Form B - DxInt. Po Form B - DxInt. Po Form B - DxInt. Positive Monitor Tracking

OMB # 0930- XXXX

Expiration Date: xx/xx/xxxx

SAMHSA FASD Center for Excellence

Form B

Diagnosis and Intervention Programs: Positive Monitor Tracking

This form is used in the SAMHSA FASD Center for Excellence Diagnosis and Intervention Programs to track the outcome of placing a child in a positive monitor. 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 if the child received a positive screen; however, participation is voluntary.

Child ID: ______________ Date completed: _______

1. What was the outcome of the positive monitor?

   1. Positive for an FASD

   2. Negative for an FASD (End Screening Questions, child not eligible for intervention)

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

3. Which criteria was used to make that determination?(Check all that apply)

   1. o Growth Deficits

   2. o CNS or Developmental abnormality

   3. o Note in medical record indicating dysmorphia

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 2 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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