Forms

A form to guide collaborative problem-solving involving those who are affected, those with authority, and those with expertise. The form encourages documentation of who is involved, the tasks planned, who is responsible, and checkpoints for follow-up. There are two attachments: the form and an example of a completed form that addresses the problem of children who bite. Reviewed and reaffirmed 11/2012.

Early care and education professionals should have an Asthma Action Plan for any child or staff member who has asthma. The Asthma Action Plan provides instruction from the health professional about what to do if the child has an asthma episode. The Asthma Action Plan explains the specific care the child or staff member may need. The form identifies known triggers, what medications to use, when and how to use them, and when to contact the health care provider or go to the hospital. Everyone who cares for a child with asthma or works with adults with asthma should follow the individual’s Asthma Action Plan. 4/2016 

This form is intended to be used by child care programs when they enroll a child with a special health care need to communicate directly with the child’s health care provider. Communication between parents/guardians, the child care program and the primary care provider (medical home) requires the free exchange of protected medical information. Confidentiality laws state that parents/guardians must give permission to release protected medical information about their child.

This form is intended to be used by teachers/caregivers to document a child’s behavior that is of concern to them. The behavior may warrant evaluation by a health care provider, discussion with parents/legal guardians, and/or consultation with other professionals. This documentation facilitates communication by recording the observations of the child and the circumstances in which the observations were made. Reviewed and reaffirmed 12/2016

This form facilitates communication from health care providers to other professionals who work with the child and family as part of formulating a coordinated and consistent plan of care for children with behavioral concerns. Reaffirmed 7/2013.

These forms explain the process and documentation needed to enroll a child with special needs. The Process to Support Enrollment of a Child with a Special Need form is an algorithm or map that describes the steps to follow to obtain and use a care plan. The Care Plan is a form to gather key information to provide care for children with special health needs.The majority of early learning practitioners enroll children with special health needs. The form collects the essential information. It includes how to care for a child's daily needs and to handle an emergency. Early learning practitioners should arrange for parents and health professionals to complete the form when the child is first considered for enrollment and anytime a new medical condition develops. Download all three forms in the links below. Reviewed and updated 9/2015

This form enables a Child Care Health Consultant to easily and consistently document the services provided to early education and child care programs. Open the two attachments: one is the form and the other is a document that offers tips for how to use the form.

The widely-used Emergency Information Form on the website of the American Academy of Pediatrics (AAP) records key health information for children with special health care needs. It should be completed and kept up-to-date, ready to give to Emergency Service Personnel who may not be familiar with the child's needs. Early education and before and after school personnel should use the information on the form to prepare for care a child might need in the event of an emergency that involves only the child or the group in the facility. It documents the child's medical history, medications, and treatments. To view and download the form, go to the AAP website at www.aap.org, and then enter "Emergency Information Form" in the search box. 

This is a 2012 version of a form originally published in Model Child Care Health Policies. Use the form to document injuries and unusual incidents in group care programs for children. Periodic review of the information recorded on the form will help identify targets for preventive measures. 1/10/12

Early education and before and after school child care providers may adapt this model letter to send to heatlh professionls to explain the need for the health professionals to complete required health forms. It one of the documents posted on the WellCareTrackerTM website. WellCareTrackerTM is a secure Internet software application developed and maintained by ECELS to evaluate and track health service reports to be sure that children are up-to-date with vaccines and screeniings. On the WellCareTrackerTM website, select the letter from the left pane under "Sample Letters."