Sample Ei/ecse Health Screening Follow-Up Report Template
ADVERTISEMENT
1
2SAMPLE EI/ECSE HEALTH SCREENING FOLLOW-UP REPORT
Child: ______________________ D.O.B.: ________ Contractor: _____________
SECTION ONE
1. Indicate service(s) provided
Review HSQ/health records
Parent Contact
Physician contact
Physical assessment
2. Health conditions/medical diagnosis/current medications: __________________________
None
3.
Child/family currently receiving services from public health nurse/community agency.
Nurse/agency doing follow-up:
Phone: _______________
4.
Child/family referred to public health nurse for follow-up re: ______________________
5.
Child/family referred to other community services (specify): ______________________
6.
Other services/recommendations (i.e., education re: immunizations, etc.):
_____________________________________________________________________
_____________________________________________________________________
SECTION TWO
7.
No health issues needing classroom recommendations identified at this time. If the
child’s status changes, contact the child’s team coordinator.
8.
Nurse needs to attend the child’s IFSP meeting. Please notify ________________
of date and time.
9.
Recommend health personnel address the following issues with child’s team:
Information to child’s team re:
health care issue
side effects of medication (specify):
_____________________________________
symptoms to report to parent or requiring immediate action
safety
Emergency protocol needed for
__________________________________________
Delegated nursing procedure for
__________________________________________
Specific transportation needs
__________________________________________
Child to have health care in place before entering school (Document health or safety
issue to be addressed before entrance.)
Other ________________________________________________________________
SCREENING NURSE:
_________________________________________
DATE:
__________________
Signature
Title
Phone
Adapted with permission form CaCoon Program at the Child Development and Rehabilitation Center, Oregon Health Sciences University, PO
Box 574, Portland, OR 97207-0574. Revised: 6/9/98
J:\Early Childhood\EI-ECSE\Forms\1-FORMS CURRENT POSTED\4-Medical Screening\Medical Screening Forms - English\English Health Screen Forms Not
Numbered\English Health Screen Forms Not Numbered WMA\hlthscrnfolouprpt.doc
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical