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How to fill out the Doh 3703 Form online
The Doh 3703 Form is essential for referring a child under three years old who may be at risk for or suspected of having a developmental delay or disability. This guide will provide you with step-by-step instructions on how to complete the form online, ensuring you have the necessary information to submit a thorough referral.
Follow the steps to complete the Doh 3703 Form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter the report date by selecting the month, day, and year when filling out the form. This ensures that the referral is time-stamped properly.
- Fill in the referral source section with the name of the person making the referral. Provide their agency or facility, address, city, state, and telephone number for contact purposes.
- Complete the child’s information section. Include the child's full name, also known as, address, sex, birthdate, dominant language used, and county of residence.
- List the family information by providing the names of the parent(s) or legal guardian and their contact details, including address, city, state, zip code, and phone number.
- If applicable, add the alternate contact information, specifying their relationship to the child and providing their telephone number.
- Choose the reason for referral by checking the appropriate box to indicate if the child has a confirmed disability or is at risk of developing one.
- In the primary health care provider section, indicate the provider's name and telephone number to ensure they can be contacted.
- Document the child’s status at the time of referral, including whether they are currently hospitalized and any facility names, if applicable.
- Specify any diagnosed conditions or comments that might be relevant to the referral.
- Select any suspected delays the child is facing and check the corresponding boxes.
- Complete the risk criteria section by checking all applicable risk factors that may be considered for the referral.
- Obtain parental/legal guardian consent by gathering their signature and date in the designated area.
- Once all sections are completed, review the form for accuracy. You can then save changes, download, print, or share the completed form as needed.
Complete your Doh 3703 Form online today to ensure timely referral for the child.
Filling out a travel request form involves entering basic information, such as your name, department, and proposed travel dates. Next, include the purpose of the travel and destination. Lastly, ensure that any necessary approvals are obtained before submission. Utilizing a structured form like the Doh 3703 Form can help you cover all necessary details efficiently.
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