Health Examination | Forms | Guidelines
Any physical performed on or after 7/1/21 must be on the Required NYS Health Examination or EHR equivalent form.
The Center does not review the Required NYS Health Examination electronic equivalent forms.
Sample notifications, a webinar, and FAQs regarding this requirement are below.
School Health Examination Guidelines 2018
School Health Examination Guidelines 2018
Provides information on student health examination requirements and guidance for administrators and school health personnel in establishing the mandated health program (NYSED Updated May 2018)
Health Exam and Screening Requirements Charts | Determination for Ungraded Students
NYS & NYC Screening & Health Examination Requirements Chart (7/1/2018)
Chronological Age/Grade Chart (NYSCSH, 6/23/21)
School Health Examination Form
Note: If a provider checks the box “Systems Review and Abnormal Findings Listed Below” but does not check each system box to indicate “reviewed,” they are indicating all systems were reviewed and normal. You may clarify with the provider that this is how they will be completing the health exam form. Make a note of this so that in the future anyone reviewing the forms in the future is aware of the practice in that healthcare provider’s office.
Required NYS School Health Examination Form (PDF NYSED 2022)
This form may be printed and completed by hand.
Required NYS School Health Examination Form (Fillable PDF NYSED 2022)
This form may be completed electronically by saving it to your computer, entering the information into the fillable fields, and saving a copy for each student.
Required New York State School Health Examination Form (Accessible Word Document - Read Only, NYSED 2022)
This form may be completed electronically by saving it to your computer, entering the information into the fillable fields, and saving a copy for each student. This copy is accessible to those using a screen reader.
Instructions for an EHR Compatible Form
Instructions for Completion of the New York State School Health Examination EHR Compatible Form
Provides directions to healthcare providers on the required components and the required presentation order of those components for an electronic health record form to be an equivalent form. (NYSED, 2020). Posted 1/28/21
School Health Examination Form Sample Resources and Webinar
Instructions for School Nurses and School Medical Directors Related to Completion of the Required Health Examination Form Effective 1/31/2021
Contains instructions and customizable, sample notifications for parents/guardians and community health care providers reminding them of the need to use the required form (NYSCSH 3/3/21)
FAQs -Required NYS School Health Examination Form
Provides answers to questions the Center has received regarding the use and completion of the form (NYSCSH 1/28/21)
Zoom Recording on the Required NYS School Health Examination Form
This Zoom discussion recording shares information regarding implementing the Required NYS School Health Exam for physical exams performed on or after 1/31/21. It reviews resources available to educate families and health care providers, including the new FAQ, which addresses using the 20-21 school year to educate families and providers about the requirement (NYSCSH 2/4//21, 25 minutes).
Interval Health History Forms
These forms may be modified by local school districts. If modified, the School Medical Director and Administration should review and approve it before use.
Sample Recommended NYSED Interval Health History for Athletics
Completed by parent/guardian no earlier than 30 days before the start of the sport. This form now includes questions related to COVID-19 (Fillable PDF Updated, 12/2020)
Sample Recommended NYSED Interval Health History for Athletics
Completed by parent/guardian no earlier than 30 days before the start of the sport. This form now includes questions related to COVID-19 (Word Updated 12/2020)
Spanish Sample Recommended NYSED Interval Health History for Athletics (Word Updated 1/2021)
Certificate of Limitations Form
Sample Recommended Form - Medical Certificate of Limitations
Used to document private provider recommendations for accommodation for PE (Updated May 2018).
Sample Athlete with Disabilities Form
This resource from the American Academy of Pediatrics may be helpful in collecting additional health information from athletes with disabilities. (AAP-Bright Futures, 2019)
Dental Certificates
Dental Certificates
Should be requested along with Health Examinations but are NOT required for school attendance.
See Also:
- NYS Education Department Screening Guidelines and Memos for Hearing, Scoliosis, and Vision Page
Includes guidelines, screening forms, School Health Exam/Screening Chart, sample parent notification, referral forms, sample teacher observation forms, documentation, and tracking forms.
Page Updated 3/29/22
