Form A - DxInt. Sc Form A - DxInt. Sc Form A - DxInt. Screening

OMB # 0930- XXXX

Expiration Date: xx/xx/xxxx

SAMHSA FASD Center for Excellence

Form A

Diagnosis and Intervention Programs: Screening and Diagnosis Tool

This is a screening and diagnosis tool to determine eligibility to participate in the SAMHSA FASD Center for Excellence Diagnosis and Intervention Programs. To protect privacy, name and any other individually identifying information will not be collected. It is important to us to obtain this information to determine eligibility; however, participation is voluntary.

Child ID: ____________ Agency Name: _______________

Section A: Demographic Data

1. Date demographic data completed: __/__/_____ (mm/dd/yyyy)

2. Child’s Gender  Male  Female

3. Child’s Date of birth _________(mm/dd/yyyy)

4. Is the child Hispanic or Latino?  Yes  No

5. What is the child’s racial background? (Select one or more)

 Alaska Native

 American Indian

 Asian

 Black or African American

 Native Hawaiian or Other Pacific Islander

 White

6. Does the child currently live in a single parent household?

 Yes  No

7. The child currently lives with: (Select all that apply)

   • Both Biological parents

   • One Biological parent

   • Both Foster parents

   • One Foster parent

   • Both Adoptive parents

   • One Adoptive parent

   • Relative (please specify)_______

   • Non-relative (please specify) _________

8. How many times has the child moved between placements in the last 12 months? _______________

Section B: Screening Data

9. Date screening completed: __/__/____ (mm/dd/yyyy)

9. Which of the criteria were positive for the child? (Check all that apply.)

Children 0-7 Years of Age

1.  Confirmed prenatal alcohol or drug exposure (4-7 yrs)

2.  (0-3 yrs) Confirmed prenatal alcohol or drug exposure AND

1.  Growth Deficits

2.  CNS or Developmental abnormality

3.  Note in medical record indicating dysmorphia

1.  Face Rank 3 or 4 using FAS Photographic Tool

2.  Sibling previously diagnosed of an FASD

3.  Has a birth mother with confirmed alcohol or drug history at some point other than pregnancy, and

1.  Growth Deficits

2.  CNS or Developmental abnormality

3.  Note in medical record indicating dysmorphia

6.  Previous diagnosis of an FASD

Children 8-18 Years of Age

7.  Face Rank 3 or 4 using FAS Photographic Screening Tool

8.  Sibling received diagnosis of an FASD

9.  Confirmed prenatal alcohol exposure

10.  Previous diagnosis of an FASD

9. Check the criterion for Positive Monitor if applicable

11.  Confirmed prenatal alcohol exposure WITHOUT

1.  Growth Deficits

2.  CNS or Developmental abnormality

3.  Note in medical record indicating dysmorphia

9. Date the child received a positive screen/positive monitor for an FASD __/__/____ (mm/dd/yyyy)

Screening Results

• Positive Screen (Yes to any item in Q 10)

• Positive Monitor (Yes to any item in Q 11)

• Negative Screen

Section C: Diagnosis Data

(Note: Only Administered to Children with Positive Screen)

13. Date the child was referred for diagnostic evaluation __/___/____ (mm/dd/yyyy)

14. Date the diagnostic evaluation was completed __/___/____ (mm/dd/yyyy)

15. Date the written diagnostic report was completed __/__/____ (mm/dd/yyyy)

16. Did the child receive an FASD diagnosis?

 No (Child not eligible for FASD intervention skip to Final Eligibility Check and check “Child does not qualify-- did not receive an FASD diagnosis”)

 Yes

17. If yes, what were the diagnosis criteria? (Check one)

 4-Digit Diagnostic Code

 MN Diagnosis criteria

 Institute of Medicine Guidelines

 CDC Guidelines

 Other, please specify: ______________________________

18. What was the diagnosis? _________________

19. If the 4 digit code was used what was the code? _____________

20. What other diagnoses did the child receive? Please list all diagnoses.

1. _____________________

2. _____________________

3. _____________________

Final Eligibility Check

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 10 minutes per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

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