New York State Center for School Health

Supporting Student Success Through Health and Education

Cumulative Record|Visit Logs|Screening Charts | Forms | Letters | Notifications

Health Office Daily Visit Logs and Cummulative|Summary Records

Sample Individual Student Health Office Visit Record (8/2012)

Sample Student Cumulative Health Record (8/2019)

Sample Student Daily Visit Form- Aids school health personnel in tracking follow-up on student visits to the health office. It is available in landscape and portrait and is customizable. (1/2018)

School Medical Director Delegation Statement-Written delegation is required for review of health examinations, interval health history for athletic, and screening students for vision, hearing, & scoliosis per Education Law, Article 19, section 905,(1). This sample may be customized by the district to comply with that requirement (6/2018).

SCREENING FORMS, CHARTS

New NYS & NYC Screening & Health Examination Requirements Chart- Effective 7/1/2018. Dental certificate requests should align with the new health exam grade levels (Created 1/2018)

Letter to Parent Regarding Required Screening for Vision, Hearing, Scoliosis, Health Examinations. (12/2018)

HEARING

Hearing Screening Parent/Guardian Notification Results and Referral Form (5/2018)

Classroom Teacher Observations- Hearing (5/2018)

SCOLIOSIS

Scoliosis Screening Parent/Guardian Notification Results and Referral Form(5/2018)

VISION:

Vision Screening Parent/Guardian Notification Results and Referral Form (10/2018)
Note: Parents must be notified of both passing and failing vision results. If a student passes it is sufficient to just indicated passed. However, if they fail you should provide the findings so the follow-up provider has a frame of reference. This form allows you to provide that information.

Classroom Teacher Observation - Vision (5/2018)

Sample Delegation

Sample School Medical Director Delegation Statement- Written delegation is required for review of health examinations, interval health history for athletic, and screening students for vision, hearing, & scoliosis per Education Law, Article 19, section 905,(1). This sample may be customized by the district to comply with that requirement.

Updated 1/10/20

Samples|Forms|Notifications|

Cumulative Record|Visit Logs|Screening Charts | Forms | Letters | Notifications