MassCANS Forms (Birth-Four and Five to 20)
If you do not have member consent to enter CANS data into the Virtual Gateway, you must document the CANS on paper. The paper version of the CANS (below) is available in both Word and PDF formats.
- CANS Birth through Four with SED Determination form (PDF)
- CANS Five through 20 with SED Determination form (PDF) file size 1MB
CANS Rating Sheets
CANS Rating Sheets may be used in place of the long form when documenting the CANS on paper.
The CANS Rating Sheet is now available in fillable PDF format. Each format includes the SED determination. Both formats contain a header section containing space for Child's Name, Organization Name, and Other. If you are unable to see the header in the RTF format click on View in the Toolbar and then click on Print Layout to view header. The header information will appear when you print this document.
Please note: When you click on the Print button within the fillable PDF a rating sheet will print to your default printer. Completing a fillable PDF rating sheet does not enter the information onto the CBHI CANS Application on the Virtual Gateway.
Please note: a “fillable” version of each of the rating forms is available in which the user can type and print the CANS.
MassCANS Consent Documents
Consent forms are used to obtain permission to share and get information for the CANS tool. Note: A prefilled cover sheet is required for faxing the Consent Information Sheet. The Consent Information Sheet must be printed directly from the CBHI CANS on the Virtual Gateway. For instructions, see page 5 of the Reference Guide: CBHI Data Entry Operator .
- English Consent Form (PDF)
- Spanish Consent Form (PDF)
- Russian Consent Form (PDF)
- Portuguese Consent Form (PDF)
- Chinese Consent Form (PDF)
- Vietnamese Consent Form (PDF)
- Khmer Consent Form (PDF)
- Haitian Creole Consent Form (PDF)
This information is provided by MassHealth .