Screening Form - Florida Department Of Health (Page 4 of 4) in pdf

Screening Form - Florida Department Of Health Page 4

LEVEL II SCREENING

For those children that screen YES in the functional limitations health domain, but answer NO to all other

questions, an additional question should be asked to assess if the reason is due to an unmet need.

1. You report that your child is limited or prevented in some way, yet you do not report that your child is

utilizing any services for their condition(s). Does your child currently need medications or services for

your child that you are unable to obtain?

_______ Yes – Let’s review your questions to determine what those needs are (go back through questions)

_______ No – End screening

For those children that answer yes to three questions, but one of those questions is not number 3 (assessing

functional limitations), an additional question should be asked to assess if the child is experiencing increased

admissions due to the reported condition(s).

1. In the last 12 months, how many times has your child been hospitalized or admitted to a behavioral

health/mental facility for the condition(s) you have mentioned?

_______ 0 – Go to question 2

_______ 1+ (if one or more admissions, the child should be screened as clinically eligible for CMS)

2. In the last 12 months, how many times has your child been seen in the emergency department for the

condition(s) you have mentioned?

_______ 0, 1, 2 – End screening

_______ 3+ (if three or more visits, the child should be screened as clinically eligible for CMS)

For those children not initially clinically eligible for CMSN, but who report health consequences related to at least

4 diagnoses, an additional question should be asked to assess if the child is experiencing increased admissions

due to the reported conditions.

1. In the last 12 months, how many times has your child been hospitalized or admitted to a behavioral

health/mental facility for the condition(s) you have mentioned?

_______ 0 – Go to question 2

_______ 1+ (if one or more admissions, the child should be screened as clinically eligible for CMS)

2. In the last 12 months, how many times has your child been seen in the emergency department for the

condition(s) you have mentioned?

________ 0, 1, 2 – End screening

________ 3+ (if three or more visits, the child should be screened as clinically eligible for CMS)

Form DH8000 (12/2015)

Rule 64C-2.002, Florida Administrative Code

Screening Form - Florida Department Of Health Page 4