Welcome to Minnetonka Schools! It s time to schedule your child s Early Childhood Screening.

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1 Early Childhood Screening 4584 Vine Hill Road Excelsior, MN Dear Parent/Guardian, Welcome to Minnetonka Schools! It s time to schedule your child s Early Childhood Screening. Screening is a free developmental check up required by the State of Minnesota for children entering public schools. Screening helps identify any needs that may require attention before your child enters school and is best completed between the ages of 3 ½ and 4 years old. During a minute appointment, you are in the room with your child as we check their height, weight, hearing, vision and immunization record, coordination, large and small motor skills, speech, learning development and social and emotional skills. After, your screener will chat with you about the results of the screening and answer any of your questions. To schedule your Screening, complete and return the enclosed forms by mail/e mail. A list of available dates and times are included in this packet. Mail/e mail completed forms to Early Childhood Screening, 4584 Vine Hill Road, Excelsior, MN or fax them to , attention: Early Childhood Screening. Once we have received your forms, you will receive an e mail or mailed a confirmation of your appointment. If you have a question on the day of your screening appointment, please call the reception Prior to your child s appointment, please gather the following documents: A copy of your child s Birth Certificate you will need this document in order to start the screening. Your child s updated immunization record If you do not have your child s immunization record, please contact your clinic and ask them to send us a copy before the appointment. If you have any questions, please do not hesitate to contact me. See you soon! Sincerely, Deb Sorteberg, Early Childhood Screening Manager (phone #) (fax) deb.sorteberg@minnetonka.k12.mn.us P.S. If your child was already screened in another district, please fax a copy of their screening record to

2 Minnetonka Early Childhood Screening Appointment Requests Please complete and return this form to: Early Childhood Screening, 4584 Vine Hill Rd., Excelsior, MN Phone : Fax: Child s Name: First Middle Last (Nickname) Address: MN Home phone: Child s Date of Birth: Male Female Mother s Name: Work/Cell Phone: address: Father s Name: Work /Cell Phone: address: Appointments for your child and a parent (s) are available on the following dates at the Minnetonka Community Education Center, 4584 Vine Hill Rd. Please indicate your first three choices; we will make every effort to schedule appointments per your request. You will receive an or written confirmation of your appointment date and time. MINNETONKA COMMUNITY EDUCATION CENTER Morning Afternoon Morning Afternoon Morning Afternoon Wed. Sept. 9 Wed. Dec. 2 Thur. March 10 Wed. Sept. 16 Tues. Dec. 10 Wed. March 16 Tues. Sept. 22 Wed. Jan. 6 Tues. March 22 Wed. Sept. 30 Tues. Jan. 12 Wed. April 6 Sat. Oct. 3 Wed. Jan. 20 Sat. April 9 Wed. Oct. 7 Thurs. Jan. 28 Wed. April 13 Wed. Oct. 14 Wed. Feb. 3 Tues April 19 Tues. Oct. 20 Sat. Feb. 6 Thurs. April 28 Wed. Oct. 28 Wed. Feb. 10 Wed. May 4 Wed. Nov. 4 Wed. Feb. 17 Thurs. May 12 Wed. Nov. 11 Tues. Feb. 23 Tues. May 17 Sat. Nov. 14 Wed. March 2 Wed. May 25 Thurs.Nov.19 Sat. March 5 Wed. June 1 Tues. Nov. 24 Please indicate any specific schedule requests

3 Minnetonka Early Childhood Screening CHILD HEALTH AND DEVELOPMENTAL HISTORY (3-5 YEARS) Date Screening Completed Person Completing Child s Legal Name Parent/Guardian Name Male Female Birth Date Age ( For office use only) Child/student MARSS ID or Record # Phone Address City Zip Who lives with your child? Language(s) spoken in the home? How often does your child see a doctor or nurse (# of visits/year)? Has your child been seen by a dentist? Yes No Has your child had a comprehensive vision exam by an ophthalmologist or optometrist? Yes, When? No Do you have health insurance? Yes No Please list any questions or concerns you have about your child: Please check the boxes if you or your child use: Child and Teen Checkups Follow-Along Program Early Childhood Family Education ( ECFE) Head Start WIC School Readiness Parenting Education Food Shelf Please check the box(es) if you have questions or concerns about your child s: health learning behavior talking growth skin/bruising, rashes eyes/vision ears/hearing nose throat teeth mouth stomach toileting activity level walking/balance social (friends) feelings/moods breathing/coughing headaches general appearance other HEALTH Please check all boxes that apply to your child and explain: allergies to foods and/or medicines takes medicines, herbs, and or vitamins visits to health specialists serious illnesses serious injuries or loss of consciousness hospital stays and/or surgeries problems during mother s pregnancy or birth at birth, stayed in the hospital longer than mother Members of the same family sometimes have the same health problems. Please list family health problems: Is it possible that before you knew you were pregnant you: drank alcohol smoked cigarettes took prescription medication (list) used street drugs were exposed to toxic chemicals (e.g. lead, mercury, PCBs, dioxin fertilizers/pesticides) If you drank alcohol, took drugs or were exposed to chemicals/toxins when was it? 1 st trimester 2 nd trimester 3 rd trimester while breastfeeding does not apply

4 EATING HABITS Please check all boxes that describe your child: drinks from a cup drinks from a bottle on a special diet Every day, eats some foods from these food groups: fruits oranges, apples, bananas, mangos, tomatoes milk, cheese, yogurt, tofu meat, fish, poultry, peanut butter, beans, legumes, eggs vegetables spinach, corn, peas, potatoes, bread, cereal, rice, tortillas, crackers, pasta cookies, cakes, candy, pie, butter, fried foods Every day, drinks: milk juice fruit drinks formula Kool-Aid water pop HOME Please check all boxes that describe your child: Does your child live or play in a home or building built before: and is being remodeled Does anyone in your home or who cares for your child: use tobacco use alcohol have a gun Is your child exposed to: violence street drugs unsafe conditions Do you need information about: adult education programs phone numbers bike helmet/safety poisoning carbon monoxide detector protective sports gear child care recreation child rearing/discipline seat belts/car seats child development severe weather plans crying sleeping resources emergency/hotline smoke detectors family relations storing cleaning supplies/meds fire escape plans stranger safety gun safety teaching your child kindergarten toilet training/strategies lead poisoning toy/playground safety nutrition/picky eaters TV watching parenting/parenting groups Other: LEARNING Please check all boxes that describe your child: says numbers from 1 to 10 stutters, stammers has trouble being understood understands other people points to or names the bigger of two objects understand one, gives you just one when asked knows how many fingers are on each hand compares things, for example, says this one is bigger, heavier counts three or more objects copies a circle or other shapes tells when one object is longer or shorter prints first name or part of it seems clumsy when using hands seems clumsy; stumbles, falls, walks poorly seldom plays with other children clings or gets very upset when leaving you seems overly friendly seems timid, fearful, or worries a lot acts much younger than age seems unhappy, cries, whines has trouble paying attention seems overly aggressive has trouble sitting still plays in a variety of ways

5 Minnetonka Early Childhood Screening Parent Consent Childs Name Birth Date / / Parent(s) Name Early Childhood Screening includes: Review of your child s immunization record Review of any other factors that might interfere with your child s health, growth, development or learning Check of your child s height and weight Your report on your child s growth and learning Tests for possible hearing problems Information about community resources and programs Tests for vision and eye health based on your child s or family s needs Check of your child s development Information about your child s health care and insurance This screening does not replace on-going care from your health care provider or dentist. Child and Parent Rights, Obligations and Assurances 1. The standards for screening are the same for every child regardless of race, income, creed, sex, national origin, or political beliefs. 2. Screening is required for your child s entry into the public school kindergarten or first grade. This requirement is met if your child has participated in a screening through Head Start, child and teen checkups, or equivalent screening through another provider within the past year. The screening summary results must be given to your child s school district. 3. Screening is not required if you are a conscientious objector to screening. 4. You have the right to refuse any of this screening for your child and still receive any of the other screening parts. 5. You have the right to refuse referral for assessment, diagnosis, and possible treatment for your child. 6. Your child s medical assistance eligibility or eligibility in any other health, education, or social service programs will not be affected if you refuse this screening or any parts of this screening. I give permission for Early Childhood Screening for (child s name) Complete screening as described above Screening described above except: Parent/Guardian Signature Date / / Relationship to child: Consent to Release Information Minnetonka Schools uses information from Early Childhood Screening to identify any possible problems that might interfere with your child s health, growth, development or learning. Under Minnesota law screening results are classified as private data. The results cannot be released or discussed with anyone without your consent. If you refuse to release this information, it will not affect your child s eligibility for medical assistance or any other health, education or social service program. Information may be used for the following purposes: 1. To obtain follow-up services for your child after the screening. 2. To arrange for further evaluation or assessment of your child s health, growth, development or learning. 3. To fulfill the requirements for your child s entrance into public school. 4. To evaluate screening programs by the Minnesota Department of Health, Minnesota Department of Education and/or the Department of Human Services. Your child s name will not be identified in any evaluation results. I hereby authorize release of my child s screening information to the following checked programs or services for the purpose of evaluation, assessment, diagnosis, treatment, follow-up, and/or programming. Early Childhood Family Education (ECFE)/Early Childhood Special Education (ECSE)/School Readiness School district Parent/Guardian Signature Date / / Relationship to child

6 Must be on file before a child attends any early childhood programs* Name Birthdate Date of Enrollment Minnesota law requires children enrolled in early education programs to be immunized against certain diseases or file a legal medical or conscientious exemption. Parent/Guardian: You may attach a copy of the child s immunization history to Type of Vaccine Early Childhood Immunization Form DO NOT USE () or () *Early childhood programs are defined as programs that provide instructional or other services to support children s learning and development and: Serve children from birth to kindergarten. Meet at least once a week for at least six weeks or more during the year. This includes but not limited to early childhood family education (ECFE), early childhood special education (ECSE), school readiness programs, and other public and private preschool and pre-kindergarten programs. this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received. Enter MED to indicate vaccines that are medically contraindicated including a history of disease, or laboratory evidence of immunity and CO for vaccines that are contrary to parent or guardian s conscientiously held beliefs. Sign or obtain appropriate signatures on reverse. Complete section 1A or 1B to certify immunization status and section 2A to document medical exemptions (including a history of varicella disease) and 2B to document a conscientious exemption. Additionally, if a parent or guardian would like to give permission to the early education program to share their child s immunization record with Minnesota s immunization information system, they may sign section 3 (optional). For updated copies of your child s immunization history, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at or st Dose 2nd Dose 3rd Dose 4th Dose 5th Dose Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please write the date in the shaded box.) Diphtheria, Tetanus, and Pertussis (DTaP, DTP) 3 doses during 1st year (at 2-month intervals) 4 th dose at months 5 th dose at 4-6 years Indicate vaccine type: DTaP or DTP Polio (IPV, OPV) 2 doses in the first year 3 rd dose by 18 months 4 th dose at 4-6 years Measles, Mumps, and Rubella (MMR) Required for children 15 months and older 1 st dose on or after 1 st birthday 2 nd dose at 4-6 years Haemophilus influenzae type b (Hib) 2-3 doses in the first year 1 dose required after 12 months or older For unvaccinated children months, 1 dose is required Not required for children 5 years or older Varicella (chickenpox) Required for children 15 months and older 1 st dose on or after 1 st birthday 2 nd dose at 4-6 years Pneumococcal Conjugate Vaccine (PCV) Required for children age 2-24 months 3 doses in the first year 4 th dose after 12 months At least 1 dose is recommended for children age months in child care Hepatitis B (hep B) 2-3 doses in the first year 3rd dose (final dose) by 18 months Hepatitis A (hep A) 2 doses separated by 6 months for children 12 months and older Recommended Rotavirus (2-3 doses between 2 and 6 months) Influenza (annually for children 6 months or older) 4th dose not required if 3rd dose was given on or after the 4th birthday 5th dose not required if 4th dose was given on or after the 4th birthday Developed by the Minnesota Department of Health - Immunization Program (12/13)

7 Name Instructions, please complete: Box 1 to certify the child s immunization status Box 2 to file an exemption (medical or concientious) Box 3 to provide consent to share immunization information (optional) 1. Certify Immunization Status. Complete A or B to indicate child s immunization status. A. Children who are 15 months or older: For children who are 15 months or older and who have received all the immunizations required by law for early childhood programs: I certify that the above-named child is at least 15 months of age and has completed the immunizations which are required by law for child care. B. Children who are younger than 15 months: For children who are younger than 15 months OR have not received all required immunizations: I certify that the above-named child has received the immunizations indicated. In order to remain enrolled this child must receive all required vaccines within 18 months from initial enrollment date. The dates on which the remaining doses are to be given are: Signature of Parent / Guardian OR Physician / Nurse Practitioner / Physician Assistant / Public Clinic Signature of Physician / Nurse Practitioner / Physician Assistant / Public Clinic 2. Exemptions to Immunization Law. Complete A and/or B to indicate type of exemption. A. Medical exemption: No child is required to receive an immunization if they have a medical contraindication, history of disease, or laboratory evidence of immunity. For a child to receive a medical exemption, a physician, nurse practitioner, or physician assistant must sign this statement: I certify the immunization(s) listed below are contraindicated for medical reasons, laboratory evidence of immunity, or that adequate immunity exists due to a history of disease that was laboratory confirmed (for varicella disease see * below). List exempted immunization(s): B. Conscientious exemption: No child is required to have an immunization that is contrary to the conscientiously held beliefs of his/her parent or guardian. However, not following vaccine recommendations may endanger the health or life of the child or others they come in contact with. In a disease outbreak, children who are not vaccinated may be excluded in order to protect them and others. To receive an exemption to vaccination, a parent or legal guardian must complete and sign the following statement and have it notarized: I certify by notarization that it is contrary to my conscientiously held beliefs for my child to receive the following vaccine(s): Signature of physician/nurse practitioner/physician assistant *History of varicella disease only. In the case of varicella disease, it was medically diagnosed or adequately described to me by the parent to indicate past varicella infection in (year) Signature of parent or legal guardian Subscribed and sworn to before me this: day of 20 Signature of physician/nurse practitioner/physician assistant (If disease occured before September 2010, a parent can sign.) Signature of notary (A copy of the notarized statement will be forwarded to the commissioner of health.) 3. Parental/Guardian Consent to Share Immunization Information (optional): Your child s early childhood program is asking your permission to share your child s immunization documentation with MIIC, Minnesota s immunization information system, to help better protect children from disease and allow easier access for you to retrieve your child s immunization record. You are not required to sign this consent; it is voluntary. In addition, all the information you provide is legally classified as private data and can only be released to those legally authorized to receive it under Minnesota law. I agree to allow early childhood program personnel to share my child s immunization documentation with Minnesota s immunization information system: Signature of parent or legal guardian Date Developed by the Minnesota Department of Health - Immunization Program (12/13)