2023-24 Registration for Early Childhood Screening

Registration for Early Childhood Screening
General information and Instructions:

Please answer the following questions to assist the registration process for Early Childhood Screening.
Anoka-Hennepin offers Early Childhood screenings at Blaine, Riverview and Sorteberg Early Childhood sites. Which location is your child's screening scheduled at?*
Appointment Date*

MonthDayYear
Date
Appointment Time

Hour Minutes

AM/PM Option
Parent/Guardian email*
example@example.com
Child’s Legal Name: (First, Middle, Last)*
Child’s Nickname or Other Name (First, Middle, Last)
Child’s Birth Date*

MonthDayYear
Date
Child’s Gender*

MaleFemale
Parent/Guardian Name*
Phone*
P.O. Box (enter N/A if you do not have one)*
Address*
City*
State*
Zip*
Parent/Guardian #2
Phone
P.O. Box
Address
City
State
Zip
PREVIOUS HEALTH AND DEVELOPMENTAL SCREENING INFORMATION
Has your child received comprehensive health and developmental screening as a preschooler (3-5-years-old)?*

YESNO
If Yes, screening dates

MonthDayYear
Date
If Yes, Location
Has your child ever been evaluated for special education or ever received special education services through an Individual Education Program (IEP) or Individual Family Education Plan (IFSP)?*

YESNO
PARENT/GUARDIAN VERIFICATION OF INFORMATION
Type a question

Checking this box, verifies I am the Parent/Guardian fo the above student, and the information on this for is true and current to the best of my knowledge.
Parent/Guardian Signature (By signing verifies I am the Parent/Guardian of the above student, and the information on this form is true and current to the best of my knowledge.)*

Clear
Today's Date*

MonthDayYear
TO BE COMPLETED BY SCHOOL DISTRICT PERSONNEL ONLY:
Screening District Number and Type
Screening Date

MonthDayYear
Date
Screening District Name
Child's Resident District Name
Resident Screening District Number and Type
Marss ID Number
Check type of screening child received - STAT AID CATEGORY (SAC) (To be completed by the Early Childhood Screeing Coordinator)

41 - Screening by District42 - Child and Teen Checkups/EPSDT43 - Head Start44 - Private Provider45 - Conscientious Objector, no screening
Check the Primary type of referral following the early childhood health and developmental screening using STATUS END CODES (SEC). Only one box may be checked. Must have a valid SEC for – STATE AID CATEGORY (SAC) 41. If unsure of referral status for SAC 42-44, use “no referral” SEC 60. (To be completed by the Early Childhood Screening Coordinator.)
Status End Codes:

60 - No referral61 - Referral to special education62 - Referral to health care provider63 - Referral to special education AND health care provider64 - Referral to early childhood programs*
(*School Readiness, Head Start, Early Childhood Family Education, family literacy)

65 - Referral offered, parent declined66 - Rescreen planned
DISTRICT VERIFICATION: I hereby verify that the above information is true and current to the best of my knowledge.
District Early Childhood Screening Coordinator Signature

Clear
Date

MonthDayYear
Date
Early Childhood Screening Consent
Parent/Guardian Name(s)
Early childhood developmental screening helps a school district identify children who may benefit from district and community resources available to help in their development. Early childhood developmental screening includes a vision screening that helps detect potential eye problems, but is not a substitute for a comprehensive eye exam. This screening does not replace on-going care from your health care provider or dentist. Screening data collected is private so it may only be shared with anyone listed on the release of information; school district staff with a legitimate educational need to know; by court order; or with others as required by law, including the state or legislative auditor.

This screeing includes:
- Review of your child’s immunization record
- Check of your child’s growth, such as height and weight
- Check for possible hearing problems
- Check for eye health, including how well your child can see
- Review of factors that might interfere with your child’s health, growth, development or learning
- Check of your child’s development
- Your report of your child’s growth and learning including emotional and behavior status
- Information about your child’s health care and insurance Information about community resources and programs based on your child’s or family’s needs
Child and Parent Rights, Obligations, and Assurances
1. The standards for screening are the same for every child regardless of race, income, creed, sex, national origin, or political beliefs.

2. Screening is required for your child’s entry into public school kindergarten or first grade. You can also meet this requirement if your child has participated in a screening in the past year through Head Start, Child and Teen Checkups, or an equivalent developmental screening through another health provider that includes all required early childhood screening components. You or your provider will need to give summary results of the equivalent to your child’s school district.

3. Screening is not required for your child’s entry into kindergarten or first grade if you are a conscientious objector to screening. You will need to provide a written statement to your child’s school district that documents your conscientious objector status.

4. You have the right to refuse to answer questions or provide information and still receive the rest of the required screening components.

5. You have the right to refuse an assessment, diagnosis, and possible treatment for your child.

6. Your child’s medical assistance eligibility or eligibility in any other health, education, or social service programs will not be affected if you refuse this screening or any parts of this screening.
Signing indicates that you have read, understand the information above and consent to screening your child indicated above.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Relationship to Child*
Updated 10/23
Early Childhood Screening Release of Information
Birthdate

MonthDayYear
Date
Parent/Guardian Name(s)
Anoka-Hennepin Schools uses information from the Child Health and Developmental Screening to identify any possible problems that might interfere with your child’s health, growth, development or learning. Under Minnesota law, screening results private data. This means the results cannot be released or discussed with anyone without your consent. If you are classified as refuse to release this information, it will not affect your child’s eligibility for medical assistance or any other health, education, or social service program. Summary data about groups of children that does not include information about individual children may be shared without consent.
Information from Your Child’s Screening May be Used for the Following Purposes:
1. To obtain follow-up services for your child after the screening, if you choose to participate.

2. To arrange for further evaluation or assessment of your child’s health, growth, development, or learning, if you choose to participate.

3. To fulfill the requirements for your child’s entrance into public school or Early Learning Scholarship, School Readiness or Voluntary Pre-Kindergarten programs.

4. To evaluate screening programs by the Minnesota Departments of Education, Health and Human Services. Your child’s name will not be identified in any evaluation results.

5. To develop appropriate educational programs to meet student needs and to design appropriate health education programs for the district.

6. To plan for early childhood programs and school entry.

7. To provide access to and accountability for government funds paid to the local school district for providing required early childhood screening services.
CONSENT TO RELEASE INFORMATION
I hereby authorize release of my child’s screening information to Anoka-Hennepin Schools and the following checked programs or services for the purpose of evaluation, assessment, diagnosis, follow-up and /or programming. Please provide names and addresses where available
I authorize release to Child Care Provider
Child Care Name and Address
I authorize release to Head Start
Head Start Name and Address
I authorize release to Health Care Provider
Health Care Provider Name and Address
I authorize release to Mental Health Agency
Mental Health Agency Name and Address
I authorize release to Public Health Agency
Public Health Agency Name and Address
I authorize release to Other Provider
Other Provider Name and Address
I authorize release to Other Provider

Other
Other Provider Name and Address
Your signature indicates that you have read, understand and agree that the information can be used as stated above.
Parent/Guardian Signature*

Clear
Today's Date*

MonthDayYear
Date
Relationship to Child
Updated 10/23
Early Childhood Screening Health and Family Information
Preschool Experience: Please check all that apply.*

ECFE/Parenting EducationDaycarePreschoolOther
CHILD’S HEALTH CARE PROVIDER INFORMATION
Child's Primary Clinic
Has your child been seen by a doctor/nurse in the last 12 month*

YesNo
Has your child been seen by a dentist in the last 12 months:*

YesNo
Has your child been seen by an eye doctor:*

YesNo
Were glasses prescribed:

YesNo
Does your child have health insurance:*

YesNo
PRENATAL CARE, PREGANCY AND BIRTH INFORMATION
Is your child adopted:*

YesNo
Were there any problems requiring special care during your pregnancy:*

YesNo
Was your child born at term:*

YesNo
If preterm, birth weight lbs lbs oz oz. How many weeks gestation gestation
Were there any chemical exposures during the pregnancy: (drugs, alcohol or cigarettes) If yes, please explain
Immunization Status:*

Up To DateNot Up To DateUnknownConscientious Objector
Does your child have ear (PE) tubes or hearing issues:*

YesNo
If yes, please explain
Does your child have a health condition/medical diagnosis/allergies/asthma etc:*

YesNo
If yes, please explain
Has your child been hospitalized, had a head injury, or currently take medication regularly:*

YesNo
If Yes, please explain
Has your child ever had an elevated lead level:*

YesNo
HOME SAFETY AND FAMILY FACTORS
Do you have concerns that your child is exposed to weapons, violence, abuse, street drugs, cigarette smoke or other: If yes, please explain.
Do you have any other concerns about your child that you would like to discuss: If yes, please explain
Has there been any unusual stresses in your family that may affect your child: If yes, please explain
Is your family currently experience a housing challenge due to loss of housing or economic hardship: Yes (shelter, doubled up, hotel/motel, public space, foster care etc)*

NoIf yes, please explain
If Yes, please explain
Do you have and use a car seat for your child*

YesNo
Does your child have and use a bike helmet

YesNo
Updated 10/23
Should be Empty:

Registration for Early Childhood Screening

General information and Instructions:

PREVIOUS HEALTH AND DEVELOPMENTAL SCREENING INFORMATION

PARENT/GUARDIAN VERIFICATION OF INFORMATION

TO BE COMPLETED BY SCHOOL DISTRICT PERSONNEL ONLY:

Early Childhood Screening Consent

Child and Parent Rights, Obligations, and Assurances

Updated 10/23

Early Childhood Screening Release of Information

Information from Your Child’s Screening May be Used for the Following Purposes:

CONSENT TO RELEASE INFORMATION

Updated 10/23

HOME SAFETY AND FAMILY FACTORS

Updated 10/23