TRIBAL PROGRAM NEWS
Siletz Tribal Head Start
Health Summary
This form must be completed and signed by a physician.
Please do not defer any tests.
Return this form to Siletz Tribal Head Start, P.O. Box 549, Siletz, OR
97380-0549.
Sex: M
Child’s Name:
Parent/Guardian Name:
DOB: --------------
Phone #: --------------------- -
Vision: R L------------
Weight:
Height:
F
Hearing: R L
Blood Pressure.
Immunizations Needed:------------------- ---------------------------------------------------
Physical Examination Summary
Date of Exam:
Examiner’s Name: --------------------------------------
This is a Very Important Piece for Head Start: Het. or Hgb.:----------------
Siletz Tribal Head Start
2007-2008 Family Needs Assessment
Siletz Tribal Head Start is conducting a survey to identify needs that exist in
our community. This information is used to determine what programs and ser
vices would be relevant for Head Start to offer in the future. Your assistance will
help ensure that our program meets your needs. Your input and support are
valuable. Thanks!
Check One (Optional):
Native American
City -------------------------------------------- ------ County
Where do you live:
Family Data:
Other
Single-Parent Household
Foster Parent/Grandparent
NO
NO
YES
YES
Total Number of Household Members:
Total Number of Children in Family:
Age(s) of Primary Caregiver: Age(s) of Children:--------------------
Are any of your children disabled?
YES
NO
Have any of your children been in Head Start?
NO
YES
Economic Information:
When recording results for the following, enter:
N-normal, A-abnormal. NE-not evaluated
General Appearance: __
Head:__
Skin:----
Abdomen: ---- Glands. ----
Nose/Mouth/Pharynx: __
Heart:
Lungs:
Muscular Coordination: ----
Bones/Joints/Muscles: __
Eyes:
Ears: ------
Genitalia: --
1. Does this child’s medical history and/or examination indicate any condition
that would limit her/his participation in Head Start activities: NONE YES
Parent(s) Employed:____ Full-time ____ Part-time
In Training/School
------ Not Employed
Gross Monthly Income: Highest Grade Completed by Caregiver:----
Does Family Receive:
TANF
____ OHP
Food Stamps
WIC
----- SSI
------ GA
Do you own or rent your home? Monthly Rent/House Payment----------
Transportation:
Specify:
Do you have reliable transportation? NO
YES
Do you have access to public transportation? NO
YES
Childcare:
2. Is any further medical treatment or specific health recommendation neces
sary for this child?
NONE
YES
Specify:__________________________________________________________
Do you have children in child care now?
Clinic/Office Address:_____________________________________________
Telephone: _____________—————————————
[
J
CTSITeam
Relay For Life Fund-raiser
[
Car Wash
May 18 • Noon to 4 p.m.
I
1
I
YES
How much do you pay for care?__ __________
Is it easy to find and use childcare services? NO
How would you rate your child care?
Physician Signature:--------------------------------- -------------------------------------
NO
Poor
YES
_ Good
—Fair —Tremendous
Please rate the following from highest to lowest priority of need; 1 = highest
priority to 14 = lowest need.
____ Education
_ Employment
____ Housing
Recreation
____Dental Care
Health Care
____ Parenting
Childcare
____Alcohol & Drug Awareness
___ Preschool/Head Start
Li teracy
____ Nutrition
___ Cultural Activities
____ Other
Should Head Start Services be (circle one for each of the 3 questions):
1. Full-day
3. Classroom
or
Part-day
or
2. Full-Year
or
Part-Year
Home Based
Should Head Start services serve children age 0 - 3 years?
Behind the USDA warehouse next to the
administration building in Siletz
YES
NO
Any other comments?________________________________________________
We are asking for a donation of $5 for cars and $8 for big trucks.
| Thank you for helping us raise money for the fight against cancer!
May 2007
Siletz News
13