Permission to Screen
Child’s Name: ______
Social-Emotional Screenings
The Ages and Stages Questionnaire: Social Emotional (ASQ-SE) screening tool helps determine a family’s need for information and/or support services, helps monitor the child’s social –emotional development and assist in the communication between parents, teachers and care givers regarding the child’s behavior. The ASQ:SE is completed by parents, and teachers in the 3-5 centers.
______I give my permission for my child to receive a developmental screening.
The EdinburgPost-Partum Screeningis completed with mothers two weeks after delivery. The screening is used to support mother’s emotional health. Mothers needing additional support will receive referrals to their doctor or local mental health provider.
______I give my permission to receive a post-partum screening.
Developmental Screenings
Ages and Stages Questionnaire –ASQ: 3
The ASQ: 3 assists teaching staff and parents to meet the individual needs of each child in Head Start. The ASQ: 3 screening tool helps staff identify infants and young children whose physical, cognitive, or language development requires further evaluation. The ASQ: 3 is completed for all children unless otherwise screened or evaluated by a special education provider.
______I give my permission for my child to receive a developmental screening.
Speech and Language Screen
A speech therapist routinely complete speech/language screenings for children in the 3-5 centers to determine if communication skills are at the age appropriate level. The results and recommendations are shared with the parent.
______I give my permission for my child to receive a speech/language screening.
M-CHAT Autism Screening
Is validated for screening toddlers between 16 and 30 months of age, to assess risk for autism spectrum disorders (ASD). The M-CHAT can be administered and scored as part of a well-child check-up, and also can be used by specialists or other professionals to assess risk for ASD. Head Start completes the M-CHAT at the age of 30 months if not already completed by your child’s physician.
______I give my permission for my child to receive an M-Chat Autism Screening.
Health Screenings
Hearing Screening
A hearing screening through Head Start must, at a minimum include two or more of the followingtests based on the child’s developmental ability:
Otoscopic examination- using a flash light the examiner looks into your child’s ears
Otoacoustic Emission-a small ear plug is placed into the ear- a machine delivers a tone that
records if the sound reaches the inner ear system.
Tympanogram- a small ear plug is placed against the child’s ear. Air is pushed into the ear to
check for movement of the ear drum. Free movement of the ear drum indicates the ear is
healthy.
Audiogram-Ear phones are placed over the ears. Tones of different pitch and volume are
delivered to each ear checking to see that your child can hear pitch and volume.
______I give my permission for my child to receive a Hearing Screening.
Vision Screening
A Vision screening through Head Start must at a minimum include one or more of the following screenings procedures completed based on the child’s developmental ability:
Light Reflexes- a flashlight is used to check each eye for response to light.
Muscle Balance- a light and objects are used to determine how the eyes move together and
individually.
Acuity- a vision chart is used to determine the eyes ability to see objects up close and at a
distance. Both eyes are checked together and each eye is checked individually.
Color Vision- a chart with mixed colored shapes is used to determine if a child can see browns
and greens
______I give my permission for my child to receive a Hearing Screening.
Height and Weight Measurements
Heights and weight measurements are complete during well child checks until a child reaches 36 months of age. At 36 months Head Start measures heights and weights of children quarterly to monitor growth. Growth Charts show health care providers how kids are growing compared with other kids of the same age and gender. Growth charts allow doctors and nurses to see the pattern of a child’s' height and weight gain over time, and whether they are developing proportionately.
______I give my permission for my child to receive a Hearing Screening.
Parent Signature ______Date ______
Staff Signature ______Date ______
Policy Council Approved October 2014