Monthly Report to Health and Nutrition Manager
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Eastern Oregon Head Start
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Teacher/HV Monthly Report to Health and Nutrition Manager
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Center: Month: Year:
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Fax to Health and Nutrition Manager as soon as you receive form:
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Faxed to H/N Manager as soon as receivedChild Medical Provider Information and/or updates (Fax)
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Child Physical Exam and/or updates (Fax)
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Child Oral Health Assessment and/or updates (Fax)
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Child Health History (Fax)
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Certificate of Immunization Status and/or updates (Fax)
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Child Nutrition Assessment (Fax)
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Any Health Services follow-ups (e-mail acombe@eou.edu)
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Consent for Well-Child Screening (Fax)
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Medical Statement of Food Substitution (Fax)
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Classroom Summary (Allergies, Medical Problems, Meds) (Fax)
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Medication Authorization (Fax)
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Student Accident Report (Fax)
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Anemia Screening Questionnaire (Fax)
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Individualized Health Protocols (Fax)
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E-Mail upon receipt of information from parent:
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Follow-up on Medical or Dental treatment (include date of appointment)
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Include Copy in Month End Report to Health and Nutrition Manager:
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1___Medication Log
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2___Food and Blood Glucose Diary
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3___Parent Update: Medication Administration in the Classroom (Copy)
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4___Ouch Report
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5___Emergency Drill Log
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6___October only:Teacher observations/Nutrition Assessment
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7___Exposure Letter
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Exclusions - List children excluded from class and reasons for exclusion:
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Resources Needed:
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Information for the Attention of the Health and Nutrition Manager:
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Report Completed by: Date:
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Forms/Quality Assurance/Reporting/Teacher/HV Report to Health and Nutrition Manager Revised 2013
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H & N