Child File Checklist 2017 Home Base

Child File Checklist 2017 Home Base

Child’s Name: ______DOB or DD: ______

Enrollment: ______45 Days: ______90 Days: ______

___*Pedestrian Safety___*Fire Safety

Original Documents
___ Income Verification Form ___ Hearing Screening

___Proof of Income___ 30 Day Determination for Health Insurance,

___Proof of BirthMedical Home, Dental Home

___ Service Agreement ___ 90 Day Determination of EPSDT

___ Physical ___ ASQ

___ Permission to Screen ___ ASQSE

___ Vision Screening ___Developmental / Social Emotional

Screening Results Form

Child and Family Info

___ Application (signed) ___ Childcare Agreement

___ Emergency Contacts___ Lapse of Employment Policy

___Change of Address Form ___Release of Information (Current Program Year)

___Priority Criteria ___ Service Agreement (Current Program Year)

___ State Birth Certificate___ Court Order(s)

___ Insurance___Permission to Screen (Current Program Year)

___ Status Verification Form___ DCF Paperwork

Family Contacts

___Communication with Family (Contact Logs, letters, etc.)

___Acknowledgement of Handbook Signature

___ Parent Contract

___Lesson Plans/ Home Visit Report

Family Partnership Info
___ PFS 1.______2. ______or Refused: 1. ______2. ______
___ Family Partnership Portfolio: ______

___Case Plan; 6 month Update ______
___ Family Service Referrals

Social/Emotional Info

___ Parent Permission Form Mental Health Consultation

___ ASQSE-2(Current Program Year)
___Mental Health Referrals

Health Information

___ Child General Health Information (Updated –Initial Annually)

___Kan-be-Healthy

___ CBC or HGB at 12 months

___ Blood Lead Screening

___ Growth Charts

___Verbal Lead Screening (Current Program Year)

___Hearing Screening (Rescreen)

___Vision Screening (Rescreen)

___ Immunizations

___Dental Examination w treatment as indicated

___Over the Counter Form as needed

___ Health Care Plan

___ Annual Individual Child File Review Health Status -2nd year

___ Nutritional Screen

___ Health/Nutrition Referrals

Education Development Information

___ 1st Home Visit Questionnaire

___M-Chat (30 months)

___ASQ3 (rescreen or update)

___Developmental/Social Emotional Screening Results (updated)

___CC Progress/Planning ______

___ Education Data Entry/Reports in myHS: ______

___ Kindergarten Transition Packet
___Transition Goals

Disabilities

___ IFSP/IEP

___ IFSP Progress Reports (every 6 months): ______
___ IEP Progress Reports every 9 weeks: ______

___Communication (Meeting notices, progress notes, emails, etc. Filed by date.)

___ Developmental Referrals

Prenatal/Postnatal

______Date of First Prenatal Doctor Visit

Medical Documentation Shows Regular Prenatal Health Visits ___ Yes___ No

______Date of Most Recent Dental Exam

______Nutrition Screening

______Hemoglobin

______Parent Permission Form: Mental Health Consultation

Date education provided to family and documented in Home Visit notes and PROMIS Service Reproductive Health:

______Prenatal Health Care

______Nutrition Education

______Mental Health interventions and follow-up

______Substance Abuse Prevention Risk of smoking and alcohol use

______Prenatal Education on Fetal Development

______Information on the Benefits of Breastfeeding

______Family Planning (Birth Control)

______Postpartum Health Care

______SIDS/ Safe Sleep

______2 week Post partum visit set and/or discussed with family

______2 week Pos t partum visit completed

______Edinburgh Postnatal Depression Screening (at 2 weeks Post partum)

Prenatal Referrals ______

Child file checklist for Home-Based Option 2017 (pg. 1 of 3)