KCI Head Start Centers



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Staff UpdatesStaff Documents • Forms Directory • Professional Development

Forms Directory

This directory is a collection of all forms currently used by Kids Central, Inc. to document services to children and families as well as management and operation of the Head Start and Early Head Start programs.

AdministrationDisabilitiesEducationFamily & Community Parnership
HealthNutritionTransportation

Health Forms

H-300

Authorization to give medication

Form authorizing Kids Central Inc.  to administer medications according to agency policy

H-301

Daily Medication Log

Used to record medications administered by Kids Central Inc. staff

H-302

Special Care Plan for Children with Asthma

Used to document child's medical history relating to asthma and instruction for using specific asthma medications

H-303

Child Incident Report

Used to document child incidents/accidents

H-304

Child Incident Report Log

Used to document child incidents/accidents occurring in a specific center/location

H-305

Sun Block Authorization

Used to authorize the application of sun block

H-306

Daily Health Observation

Used to record daily observation of child health conditions

H-306a

Child Health Summary

Used to document details about daily health observations.

H-306b

Sign and Symptom Record

Used to document signs and symptoms displayed by children when ill

H-307

Well Baby Check-Up

Used to document well baby check-up by physicians

H-308

Medical/Dental Referral

Used to document referrals made for medical and dental follow up

H-309

Newborn Welcome Visit

Used to document Newborn Visits

H-311

Consents and Permissions

Used to document consent for health screenings, releases, and emergency medical information

H-312

Seizure Care Plan

Used to document a seizure care plan for a child

H-313

Audiological Services

Used to document results of tympanometer/audiometric testing

H-314

Health Services Screening Results

Used to document health screening

H-315

Vision Observation

Form used to screen children 0-11 months.

H-315a

Vision Observation

Used to document vision observations of children 1 to 5 years old

H-317

Dental Reminder Notice

Used to inform parents of dental services provided to children

H-319

Lead Screening Questionaire

Used to assess potential at-risk conditions for lead

H-322

Important Notice

Used to notify parents of missing information

H-323

Consent to Exchange Information

Used to exchange information with other agencies

H-324

Oral Health

Used to document oral health care and treatment

H-325

Allergy Action Plan

Used to document plan of action in the event of an allergic reaction

H-326

Medical/Dental Payment Requisition

Used to request payment for non-insured medical or dental sercices

H-328

Child Nutrition Assessment

Used to record child's dietary habits

H-329

Immunization Letter

Used to notify parents/guardians that children past due immunizations

H-331

Health History

Used to document child's health history

H-332

Exposure Notice

Used to notify parents/guardians that children may have been exposed to a communicable disease

H-335

Prenatal Birth History

Used to document prenatal history (EHS Only)

H-336

Pregnancy Outcome Tracking

Used to document results/outcome of pregnancy (EHS Only)

H-337

Pregnancy History and Tracking

Used to document pregnancy history (EHS Only)

H-338

Dietary Action Plan

Used to document child's dietary action plan

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