DJJ Form HS010 "Facility Entry Physical Health Screening" - Florida

What Is DJJ Form HS010?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2007;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DJJ Form HS010 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form HS010 "Facility Entry Physical Health Screening" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
FACILITY ENTRY PHYSICAL HEALTH SCREENING
Name of Youth: ________________________________________
DJJID#:
___________________
Facility Name: _________________________________________
Date of Birth:
___________________
Age: ____
Race:
_________
Sex:
________
Eyes:
___________
Hair:
____________
Parent/Guardian: _________________________________________________________________________
Address: _____________________________________________
Home Phone:
__________________
City/State/Zip: ________________________________________
Work Phone:
__________________
Email: _______________________________________________
Cell Phone:
__________________
NO
YES
:
1. Youth has obvious injury (Please indicate on body diagram)? If yes, describe
1 2 3 4 5
Scale (circle level of pain/illness, 1 being the least):
Screener instructions: If the level of pain/illness is 3 or above, an immediate referral to a Physician/ARNP/PA must be made.
NO
YES
2. Youth appears intoxicated or under the influence of drugs: If yes, describe:
Screener instructions: A “yes” response to question 2 requires you to notify the person in charge of the facility at the time. Youth
who are intoxicated or under the influence must be taken to a hospital or mental health facility.
NO
YES
3. Youth appears ill? If yes, describe:
1
2
3
4
5
Scale (circle level of pain/illness, 1 being the least):
Screener instructions: If the level of pain/illness is 3 or above, an immediate referral to an Physician/ARNP/PA must be made.
NO
YES
4. Youth appears to have a possible developmental delay? If yes, describe:
Screener instructions: A “yes” response to question 4 requires that you notify the Program Director/Facility Superintendent and
the Mental Health staff person.
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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
FACILITY ENTRY PHYSICAL HEALTH SCREENING
Name of Youth: ________________________________________
DJJID#:
___________________
Facility Name: _________________________________________
Date of Birth:
___________________
Age: ____
Race:
_________
Sex:
________
Eyes:
___________
Hair:
____________
Parent/Guardian: _________________________________________________________________________
Address: _____________________________________________
Home Phone:
__________________
City/State/Zip: ________________________________________
Work Phone:
__________________
Email: _______________________________________________
Cell Phone:
__________________
NO
YES
:
1. Youth has obvious injury (Please indicate on body diagram)? If yes, describe
1 2 3 4 5
Scale (circle level of pain/illness, 1 being the least):
Screener instructions: If the level of pain/illness is 3 or above, an immediate referral to a Physician/ARNP/PA must be made.
NO
YES
2. Youth appears intoxicated or under the influence of drugs: If yes, describe:
Screener instructions: A “yes” response to question 2 requires you to notify the person in charge of the facility at the time. Youth
who are intoxicated or under the influence must be taken to a hospital or mental health facility.
NO
YES
3. Youth appears ill? If yes, describe:
1
2
3
4
5
Scale (circle level of pain/illness, 1 being the least):
Screener instructions: If the level of pain/illness is 3 or above, an immediate referral to an Physician/ARNP/PA must be made.
NO
YES
4. Youth appears to have a possible developmental delay? If yes, describe:
Screener instructions: A “yes” response to question 4 requires that you notify the Program Director/Facility Superintendent and
the Mental Health staff person.
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Tuberculosis Symptom Screening (Tier I) – Interview with Youth
NO
YES
1. Are you coughing up blood?
Screener instructions: A “yes” response to question 1 requires an immediate referral to the Designated Health Authority for
assessment and/or emergency transfer to the hospital.
2. Do you have a cough which has lasted longer than 3 weeks and which
NO
YES
you cough up anything (green, yellow, red mucous, phlegm, etc.)
Screener instructions: A “yes” response to question 2 requires you to notify the person in charge of the facility at the time.
3. Are you now or have you recently had any of the following:
NO
YES
 A fever (greater than 101)?
 Weight loss without dieting? # Pounds _______
 Fatigue (easy tiring)?
 Night or early evening sweats?
Screener instructions: A “yes” response to question 2 plus any three of the symptoms listed in question 3 requires that you do
not place the youth into the general population until medically evaluated by an Physician/ARNP/PA. The youth should be isolated
or taken outside of the facility (escorted by an officer) until an evaluation can be made. Transportation of the youth to the ER for
an XRAY that can be read and interpreted should take place as soon as possible. If coughing, the youth should be instructed to
cough directly into tissue, and this should be disposed of in a bio-hazardous container with a lid. If the youth refuses or cannot
follow these measures, a mask may be placed on the youth as long as it does not impair his/her ability to breathe. Transporting
staff may wear masks at their own discretion. The hospital or CHD must be telephoned in advance (while the youth is in transit). If
taken to the ER, the report from the ER should be taken back to the facility with the youth.
NO
YES
4. Are you now or have you been in the past, an IV drug user or skin injector of
any sort?
5. Has anyone with whom you have been living been recently diagnosed with
tuberculosis?
Screener instructions: Unless the youth requires immediate intervention as described in #1, 2 and 3, a “yes” response to either
question 4 or 5 requires you to notify the Designated Health Authority or the Program Director/Facility Superintendent that youth
must be medically evaluated for tuberculosis within 24 hours.
General Physical Health Screening – Screener’s Observations
NO
YES
1. Youth has difficulty moving and/or has a physical handicap? If yes, describe:
2. Youth appears to have a vision, hearing, or speech impairment? If yes,
describe:
3. Youth has evidence of lice, scabies, etc.
4. Youth has visible scars (check wrists), tattoos, other skin markings, or
piercing? If yes, describe: (See note on piercings on last page)
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Current Status – Youth Interview
NO
YES
1. Do you have any health complaints such as injuries, sickness, or pain, at the
present time? If yes, describe:
2. Have you had a recent injury? If yes, describe how this occurred, when and
where:
3. Specifically, have you had a recent head injury? If yes, describe how this
occurred, when and where:
4. For females: Are you pregnant or suspect that you might be pregnant?
5. Do you have, or have you ever had, any of the following health problems:
NO
YES
PAST
PRESENT
Adrenal Insufficiency
Alcohol or Drug Use
Asthma
Cancer
Cardiac Arrhythmias, Disorders or Murmurs
Child Birth: Post Partum in Past Two Weeks
Diabetes
Head Injury: Within Past Two Weeks
Hearing, Speech, or Visual Deficits
Heart Problems or Chest Pain When
Exercising
Hemophilia (Bleeding Disorder)
Hepatitis
High Blood Pressure (Hypertension)
History of Anaphylaxis: Use of EpiPen
HIV/AIDS
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NO
YES
PAST
PRESENT
Hypo or Hyperthyroidism
Kidney Failure (with or without Dialysis)
Lice/Scabies/Crabs
Neuromuscular Conditions: Cerebral Palsy, Muscular
Dystrophy, Multiple Sclerosis
Pregnancy
Seizures
Sickle Cell Disease (Anemia)
Sickle Cell Trait
Spina Bifida
Systemic Lupus Erythematosis
Thyroid Problems
Tuberculosis
**N
:
A
YES P
OTE
LL
RESENT RESPONSES REQUIRE NOTIFICATION
D
H
A
.
OF THE
ESIGNATED
EALTH
UTHORITY
Current Medications – Youth Interviews
NO
YES
1. Are you taking any medication for mental conditions (behavior/emotions)
or physical health?
If yes, list and include over-the-counter medication if any:
2. Specifically, do you take any of the
following?
NO
YES
Date/Time of Last Dosage
Insulin
Seizure Medication
Asthma Medication
Heart Medication
Tuberculosis Medication
Folic Acid
N
: I
,
M
A
!
OTE
F YES TO ANY ABOVE
PLACE YOUTH ON
EDICAL
LERT
Home
Parent
With Me
3. If you take any of the medications listed above, where are they?
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N
: N
DHA
D
.
OTE
OTIFY
OR
ESIGNEE IF YOUTH DOES NOT HAVE MEDICATION WITH THEM
YES
NO
4. Are you allergic to any medications, foods, or other substances?
If yes, list:
Medications
Foods
Other
N
: I
,
M
A
!
OTE
F ANY ALLERGIES ARE INDICATED
PLACE YOUTH ON
EDICAL
LERT
Physical Health Disposition
1.
Emergency health treatment needs due to injury or illness: institute on-site procedures and call “911”.
Possible active tuberculosis: institute transportation to hospital or county health department for
2.
evaluation if MD/ARNP/PA not immediately available.
Youth appears intoxicated or under the influence of other non-medical substances (cocaine, crack, LSD,
3.
etc.): Institute procedures for transportation to hospital or appropriate mental health facility for
emergency treatment and/or evaluation.
4.
Schedule sick call appointment (put on list).
5.
Schedule physician referral appointment (put on list).
No complaints or evidence of illness:
6.
Schedule for Comprehensive Physical Assessment, if needed.  Yes  No
Unsure as to action. Contact Designated Health Authority or shift supervisor per facility operating
7.
procedures to determine action.
Note: For Piercings If youth knows how to remove, he/she should remove. If on body (not tongue), area needs to be
cleansed regularly with antibacterial soap. No ointment. If oral piercing, youth should remove and mouthwash should be
used. If labial, penile or other genital piercing, only an MD/PA/ARNP should remove.
N
: S
OTE
EE ATTACHED BODY CHART FOR VISUAL BODY SKIN SCREENING
_____________________________________
__________________________________________________
Facility Staff Screener Signature
Licensed Health Care Reviewer Signature (LPN/RN/ARNP)
_____________________________________
__________________________________________________
Facility Staff Printed Name
Licensed Health Care Reviewer Printed Name
_____________________________________
__________________________________________________
Title/ Position
Title/ Position
__________________________________
_____________________________________________
Date
Date
Note: Licensed health care staff shall review this document if performed by facility (non-health care) staff.
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