Consent Form

Consent Form
Child’s Name
Birthdate

MonthDayYear
Date
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 Screening Includes:
- Review of your child’s immunization record
- Check of your child’s growth, such as height and weight
- Tests for possible hearing problems
- Tests for eye health, including how well your child can see
- Review of any other 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
- 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 Check ups, 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 referral for 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.

I give permission for the Child Health and Development Screening checked below for:
Child’s Name
Check One

Complete screening as described aboveScreening described above except:
Screening described above except
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Relationship to Child
Release of Information
Child’s Name
Birthdate

MonthDayYear
Date
Parent/Guardian Name(s)
(This organization) 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 are classified as private data. This means the results cannot be released or discussed with anyone without your consent. If you 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.

Your signature indicates that you have read, understand and agree that the information can be used as stated above.
CONSENT TO RELEASE INFORMATION

I hereby authorize release of my child’s screening information to 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
Check any persons/agencies that you wish to receive screening information about your child.

Child Care ProviderDentist (Please provide name below)Early Childhood Family Education (ECFE)Early Childhood Special EducationFollow Along ProgramHead Start (Name)Health Care Provider (Medical Clinic)Interagency Early Intervention Committee (IEIC)Mental Health AgencyPublic Health Agency (WIC)School District (Name)School ReadinessOther (regionally specific programs)
Dentist (Name)
Check any persons/agencies that you wish to receive screening information about your child.

I understand this informationI authorize release of information
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Relationship to Child
Registration Form
GENERAL INFORMATION AND INSTRUCTIONS

Page 1 of the Registration Form must be completed by the child’s parent/guardian. Page 2 is completed by school district personnel only. Please print or fill in electronically.
Child’s Legal Name: (First, Middle, Last)
Child’s Nickname or Other Name (First, Middle, Last)
Child’s Birth Date

MonthDayYear
Date
Gender

MaleFemale
Parent/Guardian Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Please complete the state race/ethnicity question below. American Indian: Person having origins in any of the original peoples of North America and maintains cultural identification through tribal affiliation or community recognition.

NO, not American IndianYes, American Indian
Please complete the federal race/ethnicity questions below. You may choose more than one answer in Part B. See top of page two for specifics on how to complete this section
*Part A – Is the child Hispanic/Latino? (choose ONE)

NO, not Hispanic/LatinoYES, Hispanic/Latino
*Part B – What is your child’s race? (choose all that apply)*

American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhite
PRIMARY/SECONDARY LANGUAGE INFORMATION

Type a question

	English	Other (specify)
Which language did your child first learn?
Which language is most often spoken in your home?
Which language does your child usually speak?

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
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
I hereby verify that the above information is true and current to the best of my knowledge.

MonthDayYear
Date
Parent/Guardian Signature

Clear
Instructions and definitions for Part A and Part B race/ethnicity questions

The question for Part A is about ethnicity, not race. No matter what is selected in Part A, have the parent continue to answer the question in Part B indicating the child’s race by marking one or more boxes.

American Indian or Alaska Native – Person having origins in any of the original people of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian – Person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent including, for example, Cambodia, China, Japan, Korea, Malaysia, Pakistan, the Philippines Island, Thailand and Vietnam.

Black or African American – Person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander - Person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.

White - Person having origins in any of the original peoples of Europe, the Middle East or North Africa.
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 – STATE AID CATEGORY (SAC)
(To be completed by the Early Childhood Screening Coordinator)

41 - Screening by District44 - Private Provider42 - Child and Teen Checkups/EPSDT43 - Head Start45 - 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:
literacy

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, parent declined66 - Rescreen planned
SCHOOL DISTRICT VERIFICATION OF INFORMATION
I hereby verify that the above information is true and current to the best of my knowledge.
School District Early Childhood Screening Coordinator Signature

Clear
Date

MonthDayYear
Date
Child Health & Developmental Health History (3-5 Years)
FAMILY INFORMATION
Child’s Full Name (first, middle, last)
Child’s Birth Date

MonthDayYear
Date
Child’s Age
Gender

MaleFemale
Parent/Guardian Names
Email Address
example@example.com
Person Completing This Form
Primary Phone Number
Who lives with your child?
Language(s) spoken in the home

Does your child see

	Yes	Date of last visit	# of visits per year
A Doctor or Nurse?
A Dentist?

Date of your child's comprehensive vision exam, if your child received one. (The comprehensive exam is performed by an optometrist or opthhamologist)

MonthDayYear
Date

Does your child have health insurance?

	Yes	No	I have Applied
Check the box that applies

GENERAL INFORMATION

Do you have questions or concerns about your child? We can talk about them today.
Please list your concerns
Please describe your child’s special needs and strengths
Please check the box(es) if you have concerns or questions about your child’s

Activity LevelBehaviorLearningEars/HearingEyes/VisionFeelings/MoodsSocial (Friends)GrowthTalkingTeethToiletingWalking/BalanceOther

Please check the box(es) if you or your child are involved with:

	Yes	Description
Child and Teen Checkups
Food Pantries
Follow-Along Program
WIC
Head start or School Readiness
ECFE/PAiiR
Early Childhood Special Education
Family or Neighbor Care
In-Home Child Care
Child Care Center
Preschool

Please check any concerns that apply to your child and describe:

	Food	Medicine	Animals/Insects	Dust/Mold	Seasonal
Allergies

Allergies: food medicine animals/insects dust/mold seasonal

Please check any concerns that apply to your child and describe:

	Yes	Describe
Takes medicine, herbs and/or vitamins
Visits to health specialist, hospital stays and/or surgeries
Head injuries (loss of consciousness?)
Lead poisoning, level if known
Trouble breathing, coughing or asthma
Skin problems or rashes
Seizures or staring spells
Vision problem or wears glasses
Ear (PE) tubes or hearing problems
Teeth - One or more cavities
Eating, stomach concerns or constipation
Mental health concerns such as anxiety, depression or attention concerns
Problems during pregnancy or birth
Born more than three weeks early or late (if yes, please list # of weeks at birth and birth weight in "Describe")
Serious injuries or illnesses, visits to Emergency Room (list date and reason in "Describe")
Adopted, If yes, at what age?
At birth, stayed at hospital longer than mother(If yes, please list reason in "Describe")

is it possible that BEFORE you knew you were pregnant you:

	Check if yes
Drank Alcohol
Smoked cigarettes
Used street drugs
Were exposed to toxic chemicals (Lead, Mercury, PCB's dioxin)
Took prescription medication (if yes, please list below)*

*Prescription medication
Please check any Family Health problems (child’s parents or siblings)

Attention problemsVision problemsDiabetesAllergyLearning problemsGrowth problemsAsthmaMental health disordersEpilepsy/seizuresDeafness/hearingSickle Cell Anemia/TraitOther health problems
DAILY ROUTINES

	PM	AM
My child typically falls asleep at and wakes up at

Check any/all that apply

	YES	Describe
Has difficulty falling/staying asleep
Takes a nap between
Gets 60 minuets or more of exercise each day
Is NOT able to/does NOT get 60 minutes of exercise
TV/Video Game/Screen time (hours per day)

Every day, my child eats some foods from these food groups

5-9 servings fruits/vegetables: oranges, apples, bananas, mangoes, berries, spinach, corn, peas3 servings calcium rich foods: milk, cheese, yogurt, soy milk, tofu2-3 servings iron rich foods: fish, poultry, meat, beans, legumes, eggs3 or more servings of whole grains: whole wheat bread, cereal, brown rice, tortillas, crackers, pastaMore than one serving of sweets, fruit drinks or junk food each day

Type a question

	Yes	NO
In the past 12 months, we worried whether our food would run out before we could buy more
In the past 12 months, the food we bought didn’t last and we didn’t have money to get more

Home Safety
Current housing situation

Renting or homeownerDoubled up with friends or familyhours/dayEmergency shelter/transitional housingUnsheltered (cars, parks, campgrounds, temporary)
Does your child live or play in a home or building built before

1978Remodeled in the last 5 years
Does anyone at your home or who cares for your child

Use tobacco/smokeUse alcoholHave a gun (use safety locks)
Do you have concerns that your child is exposed to

ViolenceStreet drugsUnsafe conditions
Do you and/or your child use/have the following?

Car seatsBike helmetsSmoke detectorCarbon monoxide detector
Learning
My child learned to do things at the same age as other children (sit, stand. walk. toilet trained, etc)

YesNo
If not, please explain
My child needs help with

ToiletingActivity/mobilityDressingNutrition/eatingOther
Please check any of the following boxes that describe your child

Says numbers 1 to 10Seems clumsy when using handsHas trouble speaking or hard to understandAble to follow directionsHas trouble being understood by othersPlays in a variety of waysUnderstands other peopleWalks or runs poorly (falls)
Do you have questions, concerns, or want information about:

Bike helmet/safetyDisciplineKindergartenFamily RelationsToilet trainingGun SafetyTV WatchingSeat belts/car seatsSleepingStranger safetyPreschool
Should be Empty:

Consent Form

This Screening Includes:

Child and Parent Rights, Obligations, and Assurances

Release of Information

CONSENT TO RELEASE INFORMATION

Registration Form

GENERAL INFORMATION AND INSTRUCTIONS

PRIMARY/SECONDARY LANGUAGE INFORMATION

PREVIOUS HEALTH AND DEVELOPMENTAL SCREENING INFORMATION

PARENT/GUARDIAN VERIFICATION OF INFORMATION

TO BE COMPLETED BY SCHOOL DISTRICT PERSONNEL ONLY

Status End Codes:

SCHOOL DISTRICT VERIFICATION OF INFORMATION

Child Health & Developmental Health History (3-5 Years)

FAMILY INFORMATION

GENERAL INFORMATION

DAILY ROUTINES

Home Safety

Learning