Special Health Care Plan Template printable pdf download

Special Health Care Plan

To be completed by the Child Care Health Consultant or Health Advocate. The Special Health Care Plan provides

information on how to accommodate the special health concerns and needs of this child while attending an early care

and education program.

Name of Child: ______________________________________________________________Date: ___/____/__________

Name of Child Care Program: __________________________________________________________________________

Description of Health Condition(s)

List description each health condition:

__________________________________________________________________________________________________

_______________________________________________________________________________________________

Team Member Names and Titles (include parents)

Parent/Guardian____________________________________________________________________________________

Health Care Provider (MD, NP)_________________________________________________________________________

On-site CareCoordinator______________________________________________________________________________

__________________________________________________________________________________________________

Team Members; Other Support Programs Outside of Child Care (name, program, contact information, frequency)

□ Physical Therapist (PT) _____________________________________________________________________________

□ Occupational Therapist (OT) _________________________________________________________________________

□ Speech & Language Therapist: _______________________________________________________________________

□ Social Worker: ____________________________________________________________________________________

□ Mental Health Professional/Consultant: ________________________________________________________________

□ Family-Child Advocate: _____________________________________________________________________________

Other: ____________________________________________________________________________________________

Communication

The team will communicate: □ Daily

□

Weekly

□

Monthly

Other__________________________________________

The team will communicate by: □ Notes, □ Communication log, □ Phone, □ E mail, □ In Person Meetings,

□ Other__________

Dates and times__________________________________________________________

Individualized Family Service Plan (IFSP) or Individualized Education Plan (IEP) is attached. □ Yes □ No

Staff Training Needs

Type of training: ____________________________________________________________________________________

Training will be provided by: __________________________________________________________________________

Training will be monitored by: _________________________________________________________________________

Staff who will receive training: _________________________________________________________________________

Dates for training:___________________________________________________________________________________

Plan for absences of trained personnel responsible for health-related procedure(s):

__________________________________________________________________________________________________

UCSF School of Nursing, California Childcare Health Program

Revised 08/2015

Special Health Care Plan Template