Stafford County Schools
Head Start
610 Gayle Street
Fredericksburg, Virginia 22405
(540) 368-2559
Fax: (540) 368-1978
schs@staffordschools.net
HEALTH REQUIREMENTS FOR HEAD START/EARLY HEAD START CHILDREN
Attention Providers: Thank you for ensuring the health and well-being of the children enrolled in the Stafford County
Schools Head Start/Early Head Start programs. Prior to program entry, please provide documentation of:
1. Administration of well-child physical exams according to Virginia EPSDT/Bright Futures/AAP intervals
2. Immunizations in accordance with all the latest CDC recommendations
3. Special dietary requirements/limitations, emergency care plans, medications needed during school hours, and any
treatment, referral or follow-up given or needed
Well Child Physical Exam Components to be documented:
Growth Assessment, including head circumference for children up to 24 months old
Oral Health Screening at 6 and 9 months, dental exams every 6 months beginning at 12 months
Hemoglobin/Hematocrit at birth,12 months, and 36 or 48 months of age for Head Start program entry
Blood Lead Test at 12 and 24 months, or at 36, 48 or 60 months if no prior history
TB Risk Screen, assess for risk at 1, 6, 12, 18, 24 months then yearly (PPD only if at risk)
Autism Screen at 18 and 24 months
Dyslipidemia Assessment at 24 months and 48 months
Blood Pressure at 36, 48 and 60 months, assess for risk from birth to 30 months
Vision Screen at 36, 48 and 60 months, assess for risk from birth to 30 months
Hearing Screen at birth, 48 and 60 months, assess for risk from 5 days to 36 months
Developmental Test at 9, 18 and 24 months, developmental/behavioral assessment at all other ages
Immunizations to be given:
Diphtheria, Tetanus and Pertussis
Influenza annually
Polio
Haemophilus Influenza Type B
Measles, Mumps, Rubella
Rotovirus
Hepatitis A and B
Pnuemococcal
Varicella
______________________________________________________________________, ________________, is ____/is not____
(Child’s name)
(Birthdate)
(Check one)
up-to-date for age according to EPSDT and CDC guidelines for preventive pediatric health care.
_________________________________________________________________
(Medical Provider Name/Signature)
______________________________
(Date)
Rappahannock Area Health District
608 Jackson Street
Fredericksburg, VA 22401
Office (540) 899-4797
FAX (540) 899-4599
TUBERCULOSIS RISK ASSESSMENT FOR ALL NEW STUDENTS AND STAFF
NAME:
GRADE/SCHOOL:
PARENT/GUARDIAN:
DATE:
The United States Public Health Services and the Center for Disease Control and Prevention recommends that
tuberculosis (TB) skin testing be performed on all individuals who may be at increased risk of TB. Please complete the
following form.
1. Was the student born in a country outside of the United States?
_____ No
_____ Yes
What country?
2. Has the student spent three or more consecutive months in a foreign country in the last five years?
_____ No
_____ Yes
What country?
3. Has the student been exposed or had contact with a person with active TB in the last year?
_____ No
_____ Yes
Whom?
4. Was the student homeless or did he/she live in a shelter during the last two years?
_____ No
_____ Yes
5. Does the student have any of the following: persistent cough, coughed up blood, fever for more than one week,
unexplained weight loss or HIV infection?
_____ No
_____ Yes
6. Is the student currently taking oral steroid medications (other than inhalers), or cancer treating drugs?
_____ No
_____ Yes
7. Has the student ever had a positive TB skin test or taken any treatment for TB disease or a positive TB test?
_____ No
_____ Yes
If yes please give results and dates:
8. Does the student have any of the following medical conditions?
a. Diabetes
No
Yes
b. Malnutrition
No
Yes
c. Cancer
No
Yes
d. Chronic renal failure
No
Yes
e. Congenital or acquired
Immunodeficiency
No
Yes
INSTRUCTIONS FOR THE HEALTH CARE PROVIDER: Please complete the following when the risk
assessment contains positive (yes) answers.
Date:
PPD Provided: No _____
Results in millimeters:
CXR Provided: No _____
Treatment provided:
Yes _____
Yes _____
Results:
Name of Health Care Provider:
Address:
Telephone:
Signature:
Rev. October 2004