Family Service Worker Monthly Checklist for Health Services and Community Partnerships FamilyFamily Service Worker: ___________________________ Month Reviewed: ____________ Health Requirements Task 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 student - 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. Comments See attached report from Health Specialist C I N/A FSW to ensure all required health forms are completed prior to any screening/services is provided. If not signed, child will not receive service. 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: NOTES: Family Service Worker Signature: _________________________________________Date: _________________________