Creating the Health & Education Passport

Health & Education Passport

Central CA Training Academy 559-278-5757 Terry Luna, CWS/CMS Project Coordinator [email protected]

Revision July 2013 Table of Contents

Legislative Cites for Health & Education Passport Page 2/3

Creating the Health & Education Passport Page 4

Client Notebook Page 5

Recording Education Information Page 6/9

Deleting an Education Notebook Page 10

Using the Health Notebook Page 11

Important Items in Health NB Page 12

Recording Psychotropic Medications Page 13/14

Developmental & Mental Health Screenings Page 15/16

Recording Well Child Exams – Contact Notebook Page 17

Service Provider Search Tips Page 18

Placement Information Page 19

Health/Education Related Outcome Measures:

Timely Medical & Dental Exams – 5B(1) & (2) Page 20

Psychotropic Medications – 5F Page 21

Individualized Education Plans – 6B Page 22

Forms:

Passport Mapping Page 23/30

Central California 2 Training Academy CALIFORNIA WELFARE AND INSTITUTIONS CODE Division 9. PUBLIC SOCIAL SERVICES Part 4. SERVICES FOR THE CARE OF CHILDREN Chapter 1. FOSTER CARE PLACEMENT

§ 16010. a) When a child is placed in foster care, the case plan for each child recommended pursuant to Section 358.1 shall include a summary of the health and education information or records, including mental health information or records, of the child. The summary may be maintained in the form of a health and education passport, or a comparable format designed by the child protective agency. The health and education summary shall include, but not be limited to, the names and addresses of the child's health, dental, and education providers, the child's grade level performance, the child's school record, assurances that the child's placement in foster care takes into account proximity to the school in which the child is enrolled at the time of placement, the number of school transfers the child has already experienced, the child's educational progress, as demonstrated by factors, including, but not limited to, academic proficiency scores, credits earned toward graduation, a record of the child's immunizations and allergies, the child's known medical problems, the child's current medications, past health problems and hospitalizations, a record of the child's relevant mental health history, the child's known mental health condition and medications, and any other relevant mental health, dental, health, and education information concerning the child determined to be appropriate by the Director of Social Services. If any other law imposes more stringent information requirements, then that section shall prevail. b) Additionally, a court report or assessment required pursuant to subdivision (g) of Section 361.5, Section 366.1, subdivision (d) of Section 366.21, or subdivision (b) of Section 366.22 shall include a copy of the current health and education summary described in subdivision (a). (c) As soon as possible, but not later than 30 days after initial placement of a child into foster care, the child protective agency shall provide the caretaker with the child's current health and education summary as described in subdivision (a). For each subsequent placement, the child protective agency shall provide the caretaker with a current summary as described in subdivision (a) within 48 hours of the placement.

DIVISION 31 REQUIREMENTS (31-200 & 400)

31-206.35

For children receiving out-of-home care, the social worker shall document in the case plan, the following:

Central California 3 Training Academy Health and Education Information about the Child:  Names and Addresses of the child’s health and education providers.  Child’s grade level performance.  Child’s school record.  Assurances that the child’s placement in foster care takes into account proximity to the school in which the child is enrolled at the time of placement.  A record of the child’s immunizations.  The child’s known medical problems.  The child’s medications. If any of the required health and education information is not contained in the case plan, the case plan shall document where the information is located.

31-206.361 Each child in placement shall receive a medical and dental examination, preferably prior to, but not later than, 30 calendar days after placement.

31-405.1 (m) Ensure that information regarding available CHDP services is provided to the out of home care provider within 30 days of the date of the placement. (n) Ensure that the child receives medical and dental care which places attention on preventive health services through the Child Health and Disability Prevention (CHDP) program, or equivalent preventive health services in accordance with the CHDP program’s schedule for periodic health assessment. (1) Each child in placement shall receive a medical and dental examination, preferably prior to, but not later than, 30 calendar days after placement. (o) Make certain that arrangements for, and monitoring of, the child’s educational progress while in placement are undertaken. (s) Provide the out-of-home care provider the child’s background information as available, including, but not limited to, the following histories:  Educational  Medical  Placement  Family  Behavioral

(q) Provide the out-of-home care provider(s) information of any known or suspected dangerous behavior of the child being placed.

Central California 4 Training Academy CREATING THE HEALTH & EDUCATION PASSPORT The Health & Education Passport is populated from several Notebooks throughout CWS/CMS. Information cannot be entered directly onto the Passport.

Client Notebook – several pages of this notebook populate the passport with basic child information. The ‘service provider’ page will populate past and present health service providers of the child.

Education Notebook – this notebook populates the passport with past and present educational information for the child.

Health Notebook – this notebook populates the passport with all relevant health history for a child, including ‘diagnosed conditions’, ‘medications’, ‘hospitalizations’, ‘immunizations’, etc.

Contact Notebook – The Associated Services page of the contact notebook must be used to document CHDP – Physical & Dental information. Only Well Child exams with an HEP indicator will populate to the passport.

Placement Notebook – Use the ID page of this notebook to document the ‘date SCP informed of the CHDP program and that brochure was given’; if ‘SCP requests CHDP services’; and ‘date SCP was given the HEP and informed of it’s purpose’. Use the ID page to note that Social Worker considered proximity to the school in which the child was enrolled at time of placement.

Use the ‘Create New Document-Client’ Notebook to generate the Passport.

Select the Time Frame parameters from the next dialog box.

This will create the Passport in Microsoft Word. It can be Saved and Printed, but CANNOT be edited! Any changes must be made in the Notebooks, then the passport can be removed – and re-created. There can only be ONE passport per

Central California 5 Training Academy child. The passport can be continually refreshed, by removing it and recreating it. It should be created/refreshed at least once every 6 months and always with each new or subsequent placement.

SAVE TO DATABASE CLIENT NOTEBOOK

Areas in GREEN are important to complete for Passport.

Enter basic identifying client information here, DOB, SS, ethnicity and language. If child is in placement, be sure to check the confidentiality in effect box.

Enter basic demographic information for the client, birthplace, arrests, etc.

Record all address changes here. Be sure to enter start and end dates for addresses. NOTE: this is NOT the place to change an address for a child in placement or when a foster parent or relative caregiver moves.

Enter any other names or AKA’s that your client may use. This will cross-reference all names when a client search is done.

Relate all clients to each other on this page. Be sure that the relationship is in the correct order as they are listed or they will populate incorrectly to many documents that CWS/CMS produces.

This page is where the county case number is entered. It is important that the number be active (no end date), if this is a child that a placement will be recorded for. Other types of numbers can be entered here for clients, for example, CII, MEDS Id, etc.

Juvenile court numbers are entered on this page for children only.

Parent search information is recorded on this page. Record searches information in the parent’s notebook. Search results entered here will populate to the Declaration of Due Diligence.

Eligibility information to Foster Care is recorded on this page.

Once an attorney has been appointed on behalf of a client, they must be attached on this page.

Central California 6 Training Academy Use this page to show service providers involved with client. Use the plus + sign to add service provider. Service providers with no END date – will populate Current Service Provider section of passport. Providers with END date entered populate the ‘past provider’ section. Only Providers that have been used in a Contact will appear under the plus. Use the Search option to located Providers that are not in the list. This page records information about a child’s Indian status – it must be completed before ICWA notices can be generated from CWS/CMS. Recording Education Information and Progress for Children – in CWS/CMS

There should only be one Education Notebook per each school the child has attended. All grades and education records for one particular school can be recorded in that school’s notebook.

To begin an Education Notebook for a child – you must search for the school first:

All public schools are loaded into CWS/CMS and updated at least once per year. Most private, independent and home schools are added into the application by each county’s designated person. Use the School Category and the County – then you can look under the ‘school’ drop down menu and look through the list of schools. Usually you will be able to find the school easily that way.

Central California 7 Training Academy Other helpful ways to search – by city and zip code. Try many different ways before determining the school is not in the system. If unable to locate the school you are looking for, contact your local help desk.

Once you have located the correct school, you can record the child’s attendance and records in the child’s case.

Central California 8 Training Academy Create New Education

If parental rights have been limited by the court – record here (this will also populate to the demographic page of the child’s client notebook.) If parental rights intact – record ‘Parent retains rights’ . Record Court Appt Rep here: must correspond with a court order date & a JV535 should be on file.

Use the plus + to activate this section. Worker can record the ‘school of origin’ here – by using the binoculars to search if it is not there. Mandatory fields include the decision to keep child in school or origin and the date of the decision. This ‘best interest’ determination will populate to the HEP. Note: only the most recent ‘best interest’ decision will populate the HEP in the event there is more than Record the date the child began one. attending school here. The end date should be filled in only if the child no longer attends this school and the reason why. These ‘green’ fields are data fields required by the NYTD (National Youth in Transition Database). Complete if indicated. The bottom fields are more likely for an older youth nearing transition from HS, Client Special Ed: should have an ‘open’ end date. complete as appropriate. If No – enter only Start Date. If Yes, enter Start Date (usually will correspond with IEP Date. (Record IEP on next page). Enter ‘end date’ only if Special Ed services are complete. Narrate briefly the details of services needed,( ie., Speech/Language, RSP, etc)

Use this page to record the child’s grade level and the child’s education records for each grade level.  Previous grades must be end dated.  Current grade needs to be entered for current school year.  Teacher should be included for grades K-6

Central California 9 Training Academy Use bottom half of page to record the records that correspond with each grade level.

Education Records: Attendance Records Child Evaluation IEP (outcome measure field) IFSP (age 0-3) Progress Record (formal and informal) Year End Report Cards

Summarize documented attendance from school according to the following template: Child's current attendance records (attached for the Court’s consideration) show that he has missed approximately # days of school. Of these # days, the child's care provider, cp name, has excused # while # of the absences were unclear, meaning that no communication was received from the care provider as to why he was not in school. Child has had # tardies this school year

Progress Record Behavior summary

Central California 10 Training Academy Behaviorally, school name has reported that there have been no problems.Ch ild's name teachers report that he is respectful. Child's demeanor in the classroom is quiet and teacher's report that he is hesistant to interact with his peers and does take initiative to participate in any classroom activities. Child' s name has been interested in participating in extra-curricular activities and is currently involved with clubs or sports teams on campus. Currently, the Child' s name is involved in the following extracurricular activities: ______.

Current Grades documented in either a Progress Record or Year-End Report Card Academically, child's name currently has a ______grade point average. This average is based on his date semester grades. A progress report that was created on date shows that he is earning A's in subjects, B's in subject, C's in subject, D's in subject, and F's in subject. C hild's name standardized test scores for 1st grade shows that he is above reading level and above math level.

Court Report  Refer to the HEP for updated educational information  Explain any need for a change regarding educational rights  Discuss any upcoming changes

Central California 11 Training Academy Deleting an Education Notebook (if entered by mistake)

Open the Education Notebook that you want to remove – and go to the Education Record Page.

Remove all rows from the page – highlight row, and use the delete key.

All rows must be deleted from this page.

Then open ‘Existing Education Notebook’:

The remove button should be available.

Central California 12 Training Academy HEALTH NOTEBOOK

Use this page to summarize a child’s current condition. When a new Summary is entered, the old Summary is erased. It will only remain on a hard copy of the previous HEP. This Summary does NOT keep history. Has the child been clinically diagnosed by a qualified professional as having at least one of the following disabilities: mental retardation; visually or hearing impaired; physically disabled; emotionally disturbed, or other medically diagnosed conditions requiring special care.

Use this page to record any conditions a child has which are diagnosed by a practitioner or a clinic. Record as much information about the condition as possible. Use start and end dates to document child’s health history. If an alert is checked, the condition will populate to first page of Passport.

Use this page to record any conditions a child may have that have been observed by someone. Record as much information about the condition as possible. Use start and end dates to document child’s health history. Observed conditions will only print to passport if the alert is checked.

Use this page to document any medications prescribed for a child. Each medication must be tied to a ‘Client Condition’ (which comes from the ‘Diagnosed Conditions’ page.)

Hospitalizations Use this page to document anytime a child has been hospitalized. The hospitalization must be tied to a ‘Client Condition’.

Medical Tests Use this page to document any medical tests ordered for a child and those test results. The medical tests must be associated with a ‘Client Condition’.

Referrals Use this page to document any medical referrals made on behalf of a child by a Health Provider. The referrals must be associated with a ‘Client Condition’.

Use this page to document a child’s immunization history.

Central California 13 Training Academy Well Child Use this page to record information regarding a child’s Well Child exam. You must enter a Well Child Exam as an Associated Service in the Contact Notebook PRIOR to completion of the information on this page.

Birth History Use this page to enter birth history information for a child. This is also a good place to record a toxicology screening. Certain information on this page is duplicated on the Demographic page of the client notebook. The information will cross populate each notebook. Screenings Document developmental and mental health screenings here.

Central California 14 Training Academy Important Items in Health Notebook

Allergies: Any allergies / medications / or foods to avoid should be listed on this tab, under Allergies. Use the narrative sections to detail reasons why. These will populate to the first page of the passport.

Some immunizations given are a combination of 2 or more vaccines, but must be entered into CWS/CMS as separate vaccines:

Polio-Inactivated = IPV in CWS/CMS Varivax/Varicella/Chickenpox = VZV in CWS/CMS Pneumococcal Conjugate/Prevnar/PCV13 = Pneumococcal in CWS/CMS Adacel = Tdap in CWS/CMS Comvax = Hep B and Hib in CWS/CMS MMRV, ProQuad = MMR and VZV in CWS/CMS Pediarix = DTaP and HepB and IPV in CWS/CMS Kinrix = DTaP and IPV in CWS/CMS Pentacel = DTaP and IPV and Hib in CWS/CMS Gardasil = HPV in CWS/CMS MCV4/Menactra = Meningococcal Conjugate in CWS/CMS

If there is no listed vaccine that corresponds with the vaccine named on the PM 160, enter the vaccine under the “Other” listing and type the actual name of the vaccine written on the PM 160 in the comment section of the dialog box.

Each page in the Health Notebook can be used to document areas of concern for children. There is narrative area on each page to expand dialogue for each area.

All pages populate to the HEP – except Observed Conditions page. Only items on this page checked with Alert will populate passport.

Central California 15 Training Academy RECORDING PSYCHOTROPIC MEDICATIONS IN THE HEALTH NOTEBOOK Outcome Measure 5F

Open the child’s Health Notebook and use the Diagnosed Conditions & Medications Pages:

DIAGNOSED CONDITION Page:

 Onset Date: Date condition was diagnosed by practitioner. This could be before or after child entered foster care.

 Condition – Health Problem: Choose the most appropriate health problem, avoid using Psychotropic Medication required.

Central California 16 Training Academy  Health Problem Description: Add the condition as written on the JV220.

MEDICATIONS Page:

One medication per line:

 Prescribed Medication is attached to the diagnosed condition it has been prescribed for.  Prescribed By: enter the doctor that prescribed the medication.  Start date – with NO end date indicates current medication. Use the actual date child begins taking the medication.  Projected End Date: Date the court order expires (should be 6 months/180 days from date of current court order).  End Date: Only use this to record a medication that the child is no longer taking.  Court Ordered Date: Date the JV220 is signed by the judge. Update this date as new court order is signed for current medication – add a new row with new date.  Comment/Instructions: o Date each entry o List the dosage or range o List alternative medications listed on the JV220 that may be given in the future o If medication is same, but new doctor – note here and Prescribed By field.

Central California 17 Training Academy  Check appropriate radio buttons if the medication is ‘psychotropic’ and if administered for ‘psychiatric purposes’.  An ‘automatic reminder’ will be generated from the court order date or if no date has been entered.

Central California 18 Training Academy Developmental and Mental Health Screenings for Children

A new page has been added to the Health Notebook that will allow worker to document the different types of screenings a child has had and when, referrals for certain services and Intervention Plan details.

BLUE section: Health Notebook

Screenings Section:

This section is used to document Developmental or Mental Health Screenings done – and when. You cannot record ‘scheduled’ screenings. Screenings are recorded by age group. You can also select N/A if a child is already receiving services or N/C if a screening was ‘not completed’ but child referred for services.

You can record who the child was screened by, whether or not a referral is needed – and detailed comments can be recorded in the narrative section: up to 4020 characters.

Central California 19 Training Academy Referrals section: of the Health Notebook

This section allows worker to document a referral made regarding Mental Health or Developmental issues, where referred to and when, and whether or not the referral was accepted. Consent can also be documented. The comment section is limited to 254 characters, so any comment entered must be brief!

Intervention Plan area: of the Health Notebook

Intervention Plan – allows you to select either Initial – Mental Health or Developmental Plan, and also Updated – MH or Dev. Plans. Plan Detail section – allows you to select the individual components for intervention (multiples can be chosen, add each using the plus + sign:

Each section – MH or Developmental – has it’s own selections for intervention activities. Record start dates for all, and if an activity ends, record end date.

Screenings and Intervention Plan data will populate to the HEP.

Central California 20 Training Academy QUICK GUIDE TO WELL CHILD EXAMS/MEDICAL/DENTAL (CHDP) Create New Contact: Use the Contact Notebook to record every Start with a ‘new’ contact, to record how the contact (narrative) that is made on behalf of a information regarding the CHDP exam was child. obtained. Be sure to complete all YELLOW fields.

Use the ‘Spell Check’ command under the Edit menu once narrative has been entered.

The participant of the contact – is who the information was received from. If the person/agency that you rec’d the information from is not under the participant list under ‘service provider’ – do a search for that provider. RECORD CHDP SERVICE BEING PROVIDED Open ANY existing contact or complete a ON BEHALF OF A CHILD: NEW contact, then click on the Associated Services page.

Use the plus button in the upper left corner to add each Service provided to child.

Be sure to complete all YELLOW fields. Check ‘hard copy on file’ if the PM 160 is on hand. If you are unable to find the Service Provider in search, go to the next step: Create New Immunizations given must be entered into the Health Notebook. Service Provider. The ‘Well Child Exam’ button will become enabled ONLY if the following services are selected: If a ‘partial exam’ is indicated on the PM160 – or only immunizations, hemoglobin recheck, hearing, urine or HEP – CHDP Equivalent Physical Exam vision rechecks, or TB test given, - a complete exam was not HEP - CHDP Physical Exam done and should not be entered as such. HEP - Required Dental Exam A Well Child Exam can be recorded for ONLY Refer to a Foster Care Public Health Nurse for questions one child at a time. relating to diagnoses or referrals. All other Medical/Dental exams can be entered Be sure to go to Diagnosed Condition Page in Health in this manner. Notebook to record any issues diagnosed by a health Document any problems found during exam professional! and follow up needed. CREATE NEW SERVICE PROVIDER: **Only create a service provider, if you were unable to locate provider using SEARCH.** Complete both pages with as much information as you can. Be sure to complete all YELLOW fields. ,

Central California 21 Training Academy SERVICE PROVIDER SEARCH Tips:

Most service providers are already in the database, the trick is finding them.

You can search with provider’s first and last name, or agency name, or any combination. There is no phonetic search – that means that your spelling has to be just right, or you will not find the provider.

You can search using City or Zip Code to narrow the search.

Only the first 50 providers will be displayed in the Search, but there will be a message telling you there are more than 50. You must enter additional search parameters in order to view more.

Use the ‘Wild Card’ for additional search power.

Example: Searching for the provider: Financial First

Surrounding the word ‘financial’ with the percent signs – is asking for any provider with the word financial in it.

Central California 22 Training Academy PLACEMENT NOTEBOOK

Open the Existing Placement:

Record the ‘Date the Substitute Care Provider was informed of the CHDP program and the brochure was given. If the Substitute Care Provider requests CHDP services be provided, check the box indicating so. Document the Date the Substitute Care Provider was given the Health and Education Passport, and informed of it’s purpose.

Rationale section:

Use this page to document that the child’s placement in foster care takes into account proximity to the school in which the child was enrolled at the time of placement and whether or not the child attends the same school as prior to the placement.

SAVE TO DATABASE

Central California 23 Training Academy Central California 24 Training Academy Timely Medical and Dental Exams State Measure – 5B(1) and 5B(2)

This measure provides the percent of children meeting the schedule for CHDP/Division 31 medical and dental exams. Minors must have a medical and/or dental exam by the end of their age period. CWS/CMS

Child must be in placement and episode open 31 days or more. Placement home is in California. Minor’s age taken at quarter end.

Excludes: Non-CWD placements (probation, etc) Placement episodes open less than 31 days Children in placement homes outside of CA Runaways Non-foster care placements Non dependent Legal Guardians

Contact Notebook:

A ‘delivered service’ must be recorded in the contact notebook on the Associated Services page of: Use these types only: CHDP Medical Exams CHDP Dental Exams Health/CHDP Services CHDP Dental Delivered CHDP Medical Delivered HEP-Periodic Dental Exam HEP-CHDP Equivalent Physical Exam HEP-CHDP Physical Exam

Medical Assessments-Age Exam Categories Dental Assessments Under 1 month 3 years and once a year thereafter till age 20 1 to 2 months 3 to 4 months 5 to 6 months 7 to 9 months 10 to 12 months 13 to 15 months 16 to 23 months 2 years 3 years 4 to 5 years 6 to 8 years 9 to 12 years 13 to 16 years 17 to 20 years Authorization of Psychotropic Medications State Measure – 5F

Central California 25 Training Academy This measure provides the percent of children in foster care with a court order or parental consent that authorizes the child to receive psychotropic medication. CWS/CMS

ID page: Agency Responsibility is County Welfare Agency

Includes:  Placement Episode Open or Closed during the quarter  Placement open or Closed during the quarter  Outgoing ICPC placements  Runaways or Closed Placement w/Open Episode Excludes:  All non child welfare agency placements (probation, other)  All placements with Legal Authorization codes other than WIC a-j, e, h, 601 & 602  Incoming ICPC placements  Non-foster care placements  Non Dependent Legal Guardians  Children in Placement Facility Type – Guardian home

One medication listed on this page must be Active – no end date. Or the medication must have been active during the review period. A Psychotropic Medication consent date must have occurred prior to the last day of the review period – either Court Order or Parental Consent date.

No end Parental Consent/Court date Order date here

Central California 26 Training Academy Individualized Education Plan (IEP) State Measure – 6B

This measure provides the percentage of children in out-of-home (OHP) placements who have ever had an IEP.

CWS/CMS

 Child must have an open case.  Child must be in placement.  Placement episode must be 31 days or longer.  Child must be placed in California.

Exclude:  Non-dependent legal guardianship placements.  ICPC placements (in or out).  Children younger than 3 years old.  Children who turned 3 years old 31 days or less before the end of the quarter.  Children 19 years of age or older.

Central California 27 Training Academy Heath & Education Passport Mapping

The Health & Education Passport is a protected document – it cannot be changed or modified in Microsoft WORD.

Use the Mapping on the following pages to determine the notebooks, pages and fields in CWS/CMS that populate to each section of the Health Passport. Each section is color coded to indicate which section in CWS/CMS each notebook is found.

Once changes have been made in CWS/CMS – Save to Database – then remove the ‘OLD’ Passport and recreate a ‘NEW’ Passport. The Passport will be refreshed with the new information added in the CWS/CMS Screens.

Central California 28 Training Academy Confidential Health and Education Passport

Instructions to Foster Parents

Please keep this Health and Education Passport while this child is in your care. Please keep the child’s Medi- Cal card, health eligibility identification cards, Medical Consent form, Birth Certificate and Immunization record with this Passport.

Take this Passport to all medical, dental, and educational visits pertaining to the child. Remind doctors, dentists, and teachers, mental health care providers, vision care providers, and other health care providers to add or correct information on the form after each visit. Please give the corrected Passport to the social worker at your next meeting. When the child leaves your care, the latest update of this Passport will go with the child to aid the next care provider.

If you have any questions, please speak with the child’s social worker and/or Public Health Nurse.

Thank you.

State of California Health and Welfare Agency HEALTH AND EDUCATION PASSPORT Confidential in accordance with Department of Social Services Penal Code Section 11167.5 and/or CWS Case Management System WIC Sections 827 and 10850 CP-OHCHEP REV (08/2010) 2018 年 4 月 8 日 Page 1 of 36 CHILD INFORMATION CHILD’S NAME BIRTH DATE AGE GENDER Client Notebook – ID Page Client Notebook Client Client – ID Page Notebook Notebook – – ID Page ID Page NAME ALSO KNOWN BY CHILD ID NUMBER COURT NUMBER Client Notebook – Names Page Client Notebook – ID Page Client Notebook – Juvenile Court Number Page CASE NUMBER MEDI-CAL MEDICAL INSURANCE COMPANY NAME / HMO POLICY NUMBER RECORD NUMBER Case Information notebook-ID Client Notebook FC-2 Eligibility Application NB – FC-2 Eligibility page – ID Num Page Insurance Page Application NB – (Medical Insurance Page Record) ADDRESS SOCIAL SECURITY NUMBER If Child is in Placement – “Confidential Address” should appear here. Client notebook-ID page – Will NOT Client Notebook, ID page – checkmark in “Confidentiality in Effect” populated even if entered PHONE Client notebook-Address page ETHNICITY RELIGION ICWA ELIGIBILITY Client Notebook – ID Page Client notebook- Client Notebook – ID Page Demographics page PRIMARY LANGUAGE SECONDARY LANGUAGE Client Notebook – ID Page Client Notebook – ID Page NAME OF SUBSTITUTE CARE PROVIDER RELATIONSHIP TO CHILD OR TYPE OF FACILITY If Child is in Placement – “Confidential Name” will If Child is in Placement – “Confidential Relationship” will appear here appear here. Client Notebook, ID page – checkmark in “Confidentiality in Effect” SCHOOL NAME SCHOOL ADDRESS GRADE Education Provider-ID page- the school name will Education Provider-Address page Education populate for the school that has a start date – and notebook, no end date. Grade Level Informatio n page PHONE Education notebook-Grade Level Information page CURRENT HEALTH INFORMATION

SENSITIVE HEALTH & MEDICAL INFORMATION ON FILE (Health Notebook-Summary page – Sensitive Checkbox)

LIMITATION PUT ON SUBSTITUTE CARE PROVIDER’S ABILITY TO MAKE HEALTH DECISIONS(Health Notebook- Summary page)

INDIVIDUAL HEALTH CARE PLAN ON FILE FOR SPECIAL NEEDS CHILD (Health Notebook-Summary page)

State of California Health and Welfare Agency HEALTH AND EDUCATION PASSPORT Confidential in accordance with Department of Social Services Penal Code Section 11167.5 and/or CWS Case Management System WIC Sections 827 and 10850 CP-OHCHEP REV (08/2010) 2018 年 4 月 8 日 Page 1 of 36 ** ALERTS ** DESCRIPTIO N Health notebook, Diagnosed Condition and Medications pages (Alert box) !@#$%(10) ALLERGIES DESCRIPTIO Health Notebook-Diagnosed Condition (Allergies) N

ONSET DATE/FIRST VISIT DIAGNOSED BY Health Notebook- Health Notebook-Diagnosed Condition Diagnosed Condition !@#$%(0) SUMMARY OF CHILD’S CURRENT HEALTH CONDITION Health notebook, Summary page – Narrative entry from this field populates here.

DEVELOPMENTAL / FUNCTIONAL LIMITATIONS VISUAL IMPAIRMENT HEARING IMPAIRMENT SPEECH IMPAIRMENT SPECIAL DIET REQUIRED NEUROLOGICAL MEDICAL EQUIPMENT REQUIRED IMPAIRMENT DEVELOPMENTALLY DISABLED NON AMBULATORY MEDICAL PROCEDURES REQUIRED DEVELOPMENTALLY DELAYED SPECIAL EDUCATION PUPIL, EMOTIONAL DISORDER, DSM, CURNT CERTIFIED REV DESCRIPTIO OTHER N Health notebook-Diagnosed Condition page (choose these under Physical, Behavioral or Emotional category)

CURRENT HEALTH ISSUES Each Health Problem without an end date on Diagnosed Conditions Page is followed by related information from the Health notebook-Medications, Hospitalizations, Medical Tests, and Referrals pages. HEALTH PROBLEM ONSET DATE/FIRST VISIT NEXT SCHEDULED VISIT DATE Health notebook-Diagnosed Condition page Health notebook-Diagnosed Health notebook-Diagnosed Condition page Condition page DIAGNOSED BY: NAME DIAGNOSED BY: PHONE COMMUNICABLE DISEASE? Health notebook-Diagnosed Condition pg Health notebook-Diagnosed Condition page Health notebook-Diagnosed YES NO UNKNOWN Condition pg HEALTH PROBLEM DESCRIPTION Health notebook-Diagnosed Condition page TREATMENT PLAN / INSTRUCTIONS Health notebook-Diagnosed Condition page !@#$%(1) WELL CHILD EXAM DATE EXAM TYPE SERVICE PROVIDER Health Notebook – Health Notebook – Well Child Page Health Notebook – Well Child Page Well Child Page (Contact notebook- Associated Services page)

State of California Health and Welfare Agency HEALTH AND EDUCATION PASSPORT Confidential in accordance with 2 Department of Social Services Penal Code Section 11167.5 and/or CWS Case Management System WIC Sections 827 and 10850 CP-OHCHEP REV (11/94) 四月 08, 2018 AGE AT TIME OF HEIGHT HEIGHT % WEIGHT WEIGHT % HEAD CIRCUMFERENCE EXAM Client notebook-ID Health Health Health Health Notebook Health Notebook – Well page Notebook – Notebook – Noteboo – Well Child Child Page Well Child Well Child k – Well Page Page Page Child Page COMMENTS / OUTCOMES / REFERRALS Health Notebook – Well Child Page !@#$%(2) IMMUNIZATIONS IMMUNIZATION TYPE DATE GIVEN OR WAIVED SOURCE OF INFORMATION / CLINIC / NEXT DUE DATE WAIVED PHYSICIAN Health notebook- Health notebook- Health notebook-Immunization page Health Immunization page Immunization page notebook- Immunization page !@#$%(3) CURRENT HEALTH SERVICE PROVIDERS Health notebook-Summary page CURRENTLY RECEIVES SERVICES CA CHILDREN’S REGIONAL OTHE FROM: SERV CENTER R SERVICE PROVIDER NAME SERVICE PROVIDER TYPE DATE LAST SEEN Client notebook-Service Providers page – Service Provider Contact notebook-Associated providers listed on this page with no end notebook-ID page Services page date will populate here. CLINIC/AGENCY NAME, IF ANY ADDRESS Service Provider notebook-ID page PHONE Service Provider notebook-Address page Service Provider notebook-ID page !@#$%(4)

PAST HEALTH INFORMATION BIRTH HISTORY BIRTH PLACE / HOSPITAL NAME BIRTH LOCATION (CITY COUNTY STATE AND COUNTRY) Health notebook-Birth History page or Health notebook-Birth History page or Client Notebook – Demog Page Client Notebook – Demog Page WEIGHT LENGTH HEAD APGAR GESTATION CIRCUMFERENCE AGE Health notebook- Health notebook-Birth Health notebook- Health notebook- Health Birth History page History page Birth History page Birth History page notebook- Birth History page TOXICOLOGY SCREENING NEWBORN SCREENING RESULTS Health notebook-Birth History page PRENATAL / PERINATAL COMMENTS Health notebook-Birth History page

State of California Health and Welfare Agency HEALTH AND EDUCATION PASSPORT Confidential in accordance with 3 Department of Social Services Penal Code Section 11167.5 and/or CWS Case Management System WIC Sections 827 and 10850 CP-OHCHEP REV (11/94) 四月 08, 2018 PAST HEALTH ISSUES Each Health Problem with an end date is followed by related information from the Health notebook- Medications, Hospitalizations, Medical Tests, and Referrals pages. HEALTH PROBLEM ONSET DATE/FIRST VISIT END DATE Health notebook-Diagnosed Condition Health notebook-Diagnosed Health notebook-Diagnosed page Condition page Condition page DIAGNOSED BY: NAME DIAGNOSED BY: PHONE COMMUNICABLE DISEASE? Health notebook-Diagnosed Condition page Health notebook-Diagnosed Condition Health notebook-Diagnosed Condition YE NO UNKNOWN page page S HEALTH PROBLEM DESCRIPTION Health notebook-Diagnosed Condition page TREATMENT Health notebook-Diagnosed Condition page !@#$%(5)

PAST HEALTH SERVICE PROVIDERS Health notebook-Summary page PREV. RECEIVED SERVICES CA CHILDREN’S REGIONAL OTHE FROM: SERV CENTER R SERVICE PROVIDER NAME SERVICE PROVIDER TYPE DATE LAST SEEN Client notebook-Service Providers page – Service Provider Contact notebook-Associated providers listed on this page with End Date notebook-ID page Services page CLINIC/AGENCY NAME, IF ANY ADDRESS Service Provider notebook-ID page Service Provider notebook-Address page PHONE Service Provider notebook-ID page !@#$%(6) FAMILY MEDICAL HISTORY MATERNAL - SIGNIFICANT HEALTH PROBLEMS Health notebook - Birth History page

PATERNAL - SIGNIFICANT HEALTH PROBLEMS Health notebook - Birth History page

State of California Health and Welfare Agency HEALTH AND EDUCATION PASSPORT Confidential in accordance with 4 Department of Social Services Penal Code Section 11167.5 and/or CWS Case Management System WIC Sections 827 and 10850 CP-OHCHEP REV (11/94) 四月 08, 2018 EDUCATION INFORMATION PARENT(S) / GUARDIANS EDUCATIONAL RIGHTS LIMITED? YE NO Education notebook-Enrollment Information page or Client S Notebook-Demog Pg COURT APPOINTED EDUCATION REPRESENTATIVE PHONE NUMBER Education notebook-Enrollment Information page Education notebook-Enrollment Information page DOES THE CHILD HAVE AN INDIVIDUALIZED YE NO MOST RECENT IEP EDUCATION PROGRAM (IEP/IIFSP)? S DATE: Education notebook-Grade Level Information page – IEP recorded as an Education Record LOCATION OF EDUCATIONAL RECORDS / ATTEMPTS TO ACQUIRE Client notebook- Demographics page ARE TRANSITIONAL INDEPENDENT LIVING SERVICES BEING YE NO PROVIDED? S Case Plan notebook-Planned Client Services page – ILP Services recorded here. HAS THE CLIENT COMPLETED AT LEAST ONE SEMESTER OF YE NO COLLEGE? S Education notebook-Enrollment Information page HAS THE CLIENT ATTENDED POSTSECONDARY/VOCATIONAL YE NO TRAINING? S Education notebook-Enrollment Information page

CLIENT SPECIAL EDUCATION INSTRUCTION START DATE END DATE RECEIVED? Education notebook- Enrollment Information page YES NO Education Education notebook-Enrollment Information page notebook- Enrollment Information page !@#$%(11)

CURRENT Education Notebook for a child completed with a start date and no end date will appear as the current school. SCHOOL NAME PHONE Education Provider notebook-ID page Education Provider notebook-ID page SCHOOL ADDRESS: Education Provider notebook-Address page

CONTACT NAME START DATE Education Provider notebook-Contact page Education notebook-Enrollment Information page EXPLANATION IF CHILD WAS NOT PLACED IN PROXIMITY OF PREVIOUS SCHOOL ENROLLMENT Placement notebook-ID page SPECIAL EDUCATION NEEDS OF THIS CHILD Education notebook-Enrollment Information page

State of California Health and Welfare Agency HEALTH AND EDUCATION PASSPORT Confidential in accordance with 5 Department of Social Services Penal Code Section 11167.5 and/or CWS Case Management System WIC Sections 827 and 10850 CP-OHCHEP REV (11/94) 四月 08, 2018 GRADE GRADE LEVEL TEACHER / COUNSELOR NAME START DATE PERFORMANCE Education Education notebook- Education notebook-Grade Level Education notebook-Grade Level notebook- Grade Level Information Information page Information page Grade Level page Information page EDUCATIONAL NEEDS / SCHOOL PERFORMANCE / STRENGTHS / INTERESTS Education notebook-Grade Level Information page !@#$%(7)

PREVIOUS Education Notebooks for a child that are ‘end dated’ will appear in this section. SCHOOL NAME PHONE Education Provider notebook-ID page Education Provider notebook-ID page SCHOOL ADDRESS: Education Provider notebook-Address page

CONTACT NAME START DATE END DATE Education Provider notebook-Contact page Education notebook- Education notebook-Enrollment Enrollment Information page Information page REASON CHILD LEFT SCHOOL Education notebook-Enrollment Information page SPECIAL EDUCATION NEEDS OF THIS CHILD Education notebook-Enrollment Information page GRADE GRADE LEVEL TEACHER / COUNSELOR NAME START DATE END DATE PERFORMANCE Education Education notebook- Education notebook-Grade Level Education Education notebook- Grade Level Information Information page notebook- notebook- Grade Level page Grade Level Grade Level Information Information Information page page page EDUCATIONAL NEEDS / SCHOOL PERFORMANCE / STRENGTHS / INTERESTS Education notebook-Grade Level Information page !@#$%(8)

State of California Health and Welfare Agency HEALTH AND EDUCATION PASSPORT Confidential in accordance with 6 Department of Social Services Penal Code Section 11167.5 and/or CWS Case Management System WIC Sections 827 and 10850 CP-OHCHEP REV (11/94) 四月 08, 2018