Form H511 336 – Fill Out and Use This PDF

Form H4 is a document that has been established by the Immigration Department to allow family members of US citizens and permanent residents to enter or appear with the United States. This form denotes the information collected such as personal biographical details, familial status, and other vital facts given by the applicant. The purpose of filling out Form H4 is not only to prove close relationship, but also it makes sure applicant meets all U.S immigration eligibility requirements before granting a Visa. For instance, individuals need to provide veritable entry documents or accompanying dependents who intend to apply for dependent VISA, intending immigrants must fill in this special privacy act statement seeking any formal nonimmigrant judgments, such as an arrest record etc. The completion of Form H4 helps determine if applicants are eligible for visa grants providing their relatives hereincountry receipt renewable when expire on designated dates according law policy .

Form H511 336 PDF Details

The Form H511 336 is a form used to request an exemption from the individual shared responsibility payment that is associated with not having qualifying health coverage. This form can be used by individuals, families or groups of taxpayers who have religious objections to health insurance, or who have other sincerely held moral or ethical beliefs against obtaining health insurance. The instructions for completing this form are very detailed, and it is important to provide all of the information requested in order to ensure a timely and accurate review. Failure to do so may result in a delay in your exemption being granted, or even a denial of your request.

Question	Answer
Form Name	Form H511 336
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	DTaP, H511, pa school physical form h511 336, physical form for school pa

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H511.336 (Rev 5/02)	COMMONWEALTH OF PENNSYLVANIA
	DEPARTMENT OF HEALTH

PRIVATE PHYSICIAN’S REPORT OF

PHYSICAL EXAMINATION OF A PUPIL OF SCHOOL AGE

DATE _________________ 20_________

NAME OF SCHOOL __________________________________________________ GRADE ______ HOMEROOM ________

NAME OF CHILD

__________________________________________________________________________

Last

First

Middle

DATE OF BIRTH

SEX

M F

ADDRESS

____________________________________________________________________________________________________

No. and Street City or Post Office Borough or Township County State Zip Code

MEDICAL HISTORY

IMMUNIZATIONS AND TESTS

Enter Month, Day, and Year each

VACCINE

immunization was given

BOOSTERS & DATES

DOSES

Diphtheria and Tetanus

(Circle): DTaP, DTP, DT, TD

Polio (Circle): OPV, IPV

Measles, Mumps, Rubella

Hepatitis B

HIB

Varicella Disease or Lab

Varicella

Evidence

Date: __________________

Other: ___________________

MEDICAL EXEMPTION The physical condition of the above named child is such that immunization would endanger life or health RELIGIOUS EXEMPTION (Includes a strong moral or ethical conviction similar to a religious belief and requires a written

statement from the parent/guardian)

If Applicable:

Tuberculin Tests
Date Applied	Arm	Device	Antigen	Manufacturer	Signature

Date Read	Results (mm)			Signature

Follow-Up of significant tuberculin tests:

Parent/Guardian notified of significant findings on _____________________________.

Result of Diagnostic Studies: _____________________________________________________________________.

Preventive Anti-Tuberculosis – Chemotherapy ordered.		___________
No	Yes	Date

	Significant Medical Conditions (√)
	If Yes, Explain
Yes	No
Allergies	_______________________________________________________________
Asthma	_______________________________________________________________
Cardiac	_______________________________________________________________
Chemical Dependency	_______________________________________________________________
Drugs	_______________________________________________________________
Alcohol	_______________________________________________________________
Diabetes Mellitus	_______________________________________________________________
Gastrointestinal Disorder	_______________________________________________________________
Hearing Disorder	_______________________________________________________________
Hypertension	_______________________________________________________________
Neuromuscular Disorder	_______________________________________________________________
Orthopedic Condition	_______________________________________________________________
Respiratory Illness	_______________________________________________________________
Seizure Disorder	_______________________________________________________________
Skin Disorder	_______________________________________________________________
Vision Disorder	_______________________________________________________________
Other (Specify)	_______________________________________________________________

Are there any special medical problems or chronic diseases which require restriction of activity, medication or

which might affect his/her education? If so, specify ____________________________________________________________

Report of Physical Examination (√)
Normal	Abnormal	Not Examined	Comments

Height (inches)

Weight (pounds) BMI

Pulse ( )

Blood Pressure

Hair/Scalp

Skin

Eyes/Vision

Ears/Hearing

Nose and Throat

Teeth and Gingiva

Lymph Glands

Heart – Murmur, etc

Lung – Adventitious Finding

Abdomen

Genitourinary

Neuromuscular System

Extremities

Spine (Presence of Scoliosis)

_____________________________________________________

Date of Examination

_____________________________________________________	______________________________________________________
Signature of Examiner	PRINT Name of Examiner
______________________________________________________	______________________________________________________
Address	Telephone Number

Form H511 336 – Fill Out and Use This PDF

Form H511 336 PDF Details

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