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Head Start Samp Program Forms

Family Service Worker Monthly Checklist for Health Services
and Community
Worker: ___________________________
Month Reviewed: ____________
Health Requirements
Entry Requirements complete for each
student – check prior to school entry
- Physical
- Dental exam
- Immunizations
Medical/Dental Home documentation
complete within 30 calendar days (source
of healthcare)
- At enrollment
- At end of enrollment (May)
EPSDT up to date for each student- within
90 calendar days run report 3015
- Physical Exam –
- Lead/ HgB (letters sent)
Health Insurance - Coverage documented
- At enrollment & (August)
- At end of enrollment (May)
- BOC /Verification of Ins. Form
and all documentation sent to Health
Specialist and documented in CP
Health Screening completed for each
- Overdue
- Untested
- Absent on screening date
Family Goals are consistent with identified
Health needs and documented appropriately
Family Outcomes accurately reflect
identified Health needs and completions.
Failed Health Screening follow up
All Failed Health Events have appropriate
Health Actions documented in Child Plus
Assist parents to obtaining transportation for
medical appointments
Classroom checks for health related
concerns. Notify Health Service Specialist
regarding any student or classroom health
concern. Check Assistant Binder
Document ANY parent concern regarding
health concerns in Child Plus
Assist and participate in parent health and
nutrition trainings.
See attached report from Health Specialist
FSW to ensure all required health forms are
completed prior to any screening/services is
provided. If not signed, child will not receive
Any child with Medicaid should also be seen by a
dentist - a completed oral health form must be
submitted to FSW documentation and entered in
Child Plus
Run Report 3015 the 5th of every month and send
notification letters for children who will expire
within the next 30 days, call parents of children
past due – document all info. In Child Plus
All attempts made in getting insurance for a child
must be documentation Child Plus -
Make sure all required forms are completed and
signed by parent. Any parent that refused health
screenings must sign a Refusal of Services Form,
especially for those wanting services after
refusing health screenings.
2nd screenings will be completed within 4 weeks of
1st failed screening Medicaid may pay for transportation for
medical/dental appt. Ensure parents know how to
set this up themselves
Check Assistant Binder to ensure any concern was
addressed appropriately.
Follow up Scheduled:
Support Needed:
Family Service Worker Signature: _________________________________________Date: _________________________