Appendix THSteps Forms E - TMHP · WIC-42 24-Hour Dietary Recall and Assessment for Infants - Birth...

A p p e n d i x

E
ETHSteps Forms
E.1 Claim Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-3

E.2 Child Health Clinical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-3

E.3 Child Health History (2 Pages). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-4

E.4 Child Health Record (Birth–1 Month) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-6

E.5 Child Health Record (2–6 Months) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-8

E.6 Child Health Record (7–12 Months) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-10

E.7 Child Health Record (13 Months–2 Years) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . E-12

E.8 Child Health Record (3–5 Years) (2 Pages). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-14

E.9 Child Health Record (6-10 Years) (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-16

E.10 24-Hour Dietary Recall, Assessment for Infants (Birth–11 Months) (2 Pages) . . . . . . E-18

E.11 24-Hour Dietary Recall and Assessment for Children (1–4 Years) (2 Pages) . . . . . . . E-20

E.12 24-Hour Dietary Recall and Assessment for Children (5–9 Years) (2 Pages) . . . . . . . E-22

E.13 24-Hour Dietary Recall and Assessment for Children (10–20 Years) (2 Pages) . . . . . E-24

E.14 Hearing Checklist for Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-26

E.15 Mental Health Interview Tool/Referral Form (Ages 0–2 Years) . . . . . . . . . . . . . . . . . E-27

E.16 Mental Health Interview Tool/Referral Form (Ages 0–2 Years) (Spanish) . . . . . . . . . . E-28

E.17 Mental Health Interview Tool/Referral Form (Ages 3-9 Years). . . . . . . . . . . . . . . . . . E-29

E.18 Mental Health Interview Tool/Referral Form (Ages 3–9 Years) (Spanish) . . . . . . . . . . E-30

E.19 Mental Health Interview Tool/Referral Form (Ages 10–12 Years) . . . . . . . . . . . . . . . E-31

E.20 Mental Health Interview Tool/Referral Form (Ages 10–12 Years) (Spanish) . . . . . . . . E-32

E.21 Mental Health Interview Tool/Referral Form (Ages 13–20 Years) . . . . . . . . . . . . . . . E-33

E.22 Mental Health Interview Tool/Referral Form (Ages 13–20 Years) (Spanish) . . . . . . . . E-34

E.23 Mental Health Parent Questionnaire (Ages Birth–2 Years) (2 Pages). . . . . . . . . . . . . E-35

E.24 Mental Health Questionnaire (Ages Birth–2 Years) (2 Pages) (Spanish) . . . . . . . . . . E-37

E.25 Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) . . . . . . . . . . . . . . . E-39

E.26 Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) (Spanish). . . . . . . . E-41

E.27 Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) . . . . . . . . . . . . . E-43

E.28 Mental Health Parent Questionnaire (Ages 10–12 Years) (2 Pages) (Spanish). . . . . . E-45

E.29 Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) . . . . . . . . . . . . . E-47

E.30 Mental Health Parent Questionnaire (Ages 13–20 Years) (2 Pages) (Spanish). . . . . . E-49

E.31 Recommended Childhood Immunization Schedule, 2004 . . . . . . . . . . . . . . . . . . . . E-51

E.32 Screening Schedule for High-Blood Leads. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-53

E.33 THSteps Primary Parent Risk Assessment for Lead Exposure Questionnaire . . . . . . . E-54

E.34 THSteps Primary Parent Risk Assessment for Lead Exposure Questionnaire (2 Pages) (Spanish) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-55

E.35 Abbreviated Parent Questionnaire: Risk Assessment for Lead Exposure . . . . . . . . . . E-57

E.36 Abbreviated Parent Questionnaire: Risk Assessment for Lead Exposure (Spanish) . . E-58

E.37 San Antonio State Chest Hospital Cervical Cancer Cytology Laboratory. . . . . . . . . . . E-59

E.38 Specimen Submission Form G-1A Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-61

E.39 Specimen Submission Form G-1A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-64

E.40 Specimen Submission Form G-1B Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-65

E.41 Specimen Submission Form G-1B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-68

E.42 Guidelines: Tuberculosis Skin Testing (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . E-69

E–2

Appendix E

E.43 Tuberculosis (TB) Screening and Education Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . E-71

E.44 TB Questionnaire. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-72

E.45 Cuestionario Para la Detección de Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . E-73

E.46 How to Determine TB Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-74

E.47 TVFC Patient Eligibility Screening Record (2 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . E-75

E.48 TVFC Provider Enrollment (3 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-77

E.49 TVFC Questions and Answers (3 Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-80

THSteps Forms

E

E.1 Claim FormsProviders must order HCFA-1500, HCFA-1450 (UB-92), and ADA Dental Claims Forms from the vendor of their choice. Copies cannot be used. Claims filing instructions and examples of the claim forms are located in Chapter 4, Claims Filing.

Refer to: “HCFA-1500 Claim Filing Instructions” on page 4-20

“HCFA-1500 Blank Claim Form” on page 4-22

“HCFA-1450 (UB-92) Claim Filing Instructions” on page 4-28

“HCFA-1450 (UB-92) Blank Claim Form” on page 4-29

“2002 ADA Dental Claim Filing Instructions” on page 4-38

“2002 ADA Dental Claim Form” on page 4-39

E.2 Child Health Clinical RecordsThe use of forms ECH 1-7, WIC 42, and ECH 13-15 is optional. These forms were developed to assist providers in documenting all components of the medical checkup and can be downloaded from the THSteps website at www.thstepsproducts.com/forms/ths_forms.htm. Lead poisoning screening questionnaires can be downloaded from the Childhood Lead Poisoning Prevention Program website at www.tdh.state.tx.us/lead/providers.htm. Tuberculosis screening questionnaires can be downloaded from the Tuberculosis Elimination Division website, www.tdh.state.tx.us/tb/tbforms.htm. These forms are also available within this chapter.

Forms CH-9W through CH-12W are only available by calling THSteps at 1-512-458-7745.

The Adolescent Health Program developed a series of health forms to assist healthcare providers in providing quality and comprehensive services for teens: Characteristic Behaviors of Adolescence, Adolescent Development Table, and Tips for Interviewing Adolescents. These forms are available on the Adolescent Health Program website at www.tdh.state.tx.us/adolescent/provider.htm, or call 1-512-458-7745 for copies.

Stock Number Form

ECH-1 Child Health History

ECH-2 Preventive Health Visit - Birth to 1 Month

ECH-3 Preventive Health Visit - 2–6 Months

ECH-4 Preventive Health Visit - 7–12 Months

ECH-5 Preventive Health Visit - 13 Months to 2 Years

ECH-6 Preventive Health Visit - 3–5 Years

ECH-7 Preventive Health Visit - 6–10 Years

CH-9W Growth Chart - Infant Girl

CH-10W Growth Chart - Infant Boy

CH-11W Growth Chart - Child Girl

CH-12W Growth Chart - Child Boy

WIC-42 24-Hour Dietary Recall and Assessment for Infants - Birth Through 11 Months

ECH-13 24-Hour Dietary Recall and Assessment for Children - 1 Through 4 Years

ECH-14 24-Hour Dietary Recall and Assessment for Children - 5 Through 9 Years

ECH-15 24-Hour Dietary Recall and Assessment for Teens - 10 Through 20 Years (Nonpregnant Teens)

Texas Health Steps Primary Parent Questionnaire Risk Assessment for Lead Exposure

Texas Health Steps Abbreviated Parent Questionnaire Risk Assessment for Lead Exposure

TB Questionnaire

E–3

Appendix E

E.3 Child Health History (2 Pages)

E–4

THSteps Forms

E

E–5

Appendix E

E.4 Child Health Record (Birth–1 Month) (2 Pages)

E–6

THSteps Forms

E

E–7

Appendix E

E.5 Child Health Record (2–6 Months) (2 Pages)

E–8

THSteps Forms

E

E–9

Appendix E

E.6 Child Health Record (7–12 Months) (2 Pages)

E–10

THSteps Forms

E

E–11

Appendix E

E.7 Child Health Record (13 Months–2 Years) (2 Pages)

E–12

THSteps Forms

E

E–13

Appendix E

E.8 Child Health Record (3–5 Years) (2 Pages)

E–14

THSteps Forms

E

E–15

Appendix E

E.9 Child Health Record (6-10 Years) (2 Pages)

E–16

THSteps Forms

E

E–17

Appendix E

E.10 24-Hour Dietary Recall, Assessment for Infants (Birth–11 Months) (2 Pages)

Texas Department of Health WIC-42 Rev. 5/24/99

Name_______________________________________ Date___________________

Diet History (Provide all answers except in shaded areas) Name:_________________________________Dietary Recall and Assessment for InfantsBIRTH through 11 MONTHS DOB:_____________________ Age:_________Assessment Questions For Infants Risk Conditions Defined CodeAll Infants:Is your infant following therapeutic diet/special feeding instructions?

Yes_ No_ Developmental, Sensory or Motor Delays Interfering with the Ability to Eat

362

Describe:______________________________________________Does your infant have any developmental feeding problems?

Yes_ No_ Disabilities that restrict the ability to chew or swallow food or require tube feeding to meet nutritional needs

Describe______________________________________________Breast-fed Infant (Total or Partial): Infrequent Breastfeeding as Sole Source of Nutrients: 418How many feedings in past 24 hours ____________Length _______ Totally breastfed (no formula/solids)

•younger than 2 mos. - less than 8 feedings in 24 hrs•2 months or older - less than 6 feedings in 24 hoursBreastfeeding/Potential Complications: 603

Problems with breastfeeding? _______________________________ •jaundice, weak/ineffective suck, latching difficultiesHow many wet diapers per day? _____________________________ •less than 6 wet diapers per dayFormula-Fed Infant: Feeding Cow’s Milk 413Brand/type of formula or milk: ________________________________ __ Powder __ Concentrated __ Ready-to-Use Inappropriate Infant Feeding: 411

•feeding goat/sheep, imitation, or substitute milksIs formula iron fortified? Yes_ No_ •formula feeding onlyIf NO, is your infant taking iron drops? Yes_ No_ •0-6 months - feeding low iron formula w/o iron supp.How is the formula diluted and mixed?__________________________ Improper Dilution of Formula 415Is anything added to the formula besides water? Yes_ No_ Adding honey

Adding corn syrup, sugar...411416

Bottle-Fed Infant, Breastmilk and/or Formula: Inappropriate Infant Feeding 411Number of bottles made at one time ___________________________ Inadequate Amount, Nonbreastfed Only:Amount of breastmilk/formula in each bottle ____________________ •0-3 months - less than 20 oz. in 24 hoursAmount of breastmilk/formula consumed at each feeding__________ •4-5 months - less than 26 oz. in 24 hoursNumber of bottles consumed in 24 hours________________________ •6-11 months - less than 24 oz. in 24 hoursTotal amount of breastmilk/formula consumed in 24 hours________ Excessive amount, Nonbreastfed Only:How long does one can of formula last?________________________ •0-4 months - more than 40 oz. in 24 hours

•5-9 months - more than 36 oz. in 24 hours•10-11 months - more than 32 oz. in 24 hoursLack of Sanitation in Preparation or Handling 417

Is water boiled before it is mixed with formula?

What is done with leftover breastmilk/formula in the bottle?________How are bottles/equipment cleaned?___________________________How are bottles of breastmilk/formula stored?__________________

Yes_ No_ Younger than 3 months and water not boiled

unsafe waterno stovefeeding formula that has been at room temperature longer than 2 hours, stored in refrigerator longer than 48 hours, or left from another feeding

Do you...put the baby to bed with a bottle?prop the bottle?

let the baby crawl or walk around with the bottle or use the bottle to pacify the baby?use the bottle to feed liquids other than breastmilk/formula/water?

Yes_ No_Yes_ No_

Yes_ No_

Yes_ No_

Inappropriate Use of Nursing Bottlesyes to any

419

All Infants:Have any foods/beverages other than formula/breastmilk been introduced?___If yes, during what month?____________________________________________Continue to the next section on the other side.

Early Introduction of Solid Foods 412•solids introduced before 4 months

Inappropriate Infant Feeding 411•no solids introduced by 7 months

No Dependable Source of Iron After 6 Monthsno iron-fortified formula, iron-fortified cereals, meats, or oral iron supplements

414

Recall taken by:_____________________________________________________________ Date:__________________Recall assessed by:___________________________________________________________

E–18

THSteps Forms

E

WIC Health History for Infants

What foods/beverages, other than breastmilk or formula, have you given the baby in the last 24 hours? (List amounts.)

No Dependable Source of Iron After 6 Months 414

•no iron-fortified formula, iron-fortified cereals, meats, or oral iron supplements

Vegan Diets 402•no animal or dairy products

Highly Restrictive Diets 403•very low in calories, severely limits intake or important food sources of nutrients, restricts timing or combination of foods, or other high-risk patterns

Inappropriate Infant Feeding 411Is your baby finger feeding or eating finger foods?...Yes ___ No ___ •7-9 months -- infant not beginning to finger feed

•fed or feeding foods that could cause choking

Inappropriate Infant Feeding 411How are solid foods being fed to baby?________________________ •feeding solids in the bottle or infant feeder

•use a syringe-type feeder•not using a spoon for solids

Do you... Feeding Foods Low in Essential Nutrients 416give water? Yes___ No___ how much?____________ •more than four oz. of water per daygive tea or coffee?............................................. Yes___ No___ •any amount of tea, coffee, cola, or caffeine-containing

foodsgive colas or other sweetened beverages?...... Yes___ No___ •any sweetened beverages or high-calorie foodsgive other high calorie non-nutritious foods? (corn syrup, sugar, or salt)............................. Yes___ No___

Inappropriate Infant Feedinggive honey?........................................................ Yes___ No___ •give honey 411

Please answer the following questions: Comments (For Staff Use Only) NV CodeWas your infant born with any medical problems? Yes__ No__Has your infant ever had any health problems? Yes__ No__has your infant been the hospital (other than when born) or emergency room? Yes__ No__Is infant on a special diet for medical reasons? Yes__ No__Are there any foods that you limit, avoid, or do not give your infant for any reason? Yes__ No__Is your infant taking any medications? Yes__ No__ 357Has your infant had:surgery? Yes__ No__ 359

burns? Yes__ No__serious injury? Yes__ No__

Do you give your infant: herbal medicine? Yes__ No__ (Inappropriate or Excessive) 423vitamins/minerals? Yes__ No__ (Fluoride, Iron) 424herbal tea? Yes__ No__

Do you have: a working stove? Yes__ No__a working refrigerator? Yes__ No__running water? Yes__ No__

Are you afraid that someone you know may injure or harm your infant? Yes__ No__

National Domestic Violence Hotline, 1-800-799-7233

901

Where does your infant get health care; how long since last visit?Doctor:_________________________________

__ 1-3 months?Shots:_______________________________ __ 4-6 months?

__ 7-9 months?Clinic__________________________________ __ 10-12 months?

E–19

Appendix E

E.11 24-Hour Dietary Recall and Assessment for Children (1–4 Years) (2 Pages)

E–20

THSteps Forms

E

E–21

Appendix E


E–22

THSteps Forms

E

E–23

Appendix E


E–24

THSteps Forms

E

E–25

Appendix E

E.14 Hearing Checklist for Parents

Lista De Cotejo Para Padres

Marque si ó no para describir la condición de su hijo(a)

Age 0 to 3 Yrs Yes No

0 to 3 months ____ ____ Does your baby get quiet for a moment when you talk to him/her?

____ ____ Does your baby act startled or stop moving for a moment when there are sudden loud noises?

4 to 6 months ____ ____ Does your baby turn his/her eyes or head to the sound of your voice if he/she cannot see you?

____ ____ Does your baby smile or stop crying when you or someone else he/she knows speaks?

7 to 9 months ____ ____ Does your baby stop and pay attention when you say “no” or call his/her name?

____ ____ Does your baby move his/her head around to try to find out where a new sound is coming from?

____ ____ Does your baby make strings of sounds (“ba ba ba, da da da”)?

10 to 15 months ____ ____ Does your baby give you toys or other objects (bottle) when you ask, without your having to use a gesture (holding out your hand or pointing)?

____ ____ Does your baby point to familiar objects if you ask (“dog,” “light”)?

16 to 24 months ____ ____ Does your child use his/her voice most of the time to get what he/she wants or to commu-nicate with you?

____ ____ Can your child go get familiar objects that are kept in a regular place if you ask him/her (“Get your shoes.”)?

25 to 36 months ____ ____ Does your child answer different kinds of questions (“When...,” “Who...,” “What...”)?

____ ____ Does your child notice different sounds (telephone ringing, shouting, doorbell)?

If you answered “no” to any of the above questions, ask your doctor about a hearing test for your baby. Babies can be tested as soon as the day of birth.

Age 0 to 3 Yrs Yes No

0 to 3 meses ____ ____ ¿Se pone calladito por unos instantes cuando le platica?

____ ____ ¿Parece asustárce o se para de mover por unos instantes cuando se hacen ruidos fuertes de repente?

4 to 6 meses ____ ____ ¿Cambia o voltea la cabeza al sonido de su voz si no puedo veria?

7 to 9 meses ____ ____ ¿Se detiene y pone atención cuando usted le dice que ‘no’ o llama su nombre?

____ ____ ¿Voltea la cabeza para diferentes lados para tratar de averiguar de dónde viene el sonido cuando oye un sonido nuevo?

____ ____ ¿Platica series de sonidos (como “bababa,” “dadada”)?

10 to 15 meses ____ ____ ¿Le da jugetes o otros objetos (como la mamila) cuando usted se los pide sin que usted tenga que usar un gesto (alargando la mano, o señalando)?

____ ____ ¿Señala objetos familiares (“perro,” “luz”) si usted le pregunta?

16 to 24 meses ____ ____ ¿Usa su voz la mayor parte del tiempo para avisarte de lo quiere o para comunicarse con usted?

____ ____ ¿Puede taer objetos familiares que son guardados en lugar habitual (“trae tus zapatos”) si usted se los pide?

25 to 36 meses ____ ____ ¿Puede contestar diferentes tipos de preguntas (“cuándo...,” “quién...,” “qué”)?

____ ____ ¿Se fija en diferentes sonidos (teléfono, gritos, timbre de la puerta)?

Si usted tiene alguna pregunta o inquietud acerca de la audición de su hijo(a) o si usted contestó ‘no’ a cualquier pregunta, informese con su doctor acerca de un exámen de audición para su bebé. Los bebés pueden ser examinados de la audición desde el dia de su nacimiento.

E–26

THSteps Forms

E

E.15 Mental Health Interview Tool/Referral Form (Ages 0–2 Years)

Mental Health Interview Tool/Referral Form Child’s Name: ____________________________

Birth Date: _______________________________

Ages 0 to 2 Date: ____________________________________

For this age group you will obtain information from the parent/caregiver and from your own observations of the child. Circle items of concern. * The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation.

Other: Are there any situations which are causing your family particular stress at this time?Has this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse?If yes, what form, when, treatment initiated, etc.?Did the mother of this child use drugs or drink alcohol during the pregnancy?

Comments:

Signature/Title: _______________________________________________________________________________________

Feelings: Does your child display feelings that concern you or seem out of the ordinary?

Infants 1 to 2 Years

❏ Anxious ❏ Irritable ❏ Sullen

❏ Cries excessively ❏ Angry ❏ Anxious

❏ Cries too little ❏ Sad ❏ Cries excessively

❏ Fearful ❏ Cries too little

Behavior: Does your child display behavior that concerns you or seems out of the ordinary for his/her age?


❏ Overactive ❏ Overactive

❏ Listlessness ❏ Listlessness

❏ Harms others

❏ Frequent temper tantrums

Social Interaction: Do you have concerns about how your child gets along with you? Other family members or adults? Siblings?


❏ No eye contact or smile ❏ * No eye contact or smile

❏ Stiffens and arches ❏ Clings excessively

❏ Not responsive ❏ Not responsive

❏ Language delay

Thinking: Do you think your child’s development is normal for age?

Infants (> 8 months) 1 to 2 Year

❏ No communication skills (pointing to request an object) or efforts to make words

❏ Mistrustful

❏ Problems concentrating or paying attention

Physical Problems: Do you have any concerns about your child’s physical health? If physical problems exist, have they been medically evaluated?

Infants to 2 Years

❏ Low weight or weight loss

❏ Frequent vomiting

❏ Eating problem (poor appetite, eats nonfoods)

❏ Sleeping problem (frequent night waking)

❏ Lethargic

E–27

Appendix E

E.16 Mental Health Interview Tool/Referral Form (Ages 0–2 Years) (Spanish)

Comentarios:

Firma/Titulo de su puesto:___________________________________________________________________TDH/OLS/6-395/10-96

Instrumento para la Evaluación de la Salud Mental y Formulario para Trata-miento con un Especialista

Nombre del Niño:_________________________Fecha de Nacimiento: _____________________Fecha: _________________________________

De Recién Nacido a 2 Años de Edad

Para los niños que pertenecen a este grupo usted obtendrá información de los padres/personas encargadas y de sus propias obser-vaciones del bebé. Marque las características que le preocupen. *La presencia de alguno de estos síntomas o comportamientos puede indicar que el niño está en una crisis, y se debe haces un esfuerzo para asegurar que se le evalúe pronto.

Sentimientos: ¿Muestra su niño sentimientos que le preocupan o que parezcan extraños?

Recién Nacidos De 1 a 2 Años❏ Ansioso ❏ Se irrita ❏ Malhumorado❏ Llora demasiado ❏ Se enoja ❏ Ansioso❏ Llora muy poco ❏ Está triste ❏ Llora demasiado

❏ Tiene miedo ❏ Llora muy poco

Comportamientos: ¿Muestra su Recién Nacidos De 1 a 2 Añosniño un compartamiento que le ❏ Es demasiado activo ❏ Es demasiado activopreocupa o que parezca extraño ❏ Es indiferente ❏ Es indiferentepara su edad? ❏ Lastima a los demás

❏ Hace berrinches temperamentales frecuentemente

Interacciones Sociales: ¿Se Recién Nacidos De 1 a 2 Añospreocupa sobre cómo se lleva su ❏ No ve a los ojos ni sonríe ❏ *No ve a los ojos ni sonríeniño con usted? ¿Con otros ❏ Se pone tieso y se dobla ❏ Se pega a usted excesivamentemiembros de la familia o adultos? arqueando la espalada ❏ No muestra mucho interés¿Con sus hermanos? ❏ No muestra mucho interés ❏ Está atrasado en el lenguaje

Pensamientos: ¿Cree usted que el desarrollo de su niño es normal para su edad?

Recién Nacidos (>8 meses) De 1 a 2 Años❏ No tiene habilidad para comuni-

carse (apunta para pedir un objeto) ni se esfuerza para decir palabras

❏ No tiene confianza❏ Tiene problemas para concentrarse o para

poneratención

Problemas Físicos: ¿Se preocupa sobre la salud física de su niño? Si existen problemas físicos, ¿han sido evaluados médicamente?

Recién Nacidos a 2 Años❏ Peso bajo o pérdida de peso❏ Se vomita frecuentemente❏ Tiene problemas para comer (poco apetito, come alimentos que no son saludables)❏ Tiene problemas para dormir (se despierta frecuentemente por las noches)❏ Es letárgico

Otra: ¿Hay alguna situación que le esté causando a su familia cierta tensión ahora?¿Ha sido este niño o sus padres sujetos a la negligencia, o al abuso físico, sexual o emocional?Si contesta sí, ¿de qué manera?, ¿cuándo?, ¿se ha comenzado algún tratamiento?, etc.¿Usó la mamá de este niño drogas o tomó bebidas alcohólicas durante su embarazo?

E–28

THSteps Forms

E

E.17 Mental Health Interview Tool/Referral Form (Ages 3-9 Years)

Mental Health Interview Tool/Referral Form Child’s Name: ____________________________Birth Date: _______________________________

Ages 3 to 9 Date: _____________________________________

For this age group you will obtain information from the parent/caregiver and from your own observations of the child’s behavior. If possible, interview the parent alone when asking questions about sexual or physical abuse. Circle items of concern. * The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation.

Comments:

Signature/Title: _____________________________________________________________________________

Feelings: Behavior:

Does your child display feelings that concern you or seem out of the ordinary for age?

Does your child frequently display behavior that seems out of the ordinary for age?

❏ Restless ❏ Problems in school

❏ Sad or cries easily ❏ * Harms other children or animals

❏ Excessively guilty ❏ Lacks interest in things s/he used to enjoy

❏ Lack of remorse ❏ Engages in sexual play with others, toys, animals

❏ Irritable, angers or temper tantrums easily ❏ * Destroys possessions or other property

❏ Sullen ❏ Steals

❏ Fearful or anxious ❏ Refuses to talk

❏ * Sets fires

❏ Overactive

❏ * Self-destructive

❏ * Has been in trouble with the police (older child)

Social Interaction: Thinking:

Do you have concerns about how child gets along with you, other family members, playmates, other adults?

Have you noticed any of the following to be a problem for your child?

❏ Withdraws including no eye contact ❏ * Frequently confused

❏ Clings excessively ❏ Daydreams excessively

❏ Difficulty making and keeping friends ❏ Distracted, doesn’t pay attention

❏ Defiant, a discipline problem ❏ * Bizarre thoughts

❏ Severe or frequent tantrums ❏ Mistrustful

❏ Aggressive ❏ * Sees or hears things that are not there (excluding imaginary friends in younger children)

❏ Argues excessively ❏ Blames others for his/her misdeeds or thoughts

❏ Refuses to go to school ❏ * Talks about death

❏ Prefers to be alone ❏ * Frequent memory loss

❏ Schoolwork is slipping (grades going down)

Physical Problems: Other:

Do you have any concerns about the following physical signs? Has this been evaluated?

Is this child accident-prone? Are there any situations that are causing your family particular stress? Has this child or his/her parents been subject to neglect, physical, sexual or emotional abuse? If yes, what type, when, treatment, etc.* Is this child at risk for out-of-home placement because of behavior problems?

❏ Daytime wetting

❏ Soils pants

❏ Refusal to eat

❏ Headaches

❏ Excessive weight loss or gain

❏ Sleep problems, nightmares, sleep-walking, early waking

❏ Vomits frequently

❏ Frequent stomachaches

❏ Lacks energy

E–29

Appendix E


Comentarios:

Firma/Titulo de su puesto:____________________________________________________________________TDH/OLS/6-396/11-96

Instrumento para la Entrevista de la Salud Mental y Nombre del Niño:________________________Formulario para Tratamiento con un Especialista Fecha de Nacimiento: ____________________

De 3 a 9 Años de Edad Fecha: _________________________________Para los niños que pertenecen a este grupo usted obtendrá informatción de los padres/tudor y de sus propias observaciones del comportamiento del niño. Si es posible, entreviste a los padres solos cuando haga preguntas sobre el abuso sexual o físico. Marque las características que le preocupen. *La presencia de alguno de estos síntomas o comportamientos pueden indicar que el niño está pasando por una crisis, y se debe hacer un esfuerzo para asegurar que se le evalúe pronto.Sentimientos: Comportamiento:¿Muestra su niño sentimientos que le preocupan o ¿Muestra su niño frecuentemente un comportamiento que le parezcaque parezcan extraños para su edad? extraño para su edad?

❏ Es inquieto ❏ Problemas en la escuela

❏ Está triste o llora fácilmente ❏ *Lastima a otros niños o a animales

❏ Muestra mucha culpabilidad ❏ No tien interés en cosas que antes disfrutaba

❏ No tiene remordimiento ❏ Participa en juegos sexuales con juguetes, animales, o con los demás

❏ Se irrita, enoja, o hace berrinches temperamentales ❏ *Destruye cosas personales o ajenas

fácilmente ❏ Roba

❏ Es malhumorado ❏ Se niega a hablar

❏ Tiene miedo o está ansioso ❏ Enciende fuegos

❏ Es demasiado activo

❏ *Tiene un comportamiento de autodestrucción

❏ *Ha tenido problemas con la policía (con otro niño)

Interacción Sociales: Pensamientos:¿Se preocupa sobre cómo se lleva su niño con usted? ¿Ha notado si alguno de los siguientes es un problem para su niño?¿Con otros miembros de la familia? ¿Con otros adultos? ❏ *Se confunde frecuentemente

o ¿Con sus amigos de juego? ❏ Sueña despierto demasiado

❏ Se retira sin dirgir la mirada a los ojos ❏ Se distrae, no pone atención

❏ Se pega a usted excesivamente ❏ *Tiene pensamientos raros

❏ Se le dificulta hacer y mantener amistades ❏ Es desconfiado

❏ Es desafiante, un problema de disciplina ❏ *Mira u oye cosas que no están allí (excepto los amigos) imaginarios en niños más pequeños

❏ Hace berrinches temperamentales fuertes o frecuent-emente

❏ Culpa a otros por algo que hizo mal o por sus pensamientos

❏ Es agresivo ❏ *Habla sobre la muerte

❏ Discute demasiado ❏ *Pierde la memoria frecuentemente

❏ Se niega a ir a la escuela ❏ Se está atrasando en el trabajo de la escuela (sus grados están bajando)

❏ Prefiere estar solo

Problemas Físicos: Otros:¿Le preocupa alguna de las siguientes señales físicas? ¿Han sido estas evaluadas?❏ Se orina durante el día❏ Se ensucia❏ Se niega a comer❏ Tiene dolores de cabeza❏ Pérdida o aumento de peso excesivo❏ Tiene problemas para dormir, pesadillas, sonambulismo, se

despierta temprano❏ Se vomita frecuentemente❏ Tiene dolores de estómago frecuentemente❏ No tiene energía

¿Tiende este niño a tener accidentes? ¿Hay alguna situación que le esté causando a su familia tensión en particular? ¿Ha sido este niño o sus padres sujetos a la negligencia, o al abuso físico, sexual o emocional? Si, sí. ¿En que forma? ¿Cuando? ¿Tipo de tratamiento?, etc. *¿Corre el riesgo su niño de ser llevado a otro lugar fuera de casa por problemas de comportamiento?

E–30

THSteps Forms

E

E.19 Mental Health Interview Tool/Referral Form (Ages 10–12 Years)


Birth Date: _______________________________

Ages 10 to 12 Date: _____________________________________

Both child and parent will be able to provide information, and it is important to incorporate the child into the interview process. In each sec-tion, a sample question is directed toward the parent. To the extent possible, elicit the child’s perception of the parent’s response with a question such as “Do you agree with what your Mom is saying?” It may be useful to allow time for discussion with the caregiver alone. The child should be interviewed alone when asking questions about sexual or physical abuse and about substance abuse. Circle items of concern. * The presence of any of these symptoms or behaviors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation..

Comments:

Signature/Title: _____________________________________________________________________________

Feelings: Behavior:

Does your child (do you) have feelings that concern you or seem out of the ordinary for age?

Does your child (do you) behave in ways that seems out of the ordinary for age?

❏ Restless ❏ Problems in school

❏ Sad or cries easily ❏ * Threatens or harms other children or animals

❏ Guilty ❏ Lacks interest in things s/he used to enjoy

❏ Irritable or angers easily ❏ Engages in sexual play with others, toys, animals

❏ Sullen ❏ * Destroys possessions or other property

❏ Fearful or anxious ❏ Steals

❏ Bored ❏ Refuses to talk

❏ * Sets fires

❏ Overactive

❏ * Has been in trouble with the police


Social Interaction: Thinking:Do you have concerns about how your child (you) gets along with family members, other adults or children?

Have you noticed any of the following to be a problem for your child (you)?

❏ Prefers to be alone ❏ * Frequently confused

❏ Difficulty making and keeping friends ❏ Daydreams excessively

❏ Defiant, a discipline problem ❏ Distracted, doesn’t pay attention

❏ Aggressive ❏ Mistrustful

❏ Argues excessively ❏ * Sees or hears things that are not there

❏ Refuses to go to school ❏ Blames others for his/her misdeeds or thoughts

❏ * Talks about death or suicide

❏ * Frequent memory loss

❏ * Bizarre thoughts


Physical Problems: Other:Do you have any concerns about the following physical signs? Has this been evaluated?

Is this child (are you) accident-prone? Are there any situations that are causing your family particular stress? Has this child or his/her parents been subject to neglect, physical, sexual or emotional abuse? If yes, what type, when, treatment, etc.

❏ Lacks energy

❏ Uses laxatives

❏ Vomits frequently ❏ * Is this child at risk for out-of-home placement because of behavior problems?❏ Food refusal, secretive eating

❏ Frequent stomachaches ❏ Has the child (have you) been treated for mental health problems or substance abuse?❏ Headaches

❏ Excessive weight loss or gain Substance Abuse Questions:❏ Sleep problems, nightmares, sleep-walking, early

waking, frequent night waking(May want to use screens such as the TACE, CAGE, MAST to obtain information concerning substance abuse.)

❏ Has been identified as a problem

E–31

Appendix E


Comentarios:

Firma/Titulo de su puesto:____________________________________________________________________TDH/OLS/6-397/11-96

Instrumento para la Entrevista de la Salud Mental y Nombre del Niño:________________________Formulario para Tratamiento con un Especialista Fecha de Nacimiento: ____________________

De 10 a 12 Años de Edad Fecha: _________________________________Ambos, el niño y los padres podrán proveer información, y es importante incorporar al niño en la entrevista. En cada sección, se le hace una pregunta ejemplar a los padres. Obtenga, lo mejor que pueda, la percepción del niño sobre la respuesta de sus padres con una pregunta como “¿Estás de acuerdo con lo que dice tu mamá?” Sería conveniente dedicar tiempo para hablar solamente con el tutor del niño. Se debe entrevistar al niño solo cuando se hagan preguntas sobre el abuso sexual o físico y sobre el abuso de sustancias como las drogas y las bebidas alcohólicas. Marque las características que le preocupan. *La presencia de alguno de estos síntomas o comportamientos pueden indicar que el niño está pasando por una crisis, y se debe hacer un esfuerzo para asegurar que se le evalúe pronto.Sentimientos: Comportamiento:¿Tiene su niño (tienes) sentimientos que le (te) preocupupan o que parezcan extraños para su (tu) edad?

¿Se (Te) comporta(s) de una manera que parecen extrañas para su (tu) edad?

❏ Problemas en la escuela

❏ Es inquieto ❏ Amenaza o lastima a otros niños o a animales

❏ Está triste o llora fácilmente ❏ No tiene interés en cosas que antes disfrutaba

❏ Se siente culpable ❏ Participa en juegos sexuales con juguetes, animales, o con los demás

❏ Se irrita o enoja fácilmente ❏ *Destruye cosas personales o ajenas

❏ Es malhumorado ❏ Roba

❏ Tien miedo o está ansioso ❏ Se niega a hablar

❏ Se aburre ❏ *Enciende fuegos

❏ Es demasiado activo

❏ *Ha tenido problemas con la policía


Interacción Sociales: Pensamientos:¿Se preocupa(s) sobre cómo se (te) lleva(s) su niño con los ¿Ha(s) notado si alguno de los siguientes es un problem para su niño

(ti)?miembros de la familia? ¿Con otros adultos? ¿O niños? ❏ *Se confunde frecuentemente

❏ Sueña despierto demasiado

❏ Prefiere estar solo ❏ Se distrae, no pone atención

❏ Se le dificulta hacer o tener amistades ❏ Es desconfiado

❏ Es desafiante, un problema de disciplina ❏ *Mira u oye cosas que no están allí

❏ Es agresivo ❏ Culpa a otros por algo que hizo mal o por sus pensamientos

❏ Discute demasiado ❏ *Habla sobre la muerte o el suicidio

❏ Se niega a ir a la escuela ❏ *Pierde la memoria frecuentemente

❏ *Tiene pensamientos raros

❏ Se está atrasando en el trabajo de la escuela (sus grados están bajando)

Problemas Físicos: Otros:¿Le (te) preocupa alguna de las siguientes señales físicas? ¿Han sido estas evaluadas?

¿Es este niño (Eres) propenso a tener accidentes? ¿Hay alguna situación que le esté causando a su (tu) familia tensión en particular? ¿Ha sido este niño (Has sido tu) o sus padres sujetos a la negligencia, o al abuso físico, sexual o emocional? Si, sí, ¿Que tipo?, ¿Cuándo?, ¿Tipo de tratamiento?

❏ No tiene energía ❏ *¿Corre el riesgo su niño de ser llevado a otro lugar fuera de casa por problemas de comportamiento?

❏ Usa laxantes ❏ ¿Ha sido este niño tratado por problemas de salud mental o por el abuso de sustancias como drogas y bebidas alcohólicas?

❏ Se vomita frecuentemente Preguntas Sobre el Abuso de Sustancias:

❏ Se niega a comer, come a escondidas (Tal vez quiera usar pruebas de detección como TACE, CAGE, MAST para obtener información sobre el abuso de sustancias como drogas y bebidas alcóholicas.)

❏ Tiene dolores de estómago frecuentemente ❏ Ha sido identificado como un problema

❏ Tiene dolores de cabeza

❏ Tiene problemas para dormir, pesadillas, sonambu-lismo, se despierta temprano, se despierta seguido por la noche

E–32

THSteps Forms

E

E.21 Mental Health Interview Tool/Referral Form (Ages 13–20 Years)g


Birth Date: _______________________________

Ages 13 to 20 Date: _____________________________________

You may begin with a joint interview or begin with separate interviews with the parent/caregiver and adolescent. It is preferable to interview the adolescent first. Circle items of concern. * The presence of any of these symptoms or behav-iors may signal that the child is in crisis, and efforts should be made to secure prompt evaluation.

Comments:

Signature/Title: ____________________________________________________________________________

Feelings: Behavior:

Do you (does your teen) have feelings that concern you or seem out of the ordinary for (their) age?

Do you (does your child) behave in ways that seems out of the ordinary for your (their) age?

❏ Restless ❏ Problems at school or work

❏ Sad or cries easily ❏ * Threatens or harms other children or animals

❏ Guilty ❏ Lacks interest in things s/he used to enjoy

❏ Irritable or angers easily ❏ Engages in sexual play with others, toys, animals

❏ Sullen ❏ * Destroys possessions or other property

❏ Fearful or anxious ❏ Steals

❏ Bored ❏ Refuses to talk

❏ * Sets fires

❏ Overactive

❏ * Has been in trouble with the police


Social Interaction: Thinking:Do you have concerns about how (you) your child gets along with family members, other adults, or peers?

Have you noticed any of the following to be a problem for you (your child)?

❏ Prefers to be alone ❏ * Frequently confused

❏ Difficulty making and keeping friends ❏ Daydreams excessively

❏ Defiant, a discipline problem ❏ Distracted, doesn’t pay attention

❏ Aggressive ❏ Mistrustful

❏ Argues excessively ❏ * Sees or hears things that are not there

❏ Refuses to go to school ❏ Blames others for his/her misdeeds or thoughts

❏ * Talks about death or suicide

❏ * Frequent memory loss

❏ * Bizarre thoughts


Physical Problems: Other:Do you have any concerns about the following physical signs? Has this been evaluated?

Are you (is this child) accident-prone? Are there any situations that are causing your family particular stress? Have you (has this child) or your (his/her) parents been subject to neglect, physical, sexual or emotional abuse? If yes, what type, when, treatment, etc.

❏ Lacks energy

❏ Uses laxatives

❏ Vomits frequently ❏ * Are you (is this child) at risk for out-of-home placement because of behavior problems?❏ Food refusal, secretive eating

❏ Frequent stomachaches ❏ Have you (has this child) been treated for mental health problems or substance abuse?❏ Headaches

❏ Excessive weight loss or gain Substance Abuse Questions:

❏ Sleep problems, nightmares, sleep-walking, early waking, frequent night waking

(May want to use screens such as the TACE, CAGE, MAST to obtain information concerning substance abuse.)

❏ Has been identified as a problem

E–33

Appendix E


Comentarios:

Firma/Titulo de su puesto:___________________________________________________________________TDH/OLS/6-398/11-96

Instrumento para la Entrevista sobre la Salud Mental/ Nombre del Adolescente:__________________Formulario para Tratamiento con un Especialista Fecha de Nacimiento: ____________________

De 13 a 20 Años Fecha: _________________________________Para los Padres: Usted puede empezar con una entrevista con ambos el tutor y el adolescente. Es preferible que entreviste al adolescente primero. Marque las características que le preocupen. * La presencia de alguno de estos síntomas o comportamientos puede indicar que el adolescente está pasando por una crisis, y se debe hacer un esfuerzo para asegurar que se le evalúe pronto.Sentimientos: Comportamiento:¿Tiene su adolescente sentimientos que le preocupan ¿Se comporta su adolescente de una manera que parece extraña para su edad?o que le parezcan extraños para su edad? ❏ Tiene problemas en la escuela o en el trabajo

❏ *Amenaza o lastima a otros niños o a animales

❏ Es inquieto ❏ No le interesan las cosas que antes disfrutaba

❏ Es triste o llora fácilmente ❏ Participa en juegos sexuales con jugetes, animales, o con los demás

❏ Se siente culpable ❏ *Destruye cosas personales o ajenas

❏ Se irrita o enoja fácilmente ❏ Roba

❏ Es malhumorado ❏ Se niega a hablar

❏ Siente miedo o ansiedad ❏ *Provoca incendios

❏ Se aburre ❏ Es demasiado activo

❏ *Ha tenido problemas con la policía


Interacciones Sociales: Pensamientos:¿Le preocupan cómo se lleva su adolescente con los miembros de la familia? ¿con otros adultos? ¿con su grupo social?

¿Ha notado si alguno de los siguientes es un problema para su adolescente?

❏ *Se confunde frecuentemente

❏ Sueña despierto demasiado

❏ Prefiere estar solo ❏ Se distrae, no pone atención

❏ Se le dificulta hacer y mantener amistades ❏ Es desconfiado

❏ Es desafiante, un problema de disciplina ❏ *Mira u oye cosas que no están allí

❏ Es agresivo ❏ Culpa a otros por algo malo que hizo o por sus pensamientos

❏ Discute demasiado ❏ *Habla sobre la muerte el suicidio

❏ Se niega a ir a la escuela ❏ *Frecuentemente pierde la memoria

❏ *Tiene pensamientos raros


Problemas Físicos: Otros:¿Le preocupan algunas de las siguientes señales físicas? ¿Han sido evaluadas?

¿Tiende a tener accidentes? ¿Hay alguna situación que le esté causando a su familia cierta tensión? ¿Ha sido es adolescente o sus padres sujetos a la negli-gencia o al abuso físico, sexual o emocional? Si sí, ¿en qué forma? ¿cuándo? ¿tipo de tratamiento?, etc.

❏ No tiene energía

❏ Usa laxantes * ¿Corre el riesgo de ser llevado a otro lugar fuera de casa por problemas de comportamiento?

❏ Se vomita frecuentemente ¿Ha sido tratado por problemas de la salud mental o por el abuso de sustancias como bebidas alcohólicas o drogas?

❏ Se niega a comer, come en secreto

❏ Tiene dolores de estómago frecuentemente

❏ Tiene dolores de cabeza Preguntas sobre el abuso de sustancias: (Tal vez quiera usar pruebas de detección como TACE, CAGE, MAST para obtener información sobre el uso de sustancias.)

❏ Ha perdido o aumentado peso excesiva-mente

❏ Tiene problemas para dormir, pesadillas, sonambulismo, se despierta temprano, frecuentemente camina en la noche

❏ El abuso de sustancias como bebidas alcohólicas y drogas ha sido identificado como un problema.

E–34

THSteps Forms

E

E.23 Mental Health Parent Questionnaire (Ages Birth–2 Years) (2 Pages)

Mental Health Parent Questionnaire Child’s Name: ____________________________Birth Date: _______________________________

Ages Birth to 2 Years Today’s Date: ____________________________

To the Parent: If you will assist us by filling out this form, we can help you find your child’s strengths and any problemareas, too. Your answers will help us to know if we need to talk with you and find out more about your child. Please check all items below that are true for your child. Some of the behaviors noted may be normal but if you are concernedplease let us know.

Feelings

Does your child show feelings that concern you or seem strange for their age? ❑ Yes ❑ No

Infants

❑ Fearful❑ Cries too much❑ Cries too little

1 to 2 Years

❑ Is irritable ❑ Fearful❑ Is angry ❑ Cries too little❑ Is sad ❑ Cries too much❑ Is sullen

Behavior

Does your child do things that concern you or seem strange for their age? ❑ Yes ❑ No

Infants

❑ Is overactive❑ Is listless (has little energy)

1 to 2 Years

❑ Is overactive ❑ Harms others❑ Is listless (has little energy) ❑ Has temper tantrums often

Social

Interaction

Do you have any concerns about how your child gets along with you? ❑ Yes ❑ NoWith other family members or adults? ❑ Yes ❑ NoWith brothers and sisters? ❑ Yes ❑ No

Infants

❑ Does not make eye contact or smile❑ Stiffens and arches back❑ Does not respond to you

1 to 2 Years

❑ Does not make eye contact ❑ Does not respond to youor smile ❑ Does not say any words yet

❑ Clings to you too much

Thinking

Do you think your child is as bright and thinks as clearly as others their age? ❑ Yes ❑ No

Infants

❑ (>8 months) Does not point to or ask for things or try to make words

1 to 2 Years

❑ Does not trust others❑ Has problems concentrating or paying attention

E–35

Appendix E

Date: ____________ Signature: ______________________________________________________

Relation to patient: _______________________________________________

Physical

Problems

Do you have any concerns about these things? ❑ Yes ❑ NoIf you think your child may have a health problem, has he/she seen a doctor or nurse about the problem? ❑ Yes ❑ No

Infants to 2 Years

❑ Is low weight or has a lot of weight ❑ Has sleeping problems (wakes a lot at night)❑ Vomits (throws up) often ❑ Has little energy❑ Has eating problems

(poor appetite, eats non-foods)

Other

Is anything causing your family stress right now? ❑ Yes ❑ NoHas this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ NoTreatment initiated? ❑ Yes ❑ NoDid the mother of this child use drugs or alcohol during the pregnancy? ❑ Yes ❑ No

Comments: (Please write anything else you want us to know about in this space.)

E–36

THSteps Forms

E

E.24 Mental Health Questionnaire (Ages Birth–2 Years) (2 Pages) (Spanish)

Cuestionario de la Salud Mental Nombre del Niño:________________________________para los Padres Fecha de Nacimiento: ___________________________

Fecha: _________________________________________De Recién Nacido a 2 Años de Edad

Para los Padres: Si nos ayuda llenando este formulario, le podremos ayudar a encontrar las áreas fuertes y también cualquier área problé-matica que tenga su bebé. Sus respuestas nos ayudarán a saber si necesitamos hablar con usted y saber más sobre su bebé. Favor de marcar todas las características abajo que son ciertas para su bebé. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está preocupado, favor de informarnos.

SENTIMIENTOS

¿Tiene su bebé sentimientos que le preocupan o tal vez parezcan extraños para su edad? ❏ Sí ❏ No

Bebés De 1 a 2 Años

❏ Siente miedo ❏ Es de mal carácter ❏ Siente miedo

❏ Llora mucho ❏ Es enojón ❏ Llora muy poco

❏ Llora muy poco ❏ Es triste ❏ Llora mucho

❏ Es malhumorado

COMPORTAMIENTO

¿Hace su bebé cosas que le preocupan o que parezcan extrañas para su edad? ❏ Sí ❏ No


❏ Es demasiado activo ❏ Es demasiado activo

❏ Es indiferente (tiene poca energía) ❏ Es indiferente (tiene poca energía)

❏ Lastima a otros

❏ Hace berrinches frecuentemente

INTE SR O A CC IC A I LO EN SES

¿Se preocupa sobre cómo se lleva su bebé con usted? ❏ Sí ❏ No¿Con otros miembros de la familia o adultos? ❏ Sí ❏ No

¿Con sus hermanos o hermanas? ❏ Sí ❏ No


❏ No ve a los ojos ni sonríe ❏ No ve a los ojos ni sonríe

❏ Se pone tieso y se dobla arqueando la espalda ❏ La mayoría del tiempo no se le despega

❏ No le responde ❏ No le responde

❏ Todavía no dice ninguna palabra

PENSAMIENTOS

¿Piensa usted que su nino es tan inteligente y que piensa tan claramente como otros niños de su edad?❏ Sí ❏ No


❏ (>8 meses) No pide ni senala a las cosas o trata ❏ No le tiene confianza a otros

de decir palabras ❏ Tiene problemas para concentrarse y poner atención

E–37

Appendix E

Fecha:_____________ Firma:________________________________________________________________

Parentesco con el paciente:_____________________________________________

BIRTH-2Y.MH2 (9-25-96)TDH/OLS/6-399/10-96

PR FO IB SL IE CM OA SS

¿Se preocupa usted sobre los siguientes problemas físicos? ❏ Sí ❏ NoSi usted piensa que su niño tiene un problema de salud, ¿lo ha llevado a consultarcon un médico o una enfermera debido a ese problema? ❏ Sí ❏ No

De recién nacidos a 2 Años

❏ Es de peso bajo o ha perdido mucho peso ❏ Tiene problemas para dormir

❏ Se vomita frecuentemente (se despierta mucho durante la noche)

❏ Tiene problemas para comer (muy pocoapetito, come alimentos que no son saludables)

❏ Tiene muy poca energía

OTROS

¿Hay algo que le esté causando tensión a su familia ahora? ❏ Sí ❏ No

¿Ha estado este niño o sus padres sujetos a la negligencia o al abuso físicos, sexual o emocional? Si sí, ¿en qué forma?_____________________ ¿Cuándo?_____________ ❏ Sí ❏ No¿Empezó el tratamiento? ❏ Sí ❏ No

¿Usó drogas o tomó bebidas alcohólicas durante su embarazo la mamá de este niño? ❏ Sí ❏ No

Comentarios: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.)

E–38

THSteps Forms

E

E.25 Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages)

Mental Health Parent Questionnaire Child’s Name: ____________________________

Birth Date: _______________________________

Ages 3 to 9 Years Today’s Date: ____________________________

To the Parent: If you will assist us by filling out this form, we can help you find your child’s strengths and any problem areas, too. Your answers will help us to know if we need to talk with you and find out more about your child. Please check all items below that are true for your child. Some of the behaviors noted may be normal but if you are concerned please let us know.

Feelings

Does your child show feelings that concern you or seem strange for their age? ❑ Yes ❑ No

❑ Is restless❑ Is sad or cries easily❑ Is overly guilty❑ Lacks remorse

❑ Is irritable, angers or temper tantrums easily❑ Is sullen❑ Fearful

Behavior

Does your child do things that seem strange for their age? ❑ Yes ❑ No

❑ Has problems in school❑ Harms other children or animals❑ Lacks interest in things s/he used to enjoy❑ Plays sexual games with others, toys, animals❑ Destroys possessions or other property❑ Steals

❑ Refuses to talk❑ Sets fires❑ Is over-active❑ Hurts himself or herself❑ Has been in trouble with the police

Social

Interaction

Do you have any concerns about how your child gets along with you? ❑ Yes ❑ NoWith other family members or adults? ❑ Yes ❑ NoWith playmates? ❑ Yes ❑ No

❑ Withdraws and does not look into peoples’ eyes❑ Clings to you too much❑ Has a hard time making and keeping friends❑ Is defiant, has a disciplinary problem❑ Severe or frequent tantrums

❑ Picks on others a lot or often gets into fights (hitting, etc.)❑ Argues too much❑ Will not go to school❑ Prefers to be alone

Thinking

Are any of these a problem for your child? ❑ Yes ❑ No

❑ Is frequently confused (does not understand what is go-ing on)❑ Daydreams a lot❑ Is distracted, doesn’t pay attention❑ Has very strange thoughts❑ Schoolwork is slipping (grades going down)

❑ Does not trust others❑ Sees or hears things that are not there❑ Blames others for his/her misdeeds or thoughts❑ Talks about death a lot❑ Often cannot remember things

E–39

Appendix E

Date: ____________ Signature: ______________________________________________________


Physical

Problems

Do you have any concerns about these things? ❑ Yes ❑ NoIf you think your child may have a health problem, has he/she seen a doctor or nurse about the problem? ❑ Yes ❑ No

❑ Has daytime wetting❑ Soils pants❑ Will not eat❑ Has headaches❑ Has lost or gained a lot of weight

❑ Has sleeping problems, nightmares, sleep-walking, early waking❑ Vomits (throws up) often❑ Has stomach aches often❑ Lacks energy

Other

Is this child accident-prone? ❑ Yes ❑ NoIs anything causing your family stress right now? ❑ Yes ❑ NoHas this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ NoTreatment initiated? ❑ Yes ❑ NoIs this child at risk for out-of-home placement because of behavior problems? ❑ Yes ❑ No


E–40

THSteps Forms

E

E.26 Mental Health Parent Questionnaire (Ages 3–9 Years) (2 Pages) (Spanish)

Cuestionario de la Salud Mental Nombre del Niño:________________________________para los Padres Fecha de Nacimiento: ____________________________

De 3 a 9 Años de Edad Fecha: _________________________________________

Para los Padres: Si nos ayuda llenando este formulario, le podremos ayudar a encontrar las áreas fuertes y también cualquier área problé-matica que tenga su niño. Sus respuestas nos ayudarán a saber si necesitamos hablar con usted y saber más sobre su niño. Favor de marcar todas las características abajo que sean ciertas para su niño. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está preocupado, favor de informarnos.

SENTIMIENTOS

¿Tiene su niño sentimientos que le preocupan o tal vez parezcan extraños para su edad? ❏ Sí ❏ No

❏ Es inquieto ❏ Es de mal carácter, enojón o hace berrinches

❏ Es triste o llora fácilmente temperamentales fácilmente

❏ Se siente muy culpable ❏ Es malhumorado

❏ No tiene remordimiento ❏ Siente miedo

COMPORTAMIENTO

¿Hace su niño cosas que le parezcan extrañas para su edad? ❏ Sí ❏ No

❏ Tiene problemas en la escuela ❏ Se niega a hablar

❏ Lastima a otros niños o a los animales ❏ Provoca incendios

❏ No le interesan las cosas que antes le gustaban ❏ Es demasiado activo

❏ Juega juegos sexuales con otros niños, ❏ Se lastima

juguetes, o animales ❏ Ha tenido problemas con la policía

❏ Destruye cosas personales u ajenas

❏ Roba


¿Se preocupa sobre cómo se lleva su niño con usted? ❏ Sí ❏ No¿Con otros miembros de la familia o adultos? ❏ Sí ❏ No

¿Con sus compañeros de juego? ❏ Sí ❏ No

❏ Se aleja y no ve a nadie a los ojos ❏ Siempre molesta a otros o frecuentemente se

❏ La mayoría del tiempo no se le despega pelea (pegando, etc.)

❏ Se le dificulta hacer y mantener amistades ❏ Discute mucho

❏ Es desafiante, tiene un problema de disciplina ❏ No quiere asistir a la escuela

❏ Hace berrinches tempermentales fuertes o ❏ Prefiere estar solo

frecuentemente

PENSAMIENTOS

¿Son algunas de estas características un problema para su niño? ❏ Sí ❏ No

❏ Se confunde frecuentemente (no entiende ❏ No le tiene confianza a los demás

lo que está pasando) ❏ Mira u oye cosas que no están allí

❏ Sueña mucho despierto ❏ Culpa a otros por algo que hizo mal o por sus

❏ Se distrae, no pone atención pensamientos

❏ Tiene pensamientos muy extraños ❏ Habla mucho sobre la muerte


❏ Frecuentemente no se acuerda de cosas

E–41

Appendix E

Fecha:_____________ Firma:________________________________________________________________


3YR-9YR.MH2 (9-25-96)TDH/OLS/6-400/10-96


¿Se preocupa usted sobre los siguientes problemas físicos?Si usted piensa que su niño tiene un problema de salud, ¿Lo ha llevado a consultar con

❏ Sí ❏ No

un médico o una enfermera debido a ese problema? ❏ Sí ❏ No

❏ Se orina durante el día ❏ Tiene problemas para dormir, pesadillas, se

❏ Ensucia sus pantalones despierta temprano y sonámbulo

❏ No quiere comer ❏ Se vomita frecuentemente

❏ Tiene dolores de cabeza ❏ Tiene dolores de estómago frecuentemente

❏ Ha perdido o aumentado mucho de peso ❏ No tiene energía

OTROS

¿Es propenso este niño a tener accidentes? ❏ Sí ❏ No¿Hay algo que le está causando tensión a su familia ahora? ❏ Sí ❏ No¿Ha estado este niño o sus padres sujetos a la negligencia o al abuso físico, sexual o emocional?

Si sí, ¿en qué forma?_________________ ❏ Sí ❏ No

¿Cuándo? ___________ ¿Empezó el tratamiento? ❏ Sí ❏ No

¿Corre el riesgo este niño de ser llevado a otro lugar fuera de su familia por problemas de comportamiento? ❏ Sí ❏ No

Comentario: (Favor de escribir en este espacio cualquier comentario que quiera compartir con nosotros.)

E–42

THSteps Forms

E


Mental Health Parent Questionnaire Child’s Name: _____________________________

Birth Date: ________________________________

Ages 10 to 12 Years Today’s Date: _____________________________

To the Parent: If you will assist us by filling out this form, we can help you find your child’s strengths and any problem areas, too. Your answers will help us to know if we need to talk with you and find out more about your child. Please check all items below that are true for your child. Some of the behaviors noted may be normal but if you are concerned please let us know.

Feelings

Does your child (do you) show feelings that concern you or seem strange for their (your) age? ❑ Yes ❑ No

❑ Is restless❑ Is sad or cries easily❑ Is guilty❑ Is irritable or angers easily

❑ Is sullen❑ Is fearful❑ Is bored

Behavior

Does your child (do you) often do things that seem strange for their (your) age? ❑ Yes ❑ No

❑ Has problems in school❑ Threatens or harms other children or animals❑ Lacks interest in things s/he used to enjoy❑ Is involved in sexual activity❑ Destroys possessions or other property❑ Steals

❑ Refuses to talk❑ Sets fires❑ Is overactive❑ Hurts himself or herself❑ Has been in trouble with the police

Social

Interaction

Do you have any concerns about how your child (you) get(s) along with family members? ❑ Yes ❑ NoWith other adults? ❑ Yes ❑ NoWith other children? ❑ Yes ❑ No

❑ Prefers to be alone❑ Has a hard time making and keeping friends❑ Is defiant, a disciplinary problem

❑ Picks on others a lot or often gets into fights (hitting, etc.)❑ Argues too much❑ Will not go to school

Thinking

Are any of these a problem for your child (you)? ❑ Yes ❑ No

❑ Is frequently confused (does not understand what is going on)

❑ Daydreams a lot❑ Is distracted, doesn’t pay attention❑ Has very strange thoughts❑ Schoolwork is slipping (grades going down)

❑ Does not trust others❑ Sees or hears things that are not there❑ Blames others for his/her misdeeds or thoughts❑ Talks about death or suicide a lot❑ Often cannot remember things

E–43

Appendix E

Date: ____________ Signature: ______________________________________________________


Physical

Problems

Do you have any concerns about these things? ❑ Yes ❑ NoIf you think your child (you) may have a health problem, has he/she (have you) seen a doctor or nurse about the problem? ❑ Yes ❑ No

❑ Lacks energy❑ Uses laxatives❑ Vomits (throws up) often❑ Won’t eat in front of people, sneaks food

later❑ Has stomach aches often

❑ Has headaches❑ Has lost or gained a lot of weight❑ Has sleeping problems, nightmares, sleep-walking, early waking,

frequent night waking

Other

Is your child (you) accident-prone? ❑ Yes ❑ NoIs anything causing your family stress right now? ❑ Yes ❑ NoHas this child or his/her parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ NoTreatment initiated? ❑ Yes ❑ NoIs this child (are you) at risk for out-of-home placement because of behavior problems? ❑ Yes ❑ NoDoes your child (do you) drink of use drugs (including street or over-the-counter)? ❑ Yes ❑ NoHas this child (have you) been treated for mental health problems or substance abuse? ❑ Yes ❑ No


E–44

THSteps Forms

E


Fecha:_____________ Firma:________________________________________________________________


Cuestionario de la Salud Mental Nombre del Niño:_________________________________para los Padres Fecha de Nacimiento: ____________________________


Para los Padres: Si nos ayuda llenando este formulario, le podremos ayudar a encontrar las áreas fuertes y también cualquier área problé-matica que tenga su hijo. Sus respuestas nos ayudarán a saber si necesitamos hablar con usted y saber más sobre su niño. Favor de marcar todas las características abajo que son ciertas para su niño. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está preocupado, favor de informarnos.

SENTIMIENTOS

¿Tiene su niño sentimientos que le preocupan o tal vez parezcan extraños para su edad? ❏ Sí ❏ No

❏ Es inquieto ❏ Es malhumorado

❏ Es triste o llora fácilmente ❏ Siente miedo

❏ Se siente culpable ❏ Se aburre

❏ Es de mal carácter o se enoja fácilmente

COMPORTAMIENTO

¿Hace su niño cosas que le parezcan extrañas para su edad? ❏ Sí ❏ No

❏ Tiene problemas en la escuela ❏ Se niega a hablar

❏ Amenaza o lastima a otros niños o a los ❏ Provoca incendios

animales ❏ Es demasiado activo

❏ No le interesan las cosas que antes le gustaban ❏ Se lastima

❏ Participa en actividades sexuales ❏ Ha tenido problemas con la policía

❏ Destruye cosas personales o ajenas

❏ Roba


¿Se preocupa sobre cómo se lleva su niño con usted? ❏ Sí ❏ No¿Con otros adultos? ❏ Sí ❏ No¿Con otros niños? ❏ Sí ❏ No

❏ Prefiere estar solo ❏ Siempre molesta a otros o frecuentemente se pelea (pegando, etc.)



PENSAMIENTOS

¿Son algunas de estas características un problema para su niño?

❏ Sí ❏ No

❏ Se confunde frecuentemente (no entiende lo que está pasando)

❏ No le tiene confianza a los demás

❏ Sueña mucho despierto ❏ Mira u oye cosas que no están allí

❏ Se distrae, no pone atención ❏ Culpa a otros por algo que hizo mal o por sus pensamientos

❏ Tiene pensamientos muy extraños ❏ Habla mucho sobre la muerte o del suicidio



E–45

Appendix E

10-12YR.MH3 (9-25-96)TDH/OLS/6-401/11-96


¿Se preocupa usted sobre los siguientes problemas físicos? ❏ Sí ❏ NoSi piensa que su niño tiene un problema de salud, ¿ha ido a consultar con un médico o una enfermera debido a ese problema?

❏ Sí ❏ No

❏ La falta energía ❏ Tiene dolores de cabeza

❏ Usa laxantes ❏ Ha perdido o aumentado mucho peso

❏ Se vomita frecuentemente ❏ Tiene problemas para dormir, pesadillas, sonambulismo, despierta temprano, despierta seguido por la noche

❏ No come delante de la gente, come después a escon-didas


OTROS

¿Es propenso a tener accidentes su niño? ❏ Sí ❏ No¿Hay algo que le está causando tensión a su familia ahora? ❏ Sí ❏ No¿Ha sido este niño o sus padres sujetos a la negligencia o al abuso físico, sexual o emocional?Si sí, ¿en qué forma?_________________ ¿Cuándo? ___________ ❏ Sí ❏ No¿Empezó el tratamiento? ❏ Sí ❏ No¿Corre este niño el riesgo de ser llevado a otro lugar fuera de su familia por problemas de comportamiento? ❏ Sí ❏ No¿Toma bebidas alcohólicas o usa drogas su niño (incluyendo las de la calle y las que se venden sin receta)? ❏ Sí ❏ No¿Ha recibido su niño tratamiento por problemas de la salud mental o por el abuso de sustancia como las drogas y bebidas alcohólicas?

❏ Sí ❏ No


E–46

THSteps Forms

E


Mental Health Parent Questionnaire Teen’s Name: ____________________________

Birth Date: _______________________________

Ages 13 to 20 Years Today’s Date: ____________________________

To the Teen or Parent: If you will assist us by filling out this form, we can help you find your (your teen’s) strengths and any problem areas, too. Your answers will help us to know if we need to talk with you (your teen) and find out more about you (your teen). Please check all items below that are true for you (your teen). Some of the behaviors noted may be normal but if you are concerned please let us know.

Date: ____________ Signature: ______________________________________________________


Feelings

Do you (does your teen) show feelings that concern you or seem strange for your (their) age? ❑ Yes ❑ No

❑Restless❑Sad or cry easily❑Guilty❑ Irritable or angered easily

❑ Sullen❑ Fearful❑ Bored

Behavior

Do you (does your teen) often do things that seem strange for your (their) age? ❑ Yes ❑ No

❑ Have problems in school or work❑ Threaten or harm other children or animals❑ Lack interest in things you used to enjoy❑ Is involved in sexual activity❑ Destroy possessions or other property❑ Steal

❑ Refuse to talk❑ Set fires❑ Over-active❑ Hurt yourself❑ Have been in trouble with the police

Social

Interaction

Do you have any concerns about how you (your teen) get(s) along with family members? ❑ Yes ❑ NoWith other adults? ❑ Yes ❑ NoWith peers? ❑ Yes ❑ No

❑ Prefer to be alone❑ Have a hard time making and keeping friends❑ Defiant, a disciplinary problem

❑ Pick on others a lot or often get into fights (hitting, etc.)❑ Argue too much❑ Will not go to school

Thinking

Are any of these a problem for you (your teen)? ❑ Yes ❑ No

❑ Frequently confused (does not understand what is going on)

❑ Daydream a lot❑ Distracted, do not pay attention❑ Have very strange thoughts❑ Schoolwork is slipping (grades going down)

❑ Do not trust others❑ See or hear things that are not there❑ Blame others for your misdeeds or thoughts❑ Talk about death or suicide a lot❑ Often cannot remember things

E–47

Appendix E

Physical

Problems

Do you have any concerns about these things? ❑ Yes ❑ NoIf you think you (your teen) may have a health problem, have you (has he/she) seen a doctor or nurse about the problem? ❑ Yes ❑ No

❑ Lack energy❑ Use laxatives❑ Vomit (throw up) often❑ Won’t eat in front of people, sneak food

later❑ Have stomachaches often

❑ Have headaches❑ Have lost or gained a lot of weight❑ Have sleeping problems, nightmares, sleep-walking, early waking,

frequent night waking

Other

Are you (is your teen) accident-prone? ❑ Yes ❑ NoIs anything causing your family stress right now? ❑ Yes ❑ NoHave you (has your teen) or your parents been subject to neglect, physical, sexual, or emotional abuse? If yes, what from? _____________________ When? ________ ❑ Yes ❑ NoTreatment initiated? ❑ Yes ❑ NoAre you (is this teen) at risk for out-of-home placement because of behavior problems? ❑ Yes ❑ NoDo you (does your child) drink of use drugs (including street or over-the-counter)? ❑ Yes ❑ NoHave you (has this teen) been treated for mental health problems or substance abuse? ❑ Yes ❑ No


E–48

THSteps Forms

E


Fecha:_____________ Firma:___ ____________________________________________________________

Parentesco con el paciente:_____________________________________________13-21YR.MH4 (9-23-96)TDH/OLS/6-402/10-96table

Cuestionario de la Salud Mental Nombre del Adolescente:__________________________para los Padres Fecha de Nacimiento: ____________________________


Para los Padres: Si nos ayuda llenando este formulario, podremos ayudarle a encontrar las áreas fuertes que tenga su hijo y también cualquier área problématica. Sus respuestas nos ayudarán a saber si necesitamos hablar con su hijo y saber más sobre él. Favor de marcar todas las características abajo que son ciertas para su hijo. Algunos de los comportamientos en las listas tal vez sean normales, pero si usted está preocupado, favor de informarnos.

SENTIMIENTOS

¿Tiene su hijo sentimientos que le preocupan o tal vez parezcan extraños para su edad?

❏ Sí ❏ No

❏ Es inquieto ❏ Es malhumorado

❏ Es triste o llora fácilmente ❏ Siente miedo

❏ Se siente culpable ❏ Se aburre

❏ Es irrita o enoja fácilmente

COMPORTAMIENTO

¿Hace su hijo cosas frecuentemente que le parezcan extrañas para su edad?

❏ Sí ❏ No

❏ Tiene problemas en la escuela o en el trabajo ❏ Se niega a hablar

❏ Amenaza o lastima a otros niños o a los animales ❏ Provoca incendios

❏ No le interesan las cosas que antes le gustaban ❏ Es demasiado activo

❏ Está envuelto en actividades sexuales ❏ Se lastima

❏ Destruye cosas personales u otras cosas ajenas ❏ Ha tenido problemas con la policía

❏ Roba

INTE SR OA CC IC A I LO EN SES

¿Le preocupa cómo se lleva su hijo con los miembros de la familia?

❏ Sí ❏ No

¿Con otros adultos? ❏ Sí ❏ No¿Con su grupo social? ❏ Sí ❏ No

❏ Prefiere estar solo ❏ Molesta mucho a otros o frecuentemente se pelea (pegando, etc.)



PENSAMIENTOS

¿Son algunas de estas características un problema para su hijo?

❏ Sí ❏ No

❏ Se confunde frecuentemente (no entiende lo que está pasando)

❏ No le tiene confianza a los demás

❏ Sueña mucho despierto ❏ Mira u oye cosas que no están allí

❏ Se distrae, no pone atención ❏ Culpa a otros por algo que hizo mal o por sus pensamientos

❏ Tiene pensamientos muy extraños ❏ Habla mucho sobre la muerte o el suicidio



E–49

Appendix E


¿Se preocupa por estas cosas? ❏ Sí ❏ NoSi piensa que su hijo tiene un problema de salud, ¿ha ido a consultar con un médico o una enfermera por este problema?

❏ Sí ❏ No

❏ No tiene energía ❏ Tiene dolores de cabeza

❏ Usa laxantes ❏ Ha perdido o aumentado mucho peso

❏ Se vomita frecuentemente ❏ Tiene problemas para dormir, pesadillas, se despierta temprano, sonámbulo y frecuentemente despierta durante la noche

❏ No come delante de la gente, come después a esconidas


OTROS

¿Es su hijo propenso a tener accidentes? ❏ Sí ❏ No¿Hay algo que le está causando tensión a su familia ahora? ❏ Sí ❏ No¿Ha sido su hijo o sus padres sujetos a la negligencia o al abuso físico, sexual o emocional? ❏ Sí ❏ No Si sí, ¿en qué forma?_________________ ¿Cuándo? ___________ ¿Empezó el tratamiento? ❏ Sí ❏ No¿Corre el riesgo su hijo de ser llevado a otro lugar fuera de su familia por problemas de comportamiento? ❏ Sí ❏ No¿Toma su hijo bebidas alcohólicas o drogas (incluyendo las de la calle y las que se venden sin receta)? ❏ Sí ❏ No¿Ha recibido su hijo tratamiento por problemas de la salud mental o por el abuso de sustancias como drogas o bebidas alcohólicas?

❏ Sí ❏ No


E–50

E–51

THS

teps Forms

E.

E

31 Recommended Childhood Immunization Schedule, 2004

E–52

Appendix E

THSteps Forms

E

E.32 Screening Schedule for High-Blood Leads

Note: A “yes” or “I don’t know” answer to any question on any parent questionnaire indicates that a blood lead test should be administered.

Age of child May use primary parent questionnaire

May use abbreviated par-ent questionnaire

Blood lead test required

Conditions

6 mths. yes

12 mths. yes

18 mths. yes

24 mths. yes

3, 4, 5, and 6 years

yes, if any answer on abbre-viated parent questionnaire is “yes”

yes if child has no record of a blood lead test, child MUST have an actual blood lead test

E–53

Appendix E

E.33 THSteps Primary Parent Risk Assessment for Lead Exposure Questionnaire

Patient’s Name: __________________________________________

Date Questionnaire Administered: ___________________________

Texas Health StepsPRIMARY PARENT QUESTIONNAIRE

SCREENING QUESTIONS FOR A CHILD WHO HAS NEVER HAD A HIGH BLOOD LEAD

This questionnaire is about lead. Lead is a dangerous substance that sometimes gets into children’s bodies. It can make them sick and affect their behavior and ability to learn. Answers to these questions will help the doctor see if your child may have been exposed to lead. If your child has been exposed to lead, the doctor will need to do a blood test. The test may show that the child has lead in his/her blood or it may show that your child is fine. Even if your child does have a high blood lead, the doctor can tell you things that you can do to help your child be healthy. If any of these questions are confusing, ask the doctor or nurse to help you with them.

1) Do you live in or often visit a house that was probably built before 1978?❏ YES ❏ NO ❏ I DON’T KNOW

2) Does your child live in or often visit a house that is being painted, remodeled, or having the paint scraped or sanded?❏ YES ❏ NO ❏ I DON’T KNOW

3) Does your child eat or chew on non-food things like paint chips or dirt?❏ YES ❏ NO ❏ I DON’T KNOW

4) Have any other members of the family or your child’s playmates had high blood leads as far as you know?❏ YES ❏ NO ❏ I DON’T KNOW

5) Does you family live near or does your child play near any of these (circle the ones that apply):smelterhazardous waste sitelead industryplace where batteries are manufactured or repairedhouse construction siteheavily traveled major highwayplace where cars are abandoned or repaired?

6) Do you give your child, or have you ever given your child, any of these products from another country:MEDICINES like greta or azarcon for empacho, alarcon, alkohl, bali goli, coral, ghasard, liga, pay-loo-ah, or rueda?

❏ YES ❏ NO ❏ I DON’T KNOWNUTRITIONAL PILLS OTHER THAN VITAMINS?

❏ YES ❏ NO ❏ I DON’T KNOW7) Does anyone living in your house work at a place where any of these things happen or have a hobby that involves these things?

(circle the ones that apply):radiator repairlead industryweldingbattery manufacture or repairhouse construction or repairsmeltingchemical preparationmaking pottery going to a firing rangestained glass with lead solderbrass/copper foundryvalve and pip fittingsbridge, tunnel and elevated highway constructionindustrial machinery and equipment reloading bullets or making fishing weightsrefinishing furnitureburning lead-painted woodautomotive repair shop

Does anybody that your child spends a lot of time with (outside of your home) do any of these things or work at a place where these things are done?

❏ YES ❏ NO ❏ I DON’T KNOW

8) Is imported or glazed pottery, or a Mexican bean pot, used to cook or store your food?❏ YES ❏ NO ❏ I DON’T KNOW

9) Does your child eat foods canned or packaged (such as candy) outside the U.S.?❏ YES ❏ NO ❏ I DON’T KNOW

E–54

THSteps Forms

E

E.34 THSteps Primary Parent Risk Assessment for Lead Exposure Questionnaire (2 Pages) (Spanish)

g ) ( p )Nombre del paciente:____________________________________________

Fecha de Administración del Cuestionario:__________________________

Pasos para la Salud en Texas

CUESTIONARIO PRIMARIO PARA LOS PADRESPREGUNTAS DE DETECCIÓN PARA NIÑOS QUE NUNCA HAN TENIDO ALTOS NIVELES

DE PLOMO EN LA SANGRE

Este cuestionario es sobre el plomo. El plomo es una substancia dañina que algunas veces se introduce en el cuerpo de los niños. Puede enfermarlos y afectar su comportamiento, así como su capacidad de aprendizaje. Las respuestas a estas preguntas ayundarán al médico a saber si su hijo(a) puede haber estado expuesto al plomo. Si su hijo(a) ha estado expuesto al plomo, el médico necesitara hacerle una prueba de sangre. La prueba puede mostrar si su hijo(a) tiene plomo en la sangre o puede indicar que su hijo(a) esta bien. Aun si su hijo(a) tien altos niveles de plomo en la sangre, el médico puede darle indica-ciones sobre lo que puede hacer para ayudar a su hijo(a) a estar sano. Si algunas de las preguntas son confusas, preguntele al médico o a la enfermera que le ayuden.

1) ¿Vive usted en o visita frecuentemente alguna casa que probablemente haya sido construida antes de 1978?

SÍ ❏ NO ❏ NO LO SE ❏

2) ¿Vive su hijo(a) en o visita frecuentemente una casa que está siendo pintada, remodelada, o que están pelando o lijando la pintura?


3) ¿Su hijo(a) come o mastica cosas que no son comida, como pedazos de pintura u objetos sucios?

SÍ o NO ❏ NO LO SE ❏

4) ¿Algún otro miembro de la familia o compañeritos de juego tienen altos niveles de plomo en la sangre, que usted esté enterada?


5) ¿Su familia vive cerca o su hijo(a) juega cerca de alguno de los siguientes lugares? (encierre en un círculo la respuesta)

fundiciónsitio de desperdicios peligrososindustria de plomolugar donde se fabrican o reparan bateríassitio de construcción de una casaautopista con mucho tránsitolugar donde los autos son reparados o abandonados

E–55

Appendix E

02/97

6) ¿Le da usted o le ha dado alguna vez a su hijo(a) alguno de los siguientes productos provenientes de otro páis?

- MEDICINAS tales como greta, o azarcon para el empacho, alarcon, alkohl, bali goli, coral ghasard, liga, pay-loo-ah, o rueda?

SI ❏ NO ❏ NO LO SE ❏

- PÍLDORAS NUTRICIONALES QUE NO SEAN VITAMINAS

SI ❏ NO ❏ NO LO SE ❏

7) ¿Hay alguna persona viviendo en su casa que trabaje en un lugar donde se realice alguna de las cosas ques cribimos a continuacion o que tengan un pasatiempo que involucre alguna de los siguientes? (encierre en un círculo la respuesta):

reparación de radiadorindustria del plomosoldadurafabricación y reparación de bateríasconstrucción o reparación de casasfundición (de metales)preparación de químicosfabricación de bitrales con soldadura de plomofundición de latón/cobrepartes sueltas para tubos de cañerias y válvulasconstrucción de una autopista elevada, puente, túnelequipo y maquinaria industrialrecargo de balas de armas de fuego o fabricación de pesas para pescarterminado de mueblesquema de madera pintada con plomotaller mecánico para autos

¿Alguna persona con quien su hijo pasa largo tiempo, hace alguna de las siguientes cosas o trabaja en lugares (fuera de la casa)donde se realizan las actividades antes mencionadas?


8) ¿Usa usted productos de ceramica importada o con recubrimiento de barniz, o una olla para frijoles de México, para cocinar o para guardar su comida?


9) ¿Come su hijo(a) productos enlatados o empacados (tales como dulces) fuera de los Estados Unidos?


E–56

THSteps Forms

E

E.35 Abbreviated Parent Questionnaire: Risk Assessment for Lead Exposure

Patient’s Name: _____________________________________________

Date Questionnaire Administered: ______________________________

ABBREVIATED PARENT QUESTIONNAIRERISK ASSESSMENT FOR LEAD EXPOSURE

1. Has your residence changed since your child’s last lead screen?YES ❏ NO ❏

2. Has your child changed babysitters or daycare centers since the last lead screen?YES ❏ NO ❏

3. Has anyone in your home changed jobs since your child’s last lead screen?YES ❏ NO ❏

4. Has anyone in your home been:- reloading bullets - refinishing furniture- making pottery - working on autos- making stained glass - going to a firing range

5. Since the last lead screen, has your child been around any home remodeling or houses that are having the paint removed?YES ❏ NO ❏

6. Are you giving your child medications produced outside the United States, like Greta or Azarcon?YES ❏ NO ❏

You may use the Abbreviated Parent Questionnaire for lead screening:1. At the patient’s 3, 4, 5, and 6 year visits.2. If the patient has never had an elevated blood lead level.3. If the parent answered “no” to all questions on the primary lead screening parent questionnaire at the 6-month and

18-month visits.

If the parent answers “yes” to any of the questions below, you must administer the Primary Parent Questionnaire or give the child a blood lead test.

E–57

Appendix E

E.36 Abbreviated Parent Questionnaire: Risk Assessment for Lead Exposure (Spanish)

Nombre del paciente:___________________________________________________

Fecha de Administración del Cuestionario:__________________________________

CUESTIONARIO ABREVIADO PARA LOS PADRESEVALUACIÓN DE RIESGO POR EXPOSICIÓN AL PLOMO

02/97

Usted puede usar el Cuestionario Abreviado para los Padres para la detección de Plomo en la sangre:1. En las visitas anuales 3, 4, 5, y 6 del paciente.2. Si el paciente nunca ha tenido un elevado nivel de plomo en la sangre.3. Si los padres contestaron “no” a todas las preguntas del cuestionario para los padres para la detección pri-

maria de plomo durante las visitas de los 6 y 18 meses.

Si los padres contestan “si” a cualquiera de las preguntas que siguen, usted debe administrar el CuestionarioPrimario para Padres o hacerle al niño un examen para la detección de plomo en la sangre.

1. ¿Se ha cambiado de domicilio desde que su hijo(a) tuvo el último examen para la detección de plomo en la sangre?

SÍ ❏ NO ❏

2. ¿Ha cambiado a su hijo(a) de niñera o de guardería desde que su hijo(a) tuvo el último examen para la detección de plomo en la sangre?

SÍ ❏ NO ❏

3. ¿Alguna de las personas que viven en su casa ha cambiado de trabajo desde que su hijo(a) tuvo el último examen para la detección de plomo en la sangre?

SÍ ❏ NO ❏

Si contestó sí, escriba el nombre del nuevo trabajo:_________________________________________________

4. Alguna persona en su casa ha estado:- recargando balas en armas - terminado de muebles- trabajando con cerámica - trabajando en automóviles- trabajando con vitrales - yendo a un campo de tiro

SÍ ❏ NO ❏

5. ¿Desde que su hijo(a) tuvo el último examen para la detección de plomo en la sangre ha estado él en cualquier casa que se esté remod-elando o casas donde estén quitando la pintura?

SÍ ❏ NO ❏

¿Le está dando a su hijo(a) alguna medicación producida fuera de los Estados Unidos, tales como Greta o Azarcón?

SÍ ❏ NO ❏

E–58

THSteps Forms

E

E.37 San Antonio State Chest Hospital Cervical Cancer Cytology Laboratory

Please Print Legibly

Women's Health Laboratories 2303 S.E. Military Dr., Bldg 533, Suite #1

San Antonio, TX 78223-3597

Phone (210) 531-4596 Toll-Free (888) 440-5002

FAX (210) 531-4506

CLIA: 45D0911298 / CAP: 2140102

Patient Name Last First

M.I. Date of Birth

Street Address City State Zip

Patient Phone Patient ID SSN

Sex: Female Male Race: W H B AI Asian Other:

Clinic Code Clinic: FP MTY AH DYS

THS STD CD TB

Ordering Clinician

Date Collected (time if applicable) ICD9 #1 ICD9 #2 ICD9 #3 Attending Physician (if applicable)

*Clinical Consultant Available*

Patient Funding:

Title V Title X Title XX

THS BCCCP TB Elim

SDI STD/HIV Indigent

Medicaid Medicare IPP

Recipient Number:___________________

Service Contract Bill Patient

Private Insurance. Please include copy of

patient's insurance card, front and back.

CLINICAL HISTORY / NARRATIVE: __________________________________________________________ LMP:____________________ High Risk Prev Abn Hormone Pregnant Post Partum PMP

Cryo Hysterectomy Prior Bx LEEP Laser Chemo IUD

Tuberculosis Diabetes Anemia Hypertension Hx of STD Tubal Ligation Colposcopy

Surgical Pathology: Biopsy 88305 Leep 88307 (please include colposcopy or exam form) Leep at _____________ Leep at ________

Cx Bx at ________ Cx Bx at ________ ECC EMB Other ________________ Other __________

Cytology Glucose,2 spec. 82950 Chemistry (continued) Reference Pap Smear * 88150 Glucose,3 spec. 82951 Calcium 82310 CEA 82378

Liquid Based Pap * 88142 Glucose,4 spec. 82951/82952 Cholest, HDL 83718 Hgb A1C 83036

NonGyn Cytology * 88160 Glucose,5 spec. 82951/82952 x2 Cholest, Tot. 82465 PSA 84153

* For all above please state Site(s): Microbiology Creatinine 82565 T3, Total 84480

Cervix ❑ Endocervix Occult Blood, Stool 82270 Ferritin 82728 T4, Free 84439

Vagina Urine Culture clean catch 87086 FSH 83001 HSV I & II Ab serum

Other: Bacteria Culture * 87070 Glu, Fasting 82947 86695/86696

HPV Testing Gram Stain * 87205 Glu, Random 82947 Immunology HPV 87621 Grp B Strep DNA probe * 87149 Glu, 1hr 82947 ANA 86255

HPV reflex 87621 Acid Fast Smear * 87206 Glu, 2hr pp 82947 Hep A Ab, IgM 86709

STD Screen Acid Fast Culture * 87015/87116 HCG, Quant 84702 Hep A Ab, Total 86708

DNA probe CT/GC 87490/87590 KOH Exam * 87210/87220 HCG, Qual 84703 Hep Bs Ab 86706

Amp DNA CT/GC 87491/87591 Fungal Culture * 87101/87102 Iron, Total 83540 Hep Bs Ag 87340

HSV I&II Rpd Mtd* 87252/87274 * For all above please state Site: Iron, TIBC. 83550 Hep Bc Ab 86704

* For above please state Site: LH 83002 Hep C Ab 86803 Note: If indicated, ID & Sensitivity will be Potassium 84132 HIV, Oral 86701

Panels *See back for Panels* performed with additional charges. Prolactin 84146 HIV, Serum 86701

Basic Metabolic Panel 80048 Hematology Sodium 84295 WesternBlot (reflex) 86689

Comprehensive Panel 80053 CBC w/Auto Diff 85025 T3, Uptake 84479 RPR w/reflex IgG 86592

Electrolyte Panel 80051 CBC Manual Diff 85023 Thyroxin (T4) 84436 Rubella Ab 86762

Acute Hepatitis Panel 80074 Hemoglobin 85018 Triglycerides 84478 Rheumatoid Factor 86430

Hepatic Function 80076 Hematocrit 85014 TSH 84443 Mono Screen 86308

Lipid Panel 80061 Reticulocyte count 85044 Uric Acid 84550 UrinalysisHigh Risk Panel custom Sickle cell screen 85660 Transfusion Medicine Urinalysis w/o

OB Panel 80055 Chemistry ABO, Rh 86900/86901 Scope 81003

OB Panel w/out CBC custom Albumin 82040 Antibody Screen 86850 UA w/Scope & Culture

Iron Panel custom Alkaline Phos 84075 Direct Coombs 86880 If indicated 81000/87086

Triple Screen (attach MSAFP form) Amylase 82150 Cord Blood Urine Culture 87086

AFP Serum 82105 ALT 84460 TB Elimination Testing FOR LAB USE ONLY: ßhCG Quantitative 84702 AST 84450 LFT – 4 Test custom Red ___ Urine Cup ___

Free Estriol 82677 Bilirubin, Direct 82248 LFT – 6 Test custom GrayTop___ Gray UR ___

Drug Screen: ❑ 3test ❑ 7test Bilirubin, Total 82247 Other Testing Yellow ___ Yellow UR ___

Glucose. Gest.2spec. 82947/82950 BUN 84520 Purple ___ Cltr Swab ___

Clinic Name & Address: WHL-Public500(M47) Revised: 06/04 Serum ___ Digene ___

SST ___ SurePath ___

Other ___ Amp ___

E–59

Appendix E

Laboratory Protocols

CBC w/Auto Diff Reflex:

• Abnormal CBC: Manual Diff reported

• A CBC is abnormal when it meets the approved

criteria. (Criteria available upon request.)

Urinalysis Reflex:

• Abnormal UA: microscopic and /or

confirmatory testing performed

when abnormal results are observed for protein,

nitrite, leukocyte esterase and/or blood.

Urine Culture Reflex: Abnormal UA with positive nitrite, leukocyte

esterase, >5 WBC’s or >2+ bacteria: Culture

performed.

TSH Reflex:

• Abnormal TSH (<0.1 or >10.0 mIU/ml): Free

T4 performed.

RPR:

• Positive Syphilis IgG AB, AB Index and RPR

quantitative (titer).

Rheumatoid Factor Reflex:

• Positive RA Factor: titer performed.

HIV Reflex:

• Positive HIV: Western Blot performed.

Hepatitis B Surface Ag (HBsAg) Reflex:

• HbsAg borderline or positive samples will be

confirmed by neutralization.

Hepatitis B Surface Ab (HbsAB):

• Positive: Semi-quantitative value reported for

immune status.

Antibody Screen Reflex:

• Positive AB Screen: antibody identification will

be performed.

Direct Coombs (DAT) Reflex:

• Positive DAT: IgG, C3 testing.

Cryptococci Reflex:

• Positive: Titer performed.

ANA Screen Reflex:

• Positive: anti-DNA testing performed

(reference lab).

Panels

80048 Basic Metabolic Panel (BMP) Calcium

CO2

Chloride

Creatinine

Glucose

Potassium

Sodium

Urea Nitrogen (BUN)

80053 Comprehensive Metabolic Panel (CMP) Albumin Calcium

Alk. Phosphatase ALT (SGPT)

Bilirubin (total) AST (SGOT)

CO2 Sodium

Chloride Potassium

Creatinine Total Protein

Glucose Urea Nitrogen (BUN)

80051 Electrolyte PanelSodium

Potassium

Chloride

CO2

Anion Gap (Calculated)

80074 Acute Hepatitis Panel Hepatitis A antibody, IgM

Hepatitis B core antibody, IgM

Hepatitis B Surface antigen

Hepatitis C antibody

80076 Hepatic Function Panel Albumin

Bilirubin (total)

Bilirubin (direct)

Alk. Phosphatase

Total Protein

ALT (SGPT)

AST (SGOT)

80061 Lipid Panel Cholesterol

HDL

Triglycerides

Custom High Risk Panel Glucose 82947 Cholesterol 82465 Triglycerides 84478

80055 OB Panel CBC w/diff

Hepatitis B surface antigen

Rubella antibody

RPR

Antibody Screen, RBC

ABO/Rh

Custom OB Panel without CBC Hepatitis B surface antigen

Rubella antibody

RPR

Antibody Screen, RBC

ABO/Rh

Custom Iron Panel Iron, Total 83550 TIBC 83550 Transferrin Sat.

Ferritin 82728

80100 Urine Drug Screen Panel 3 Cocaine

THC

Opiates

80100 Urine Drug Screen Panel 7 Amphetamines Methadone

Barbiturates Opiates

Benzodiazepines THC

Cocaine

82947/82950 Glucose, Gest. 2 specimens Glucose, Fasting BS

Glucose, 1hr

82950 Glucose, 2 specimens Glucose, Fasting BS

Glucose, 2hr

82951 Glucose, 3 specimens Glucose, Fasting BS

Glucose, 1hr

Glucose, 2hr

82951/82952 Glucose, 4 specimens Glucose, Fasting BS

Glucose, 1hr

Glucose, 2hr

Glucose, 3hr

82951/82952 x2 Glucose, 5 specimens Glucose, Fasting BS

Glucose, 1hr Glucose, 3hr

Glucose, 2hr Glucose, 4hr

Triple Screen AFP Serum 82105 hCG Quantitative 84702 Free Estriol 82677

Custom LFT 4 (TB Elimination) ALT (SGPT) 84460 AST (SGOT) 84450 Bilirubin, Total 82247 Alk. Phosphatase 84075

Custom LFT 6 (TB Elimination) ALT (SGPT) 84460 AST (SGOT) 84450 Bilirubin, Total 82247 Alk. Phosphatase 84075 BUN 84520 Creatinine 82565

Note: Medicare does not pay for routine screening tests (except PAP smears and some occult blood tests, please see current Medicare guidelines for

approved screening intervals). Medicare will only pay for tests that are medically necessary for the diagnosis or treatment of the patient. The

ordering physician must obtain a signed Advance Beneficiary Notice, (ABN), prior to submitting specimen to the laboratory if it is believed that

Medicare is likely to deny payment. Components of panels may be ordered individually and billed separately to ensure physicians have adequate

choice when making decisions regarding which tests are medically necessary for an individual patient. Physicians shall provide ICD-9 codes for all

tests or panels in the space provided. The Office of the Inspector General takes the position that a physician who orders medically unnecessary tests

may be subject to civil penalties.

Microbiology CPT codes for additional procedures (such as susceptibility testing, sero-typing, etc) will be billed in addition to primary culture codes

when appropriate.

The M47 test requisition form is only a partial list of tests available. If a test you require is not listed on the requisition form please call 1-888-440-5002 for information. WHL-Public500 (M47) Page2 Revised: 6/04

E–60

THSteps Forms

E

E.38 Specimen Submission Form G-1A InstructionsInstructions for G-1A Microbiology Form

Section 1. SUBMITTER INFORMATIONSubmitter Number, Submitter Name and Address: A master form with submitter information has been supplied for your convenience. Please use it as a master and submit photocopied forms for submission of your specimens. The Submitter number is a unique number that the Bureau of Laboratories assigns to each of our submitters. If you need a submitter number, your submitter information changes, or you need a new master form, please contact us at the Texas Department of Health (TDH), Bureau of Laboratories 512-458-7578, fax 512-458-7294.

Contact Information: Give the name, telephone, and fax number of the person to contact at the submitting facility if additional information about the specimen/isolate is needed.

Clinic Code: Provide clinic code if applicable. If a submitter has a primary mailing address with satellite offices, a clinic code can be entered so the TDH laboratory can send the results directly to the satellite office.

Section 2. PATIENT INFORMATION Date of Collection: Give the date the specimen was collected from the patient or other source. Do not give the date it was sent to TDH.

Previous TDH Number: If this patient has had a previous specimen submitted to the TDH laboratory, provide the TDH specimen number.

Patient Name and Address: Complete all patient information including first and last name, address, city, state, zip, sex, race, ethnicity, and SSN. Information that is required to bill Medicare and Medicaid has been marked with double asterisks (**). You may use a pre-printed patient label. For anonymous HIV testing, provide a synonym for the name and indicate only state, zip, DOB, and patient ID number.

DOB: Give both the DOB and age. If DOB is not available, give the age of the patient and tell us whether the age is in days, months or years.

Pregnant: If patient is a female indicate Yes, No, or Unknown. Pregnancy can affect test results.

Patient ID Number: Provide identification number for matching purposes. For HIV screening, this number may be the eight-digit CDC number assigned to the patient. The CDC form sticker may be placed anywhere on the lower part of the form, as long as it does not obscure any tests ordered.

ICD Diagnosis Code, Country of Origin, Date of Onset, Diagnosis/Symptoms, Risk (if applicable): Indicate any diagnosis or findings that would help in processing and identification of this specimen/isolate. Provide the patient’s country of origin if it is other than US.

Inpatient or Outpatient(if applicable): Indicate if the patient is currently admitted to a hospital (required for TB patients).

Outbreak/Surveillance(if applicable): Tell us whether the specimen/isolate is part of an outbreak or cluster, or if the specimen is for routine surveillance. If the specimen is being submitted because of an outbreak write in the associated name of the outbreak next to the outbreak box.

If this form is being submitted for flu surveillance, the following patient information is required: Date of onset, Date of collection, Diagnosis/Symptoms, and Risk. Dates must be entered into the Date of onset and Date of collection boxes. In the Diagnosis/Symptomsbox list all the symptoms from the following list that apply: 1) malaise, 2) sore throat, 3) nasal congestion, 4) fever, 5) chills, 6) cough, 7) headache, 8) myalgia. In the Risk box, indicate whether the patient received the flu vaccine this season and the date given.

Section 3. PHYSICIAN INFORMATIONPhysician Name and UPIN(if applicable): Give the name of the physician and their unique physician ID number (UPIN) if applicable. This information is required to bill Medicare.

Section 4 PAYOR SOURCEIndicate whether we should bill the submitter, Medicaid, Medicare, private insurance, or other. If Medicaid or Medicare is selected, the

Medicaid/Medicare number is required. If private insurance or other is selected, the required billing information is indicated with an (*). If required information is not provided, THE SUBMITTER WILL BE BILLED.

If you are contracting with and/or enrolled with a TDH program to provide services that require laboratory testing, please indicate which program. See one of the following pages for program descriptions.

(For anonymous HIV/STD testing, the following information is not required.) HMO/Managed Care/Insurance Company: Print the name, address, city, state, and zip of the HMO, managed care, or insurance company to be billed. Please attach a copy of both sides of the responsible party’s insurance card if it is available.

Responsible Party: Print the name of the responsible party, the insurance ID number, group name, and group number.

Signature and Date: Have the responsible party sign a release if we are to bill their insurance or HMO.

Section 5. SPECIMEN SOURCE OR TYPESpecimen Source or Type: Indicate the kind of material you are submitting or the source of the specimen or isolate.

Tests requiring Acute/Convalescent sera and dates are indicated with an χ in the testing area of the form.

For tuberculosis treatment, a specimen source or type MUST be provided for specimens used for the diagnosis or monitoring of TB.DO NOT leave this section blank. For specimens other than those listed, check the ‘Other’ box and write in the site and source selected from the TB Elimination Division’s list of Anatomic Sites and Corresponding Specimen Sources, which can be obtained from your local or regional health department.

TESTTest Requested: Check or specify the specific test(s) to be performed by the TDH Bureau of Laboratories. Each test block requires a separate form AND a separate specimen. Examples of separate blocks are Reference Serology/Immunology or Virology or Bacteriology. If a second specimen is submitted, please review the Payor Source information to make sure the information is accurate for the second specimen. For specific test instructions see the Bureau of Laboratories’ Manual of Services.

If you have questions, want to order copies of the Manual of Services or would like additional information on a specific assay, please call the TDH Bureau of Laboratories 512-458-7318, fax 512-458-7294 or visit our web site at http://www.tdh.state.tx.us/lab/.

MAILING INSTRUCTIONSFold the form with the information on the form showing. Roll the form around the inner container with the test requested side up. Package the specimen according to instructions in the Bureau of Laboratories’ Manual of Services. Attach a white TDH label to the outside of the package or container.

For mailing supplies or questions about mailing a specimen call512-458-7661.

E–61

Appendix E

Instructions for Microbiology Specimens

General Instructions: 1) Clearly label each specimen with the patient’s first and last name exactly the way it is written on the laboratory request form. Retain a copy of

submission form for your records. 2) Pre-printed patient labels used for specimen identification MUST match the patient name on the submission form. 3) Triple contain specimens with sufficient absorbent materials to avoid breakage. 4) Specimens may be sent at room (ambient) temperature unless otherwise noted. 5) Include a completed G-1A form for each patient with corresponding specimen tube. 6) Mark specimen source or type on form. Include date collected for acute and convalescent serum specimens. Include site for abscess, lesion, lymph

node, tissue and wound biopsies. 7) Specimens marked with an @ symbol require patient history including date of onset, date(s) of collection, symptoms, exposure and travel history.

Please provide on reverse side of form. 8) Further details of test and specimen requirements may be found in the Bureau of Laboratories’ Manual of Services. Visit our web site at

http://www.tdh.state.tx.us/lab/.

TEST GROUP REQUIRED SPECIMEN TYPE SPECIAL INSTRUCTIONS

Reference Serology/Immunology 1 red or tiger top tube Cerebrospinal fluid (CSF)

Specimens marked with a χ require acute and convalescent serum specimens for diagnosis. A single specimen may be submitted for immune status only.

CDC Reference Tests 1 red or tiger top tube (CSF is acceptable for certain tests. See Reference Manual for further instructions.)

Specimens MUST be submitted with a complete patient history (see #7 above).

MCH Screening 1 red or tiger top tube This test block is to be used for Title V MCH only and Title V Family Planning when requesting Rubella only. For other patients, please order the tests separately under Reference Serology (Hepatitis B and Rubella), HIV Screening and Syphilis Serology.

Syphilis Serology 1 red or tiger top tube CSF (for suspected neurosyphilis only)

Please mark syphilis screen or test of cure. Two tubes of blood are needed if syphilis testing is requested with any other serology.

HIV/HCV Screening 1 red or tiger top tube 1 oral transudate (Ora-Sure) sample Dried blood spot filter card

Plasma, collected in a green or purple top tube, is alsoacceptable for HIV screening.Ora-Sure and filter card specimens are not acceptable for Hepatitis C testing. HCV screening available only for approved Counseling and Testing sites. For other HCV testing, see under Reference Serology/Immunology.

Mycobacteriology/Mycology Clinical specimens collected and stored at room (ambient) temperature in a single, sterile, leak-proof, disposable plastic container.

Refrigerate the specimen until it can be transported. Exception: store blood and cerebrospinal fluid

specimens for fungal isolation at 30°C to 37°C if transport delayed by more than several hours. Submit at least 3 mL of a liquid specimen; add 3 to 10 mL of sterile saline to a solid specimen prior to submission to prevent dehydration.

Virology Clinical specimens for viral isolation, if

delivered in <48 hr, send at 2-8° C; >48 hr, send frozen on dry ice

For viral identification (of isolates), send cell culture monolayer with CPE at room temperature (or) frozen isolate on dry ice.

Entomology Skin biopsy or skin scrapings from site of lesion, send on wet ice; frozen thin sections from skin biopsy, send on dry ice. Whole blood or CSF may be sent on wet ice.

Insect ID - All insects, except flies, can be submitted in alcohol. Flies must be submitted dry in a secure container (i.e. zip-lock bag).Send specimens at room temperature.

Parasitology Stool specimens collected in a dry, clean, leak proof container. Two to five hours after collection the stool sample should be placed in preservative. Adult worms should be placed in a preservative.Blood specimens should be collected with an anticoagulant, preferably EDTA unless for malaria, then the preferred specimen is a capillary blood sample. Specimens should be sent at room temperature.

Please state type of preservative on the form.

If tissue specimen is going to be set up for culture, then the tissue sample should be placed into a sterile container. If tissue will not be set up for culture, then it can be sent in a preservative such as formalin.

Bacteriology Clinical specimens collected on appropriate media. Gen-Probe swabs. Stool specimens must be kept cold and submitted on cold packs or wet ice.

Pure cultures submitted on appropriate transport media, safely contained and labeled as infectious material.For pure culture identification, please provide biochemical data on reverse side of form.

E–62

THSteps Forms

E

Program Descriptions

THStepsTexas Health Steps (THSteps) is the preventive care and treatment program for eligible children and adolescents under 21 years of age in the Texas Medicaid program. Required laboratory specimens obtained during a THSteps periodic preventive medical check-up must be submitted to the Texas Department of Health (TDH) Laboratory and are paid for by the THSteps program.

HIV/STD Program The HIV/STD Program encompasses prevention activities supported by the Bureau of HIV and STD Prevention (Bureau). These include HIV/STD/HCV counseling and testing, disease investigation and follow-up, prevention counseling and partner management. Agencies eligible to submit specimens for chlamydia/gonorrhea testing through the HIV/STD program are STD clinics, Infertility Prevention Project Sentinel Sites, or agencies examining a client for STDs at the request of an STD program. Agencies eligible to submit specimens for HIV and/or syphilis testing are STD clinics, agencies examining a client at the request of an STD program, and Bureau prevention contractors. Agencies eligible to submit specimens for HCV testing are Bureau HCV contractors or other agencies having prior Bureau approval to submit HCV tests at the Bureau’s expense.

Immunizations The Immunization Division works with regional TDH programs and local health departments to ensure prompt reporting, investigating, laboratory testing, and implementation of control measures for vaccine-preventable diseases (measles, mumps, rubella, CRS, pertussis, hepatitis B, perinatal hepatitis B, tetanus, paralytic polio, diphtheria, invasive Haemophilus influenza type B,and varicella).

Infectious Disease Epidemiology and Surveillance Division (IDEAS)The IDEAS Division is responsible for assisting local and regional public health officials in investigating outbreaks of acute nonprogrammatic infectious diseases (e.g. foodborne, respiratory, and bloodborne pathogens). The IDEAS program conducts routine surveillance of diseases designated by the Board of Health as reportable.

Primary Health Care ProgramThe Primary Health Care (PHC) Program provides primary and preventive health care services to individuals at or below 150% of the Federal Poverty Income Level (FPIL) who do not have access

to the same services through other funding sources.

Refugee Health Screening ProgramThe TDH Refugee Health Screening Program (RHSP) brings newly arrived official refugees and other program-eligible legal immigrants into the public health system for evaluation for conditions of public health importance or which would impede a refugee's resettlement process. Health assessment, health education, immunizations, limited treatments, and/or referrals for identified problems are provided.

Service Delivery IntegrationService Delivery Integration (SDI) is an initiative of Texas Department of Health to streamline delivery of health care services to clients and reduce administrative burden to contractors. Currently it has 4 pilot projects, located at Smith County Public Health District, Tarrant County Health Department, Fayette Memorial Hospital in LaGrange and Giddings, and Denton County Health Department. The current in-scope programs are: Title V Maternal and Child Health, Titles X & XX Family Planning, Primary Health Care and Tuberculosis Elimination.

Title V- Maternal and Child HealthThe Maternal and Child Health Fee For Service (MCH FFS) Program provides primary and preventive care to women of reproductive age and children from birth to 21 years of age (e.g., prenatal care, dysplasia services, well child care, some acute child care, and dental services for children) who are at or below 185% of the Federal Poverty Income (FPIL), reside in Texas,and are not covered under another funding source for the same services.

Title V- Family Planning The Title V Family Planning (FP) Program provides family planning services to females 12 years to 45 years of age, other potentially fertile women age 45 years and older, and males 21 years of age or older seeking a vasectomy who are at or below 185 % of the Federal Poverty Income Level (FPIL), reside in Texas, and are not covered under another funding source for the same services.

Title XTitle X (Public Health Services Act 42 U.S.C. 300 et seq) family planning funding is used to develop and maintain infrastructure for contractors. The funding can be used to support payment for clinic facilities, staff salaries, utilities, medical and office supplies, equipment, and travel, as well as direct medical services for reproductive health. Contract agencies bill on a monthly basis using a cost-reimbursement allocation.

Title XXTitle XX (Social Services Block Grant of the Social Security Act) family planning funding is used for individual and community-wide educational activities as well as for direct medical care for reproductive health. Contractors bill for Title XX reimbursable services on a fee-for-service basis.

Tuberculosis The Tuberculosis Elimination Division assists local and regional health departments to identify and provide treatment for people in Texas with tuberculosis disease, to identify people with latent tuberculosis infection through contact investigations and targeted tuberculosis screening programs, and to provide treatment for people with latent tuberculosis infection. Agencies submit specimens to TDH laboratories to confirm a diagnosis of tuberculosis disease, to screen for resistance for anti-tuberculosis medications, to monitor response to treatment, and to identify the strain of bacteria for epidemiological surveillance studies.

Zoonosis The Zoonosis Control Division is responsible for the control and prevention of diseases that are transmittable from animals to people (including, among others, rabies, West Nile and other arboviruses, hantavirus, and plague) through arthropod and animal surveillance, human case investigations, education and consultation, outbreak investigation, and implementation of control measures.

Other Only use this box if you have contracted to do a special study with a TDH program that is not already listed and indicate which program you are working with.

E–63

Appendix E

E.39 Specimen Submission Form G-1A

E–64

THSteps Forms

E

E.40 Specimen Submission Form G-1B Instructions

Instructions for Biochemistry and Genetics G-1B

Section 1. SUBMITTER INFORMATIONSubmitter number/TPI, Submitter name and Address: The Submitter number is a unique number that the Texas Department of Health (TDH) Bureau of Laboratories assigns to each of our submitters. If you need a submitter number, your submitter information changes, or you need a new master form please call (512) 458-7578. For THSteps specimens, use the pre-assigned TPI (Texas Provider Identifier) number. Contact NHIC to obtain a TPI number at 1-800-925-9126. All submitter information is required. Indicate submitter name, address, city, state. Please print clearly, or use a pre-printed label. A form with completed submitter information may be used as a master form, which can be photocopied.

Contact Information: Indicate the name, telephone, and fax number of the person to contact at the submitting facility in case the laboratory needs additional information about the specimen/isolate.

Clinic Code: Provide if applicable. If a submitter has a primary mailing address with satellite offices, a clinic code can be entered so the TDH laboratory can send the results directly to the satellite office.

Section 2. PATIENT INFORMATIONPatient name and Address: Complete all patient information including first name, middle initial and last name, address, city, state, zip, race, ethnicity, sex, and SSN. Information that is required to bill Medicare and Medicaid has been marked with double asterisks (**). You may use a pre-printed patient label. For anonymous HIV testing, indicate only state, zip, date of birth, and patient ID number.

Date of birth(DOB): Give both the date of birth and age. If date of birth is not available, give the age of the patient and tell us whether the age is in days, months, or years.

Pregnant: If patient is a female indicate Yes, No, or Unknown. Pregnancy can affect test results.

Date of collection: Indicate the date and time the specimen was collected from the patient or other source and who collected the specimen. Do not give the date the specimen was sent to TDH.

Patient ID number: Provide the identification number for matching purposes. For HIV screening, this number may be the eight digit CDC number assigned to the patient. The CDC form sticker may be placed anywhere on the lower part of the form, as long as it does not obscure any tests ordered.

ICD diagnosis code: Indicate the diagnosis code that would help in processing, identification, and billing of this specimen/isolate.

Previous TDH specimen number: If this patient has had a previous specimen submitted to the TDH laboratory, provide the TDH specimen number.

Section 3. SPECIMEN TYPESpecimen type: Tell us what kind of specimen you are submitting.

Section 4. FAMILY INFORMATION FOR DNA STUDIESIf submitting specimen for a DNA study, please provide information about all other family members being tested. On the back of the form, draw a pedigree showing the relationship and clinical diagnosis of each family member participating in the study.

Section 5. TRIPLE SCREEN REQUEST & PATIENT INFORMATIONTo order this test, check the box Triple Screen. In order to interpret this test all patient information in Section 5 of this form must be provided, including patient's name, date of birth, date of collection, race, and current weight. Without date of collection of the specimen, accurate gestational age, maternal weight, maternal date of birth, maternal race, and information about maternal health status, a complete assessment cannot be made. When information is incorrectly recorded or left out it will not only delay test results, but can also produce incorrect test results. For information on triple screens: 1-800-687-4363 Fax 512-458-7139.

Section 6. PHYSICIAN INFORMATIONPhysician’s name and UPIN: Give the name of the physician and their unique physician ID number if applicable. This information is required to bill Medicare.

Section 7. PAYOR SOURCEIndicate whether we should bill the submitter, Medicaid, Medicare, private insurance, or other. If Medicaid or Medicare is selected, the Medicaid/Medicare number is required. If private insurance or other is selected, the required billing information is indicated with an (*). If required information is not provided, THE SUBMITTER WILL BE BILLED.

If you are contracting and/or enrolled with a TDH program to provide services that require laboratory testing, please indicate which program. See one of the following pages for program descriptions.

(For anonymous HIV/STD testing, the following information is not required.) HMO/Managed care/Insurance company: Print the name, address, city, state, and zip of the insurance company to be billed. Please attach a copy of both sides of the responsible party’s insurance card if it is available.

Responsible party: Print the name of the responsible party, the insurance ID number, insurance company phone no., group name, and group number.

Signature and Date: Have the responsible party sign a release if we are to bill their insurance or HMO.

Sections 8, 9, 11 Test Requested: Check or specify the specific test(s) to be performed by the Bureau of Laboratories. Information about tube types for different tests and specific instructions for submitting samples are on the following page. For specific tests instructions see the Bureau of Laboratories’ Manual of Services. If you have questions, want to order copies of the Manual of Services or would like additional information on a specific assay, please call the TDH Bureau of Laboratories at 512-458-7318, fax 512-458-7294 or visit our web site at http://www.tdh.state.tx.us/lab/.

Section 9Please specify one or more of the following categories in the “RISK” space provided on the form: (A) Close blood relative of known diabetic (B) Obese (C) Mother of baby 9 lbs. or over (D) Control check on known diabetic

Section 10Section 10 is to be used only when a THSteps provider is completing a comprehensive medical check-up or a Title V provider is completing a well child visit.

MAILING INSTRUCTIONSFold the form with the information on the form showing. Roll the form around the inner container with the test requested side up. Package the specimen according to instructions in the Bureau of Laboratories’ Manual of Services. Attach a TDH label to the outside of the package or container. For mailing supplies or questions about mailing a specimen call 512-458-7661.

E–65

Appendix E

Instructions for Biochemistry and Genetics Specimens

General Instructions: 1) Clearly label each specimen with the patient’s first and last name exactly the way it is written on the laboratory request form.2) Retain a copy of submission form for your records. 3) Pre-printed patient labels used for specimen identification MUST match the patient name on the submission form. 4) Triple contain specimens with sufficient absorbent materials to avoid breakage. 5) Include request form for each patient with corresponding specimen tube. 6) Mail specimens within 24 hours of collection except specimen for Triple Screen testing and DNA studies. DNA Studies and Triple Screen samples

should be shipped overnight. If specimen must be held, store under refrigeration (DO NOT FREEZE), but do not hold more than 3 days.7) Air dry filter paper specimens 3 to 4 hours before mailing.

Special Requirements: Each test request must be submitted with a separate form and specimen.

EXCEPTIONS: See special instructions below for DNA studies and THSteps submissions.

TEST GROUP REQUIRED SPECIMEN TYPE SPECIAL INSTRUCTIONS

*Submit only one form on each patient for the tests in the shaded areas.

Section 5. TRIPLE SCREEN

2 mL serum transferred to blue top tube specific for Triple Screen

Specimen must be collected between 15 and 21 completed gestational weeks, preferably weeks 16-18. Specimen MUST be shipped overnight the same day of collection. Be sure to check Saturday delivery if shipping out on Friday. Without date of collection of the specimen, accurate gestational age, maternal weight, maternal date of birth, maternal race, and information about maternal health status, a complete assessment cannot be made. When information is incorrectly recorded or left out it will not only delay test results, but can also produce incorrect test results. For information on triple screens: 1-800-687-4363 Fax 512-458-7139

Section 8. DNA STUDIES

For all tests Filter paper or 1 purple top 5 – 10 mL whole blood. Whole blood MUST be shipped overnight the same day of collection. For family study, please fill in information for each relative being tested in Section 4 of the G1-B form and draw pedigree between affected individuals and family members on reverse side of form.

Section 9. CLINICAL CHEMISTRY

Hyperlipidemia 1 red top

Lead testing 1 purple top

Hemoglobin, total 1 purple top

Hemoglobin, electrophoresis 1 purple top

HDN screening (Rhogam) 1 red top

Diabetes 1 gray top – 1mL plasma may be separated from cells and submitted.

Gray top containing sodium fluoride/potassium oxalate.Each tube must be submitted with a separate form. Pleasespecify one or more of the following categories in the “RISK” space provided on the form: (A) Close blood relative of known diabetic (B) Obese (C) Mother of baby 9 lbs. or over (D) Control check on known diabetic

Section 10. THSteps/TITLE V WELL CHILD HEALTH

Hemoglobin, total 1 purple top

Hemoglobin, electrophoresis 1 purple top

Lead screen 1 purple top

Syphilis (RPR) 1 red top

Fill blood collection tubes ½ full. Submit only one purple top and/or red top for each patient. Only one completed G-1B form is needed for these four tests. For Medicaid patients ensure patient’s name on the form exactly matches patient’s name on Medicaid card.

Total cholesterol 1 red top

Lipid profile 1 red top

Gonorrhea/Chlamydia (gen probe) 1 Gen-Probe swab

HIV 1 red top

Section 11. NEWBORN REFERENCE TESTING

Phenylalanine Filter paper dried blood spot or 1 red top or 1 purple top

Tyrosine 1 red top or 1 purple top

At least 0.5mL of plasma or serum

Hemoglobin, electrophoresis 1 purple top At least 0.5mL whole blood

Thyroid profile 1 red top At least 1.0mL of serum

E–66

THSteps Forms

E

Program Descriptions

THStepsTexas Health Steps (THSteps) is the preventive care and treatment program for eligible children and adolescents under 21 years of age in the Texas Medicaid program. Required laboratory specimens obtained during a THSteps periodic preventive medical check-up must be submitted to the Texas Department of Health (TDH) Bureau of Laboratories and are paid for by the THSteps program.

TX CLPPP-Childhood Lead Poisoning Prevention ProgramThe Texas Childhood Lead Poisoning Prevention Program manages the childhood lead poisoning surveillance program which includes a registry of Texas children and their blood lead levels; a program to ensure follow-up of children with elevated blood lead levels; and appropriate investigation, education, and intervention to prevent additional incidents of childhood lead poisoning.

Service Delivery IntegrationService Delivery Integration (SDI) is an initiative of the Texas Department of Health to streamline delivery of health care services to clients and reduce administrative burden to contractors. Currently it has 4 pilot projects, located at Smith County Public Health District, Tarrant County Health Department, Fayette Memorial Hospital in LaGrange and Giddings, and Denton County Health Department. The current in-scope programs are: Title V Maternal and Child Health, Titles X & XX Family Planning, Primary Health Care and Tuberculosis Elimination.

Primary Health Care Program The Primary Health Care (PHC) Program provides primary and preventive health care services to individuals at or below 150% of the Federal Poverty Income Level (FPIL) who do not have access to the same services through other funding sources.

Refugee Health Screening ProgramThe TDH Refugee Health Screening Program (RHSP) brings newly arrived official refugees and other program-eligible legal immigrants into the public health system for evaluation for conditions of public health importance or which would impede a refugee's resettlement process. Health assessment, health education, immunizations, limited treatments, and/or referrals for identified problems are provided.

Newborn Screening Case Management ProgramThe Newborn Screening (NBS) Case Management Program follows up on the abnormal newborn screens and ensures that babies with abnormal tests are evaluated by a physician, confirmatory testing is done and treatment is started if a diagnosis is confirmed. Specimens for NBS reference testing and DNA studies may be submitted to the TDH laboratory.

Title V- Maternal and Child HealthThe Maternal and Child Health Fee For Service (MCH FFS) Program provides primary and preventive care to women of reproductive age and children from birth to 21 years of age (e.g., prenatal care, dysplasia services, well child care, some acute child care, and dental services for children) who are at or below 185% of the Federal Poverty Income (FPIL), reside in Texas, and are not covered under another funding source for the same services.

Title V- Family Planning The Title V Family Planning (FP) Program provides family planning services to females 12 years to 45 years of age, other potentially fertile women age 45 years and older, and males 21 years of age or older seeking a vasectomy who are at or below 185 % of the Federal Poverty Income Level (FPIL), reside in Texas, and are not covered under another funding source for the same services.

Title XTitle X (Public Health Services Act 42 U.S.C. 300 et seq) family planning funding is used to develop and maintain infrastructure for contractors. The funding can be used to support payment for clinic facilities, staff salaries, utilities, medical and office supplies, equipment, and travel, as well as direct medical services for reproductive health. Contract agencies bill on a monthly basis using a cost-reimbursement allocation.

Title XXTitle XX (Social Services Block Grant of the Social Security Act) family planning funding is used for individual and community-wide educational activities as well as for direct medical care for reproductive health. Contractors bill for Title XX reimbursable services on a fee-for-service basis.

Other Only use this box if you have contracted to do a special study with a TDH program that is not already listed and indicate which program you are working with.

E–67

Appendix E

E.41 Specimen Submission Form G-1B

E–68

E–69

THS

teps Forms

E.

PT

P

N1 s not cancel the need for tuberculin skin

2 ss syringe.

3 e of the left arm is practiced universally y the health care worker who reads the exact site of injection.

45 gle at the skin surface, promoting the

6 deep), or the wheal is smaller than 6 mmhe antigen leaked on the outer surface of eters (two inches) from the original site.

T1 y.23 s.

4

5 ered to be of no significance.

E

42 Guidelines: Tuberculosis Skin Testing (2 Pages)

DEPARTMENT OF STATE HEALTH SERVICESGUIDELINES: TUBERCULOSIS SKIN TESTING

(PPD/MANTOUX)

urpose: Equipment:he tuberculosis intradermal skin test is used to detect tuberculosis infection. • PPD (purified protein derivative) tuberculin antigen • To detect infection, either past or present, with Mycobacterium tuberculosis. • Tuberculin syringe • To serve as a diagnostic procedure in selected patients. • 1/4” to 1/2”, 27-gauge needle

• Alcohol sponge or swab

rocedures:

ursing Action: Rationale/Amplification:. Determine if patient has ever had BCG vaccine, a previously positive skin test,

recent viral disease or immunization with a live virus vaccine within the last 30 days,immunosuppression by disease, drugs, or steroids.

1. A history of BCG vaccine should be documented but doetesting.

. Draw up 0.1 ml of PPD-tuberculin into tuberculin syringe. Each 0.1 ml should contain5 TU (tuberculin units of PPD-tuberculin).

2. Use immediately to avoid absorption onto the plastic/gla

. Cleanse the skin of the volar (palm side) surface of the left arm with alcohol. Allow to dry.

3. An intradermal test may be applied at any site but the usto facilitate identifying the location of the injection site btest. If the test is applied at another site, document the

. Stretch the skin taut. 4. Facilitates the introduction of the needle.

. Hold the tuberculin syringe close to the skin, bevel up, so that the hub of the needle touches it as the needle is introduced.

5. Holding the syringe in this way will reduce the needle ancorrect entry for a proper intradermal injection.

. Inject the tuberculin into the superficial layer of the skin to form a wheal 6mm to 10 mm in diameter.

6. If no wheal appears (because the injection was made too(because the needle was not under the skin and part of tthe skin), reapply test at another site at least five centim

o Read the Test: Further Clarification to Reading the Test:. Read the test within 48–72 hours. 1. Tuberculin skin tests are tests of delayed hypersensitivit. Have a good light available. Flex the forearm slightly at the elbow.. Inspect for the presence of induration. Inspect from a side view against the light.

Inspect by direct light.3. Induration refers to hardening or thickening of the tissue

. Palpate: lightly rub the finger across the injection site from the area of normal skin to the area of induration. Outline the diameter of induration.

. Measure the maximum transverse diameter of induration (not erythema) in milli-meters with a flexible ruler.

5. Erythema (redness) without induration is generally consid

E–70

Appendix E

sitivity or a low grade sensitivity that most likely is test does not rule out the presence of tuberculosis.ive result, the tuberculin skin test should never be isease among persons for whom the diagnosis is

t has had contact with the bacillus that causes n that active disease is present in the lung;

ersons with active tuberculosis and who have ositive and be evalutated for treatment of either rculosis disease.

m should be evaluated for treatment of either rculosis disease.

skin test reactions who undergo repeat skin ease in reaction size of 10 mm or more within a n test conversion indicative of recent infection with ave been infected with nontuberculous mycobac-

the skin test may show some degree of induration. sitive” is defined as an increase in induration by

sk and are tested at entry into employment, a red positive.

f Tuberculosis in Adults and Children, Am J Respir

is: What the Clinician Should Know, CDC, 2004, eCurr/index.htm

uide, CDC, 2003, www.cdc.gov/nchstp/tb/pubs/

DEPARTMENT OF STATE HEALTH SERVICESGUIDELINES: TUBERCULOSIS SKIN TESTING

(PPD/MANTOUX)Procedures

Interpretation1. Negative reaction: An induration of 0–< 5 mm 1. This shows either a lack of tuberculin sen

not caused by M. tuberculosis. A negative Because of the possibility of a false-negatused to exclude the possibility of active dbeing considered.

2. Positive Reaction:a. An induration of 5 mm or more is considered to be positive for: 2a. A positive reaction indicates that a patien

tuberculosis. It does not necessarily meahowever, further evaluation is required.Individuals who are in close contact with preactions > 5 mm should be considered platent tuberculosis infection or active tube

1) HIV-positive persons2) Recent contacts of TB case3) Individuals with fibrotic changes on chest radiograph consistent with old TB4) Patients with organ transplants and other immunosuppressed patients

(receiving the equivalent of > 15 mg/d Prednisone for > 1 month)b. An induration of 10 mm or more is considered to be positive for: 2b. Individuals with skin test results of > 10 m

latent tuberculosis infection or active tube1) Recent arrivals (< 5 yr) from high-prevalence countries2) Injection drug users Note: For persons with negative tuberculin

testing (e.g., healthcare workers), an incrperiod of 2 yrs should be considered a skiM. tuberculosis. In some individuals who hteria or have undergone BCG vaccination, For these individuals, a conversion to “po10 mm on subsequent tests.

3) Residents and employees* of high-risk congregate settings: prisons and jails, nursing homes and other healthcare facilities, residential facilites for AIDS patients, and homeless shelters

4) Mycobacteriology laboratory personnel5) Persons with clinical conditions that make them high-risk: silicosis, diabetes

mellitus, chronic renal failure, some hematologic disorders (e.g., leukemias and lymphomas), other specific malignancies (e.g., carcinoma of the head or neck and lung), weight loss of > 10 % of ideal body weight, gastrectomy, jejunoileal bypass

2b3. * For persons who are otherwise at low rireaction of > 15 mm induration is conside

6) Children < 4 yrs of age or infants, children, and adolescents exposed to adults in high-risk categories

c. An induration of 15 mm or more is considered to be positive in individuals with no riskfactors for tuberculosis

Documentation References1. Record name of antigen, manufacturer, lot number, date of testing, and date of reading. 1. Diagnostic Standards and Classification o

Crit Care Med; 161, pp 1376–1395, 20002. Record site of application of test if applied at site other than the left volar surface.3. Record the size of induration. 2. Interactive Core Curriculum on Tuberculos

www.cdc.gov/nchstp/tb/webcourses/Cor

3. Mantoux Tuberculin Skin Test Facilitator GMantoux/tableofcontents.htm

THSteps Forms

E

E.43 Tuberculosis (TB) Screening and Education ToolThis screening tool for tuberculosis (TB) exposure risk is to be used annually to determine the need for tuberculin skin testing. The screening tool need not be done at visits for which tuberculin skin testing is required: ages 12-15 months and 5 years.

The questions in this screening tool are intended as a minimum screen. Follow up questions may be necessary to clarify hesitant or ambiguous responses. Questions specific to TB exposure risks in the child’s community may need to be added.

• If all the answers are unqualified negatives the child is considered at low risk for exposure to TB and will not need tuber-culin skin testing.

• If the answer to any question is “Yes” or “I don’t know,” the child should be tuberculin skin tested.

• In the case of the child for whom an answer in the past of “Yes” or “I don’t know” prompted a skin test, which was negative, the skin test may not have to be repeated annually.

• The decision to skin test must be made by the medical provider based upon an assessment of the possibility of exposure. A negative tuberculin skin test never excludes tuberculosis infection or active disease.

• BCG vaccinated children should also have the screening tool administered annually. Previous BCG vaccination is not a contraindication to tuberculin skin testing. Positive tuberculin skin tests in BCG vaccinated children are interpreted using the same guidelines used for non-BCG vaccinated children.

• Children who have had a positive TB skin test in the past (whether treated or not), should be re-evaluated at least annually by a physician for signs and symptoms of TB.

Care of children who are newly discovered to be tuberculin skin test positive includes:

• An evaluation for signs and symptoms of TB

• A chest X-ray to rule out active disease

• Oral medications to prevent progression to active disease or multi-drug therapy if active disease is present

• Referral for consultation by a pediatric TB specialist is recommended if active disease is present

• A report to the local health authority for investigation to find the source of the infection

Feel free to photocopy the screening and education tool from this publication.

E–71

Appendix E

E.44 TB Questionnaire

Name of Child____________________________________________________________Date of Birth ________________

Organization administering questionnaire______________________________________ Date_______________________

Tuberculosis (TB) is a disease caused by TB germs and is usually transmitted by an adult person with active TB lung

disease. It is spread to another person by coughing or sneezing TB germs into the air. These germs may be breathed in by

the child.

Adults who have active TB disease usually have many of the following symptoms: cough for more that two weeks duration,

loss of appetite, weight loss of ten or more pounds over a short period of time, fever, chills and night sweats.

A person can have TB germs in his or her body but not have active TB disease (this is called latent TB infection or LTBI).

Tuberculosis is preventable and treatable. TB skin testing (often called the PPD or Mantoux test) is used to see if your

child has been infected with TB germs. No vaccine is recommended for use in the United States to prevent tuberculosis.

The skin test is not a vaccination against TB.

We need your help to find out if your child has been exposed to tuberculosis.

Place a mark in the appropriate box: Yes No Don't

Know

TB can cause fever of long duration, unexplained weight loss, a bad cough (lasting over two

weeks), or coughing up blood. As far as you know:

has your child been around anyone with any of these symptoms or problems? or

has your child had any of these symptoms or problems? or

has your child been around anyone sick with TB?

Was your child born in Mexico or any other country in Latin America, the Caribbean, Africa,

Eastern Europe or Asia?

Has your child traveled in the past year to Mexico or any other country in Latin America, the

Caribbean, Africa, Eastern Europe or Asia for longer than 3 weeks?

If so, specify which country/countries?______________________________________

To your knowledge, has your child spent time (longer than 3 weeks) with anyone who is/has

been an intravenous (IV) drug user, HIV-infected, in jail or prison or recently came to the

United States from another country?

Has your child been tested for TB? Yes___ (if yes, specify date ____/____) No___

Has your child ever had a positive TB skin test? Yes___ (if yes, specify date ____/____) No___

For school/healthcare provider use only

***************************************************************************************************

PPD administered Yes___ No___

If yes,

Date administered _____/_____/______ Date read ______/______/_______ Result of PPD test __________ mm response

Type of service provider (i.e. school, Health Steps, other clinics) _______________________________________________

PPD provider __________________________________________ ______________________________________

signature printed name

Provider phone number ___________________________________

City ________________________________________________ County ________________________________________

If positive, referral to healthcare provider Yes___ No___

If yes, name of provider _______________________________________________________________________________

EF12-11494 TB Questionnaire for Children (Rev. 08/04)

E–72

THSteps Forms

E

E.45 Cuestionario Para la Detección de Tuberculosis

Nombre del niño o niña _____________________________________________________________________________________

Organización ____________________________________________________________ Fecha ___________________________

La Tuberculosis (TB) es una enfermedad causada por gérmenes de TB y en la mayoriá de los casos es trasmitida por una persona

adulta con tuberculosis pulmonar activa. Se transmite a otra persona por la tos y por el estornudo al expelir gérmenes de TB al aire

que pueden ser respirados por los niños.

Los adultos que tienen la enfermedad activa casi siempre tienen varios de los siguientes síntomas: tos con duración de más de dos

semanas, pérdida de apetito, pérdida de peso de diez libras o más en un período corto de tiempo, fiebre, escalofríos y sudores

nocturnos.

Una persona puede tener gérmenes de TB en su cuerpo pero no tener la enfermedad activa. Esto se llama infección latente de TB

(o LTBI por su sigla en inglés).

La TB es prevenible y curable. La prueba tuberculínica, también llamada PPD o prueba de Mantoux, se utiliza para saber si su

niño o niña ha sido infectado/a con el germen de TB. No se recomienda ninguna vacuna para prevenir la tuberculosis. La prueba

tuberculínica no es una vacuna contra la tuberculosis.

Necesitamos de su ayuda para saber si su niño/niña ha sido expuesto/a a la tuberculosis.

Sí No No se

sabe

La tuberculosis puede causar fiebre de larga duración, pérdida de peso inexplicable, tos severa

(con más de dos semanas de duración), o tos con sangre. ¿Es de su conocimiento si:

su niño o niña ha estado cerca de algún adulto con esos síntomas o problemas?

su niño o niña ha tenido algunos de estos síntomas o problemas?

su niño o niña ha estado cerca de alguna persona enferma de tuberculosis?

¿Su niño o niña nació en México en o cualquier otro país de América Latina, el Caribe, Africa,

Europa Oriental o Asia?

¿Su niño o niña viajó a México o a cualquier otro país de América Latina, el Caribe, Africa,

Europa Oriental o Asia durante el último año por más de 3 semanas?

Si su respuesta es positiva, favor de especificar a qué país o países.

¿Es de su conocimiento, si su niño o niña pasó un tiempo (más de 3 semanas) con alguna persona

que es o ha sido usuario de droga intravenosa (IV), infectado por VIH, en la prisión, o haya

llegado recientemente a los Estados Unidos?

¿A su niño o niña se le ha realizado la prueba tuberculínica recientemente? Sí___ (si sí, especifique la fecha ____/____) No___

¿Su niño o niña alguna vez tuvo reacción positiva a la tuberculina? Sí___ (si sí, especifique la fecha ____/____) No___

Solamente para uso de la escuela o del proveedor de servicios médicos

******************************************************************************************************

¿Se administró PPD? Sí___ No___

Si sí,

Fecha en que fue administrada_____/_____/_____ Fecha de lectura _____/______/_____ Resultado de la prueba_____ mm

Tipo de proveedor de servicio (ej.: escuela, Health Steps, otras clínicas) ____________________________________________

Administrador de PPD ___________________________________________ _____________________________________

firma nombre en letra de molde (imprenta)

Número de teléfono del administrador de PPD ___________________________________

Ciudad________________________________________________ Condado_______________________________________

Si resultó positivo, ¿se refirió al proveedor de servicios de salud? Sí___ No___

Si sí, nombre del proveedor (médico o clínica, etc.) ____________________________________________________________

EF12-11494A (Rev. 08/04)

E–73

Appendix E

E.46 How to Determine TB Risk

Risk of potential tuberculosis exposureas revealed by questionnaire

NO

No skin testPast TB skin test

(+)Positive (-) Negative

No skin test

No skin test

Skin test

Clinical exam*

Clinical exam*

* Clinical exam includes:medical/social historyphysician examchest x-ray Consult physician/TB healthexperts about need for:bacteriologytreatment


No further action

Skin test

Clinical exam*


No further action

YES

YES NO

Has risk occurred since last negative skin test

YES NO

Therapy completed

YES NO

No further action

Symptoms of TB disease

YES NO

Clinical exam*

E–74

THSteps Forms

E

E.47 TVFC Patient Eligibility Screening Record (2 Pages)

TEXAS VACCINES FOR CHILDREN PROGRAM (TVFC) PATIENT ELIGIBILITY SCREENING RECORD

Purpose: To determine eligibility and the source of funds for the Texas Department of State Health Services to be reimbursed for vaccines. A record must be kept in the office of the health care provider that reflects the status of all children 18 years of age or younger, who receive immunizations through the Texas Vaccines for Children Program. The record may be completed by the parent, guardian, or individual of record, or by the health care provider. This same record may be used for all subsequent visits as long as the child’s eligibility status has not changed. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccines.

Date of Screening: ______________________

Child’s Name: ______________________________________________________________________________ Last Name First Name MI

Child’s Date of Birth: / / .

Parent/Guardian/Individual of Record: ________________________________________________________________________ Last Name First Name MI

Provider’s/Clinic’s Name: ___________________________________________________________________________

The above named child qualifies for vaccines through the Texas Vaccines for Children Program because he/she (check 1st category that applies, check only one)*: � (a) is enrolled in Medicaid or

� (b) does not have health insurance or � (c) is an American Indian or � (d) is an Alaskan Native or � (e) is underinsured (has health insurance that Does Not pay for vaccines, has a co-pay or deductible the family cannot meet, or

has insurance that provides limited wellness or prevention coverage) or � (f) is a patient who is served by any type of public health clinic and does not meet any of the above criteria or � (g) CHIP: is a patient who receives benefits from the Children’s Health Insurance Plan (CHIP)

*Pneumococcal conjugate vaccine may be administered in all TVFC-enrolled clinic sites to children in Categories “a”, “b”, “c”, “d”,and “g” only. This vaccine can only be given to children in Category “e” who have health insurance that does not pay for vaccineAND present for services in a Federally Qualified Health Center, Migrant Health Clinic, or Rural Health Clinic.

Texas Immunization Registry – ImmTrac Consent

The following is OPTIONAL. Checking “NO” will have no effect on your child’s eligibility to receive immunizations.

Consent for Registration of Child and Release of Immunization Records to Authorized Entities I understand that by granting consent below, I register my child in the Texas Department of State Health Services immunization registry and

authorize the registry to include my child’s information in the registry and to release past, present, and future immunization records on my child to a

parent of the child and any of the following: A) public health district or local health department; B) physician or health care provider; C) insurance

company, health maintenance organization or payor; D) school or child care facility in which the child is enrolled; and/or E) state agency having legal

custody of the child.

I understand that I may withdraw the consent to include information on my child in the ImmTrac Registry and my consent to release information

from the registry at any time by written communication to the Texas Department of State Health Services, Immunization Registry, 1100 West 49th

Street, Austin, Texas 78756. Please mark the box to indicate your consent.

YES. I GRANT CONSENT for registration. I WISH TO INCLUDE my child’s information in the Texas immunization registry.

NO. I DENY CONSENT for registration. I DO NOT WISH TO INCLUDE my child’s information in the Texas immunization registry.

_____________________ ______________________________________________________

Date Signature of Parent, Legal Guardian, or Managing Conservator

PRIVACY NOTIFICATIONWith few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the

information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.tdh.state.tx.us for

more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003 and 559.004)

Privacy Notice: “I acknowledge that I have received a copy of my immunization provider's HIPAA Privacy Notice.”

Texas Department of State Health Services Stock Number: C-10

Immunization Division Revised 08/2004

E–75

Appendix E

TEXAS VACCINES FOR CHILDREN (TVFC) PROGRAMA EN TEXAS DE VACUNAS PARA NIÑOS (TVFC)

REGISTRO SOBRE LA ELEGIBILIDAD DEL PACIENTE

Propósito: Determinar la elegibilidad del paciente y procedencia de fondos para el reembolso del costo de las vacunas al Departamento Estatal de

Servicios de Salud de Texas. Debe mantenerse un registro en la oficina del proveedor de atención de salud que refleje el estatus de todos los niños(as)

y jóvenes de 18 años o menores, quienes reciben inmunizaciones a través del Programa Texas Vaccines for Children. El registro puede ser llenado por

uno de los padres, por el tutor, por la persona que se está registrando, o por el proveedor de atención de salud. Este mismo registro puede ser utilizado

en todas las visitas siguientes, siempre y cuando el estatus de elegibilidad del niño no haya cambiado. Aún cuando no es necesario verificar las

respuestas, es necesario conservar este registro o uno similar, de cada uno de los niños a quienes se les aplican las vacunas.

Fecha de revisión de los antecedentes: .

Nombre del niño: .Apellido Nombre Inicial del segundo nombre

Fecha de nacimiento del niño: / /_________

Padre/ Tutor/ Persona que se registra: . Apellido Nombre Inicial del segundo nombre

Nombre del proveedor de atención de salud: .

(Marque la primera categoría que corresponda, marque solamente una*) El niño arriba mencionado tiene derecho a recibir las vacunas a través del Programa Texas Vaccines for Children debido a que él o ella:

(a) está inscrito en MEDICAID, o

(b) no tiene seguro para la atención de salud, o

(c) es Indio Americano, o

(d) es originario de Alaska, o (e) tiene poca cobertura de seguro (tiene seguro que No Paga por las vacunas, tiene un co-pago o deducible que la familia no alcanza a pagar, o tiene seguro que proporciona cobertura limitada para la prevención o el bienestar de la salud), o (f) es un paciente a quien se le da servicio en una clínica de salud pública y quien no cumple con los criterios arriba descritos, o (g) está inscrito en CHIP: es paciente quien recibe prestaciones a través del Children’s Health Insurance Plan (CHIP).

*La vacuna neumocócica conjugada puede ser administrada en todas las clínicas inscritas con TVFC en los niños de las Categorías “a”, “b”, “c”, “d”, y “g” únicamente. Esta vacuna solamente se puede administrar a los niños de la Categoría “e”, que tienen seguro de salud que no cubre las vacunas, TAMBIÉN, se les puede administrar a aquellos que se presentan a recibir servicios en un Centro Federal de Salud Aprobado, Clínica de Salud para Trabajadores Migratorios, o Clínica Rural de Salud.

Consentimiento del ImmTrac – Registro de Inmunización de Texas

La siguiente información es OPCIONAL. El marcar “NO” en la casilla, no tendrá efecto alguno sobre el derecho de su niño de recibir las vacunas.

Consentimiento para registrar al niño(a) y para poder dar a conocer a entidades autorizadas el récord de inmunizaciones del niño(a)

Entiendo y acepto que al autorizar mi consentimiento en la parte inferior, registro a mi niño(a) en el registro de inmunización del Departamento Estatal

de Servicios de Salud de Texas y autorizo al registro para que incluya la información de mi niño(a) en el registro y que el récord de inmunizaciones de mi

niño(a) del pasado, presente y futuro sea dado a conocer a alguno de los padres del niño(a), y a cualquiera de los siguientes: A) distrito de salud pública o

departamento de salud local; B) médico o proveedor de atención de salud; C) compañía de seguros, organización para el mantenimiento de salud o pagador;

D) escuela o centro de cuidado de niños, en el que el niño(a) está inscrito; y/o E) agencia estatal que tenga custodia legal del niño.

Reconozco y acepto que en cualquier momento puedo retirar mi consentimiento de poder incluir la información de mi niño(a) en el Registro

ImmTrac, y también retirar mi consentimiento para poder dar a conocer la información del registro, por medio de comunicación escrita dirigida al

Texas Department of Health, Immunization Registry, 1100 W. 49th Street, Austin, Texas 78756. Marque la casilla para indicar su consentimiento.

SÍ. Yo AUTORIZO EL CONSENTIMIENTO para registrarlo. Deseo INCLUIR la información de mi niño en el registro de inmunización de Texas.

NO. Yo NIEGO EL CONSENTIMIENTO para registrarlo. NO DESEO INCLUIR la información de mi niño en el registro de inmunización de

Texas.

_____________________ _______________________________________________________

Fecha Firma de alguno de los padres, tutor legal o administrador de bienes

NOTIFICACIÓN SOBRE LOS DERECHOS DE LA VIDA PRIVADA Tan solo por unas cuantas excepciones, usted tiene el derecho de solicitar y de ser informado sobre la información que el Estado de Texas reúne sobre usted. A usted se le

debe conceder el derecho de recibir y revisar la información al requerirla. Usted también tiene el derecho de pedir que la agencia estatal corrija cualquier información que se

ha determinado sea incorrecta. Diríjase a http://www.tdh.state.tx.us para más información sobre la Notificación sobre los Derechos de la Vida Privada. (Referencia:

Government Code, sección 552.021, 552.023, 559.003 y 559.004).

Aviso sobre derechos de la vida privada: “Yo admito haber recibido una copia de la Notificación sobre los derechos de la vida privada de

parte de mi proveedor de inmunizaciones sobre la Ley de Responsabilidad y Transferibilidad de Seguros Médicos (HIPAA)."

Texas Department of State Health Services Stock Number: C-10

Immunization Division Revised 08/2004

E–76

THSteps Forms

E

E.48 TVFC Provider Enrollment (3 Pages)

TEXAS VACCINES FOR CHILDREN PROGRAM (TVFC): PROVIDER ENROLLMENT

�Initial enrollment * �Re-enrollment Provider PIN Number .*Contact the PHR in your area to obtain PIN

Name of Facility, Practice, or Clinic: _

Provider Name (M.D., D.O., N.P., P.A., or C.N.M.*): _ (Last Name) (First Name) (MI) (Title)

Contact: ___________________________________________________________ ___________________________(Last Name) (First Name) (MI) (Title)

Mailing Address: _____________________________________________________________________________ ____ (P.O. Box or Street Address) (City) (Zip)

Address for Vaccine Delivery: _________________________________________________________________________ (Street Address and Suite Number) (City) (County) (Zip)

Telephone Number: (_______)_________-___________ Fax Number: (________)________-__________ ___

E-mail Address:

In order to participate in the Texas Vaccines for Children Program and/or to receive federally- and state-supplied vaccines provided to me at no cost, I, on behalf of myself and any and all practitioners associated with this medical office, group practice, health department, community/migrant/rural health clinic, or other organization, agree to the following:

1) Before administering vaccines obtained through the Texas Vaccines for Children Program (TVFC), my office will determine VFC eligibility. The Patient Eligibility Screening Form will be provided to the parent or guardian to declare each child’s eligibility.

2) My office will maintain records of the parent/guardian/authorized representative’s responses on the Patient Eligibility ScreeningForm for at least three years. If I use the Patient Eligibility Screening form as the sole source of documenting ImmTrac consent, I will maintain this record until the child has reached his/her 19

th birthday. If requested, my office will make such records available to

the Texas Department of State Health Services (TDSHS), the local health department/authority, or the U.S. Department of Health and Human Services.

3) My office will comply with the appropriate vaccination schedule, dosage, and contraindications, as established by the Advisory Committee on Immunization Practices, unless (a) in making a medical judgment in accordance with accepted medical practice, my office deems such compliance to be medically inappropriate, or (b) the particular requirement is not in compliance with Texas Law, including laws relating to religious and medical exemptions.

4) My office will provide Vaccine Information Statements (VIS) to the responsible adult, parent, or guardian and maintain records in accordance with the National Childhood Vaccine Injury Act. (Signatures are not required for the Vaccine Information Statementsbut are recommended.)

5) My office will not charge for vaccines supplied by TDSHS and administered to a child who is eligible for the TVFC.

6) My office may charge a vaccine administration fee. My office will not impose a charge for the administration of the vaccine in any amount higher than the maximum fee established by TDSHS. Medicaid patients cannot be charged for the vaccine, administration of vaccine, or an office visit associated with Medicaid services.

7) My office will not deny administration of a TVFC vaccine to a child because of the inability of the child’s parent or guardian/individualof record to pay an administrative fee.

8) My office will comply with the State’s requirements for ordering vaccine and other requirements as described by TDSHS.

9) My office or the State may terminate this agreement at any time for personal reasons or failure to comply with these requirements.

10) My office will allow TDSHS (or its contractors) to conduct on-site visits as required by VFC regulations.

_____________________________________ ____________________________ (Signature*) (Date)

*The TVFC Enrollment form must be signed by a licensed Medical Doctor, Doctor of Osteopathy, Nurse Practitioner, Physician Assistant, or a Certified Nurse Midwife.

Texas Department of State Health Services Page 1 Stock Number 6-102 Immunization Division Revised 07/2004

E–77

Appendix E

TEXAS VACCINES FOR CHILDREN PROGRAM

PROVIDER PROFILE FOR PIN ___ ___ ___ ___ ___ ___

Is your facility a Federally Qualified Health Center, Migrant Health Clinic, or Rural Health Clinic?

(circle one) YES NO

Type of Clinic: ( check one)

Public Health Department/District

Public Hospital

Other Public Clinic

Private Hospital

Private Practice (Individual or Group)

Other Private Clinic

PATIENT PROFILE:Please enter the number of children for each of the following categories and by age group who will be vaccinated at your clinic in the next 12 month period.

NUMBER OF CHILDREN IN EACH CATEGORY < 1 year old 1-6 years 7-18 years Total

Enrolled in Medicaid.

Uninsured. (Note: Children enrolled in Health Maintenance Organizations are considered insured)

American Indians.

Alaskan Natives.

Underinsured. (Has health insurance that Does Not pay for vaccines, has a co-pay or deductible the family cannot meet, or has insurance that provides limited wellness or prevention coverage)

(For Public Health Clinic Use ONLY) Children who do not meet any of the

above criteria, but still receive vaccinations at public health clinics.

Children who receive benefits from the Children’s Health Insurance Plan (CHIP).

Children who are vaccinated in your practice, but are NOT TVFC-eligible.

TOTAL PATIENTS: (Add columns)


PROVIDER LIST

Please list all individuals within the practice who will be administering TVFC supplied vaccine.

Last Name (list provider who signed Provider Enrollment Form first)

First Name Middle Initial

Title (M.D., D.O., N.P., P.A.,R.N., L.V.N., M.A.)

Texas ProviderIdentification

Medical License Number

Speciality (Family Medicine, Pediatrics, etc.)

Texas Department of State Health Services Page 2 Stock Number 6-102

E–78

THSteps Forms

E


Provider List-Addendum for PIN ___ ___ ___ ___ ___ ___

Please list all individuals within the practice who will be administering TVFC supplied vaccine.

Last Name (list provider who signed Provider Enrollment Form first)

First Name Middle Initial

Title (M.D., D.O., N.P., P.A.,R.N., L.V.N., M.A.)

Texas ProviderIdentification

Medical License Number

Speciality (Family Medicine, Pediatrics, etc.)

Texas Department of State Health Services Stock Number 6-102 Immunization Division Page 3 Revised 07/2004

E–79

Appendix E

E.49 TVFC Questions and Answers (3 Pages)

Texas Department of State Health Services Page 1 Stock No. 11-11221 Immunization Division Revised 07/2004

Questions and Answers

Texas Vaccines For Children Program

Question 1: What is the Texas Vaccines For Children Program (TVFC)?

Answer: This is our version of the Federal Vaccines For Children (VFC)

Program. The TVFC was initiated by the passage of the Omnibus

Budget Reconciliation Act of 1993. This legislation guaranteed that

vaccines would be available at no cost to providers, in order to

immunize children who meet the eligibility requirements.

Why Enroll?

Question 2: Why should a health care provider enroll in the TVFC Program?

Answer:

You can get free vaccine for your eligible patients.

You will not need to refer patients to public clinics for vaccines.

You can provide immunizations to your patients as part of a comprehensive

care package, this will enhance the opportunity for patients to find a

medical home.

Patients Served

Question 3: Once enrolled, are providers required to immunize children who are

not their patients?

Answer: No. You control whom you see in your practice.

Children Who Qualify

Question 4: Which children qualify for free vaccines?

Answer: All children are eligible for free vaccine, except:

1) children with insurance that pays for immunization services, and

2) children whose parents or guardians are able to pay for

copayments or deductibles for immunization services.

E–80

THSteps Forms

E



CHIP Enrollment

Question 5: Are children who are enrolled in CHIP eligible?

Answer: Yes, through special arrangement CHIP children are also eligible.

Medicaid Enrollment

Question 6: To participate in TVFC, must providers enroll as a state Medicaid

provider?

Answer: No. However, if you are enrolled in the state Medicaid Program,

you must enroll in the TVFC Program in order to receive free

vaccine.

Question 7: Will the Texas Medicaid Program reimburse private practitioners for

vaccines administered to Medicaid patients?

Answer: No. Medicaid will not reimburse for vaccine cost. Medicaid will

reimburse for a vaccine administration fee, which is $5.00 per

vaccine administered.

Vaccine Related Fees

Question 8: Will DSHS or Medicaid pay an administration fee for non-Medicaid,

TVFC eligible children?

Answer: No. For non-Medicaid, TVFC eligible children, providers have two

options:

1) charge a maximum of $14.85 per vaccine, administration fee

may not exceed this amount. (Combination vaccines such as DTaP

are considered one vaccine.)

2) charge a fee based on the Texas Department of State Health

Services (TDSHS) Income Guidelines and Schedule of charges for

Clinical Health Services. This schedule is updated annually, and a

copy can be obtained through TDSHS.

E–81

Appendix E



Duty to Warn Unchanged

Question 10: Will providers be required to increase the amount of vaccine

information materials they provide to parents because of the TVFC

Program?

Answer: No. Materials required of all providers through the National

Childhood Vaccine Injury Act are sufficient.

Eligibility Status

Question 11: Must providers ask the patient’s eligibility status each time the

patient comes for a vaccine visit?

Answer: No. Providers need only update eligibility status whenever there is

reason to believe a child’s eligibility status has changed.

Question 12: How are providers expected to verify responses for vaccine

eligibility?

Answer: Providers are not expected to do anything more than ask the

patient what the child’s eligibility status is and then record the

response. The parent can complete the Patient Eligibility

Screening Form.

Question 13: Why must providers complete a Provider Profile describing

patients by eligibility category?

Answer: This information allows the Texas Department of State Health

Services to determine how the cost of vaccine will be divided

among state and federal funds. Each year, you may find your

profile information has changed. The Provider Profile must be

updated annually, in accordance with Federal requirements.

E–82

Appendix THSteps Forms E - TMHP · WIC-42 24-Hour Dietary Recall and Assessment for Infants - Birth...

Documents

Transcript of Appendix THSteps Forms E - TMHP · WIC-42 24-Hour Dietary Recall and Assessment for Infants - Birth...