Quarterly Screening Report Health Department: Reporting Date: Program: Fiscal Year: Quarter: Outcomes Services Provided Passed Referred Under Care / Other Doctor Evals Diagnosed Loss Total of all screenings Total of all screenings with Total of all screenings resulting of all screenings with an Doctor / parent reports of passing outcomes. in a doctor referral. inconclusive outcome either follow up care. attempted. Screenings resulting in non-passing due to UTS or pending outcomes for who have received rescreens that could not be doctor care for related concerns within a completed. recent, specified time frame. Screenings of doctor diagnosed losses, deficits, and/or permanent difficulties with outcomes indicating no significant changes. Early Childhood 3 Years …Under Early Head Start …Includes Preschool Years, Has Not Started Kdg. …3+ All PreK Programs …Includes (Preschool, PreK, Jr K, Young 5, Head Start, Begindergarten, etc) School Age K - 12 …Grades 0 0 0 0 0 0 Totals Reporting Deadlines: Submit Completed Reports to: Report must be submitted to MDHHS within 30 days of the end of each quarter. Copy Hearing to: Copy Vision to:
Quarterly Screening Report Health Department: Reporting Date: Program: Fiscal Year: Quarter: Outcomes Services Provided Total of all screenings attempted. Passed Total of all screenings with passing outcomes. Referred Total of all screenings resulting in a doctor referral. Under Care / Diagnosed Loss Screenings resulting in non-passing outcomes for who have received doctor care for related concerns within a recent, specified time frame. Screenings of doctor diagnosed losses, deficits, and/or permanent difficulties with outcomes indicating no significant changes. Other of all screenings with an inconclusive outcome either due to UTS or pending rescreens that could not be completed. Doctor Evals Doctor / parent reports of follow up care. Early Childhood …Under 3 Years …Includes Early Head Start Preschool …3+ Years, Has Not Started Kdg. …Includes All PreK Programs (Preschool, PreK, Jr K, Young 5, Head Start, Begindergarten, etc) School Age …Grades K - 12 Totals 0 0 0 0 0 0 Reporting Deadlines: Submit Completed Reports to: Report must be submitted to MDHHS within 30 days of the end of each quarter. Copy Hearing to: Copy Vision to:
Totals_Quarterly_Report_MDHHS_Hearing__Vision_rev_12_15_15_523013_7.docx