HC New test Todays Date * Provider Community * African-American Ethiopian-Oromo Eritrean Somali Other Community Health Worker * Dahabo M Elsa O Fadumo A Jenel S Nadifo J Nizala MS Suleqo O SIC Other Staff Provider ID Number * 153102 153103 153104 153105 153106 153107 153108 153109 153110 153111 153112 153113 153114 153115 153116 153119 153120 153121 153123 153124 153125 153127 153128 153129 153130 153131 153132 153133 153134 153135 153136 153137 153138 153139 153140 153141 153142 153143 153144 153145 153147 153148 153150 153151 153152 153153 153154 153155 153156 153157 153158 153159 153160 153161 153163 153164 153165 153166 153167 153168 153169 153170 153171 153172 153173 153174 153175 153176 153177 153178 153179 153180 153181 153182 153183 153184 153185 153186 153187 153188 153189 153190 153191 153192 153193 153194 153195 153196 153197 153198 153199 153200 153201 153202 153203 153205 153206 153207 153208 153209 153210 153211 153212 153213 153214 153215 153216 153217 153218 153219 153221 153222 153223 153224 153225 153226 153227 153228 153229 153230 153231 153232 153233 153234 153235 153236 153237 153238 153239 153240 153241 153242 153243 153244 153245 153246 153247 153248 153249 153250 153251 153252 153253 153254 153255 153256 153257 153258 153259 153260 153261 153262 153263 153264 153265 153266 153267 153268 153269 153270 153271 153272 153273 153274 153275 153276 153277 153278 153279 153280 153281 153282 153283 153284 153285 153286 153287 153288 153289 153290 153291 153292 153293 153294 153295 153296 153297 153298 153299 153300 153301 153302 153303 153304 153305 153306 153307 153308 153309 153310 153311 153312 153313 153314 153315 153316 153317 153318 153319 153320 153321 153322 153323 153324 153325 153326 153327 153328 153329 153330 153331 153332 153333 153334 153335 153336 153337 153338 153339 153340 153341 153342 153343 153344 153345 153346 153347 153348 153349 153350 153351 153352 153353 153354 153355 153356 153357 153358 153359 153360 153361 153362 153363 153364 153365 153366 153367 153368 153369 153370 153371 153372 153373 153374 153375 153376 153377 153378 153379 153380 153381 153382 153383 153384 153385 153386 153387 153388 153389 153390 153391 153392 153393 153394 153395 153396 153397 153398 153399 Caregivers for this family are: * FFN Caregiver (Get Check from the State) Informal Caregiver (Do not get Check from the State) How many children were served today (OPTIONAL)? select number 1 2 3 4 5 6 7 8 9 10 During this visit did you deliver the any of the following Consultation services What type of Consultation was it? * In-person consultation session Phone or virtual consultation session Consultation with providers/caregivers on administering ASQ * Yes No Did you make a Child Development Referral (Not Screening) * Yes No If yes how many select number 1 2 3 4 5 6 7 8 9 10 Get information on how to help me cover my basic needs (food - clothing - housing - medical attention) * Yes No Healthy and Safe Environment Concerns Is your home safe for children? * Yes No Safe Sleep * Yes No How to prevent the spread of illness * Yes No First Aid * Yes No Car Seat Safety * Yes No CPR * Yes No Toxic * Yes No Being ready for a natural disaster * Yes No Child Development Concerns How do I incorporate activities from my homeland that will support the healthy development of my children? * Yes No How do I help children that have difficult? behavior (setting limits and sticking to them)? * Yes No How do I know that the children in my care are learning and developing OK? * Yes No What can I do if they are not learning/talking like I think they should? * Yes No Developmental Screening? * Yes No Early Intervention * Yes No How do I help babies brain develop? * Yes No How to help the children in your care get ready for school. * Yes No How my relationship with the children can help them feel secure about themselves. * Yes No Childcare Play and Learn and / or outdoor time * Yes No Referral to early intervention for a special needs child * Yes No Healthy Children Working with children with special healthcare needs * Yes No Immunizations and Well Child Schedules * Yes No Hand-washing - diapering - toileting * Yes No Medication Management Children (Non-clinical) * Yes No Nutrition (meal planning - allergies - infant Feeding) * Yes No Social/Emotional development * Yes No Mental/Behavioral Health Services (Child) * Yes No Healthy Caregivers Taking care of yourself (Whole Person) * Yes No Getting further training or school or Certification to improve my Health-Related Social Needs (HRSN) * Yes No How to help me cover my HRSN (e.g. food, transportation, housing, medical needs, employment) * Yes No Coping with stressful situations * Yes No Mental / Behavior Health Services (Non Clinical) * Yes No Medication Management Adult (Non Clinical) * Yes No Child Caregiver relationship * Yes No Caregiver of Child relationship * Yes No Did you make a Community Resource-Referral * Yes No Resource-Referral Type (If answered yes to above check all that apply) * Housing instability Food insecurity Transportation problems Utility help needs Interpersonal safety Financial strain Employment Family and community support Education Physical activity Substance use Mental health Disabilities None Of The Above Time Spent on Consultation Start Time * 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM End Time * 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM Select time period * 15 mins 30 mins 45 mins 60+mins Goal not completed? * Yes No Goal Completed? Yes No Notes About Yes Answers (Required to Submit): * Next
