Child & Family Services

Child/Family Services Head Start Forms - Health Hot Sheets

Health

• H-3a Health History and Nutritional Assessment
• H-3c_Infant_Health_History
• H-3.1c_Infant_Health_History_(S)
• H-4a Immunization Referral
• H-4b c CA Immunization Registry Refusal
• H-5a Dental Care Report
• H-5b Dental Examination Result Form (Hot Sheet)
• H-6 Vision Screening Referral
• H-7a Pediatric Hearing & Vision Screening Resukts Form
• H-7c On Site Screening Results
• H-7e & f Diagnostic Follow-up form (referral from hearing screening)
• H-8a & 8b Consent for Administration for Medication
• H-8c Individualized Health Care Plan
• H-8d Medication Box Labels
• H-8e Temporary Individualized Health Care Plan(Respiratory Distress)
• H-8f Temporary Individualized Health Care Plan (Anaphylaxis)
• H-9 Appointment Reminder
• H-10 Physical Screening for Children
• H-11a EHS Child Health Tracking Form
• H-11b Newborn Health Visit EHS
• H-12 Notice of Needed Information/Exclusion
• H-13a Volunteer TB Record
• H-13b TB Clearance Documentation Form
• H-13c Head Start Medical Billing Form
• H-13d Tuberculosis Risk Assessment
• H-13e Tuberculosis Concern Referral
• H-14a Snack Menu
• H-14b Food Temperature Record
• H-14c Medical Statement to Request Special Meals/Accommodations
• H-14d Nutrition Concern Form
• H-14e Food Preference Request
• H-15 a&b Daily Indoor/Outdoor Safety Inspection Checklist Interim 3-17
• H-16 Parent/Guardian Release of Lead Level Results
• H-17 Asthma Action Tracking Form
• H-18 Fax Cover Sheet
• H-19 Field Trip Checklist
• H-20 Infant Meal Record
• H-21 Treatment Refusal

Safety

• H-15a & b Indoor Outdoor Safety Inspection Checklist
• H-15c Active Supervision Plan
• H-15d Active Supervision Plan FCCH
• H-22 Unannounced Active Supervision Monitoring Report Interim 3-17

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Head Start Order Form (Health and Safety)
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