New Jersey Department of Health

CHILD HEALTH SERVICES QUARTERLY SUMMARY REPORT	Type of Service

A.	CHC Municipality Code

B.	CHC Location (Street Address)

C.	City, Municipality, Township

D.	County

E.	Zip Code

F.	Reporting Period

G.	Total No. of Sessions

H.	Average Session Length

I.	Average Number of Each Staff Title per CHC Session:
Health Educator
Physician	LPN	Clerk
Nurse Practitioner	Nutritionist	Volunteer
RN	Health Aide	Interpreter
J.	Visit or Service	Infants

Under 1 Year	Children

1-4 Years	Children

5 Years

and Over	Total	Referred
1.	New Cases
2.	First Visit This Calendar Year
3.	Revisits
4.	Physician Complete PE (Unclothed)
5.	PNP/FNP Complete PE (Unclothed)
6.	Nurse Counseling/Assessment
7.	Immunization
8.	Tuberculin Test
9.	Vision Screening
10.	Hearing Screening
11.	Lead Screening
12.	Anemia Screening
13.	Ages and Stages Questionnaire
14.	Nutritional Assessment
15.	Oral Assessment
Name of Nurse in Charge

Agency Name and Mailing Address

Telephone Number

Email Address

INSTRUCTIONS FOR COMPLETING THE

CHILD HEALTH SERVICES QUARTERLY SUMMARY REPORT (CH-7)

One quarterly report form (CH-7) is to be submitted to report all CHC sessions and/or any other service component(s) provided separate from the CHC (see following bullet). If any agency has multiple sites located within the same municipality code, one aggregate report is to be used to report the data from all sites. In cases where an agency is the sole agency for the county, that agency may choose to forward one aggregate report for all of its sites.

In the top right-hand box of the quarterly report, identify the report as one of the following:

1)	CHC,

2)	Immunization only,

3)	Vision/Hearing,

4)	Lead/Anemia,

5)	WIC,

6)	Oral Assessment,

7)	Other (which can be a combination of #2 through #6 or something entirely different from what is listed here), or

8)	Home visits.

(Letters A through J and numbers 1 through 15 directly correspond to the items listed in the headings and visit/service column on the CH-7.)

A.	Municipality Code: The 4-digit numerical identifier obtained from the NJ Treasury Code list—the first two digits indicate the county and the second two digits, the municipality.

B.	Station Location: The street address of the CHC, or, in the case of multiple sites being reported in one quarterly report, the address of the primary site.

C, D, E.	City/Municipality/Twp, County and Zip code: To be completed as stated for B. above.

F.	Reporting Period: To include beginning and ending month, day and year of the data being reported, i.e., 01/01-3/31; 04/01-06/30; 7/01-09/30; or 10/01-12/31 followed by the year.

G.	Total Number of Sessions: Total number of CHCs, immunization or special clinic sessions represented in the data reported, as indicated in the top-right hand box.

H.	Average Session Length: The average length of time in hours of the sessions listed in space “G”. (For example, if 20 sessions are reported each lasting 3 hours, the average session time is 3.0 hours. However, if 20 sessions are reported, and 6 of those sessions were 6 hours, 4 were 4 hours and 10 were 3 hours, the computed average session time is 4.1 hours.)

I.	Average Number of each staff title per CHC session: The usual number of each staff title that provides the services represented in the reported data. In situations where a staff person is not present for each service session, a fraction or decimal can be used to represent the average. For example, if 20 sessions are reported and a physician was present for 10 of those sessions, and a PNP was present for 10 sessions each of those titles would be listed as 1/2 or .50. If a health educator is present for only one out of every 4 CHC sessions, the health educator title would be listed as ¼ or .25.

J.	Visit or Service

1.	New cases: Any child coming to your service for the first time.

2.	First visit this calendar year: Any child previously known to your service who is coming for the first time in the current calendar year.

3.	Revisits: Any child coming for service following an initial visit counted in either #1 or #2 above.

Please note that the total of line 1 & 2 provides the number of children (unduplicated visits) receiving service, and the total of lines 1, 2 & 3 provide the total # or visits/encounters/contacts that children have made for services provided.

4.	Physician Complete PE: Complete unclothed physical examination done by a physician.

5.	PNP/FNP Complete PE: Complete unclothed physical examination done by a pediatric or family nurse practitioner.

6.	Nurse Counseling/Assessment: It is expected that any child coming for service will be interviewed by the nurse and will be assessed and counseled appropriate to the purpose of the contact. For instance, a child returning for follow-up on a low hemoglobin/hematocrit is counted as a revisit and is provided with necessary health teaching. Thus, the items checked on the service report include #3 (revisit), #6 (nurse counseling), and #16 (nutritional assessment.)

7.	Immunization: This item is to be recorded as a service. As such, if the child is immunized, regardless of the number of vaccines given, the count per visit/contact can never be greater than 1.

8.	Tuberculin Test: Record the number of skin tests done.

9.	Vision Screening: Record any age appropriate vision screening used to detect potential visual impairment including that which, for children under the age of 3, might be done as part of the comprehensive physical examination.

10.	Hearing Screening: Record any age appropriate hearing screening used to detect potential hearing impairment including that which, for children under the age of 3, might be done as part of the comprehensive physical examination.

11.	Lead Screening: Record any capillary or venous sample drawn to detect blood lead levels. A verbal questionnaire to identify potential risk of lead exposure does not constitute lead screening.

12	Anemia Screening: Includes blood testing for hemoglobin, hematocrit or EP level.

13.	Ages and Stages Questionnaire (ASQ): The ASQ is a parent-report, age-specific, developmental screening tool completed by the parent prior to or at the CHC visit. This standardized developmental screening tool is required to be used in the CHC as the best practice standard for identifying developmental delays in children 3 to 60 months of age and is an integral part of the preventive health care visit. Responses to the completion of the tool should be reviewed with the parent and are used to guide content of anticipatory guidance.

14.	Nutritional Assessment: Assessment and counseling of the child’s nutritional intake, done by the nurse, a nutritionist or dietician.

15.	Oral Assessment: Examination of the oral cavity including the teeth, gums and mucosa, done by the nurse, physician, or dental hygienist.

In the bottom four boxes, please include the name of the nurse in charge, coordinator, or supervisor of the CHC, and all required contact information for that individual. The mailing address should include the name of the agency/local health department, street or PO Box, municipality, and zip code. The phone number should include the area code, and extension as appropriate. Please provide an e-mail address.

Please note that ANY REFERRAL RESULTING FROM THE PROVISION OF A SERVICE COMPONENT IS TO BE RECORDED ON THE APPROPRIATE SERVICE COMPONENT LINE UNDER THE “REFERRED” COLUMN. Referrals are appropriate only for items 4 through 16. REFERRALS ARE NOT TO BE LISTED FOR ITEMS 1, 2 OR 3.

The CH-7 can be completed and forwarded electronically to the Child Health Program. If forwarding the CH-7 electronically, select the WORD version of the form and forward the completed form to Anna Preiss at anna.preiss@doh.state.nj.us.

If mailing a hard copy of the CH-7, download the WORD version or the PDF format of the form, and send the completed quarterly summary report to:

Anna Preiss

NJDOH--Child Health Program

PO Box 364

Trenton, NJ 08625-0364

Any questions about the completion or forwarding of the quarterly CH-7 Report should be addressed to the Child Health Program at 609-292-5666.

CH-7

JUL 12

CH-7 (Instructions)	-2-

-1-

INSTRUCTIONS FOR COMPLETING THE

CHILD HEALTH SERVICES REPORT (CH-7)

(Continued)

ch-7, Child Health Services Quarterly Summary Report

CH-7, Child Health, child health services quarterly summary report, quarterly report, child health conference

Elaine White

2012-03-20

ewhite

NJDOH