Child & Family Services

Child/Family Services Head Start Forms- Health

**Useable Forms

Health

• H-3a Health History/Nutrition Assessment (E)
• H-3.1a Historial de Salud/Evaluacion De Nutrition (S)
• H-3c Infant Health History Form (E)
• H-3.1c_Infant_Health_History_(S)
• H-4a Immunization Referral (E-S)
• H-4b CA Immunization Registry Refusal/Info Request (E)
• H-4.1b CA Immunization Registry Refusal/Info Request (SP)
• H-4c CA Immunization Registry Disclosure Statement (E-S)
• H-5a Dental Care Report (E)
• H-5b Dental Exam Result (E-S)
• H-6 Vision Screening Referral (E)
• H-7a Hearing and Vision Screening Form (E-S)
• H-7c On Site Screen Results (E)
• H-7e Diagnostic Follow-up Form (hearing screening referral)
• H-7f Hearing Referral Information to Parents (ES)
• H-8a Consent for Medication/Consentimiento para medicinas (S)
• H-8b Medication Chart (E-S)
• H-8c Individualized Health Care Plan (E)
• **H-8c Individualized Health Care Plan (E)
• H-8d Medication Box Labels (E)
• H-8e Temporary Individual Health Care - Emergency Plan
• H-8_1e Temporary Individual Health Care - Emergency Plan for Respiratory Distress (S)*
• H-8f Temporary Individulaized Health Care Plan for Anaphylaxis (E)
• H-8.1f Temporary Individualized Health Care Plan for Anaphylaxis (S)
• H-9 Appointment Reminder (E-S)
• H-10 Physical Screening for Children (E)
• H-11a EHS Child's Health Tracking Form (E)
• H-11b Newborn Health Visit (E)
• H-11.1b Newborn Health Visit (S)
• H-12 Notice of Needed Information/Exclusion (E)
• H-12.1 Noticia de Información Necesitada/Exclusión (S)
• H-12a Home Base Notice of Needed Info (E)
• H-12.1a Home Base Notice of Needed Info (S)
• H-13a Volunteer TB Record (E)
• H-13b TB Clearance Documentation (E)
• H-13c Medical Billing Form (E)
• H-13d_Tuberculois_Risk_Assessment (E)
• H-13.1d _Tuberculosis_Risk_Assesment_(S)
• H-13e_Head_Start_Tuberculosis Concern Referral (E)
• H-14a Snack Menu (E)
• H-14b Food Temperature Record (E)
• H-14c_Medical_Statement_to_Request_Special_Meal_Request (E)
• H-14d Nutrition Concern (E)
• H-14e Food Preference Request
• H-16 Parent/Guardian Release of Lead Level Results (E)
• H-17 Child Asthma Plan (E)
• H-17 Child Asthma Plan - backside use for E & S
• H-18 Requesting Information from Doctor Fax Cover Sheet (E)
• H-20 Infant Meal Record (E)
• H-21 Treatment Refusal (E)
• H-21.1Treatment Refusal (S)

Safety

• H-15a Daily Indoor Safety Checklist (E) Interim 2-17
• H-15_1a Daily Indoor Safety Checklist (S) Interim 2-17
• H-15b Daily Outdoor Safety Checklist (E) Interim 2-17
• H-15_1b Daily Outdoor Safety Checklist (S) Interim 2-17
• H-15c Child Active Supervision Plan (E)
• **H-15c Active Supervision Plan (E)
• **H-15_1c Active Supervision Plan (S)
• H-15.1c Child Active Supervision Plan (S)
• H-15d Child Active Supervision Plan for (FCCH) (E)
• **H-15d Active Supervision Plan FCCH (E)
• H-15.1d Child Active Supervision Plan for (FCCH) (S)
• **H-15_1d Active Supervision Plan FCCH (S)
• H-19 Field Trip Checklist (E)
• H-22 Unannounced Safety and Supervision Visit Report
• **H-22 Unannounced Active Supervision Monitoring Report

 

---

Head Start Order Form (Health and Safety)
Hot Sheets for Health forms
Back to Forms menu