Army Child And Youth Services Health Screening - Tool #1 printable pdf download

ARMY CHILD AND YOUTH SERVICES HEALTH SCREENING – TOOL #1

Form Updated 16 Sep 11

PRIVACY ACT STATEMENT

SNAP Case Number: ________________

AUTHORITY:

10 U.S.C. 3013, Secretary of the Army; 29 U.S.C. 794, Nondiscrimination Under Federal Grants and

Programs, DoDD 1342.17 Family Policy; AR 608-75, Exceptional Family Member Program: AR 608-

FOR CER COMPLETION ONLY

10, Child Development Services; and E.O. 9397 (SSN).

□ Initial Registration

Information will be used to assist Army activities in their responsibilities in overall execution of the

PRINCIPAL PURPOSE:

Date in from Patron:

Army’s Exceptional Family member Program (EFMP) and the Army Child and Youth Services

Is child on waiting list? □ Yes □ No

Program.

Date care needed? ________________

The DoD “Blanket Routine Uses” that appear at the beginning of the Army’s compilation of systems of

ROUTINE USES:

Date out to APHN:

□ Re-registration/Child Already in Program

records apply to this system

□ Change in Program

Disclosure of requested information is voluntary; however; if information is not provided individual may

DISCLOSURE:

not be able to participate in Army Child and Youth Services Program.

Part A – General Information

Child/Youth Name

Child/Youth School Grade

Date of birth

Age

(example: 3

Grade )

(YYYYMMDD)

Type of Placement Requested: (check all that apply)

□ Hourly Care

□ Full Day Care

□ Middle School/Teen Program

□ Summer Camp

□ Other: (specify)

□ Part Day Care

□ Before/After School Care

□ SKIES/Instructional Classes

□ Sports

Sponsor Name

Sponsor E-mail

Sponsor DOB

Last 4 of SSN

Spouse Name

Spouse E-mail

Home Phone

Cell Phone

Sponsor Unit

Home Address

Sponsor Duty Phone

Part B – Identification of Child/Youth Condition/Restrictions

Does you child have any of the following conditions/restrictions: (check no or yes and answer questions as appropriate)

1. Allergies

7. Behavior/ conduct concerns (oppositional defiant disorder,

□ No

□ Yes

a. Life threatening reaction?

□ No

□ Yes

anxiety, depression, bipolar, other)?

b. Rescue Medication (Epi-pen, Benadryl, Inhaler)

□ No

□ Yes

8. Autism Spectrum Disorders (Autism, Aspergers, Rett

□ No

□ Yes

c. Does child/youth need rescue inhaler?

□ No

□ Yes

Syndrome, PDD-NOS)

If your child/youth has an allergy, please list: ___________________________

9. Does your child have any of the following health concerns?

□ No

□ Yes

______________________________________________________________

(circle all that apply)- Hearing impairment, vision impairment

Reaction: ______________________________________________________

other than corrective lenses, heart, kidney, physical disability

______________________________________________________________

SEVERE skin condition

2. Special Diet

□ No

□ Yes

Please specify __________________________________________________

a. Is your child on a complex diet (i.e. gluten free, diabetic)

□ No

□ Yes

______________________________________________________________

b. Does your child have a food intolerance/mild food

10. Does your child have a speech/language and/or hearing

□ No

□ Yes

allergy (i.e. rash from strawberries/milk intolerance)?

□ No

□ Yes

loss that affects their ability to communicate their basic

c. Does your child have a dietary religious restriction?

□ No

□ Yes

needs (hurt, bathroom, fear, thirst)?

3. Asthma/Reactive Airway Disease/Breathing Problems?

□ No

□ Yes

Explain: _______________________________________________________

a. Does your child need a rescue med?

□ No

□ Yes

______________________________________________________________

4. Does your child have diabetes?

□ No

□ Yes

______________________________________________________________

5. Does your child have seizures?

□ No

□ Yes

11. Does your child have developmental delays other than

□ No

□ Yes

6. Attention Deficit Disorder (ADD/ADHD)

MILD speech language/MILD hearing loss?

While on meds, are there behavior/conduct

□ No

□ Yes

Explain: _________________________________________________________

concerns?

b. List ADD/ADHD medications: ____________________________________

______________________________________________________________

12. Are there any other conditions or concerns that you would

□ No

□ Yes

______________________________________________________________

Like staff to be aware of?

______________________________________________________________

Explain: __________________________________________________________

Part C – Medications

List any medications that are prescribed for your child/youth other than those listed above:

Will your child require medication administration during child care/youth supervision hours?

□ No

□ Yes

Part D – Early Intervention and Special Education

Does your child/youth receive special services/therapies? □ No □ Yes

Does your child/youth have an Individualized Education □ No □ Yes

Please specify: _____________________________________________

Plan (IEP), Individualized Family Service Plan (IFSP) or 504 Plan?

Part E – Exceptional Family Member Program (EFMP) Enrollment

Is your child enrolled in the EFMP? □ No □ Yes If yes, specify for what condition: _____________________________________

_________________________________________________________________

__________________________________

Printed Name and Signature of Parent/Personal Representative of Child/Youth

Date (YYYYMMDD)

If you have answered NO to all the questions above you are now finished with this form.

Please sign and date indicating that the information above is accurate and complete to the best of your knowledge.

Child, Youth and School Services strives to provide the safest and healthiest environment for your child/youth and relies on your accurate and honest information

to support this goal. Please understand that placement and/or care for your child/youth could be delayed/suspended if information is falsified or intentionally

omitted on registration documentation. If there are any changes to your child/youth’s health please notify CYS Services immediately.

If you answered YES to any of the questions above, complete Part F on the next page.