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 5/2019.
Action Plan for Health and Safety
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. Reviewed and reaffirmed 6/2018.
Asthma Action Plan
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.
Parents/guardians should be encouraged to sign the “Authorization for Release of Information” form to enable child care staff to communicate directly with the child’s medical home/primary care provider for information or questions about the care of a child with a special medical, developmental or behavioral need. This form is from Model Child Care Health Policies, 5th Edition, available on the ECELS website under the Publications tab.
Authorization for Release of Information
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.
Behavioral Data Collection Sheet
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.
Care Plan for a Child with Behavioral Concerns
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 early childhood programs 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 the forms in the links below. The Care Plan Checklist lists elements that may be required in a care plan for a child with a special health care need (if not using the care plan template included on this posting).