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Run: Head Start Health Requirements Tracking Form

Track each enrolled child's required health screenings and exams in one place, with deadline monitoring, follow-up, and audit-ready documentation for the 45-...

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Child Enrollment and Tracking Details

Child ID or Internal Tracking Number (required)

Use an internal identifier instead of full name whenever possible to minimize PII.

Program Site (required)

First Attendance Date (required)

This date is used to calculate the 45 calendar day deadline under 45 CFR 1302.42(b)(2).

45-Day Deadline Date (required)

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 (required)

Dental Exam Status (required)

Immunization Status (required)

Vision Screening Status (required)

Hearing Screening Status (required)

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? (required)

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.

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