ASQ REFERRAL TRACKING & FOLLOW-UP – INDEX CHILD

*For Children who Screened at Risk for Developmental Delay*

Please complete this form with Referral and/or Service Dates as updates occur and

enter in THEO (EHS/HFA) or send to State (NFP)

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon	Nurse Family Partnership

Name of Child & ID #:

Name of Parent & ID #:

To count towards the Developmental Referral performance measure: Children screened positive for being at risk must receive at least one of the supports/services below (according to timelines found in Follow-Up information).

FOLLOW-UP	INFORMATION
Type of Service	Date Provided	About Individualized Developmental Support
1) Individualized Developmental Support	/ / 20	Individualized Developmental Support can be done at any time by a home visitor and counts as a completed referral regardless of whether the client is also referred to Early Intervention or another community service. Examples of this include activities by model curriculum, ASQ activities, and CDC materials to target the developmental skill or domain for which there was a concern or positive screen.

INITIAL REFERRAL CONTACT	FOLLOW-UP	INFORMATION
Type of Service	Date Service Referral Contacted	Date Service Started/Received	About Another Community Service
2) Another Community Service: Type:	/ / 20	/ / 20	A community services must be started or received within 30 days of initial contact to count towards the measure. Examples may include referrals to health or mental health services, speech, occupational or physical therapy services, parent-child groups, parent classes or early literacy supports.

INITIAL REFERRAL CONTACT	FOLLOW-UP	INFORMATION
Type of Service	Date EI Referral Contacted	Date of EI Evaluation	About Early Intervention Services
3) Early Intervention Services	/ / 20	/ / 20	An EI evaluation must occur within 45 days of initial contact to count towards the measure.