WEEKS EARLY OR LATE? 5. WHAT WAS CHILD S BIRTH WEIGHT? lbs., oz. 6. WAS ANYTHING WRONG WITH CHILD AT BIRTH? 7. WAS ANYTHING WRONG WITH CHILD IN THE NURSERY? 8. DID CHILD OR MOTHER STAY IN HOSPITAL FOR MEDICAL REASONS LONGER THAN USUAL? 9. IS MOTHER PREGNANT NOW? (If yes, ask about prenatal care, or schedule time to discuss prenatal care arrangements.) HOSPITALIZATIONS AND ILLNESSES YES NO EXPLAIN YES ANSWERS 10. HAS CHILD EVER BEEN HOSPITALIZED OR OPERATED ON? 11. HAS CHILD EVER HAD A SERIOUS ACCIDENT (broken bones, head injuries, falls, burns, poisoning)? 12. HAS CHILD EVER HAD A SERIOUS ILLNESS? HEALTH PROBLEMS YES NO EXPLAIN (Use additional sheets if needed) 13. DOES CHILD HAVE FREQUENT SORE THROAT; Cough; URINARY INFECTIONS OR TROUBLE URINATING; STOMACH PAIN, VOMITING, DIARRHEA? 14. DOES CHILD HAVE DIFFICULTY SEEING (Squint, cross eyes, look closely at books)? * 15. IS CHILD WEARING (Or supposed to wear) GLASSES? 16. DOES CHILD HAVE PROBLEMS WITH EARS/HEARING (Pain in ear, frequent earaches, discharge, rubbing or favoring one ear)? 17. HAVE YOU EVER NOTICED CHILD SCRATCHING HIS/HER BEHIND (Rear end, anus, butt) WHILE ASLEEP? 18. HAS CHILD EVER HAD A CONVULSION OR SEIZURE? IS CHILD TAKING MEDICINE FOR SEIZURES 19. IS CHILD TAKING ANY OTHER MEDICINE NOW? (Special consent form must be signed for Head Start to administer any medication). 20. IS CHILD NOW BEING TREATED BY A PHYSICIAN OR A DENTIST? 21. HAS CHILD HAD: BOILS, CHICKENPOX, ECZEMA, GERMAN MEASLES, MEASLES, MUMPS, SCARLET FEVER, WHOOPING COUGH? 22. HAS CHILD HAD: HIVES, POLIO? * 23. HAS CHILD HAD: ASTHMA, BLEEDING TENDENCIES DIABETES, EPILEPSY, HEART/BLOOD VESSEL * DISEASE, LIVER DISEASE, RHEUMATIC FEVER, SICKLE CELL DISEASE? 24. DOES CHILD HAVE ALLERGY PROBLEMS (Rash, itch swelling, difficulty breathing, sneezing)? a. WHEN EATING ANY FOODS? * b. WHEN TAKING ANY MEDICATION? c. WHEN NEAR ANIMALS, FURS, INSECTS, DUST, ETC? 25. (If any yes answers to questions 14, 16, 18, 22, 23, or 24 ask:) DO ANY OF THE CONDITIONS WE VE TALKED ABOUT SO FAR GET IN THE WAY OF THE CHILD S EVERYDAY ACTIVITIES? * * (If yes ) WAS LAST CHECKUP MORE THAN ONE YEAR AGO? If yes, ask WHEN DID IT LAST HAPPEN? WHAT MEDICINE? WHAT MEDICINE? (If yes ) WILL IT NEED TO BE GIVEN WHILE CHILD IS AT HEAD START? HOW OFTEN? (PHYSICIAN S NAME: ) If yes, transfer information to Forms 1 & 5. If yes, TRANSFER INFORMATION TO Forms 1 & 5. WHAT FOODS? WHAT MEDICINE? WHAT THINGS? HOW DOES CHILD REACT? DESCRIBE HOW: DID A DOCTOR OR OTHER HEALTH PROFESSIONAL TELL YOU THE CHILD HAS THIS PROBLEM? WHEN? 26. ARE THERE ANY CONDITIONS WE HAVEN T TALKED ABOUT DESCRIBE HOW: THAT COULD GET IN THE WAY OF THE CHILD S EVERYDAY ACTIVITIES? DID A DOCTOR OR OTHER HEALTH PROFESSIONAL TELL YOU THE CHILD HAS THIS PROBLEM? WHEN? * If starred (*) questions have yes answers, go to question 25. 4/06

33 CHILD HEALTH RECORD: FORM 2A, HEALTH HISTORY (Continued) PERSON INTERVIEWED: DATE: RELATIONSHIP: NAME OF INTERVIEWER: TITLE: PHYSICAL, PSYCHOLOGICAL, AND SOCIAL DEVELOPMENT THESE QUESTIONS WILL HELP US UNDERSTAND YOUR CHILD BETTER AND KNOW WHAT IS USUAL FOR HIM/HER AND WHAT MIGHT NOT BE USUAL THAT WE SHOULD BE CONCERNED ABOUT: 27. CAN YOU TELL ME ONE OR TWO THINGS YOUR CHILD IS INTERESTED IN OR DOES ESPECIALLY WELL? 28. DOES YOUR CHILD TAKE A NAP? NO, YES. IF YES DESCRIBE WHEN AND HOW LONG. 29. DOES YOUR CHILD SLEEP LESS THAN 8 HOURS A DAY OR HAVE TROUBLE SLEEPING (SUCH AS BEING FRETFUL, HAVING NIGHTMARES, WANTING TO STAY UP LATE)? NO, YES. IF YES DESCRIBE ARRANGEMENTS (OWN ROOM, OWN BED, AND SO FORTH). 30. HOW DOES YOUR CHILD TELL YOU HE/SHE HAS TO GO TO THE TOILET? 31. DOES YOUR CHILD NEED HELP IN GOING TO THE TOILET DURING THE DAY OR NIGHT, OR DOES YOUR CHILD WET HIS/HER PANTS? NO, YES. IF YES DESCRIBE. 32. HOW DOES YOUR CHILD ACT WITH ADULTS THAT HE/SHE DOESN T KNOW? 33. HOW DOES YOUR CHILD ACT WITH A FEW CHILDREN HIS/HER OWN AGE? 34. HOW DOES YOUR CHILD ACT WHEN PLAYING WITH A GROUP OF OTHER CHILDREN? 35. DOES YOUR CHILD WORRY A LOT, OR IS HE/SHE VERY AFRAID OF ANYTHING? NO, YES. IF YES, WHAT THINGS SEEM TO CAUSE HIM OR HER TO WORRY OR TO BE AFRAID? 36. CHILDREN LEARN TO DO THINGS AT DIFFERENT AGES. WE NEED TO KNOW WHAT EACH CHILD ALREADY CAN DO OR IS LEARNING TO DO EASILY AND WHERE THEY MIGHT BE SLOW OR NEED HELP SO WE CAN FIT OUR PROGRAM TO EACH CHILD. I M GOING TO LIST SOME THINGS CHILDREN LEARN TO DO AT DIFFERENT AGES AND ASK WHEN YOUR CHILD STARTED TO DO THEM, AS BEST YOU CAN REMEMBER. (INTERVIEWER: Read question for each item listed below, and check off the parent s answer in the appropriate space). EARLIER WHEN LATER AGE EXPECTED a. WOULD YOU SAY YOUR CHILD BEGAN TO EARLIER THAN YOU EXPECTED, ABOUT WHEN YOU EXPECTED, OR LATER THAN YOU EXPECTED? b. WHEN DID HE/SHE BEGIN TO? (a) SIT UP WITHOUT HELP (b) CRAWL (c) WALK (d) TALK (e) FEED AND DRESS SELF (f) LEARN TO USE THE TOILET (g) RESPOND TO DIRECTIONS (h) PLAY WITH TOYS (i) USE CRAYONS (j) UNDERSTAND WHAT IS SAID TO HIM/HER 37. DOES YOUR CHILD HAVE ANY DIFFICULTIES SAYING WHAT HE/SHE WANTS TO DO OR DO YOU HAVE ANY TROUBLE UNDERSTANDING YOUR CHILD? NO, YES. IF YES PLEASE DESCRIBE. 38. CHILDREN SOMETIMES GET CRANKY OR CRY WHEN THEY RE TIRED, HUNGRY, SICK, AND SO FORTH. DOES YOUR CHILD OFTEN GET CRANKY OR CRY AT OTHER TIMES, WHEN YOU CAN T FIGURE OUT WHY? NO, YES. IF YES CAN YOU TELL ME ABOUT THAT? WHEN THIS HAPPENS, WHAT DO YOU DO ABOUT IT TO HELP THE CHILD FEEL BETTER? 39. HAVE THERE BEEN ANY BIG CHANGES IN YOUR CHILD S LKIFE IN THE LAST SIX MONTHS? NO, YES. IF YES PLEASE DESCRIBE. 40. ARE YOU OR YOUR FAMILY HAVING ANY PROBLEMS NOW THAT MIGHT AFFECT YOUR CHILD? NO, YES. IF YES PLEASE DESCRIBE. 41. IS THERE ANYTHING ELSE YOU WOULD LIKE US TO KNOW ABOUT YOUR CHILD? NO, YES. IF YES PLEASE DESCIBE. 4/06

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