Health Examination & Dental Forms | Parent Letters | Notifications

Health examinations are required for new entrants and in grades Pre-K or K, 1, 3, 5, 7, 9, and 11.
(Section 136.3 Health Examinations and Screenings. Effective 7/1/18)

 

School Health Examination Form and Instructions for an EHR Compatible Form

Required NYS School Health Examination Form 
The form may be printed and completed by hand. (NYSED 2020). 

Required NYS School Health Examination Form (Fillable PDF)
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 (NYSED 2020). 

Instructions for Completion of the New York State School Health Examination EHR Compatible Form
Provides direction 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

Instructions for School Nurses and School Medical Directors Related to Completion of the Required Health Examination Form Effective 1/31/2021-Contains instructions for school nurses and school medical directors and customizable, sample notifications for parents/guardians and community health care providers reminding them of the need to use the required form,(NYSCSH 1/28/21)

Required NYS School Health Examination Form FAQ's-Provides answers to questions the Center has received regarding use and completion of the form (NYSCSH 1/28/21)

Interval Health History Forms may be modified by local school districts. If modified, it should be reviewed and approved by the School Medical Director and Administration prior to use.

Sample Recommended NYSED Interval Health History for Athletics- Completed by parent/guardian no earlier than 30 days prior to 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 prior to 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)

Medical Certificate of Limitations Form

Sample Recommended Form-Medical Certificate of LimitationsUsed 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)

Sample Athlete with Special Needs Supplemental Form- American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.PDF (2010) 

Sample Medical History Update Form -Optional form that may be used to obtain current health information from the parent/guardian in non-mandated health examination yeas or to provide student history prior to a school-provided physical exam (2/2018) 

Health Exam and Screening Requirements Charts|Determination for Ungraded Students

NYS & NYC Screening & Health Examination Requirements Chart (Effective 7/1/2018).

Chronological Grade Level Chart 2019-2020 for ungraded classes (3/2019)

Dental Certificate|Dental Providers|Letter to Parents/Guardians Regarding Dental Exams

Sample Dental Certificate-NYSED- This form aligns with health exam grade levels. NYS law (Chapter 281) permits schools to request an oral health assessment when requesting the health exam. It may be completed by a registered dentist or NYS registered dental hygienist.

NYSED List of Dental Providers Offering Free or Reduced Care (4/28/2017)

Letter to Parents Regarding Health and Dental Examination Requirements.-Informs parents/guardians of the mandated requirements for health appraisal within 30 days of school entry (4/2018).

Sample Parent Notification/Request for Mandated Health Appraisal and notification of medical director providing health appraisal if not provided by the private health care provider. (1/9/20)

School Medical Director Delegation Statement 

 
Page updated 1/29/21