Child Development and Family Center
Family Screening Form

Child/Parent/Guardian Information

Are you employed? *

Medical Information

Is your child under a doctor's care? *
Has your child taken medicine in the last 24 hours? *
Has your child ever been hospitalized or had a serious injury? *
Does your child wear glasses? *
Does your child have any allergies? *
Has your child experienced lead poisoning or a chronic illness? *
Do you have other concerns regarding your child’s health? *

Development Information

At what age did your child... *
 Age? (write N/A if child has not yet completed task)
Sit
Stand
Walk without help
Speak first words
Speak in sentences
Dress themselves
Toilet trained
Full-term pregnancy? *

Family Information

Does your child speak and/or understand a language other than English *
Please all list individuals in household
 NameAgeRelationshipConcerns
1
2
3
4
5
6
Please check any public benefits that your child/family is presently receiving *
Are you currently receiving childcare subsidy payments? *
Using the table below, is your household income at our below the 200% Federal Poverty Level for the past or current year? Note: This amount is gross – before taxes)  *

2018 Federal Poverty Guidelines
Source: Federal Register /Vol. 83, No. 12 /January 31, 2018 /Notices

Persons in Family/Household 50% of Federal Poverty Level 100% of Federal Poverty Level 200% of Federal Poverty Level
1 $6,070 $12,140 $24,280
2 $8,230 $16,460 $32,920
3 $10,390 $20,780 $41,560
4 $12,550 $25,100 $50,200
5 $14,710 $29,420 $58,840
6 $16,870 $33,740 $67,480

For families/households with more than 6 persons, add $4,320 for each additional person at 100% FPL level; $2,160 at 50% FPL; and $8,640 at 200% FPL.

Permission

Permission to screen *
Signature of parent or guardian * 🛈
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