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 (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)
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.
Spanish Sample Recommended NYSED Interval Health History for Athletics (Word Updated 1/2021)
Medical 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)
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
NYSED List of Dental Providers Offering Free or Reduced Care (4/28/2017)
School Medical Director Delegation Statement