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Question	Answer
Form Name	Form Har 3
Form Length	3 pages
Fillable?	Yes
Fillable fields	185
Avg. time to fill out	37 min 49 sec
Other names	ct health assessment form 2019, state of connecticut health assessment record, state of ct health assessment form 2020, ct health assessment form

12

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State of Connecticut Department of Education

Health Assessment Record

To Parent or Guardian:

In order to provide the best educational experience, school personnel must understand your child’s health needs. This form requests information from you (Part I) which will also be helpful to the health care provider when he or she completes the medical evaluation (Part II).

State law requires complete primary immunizations and a health assess- ment by a legally qualiied practitioner of medicine, an advanced practice

registered nurse or registered nurse, licensed pursuant to chapter 378, a physi-

cian assistant, licensed pursuant to chapter 370, a school medical advisor, or a legally qualiied practitioner of medicine, an advanced practice registered

nurse or a physician assistant stationed at any military base prior to school entrance in Connecticut (C.G.S. Secs. 10-204a and 10-206).An immunization

update and additional health assessments are required in the 6th or 7th grade and in the 9th or 10th grade. Speciic grade level will be determined by the

local board of education. This form may also be used for health assessments required every year for students participating on sports teams.

Please print

Student Name (Last, First, Middle)

Birth Date

❑Male ❑ Female

Address (Street, Town and ZIP code)

Parent/Guardian Name (Last, First, Middle)	Home Phone	Cell Phone

School/Grade	Race/Ethnicity	❑ Black, not of Hispanic origin
	❑ American Indian/	❑ White, not of Hispanic origin
	Alaskan Native	❑ Asian/Paciic Islander
Primary Care Provider	Alaskan Native	❑ Asian/Paciic Islander
	❑ Hispanic/Latino	❑ Other

Health Insurance Company/Number* or Medicaid/Number*

	Does your child have health insurance?	Y	N	If your child does not have health insurance, call 1-877-CT-HUSKY
	Does your child have dental insurance?	Y	N
	Does your child have dental insurance?	Y	N

	* If applicable

Part I — To be completed by parent/guardian.

Please answer these health history questions about your child before the physical examination.

Please circle Y if “yes” or N if “no.” Explain all “yes” answers in the space provided below.

Any health concerns	Y	N	Hospitalization or Emergency Room visit Y		N	Concussion	Y	N
Allergies to food or bee stings	Y	N	Any broken bones or dislocations	Y	N	Fainting or blacking out	Y	N
Allergies to medication	Y	N	Any muscle or joint injuries	Y	N	Chest pain	Y	N
Any other allergies	Y	N	Any neck or back injuries	Y	N	Heart problems	Y	N
Any daily medications	Y	N	Problems running	Y	N	High blood pressure	Y	N
Any problems with vision	Y	N	“Mono” (past 1 year)	Y	N	Bleeding more than expected	Y	N
Uses contacts or glasses	Y	N	Has only 1 kidney or testicle	Y	N	Problems breathing or coughing	Y	N

Any problems hearing	Y	N	Excessive weight gain/loss	Y	N	Any smoking	Y	N
Any problems with speech	Y	N	Dental braces, caps, or bridges	Y	N	Asthma treatment (past 3 years)	Y	N

Family History						Seizure treatment (past 2 years)	Y	N
Any relative ever have a sudden unexplained death (less than 50 years old)				Y	N	Diabetes	Y	N

Any immediate family members have high cholesterol				Y	N	ADHD/ADD	Y	N

Please explain all “yes” answers here. For illnesses/injuries/etc., include the year and/or your child’s age at the time.

Is there anything you want to discuss with the school nurse? Y N If yes, explain:

Please list any medications your child will need to take in school:

All medications taken in school require a separate Medication Authorization Form signed by a health care provider and parent/guardian.

I give permission for release and exchange of information on this form between the school nurse and health care provider for conidential


use in meeting my child’s health and educational needs in school. Signature of Parent/Guardian		Date

HAR-3 REV. 4/2012	To be maintained in the student’s Cumulative School Health Record

Part II — Medical Evaluation

HAR-3 REV. 4/2012

Health Care Provider must complete and sign the medical evaluation and physical examination

Student Name

Birth Date

Date of Exam

❑I have reviewed the health history information provided in Part I of this form

Physical Exam

Note: *Mandated Screening/Test to be completed by provider under Connecticut State Law

*Height _____ in. / _____% *Weight _____ lbs. / _____%

BMI _____ / _____% Pulse _____

*Blood Pressure _____ / _____

Normal

Describe Abnormal

Ortho

Normal

Describe Abnormal

Neurologic

Neck

HEENT

Shoulders

*Gross Dental

Arms/Hands

Lymphatic

Hips

Heart

Knees

Lungs

Feet/Ankles

Abdomen

*Postural

❑ No spinal

❑ Spine abnormality:

Genitalia/ hernia

abnormality

❑ Mild

❑ Moderate

❑ Marked ❑ Referral made

Skin

Screenings

*Vision Screening

*Auditory Screening

History of Lead level

Date

Type:

Right

Left

Type:

Right

Left

≥ 5µg/dL ❑ No ❑ Yes

❑ Pass

❑ Pass

With glasses

20/

20/

*HCT/HGB:

❑ Fail

❑ Fail

Without glasses

20/

20/

*Speech (school entry only)

❑ Referral made

❑ Referral made

Other:

TB: High-risk group?

❑ No

❑ Yes

PPD date read:

Results:

Treatment:

*IMMUNIZATIONS

❑Up to Date or ❑ Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED

*Chronic Disease Assessment:

Asthma	❑ No	❑ Yes:	❑ Intermittent ❑ Mild Persistent ❑ Moderate Persistent ❑ Severe Persistent ❑ Exercise induced
	If yes, please provide a copy of the Asthma Action Plan to School
Anaphylaxis ❑ No		❑ Yes:	❑ Food	❑ Insects	❑ Latex	❑ Unknown source
Allergies	If yes, please provide a copy of the Emergency Allergy Plan to School
	History of Anaphylaxis			❑ No	❑ Yes	Epi Pen required ❑ No	❑ Yes
Diabetes	❑ No	❑ Yes:	❑ Type I	❑ Type II		Other Chronic Disease:
Seizures	❑ No	❑ Yes, type:

❑This student has a developmental, emotional, behavioral or psychiatric condition that may affect his or her educational experience. Explain: ____________________________________________________________________________________________________

Daily Medications (specify): ____________________________________________________________________________________

This student may: ❑ participate fully in the school program

❑participate in the school program with the following restriction/adaptation: _____________________________

___________________________________________________________________________________________________________

This student may: ❑ participate fully in athletic activities and competitive sports

❑participate in athletic activities and competitive sports with the following restriction/adaptation: ____________

___________________________________________________________________________________________________________

❑Yes ❑ No Based on this comprehensive health history and physical examination, this student has maintained his/her level of wellness.

Is this the student’s medical home? ❑ Yes ❑ No ❑ I would like to discuss information in this report with the school nurse.


	Signature of health care provider MD / DO / APRN / PA	Date Signed	Printed/Stamped Provider Name and Phone Number

Student Name: ______________________________________ Birth Date: ___________________

Immunization Record

To the Health Care Provider: Please complete and initial below.

HAR-3 REV. 4/2012

Vaccine (Month/Day/Year) Note: *Minimum requirements prior to school enrollment. At subsequent exams, note booster shots only.

Dose 1

Dose 2

Dose 3

Dose 4

Dose 5

Dose 6

DTP/DTaP

*

*

*

*

DT/Td

Tdap

*

Required for 7th grade entry

IPV/OPV

*

*

*

MMR

*

*

Required K-12th grade

Measles

*

*

Required K-12th grade

Mumps

*

*

Required K-12th grade

Rubella

*

*

Required K-12th grade

HIB

*

PK and K (Students under age 5)

Hep A

*

*

PK and K (born 1/1/2007 or later)

Hep B

*

*

*

Required PK-12th grade

Varicella

*

*

2 doses required for K & 7th grade as of 8/1/2011

PCV

*

PK and K (born 1/1/2007 or later)

Meningococcal

*

Required for 7th grade entry

HPV

Flu

*

PK students 24-59 months old – given annually

Other

Disease Hx ________________________________

________________________________

________________________________

of above

(Specify)

(Date)

(Conirmed by)

Exemption

Religious _____ Medical: Permanent _____

Temporary _____

Date _____

Recertify Date _________ Recertify Date _________ Recertify Date ________

Immunization Requirements for Newly Enrolled Students at Connecticut Schools

KINDERGARTEN

•DTaP: At least 4 doses. The last dose must be given on or after 4th birthday.

•Polio: At least 3 doses. The last dose must be given on or after 4th birthday.

•MMR: 2 doses given at least 28 day apart – 1st dose on or after the 1st birthday.

•Hib: 1 dose on or after 1st birthday (Children 5 years and older do not need proof of Hib vaccination).

•Pneumococcal: 1 dose on or after 1st birthday (born 1/1/2007 or later and less than 5 years old).

•Hep A: 2 doses given six months apart-1st dose on or after 1st birthday.

•Hep B: 3 doses-the last dose on or after 24 weeks of age.

•Varicella: For students enrolled before August 1, 2011, 1 dose given on or after 1st birthday; for students enrolled on or after August 1, 2011

2 doses given 3 months apart – 1st dose on or after 1st birthday or veriication of disease*.

GRADES 1-6

•DTaP /Td/Tdap: At least 4 doses. The last dose must be given on or after 4th birthday; students who start the series at age 7 or older only need a total of 3 doses of tetanus-diph- theria containing vaccine.

•Polio: At least 3 doses. The last dose must be given on or after 4th birthday.

•MMR: 2 doses given at least 28 days apart- 1st dose on or after the 1st birthday.

•Hep B: 3 doses – the last dose on or after 24 weeks of age.

•Varicella: 1 dose on or after the 1st birthday or veriication of disease*.

GRADE 7

•Tdap/Td: 1 dose of Tdap for students 11 yrs. or older enrolled in 7th grade who completed their primary DTaP series; For those students who start the series at age 7 or older a total of 3 doses of tetanus-diphtheria containing vac- cines are needed, one of which must be Tdap.

•Polio: At least 3 doses. The last dose must be given on or after 4th birthday.

•MMR: 2 doses given at least 28 days apart – 1st dose on or after the 1st birthday.

•Meningococcal: one dose for students enrolled in 7th grade.

•Hep B: 3 doses-the last dose on or after 24 weeks of age.

•Varicella: 2 doses given 3 months apart – 1st dose on or after 1st birthday or veriication of

disease*.

GRADES 8-12

•Td: At least 3 doses. Students who start the series at age 7 or older only need a total of 3 doses of tetanus-diphtheria containing vaccine one of which should be Tdap.

•Polio: At least 3 doses. The last dose must be given on or after 4th birthday.

•MMR: 2 doses given at least 28 days apart- 1st dose on or after the 1st birthday.

•Hep B: 3 doses-the last dose on or after 24 weeks of age.

•Varicella: For students <13 years of age, 1 dose given on or after the 1st birthday. For students

13 years of age or older, 2 doses given at least

4 weeks apart or veriication of disease*.

*Veriicationofdisease:Conirmation in writ- ing by a MD, PA, or APRN that the child has a previous history of disease, based on family or medical history.

Note: The Commissioner of Public Health may issue a temporary waiver to the schedule for active immunization for any vaccine if the National Centers for Disease Control and Prevention recognizes a nation-wide shortage of supply for such vaccine.


	Initial/Signature of health care provider MD / DO / APRN / PA	Date Signed	Printed/Stamped Provider Name and Phone Number

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Write the information in Signature, of, Parent, Guardian Date, and HAR, REV

stage 2 to completing ct health assessment form

The system will request you to provide certain fundamental details to easily complete the part BirthDate, Date, of, Exam Normal, Describe, Abnormal Ortho, Normal, Describe, Abnormal Neurologic, HE, ENT Gross, Dental Lymphatic, Heart, Lungs, Abdomen, and Genitalia, hernia

Entering details in ct health assessment form step 3

The HC, TH, GB Speech, school, entry, only With, glasses Without, glasses Pass, Pass, Fail, Fail Referral, made Referral, made Other, TB, High, risk, group, NoYes PPD, date, read Results, Treatment, IMMUNIZATIONS, Chronic, Disease, Assessment and Asthma section allows you to point out the rights and responsibilities of both sides.

Filling in ct health assessment form part 4

Finish by reviewing the following fields and writing the relevant details: Signature, of, healthcare, provider MD, DO, APR, NPA and Date, Signed

ct health assessment form Signatureofhealthcareprovider, MDDOAPRNPA, and DateSigned blanks to complete

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