Head Start Health Requirements Tracking Form

Tracks each enrolled child's required health screenings and exams, including well-child exams, dental exams, immunizations, and vision and hearing screenings, to support timely completion within 45 calendar days after first attendance under 45 CFR 1302.42(b)(2).

Child Enrollment and Tracking Details

• Child ID or Internal Tracking Number
  Use an internal identifier instead of full name whenever possible to minimize PII.
• Program Site
• First Attendance Date
  This date is used to calculate the 45 calendar day deadline under 45 CFR 1302.42(b)(2).
• 45-Day Deadline Date
  Calculated or entered deadline based on the child's first attendance date.
• Assigned Health Services Staff
  Optional staff name or role for internal follow-up.

Required Health Requirements Status

• Well-Child Exam Status
• Dental Exam Status
• Immunization Status
• Vision Screening Status
• Hearing Screening Status

Documentation and Follow-Up

• Documentation Received
  Select all records that have been received and verified.
• Missing Items
  Select any items still needed for compliance.
• Follow-Up Action
• Follow-Up Due Date
  Use when follow-up is needed for missing documentation or services.
• Notes
  Include brief, objective notes only. Do not enter unnecessary PII.

Compliance Review and Audit Trail

• Completed Within 45 Calendar Days?
• Reason for Delay or Exception
  Explain any delay, missing record, or approved exception.
• Reviewed By
  Internal reviewer name or role.
• Review Date
• Audit Trail Notes
  Record verification steps, source documents reviewed, and any follow-up history.