Form Mdch Bcal 3305 PDF Details

Ensuring the health and well-being of children as they embark on their educational journey is a pivotal aspect of collaborative care among parents, schools, and healthcare providers. The Mdch Bcal 3305 form, a comprehensive health appraisal document, serves as a cornerstone for this collaborative effort. It requests detailed information to assist schools in accommodating the physical, intellectual, and emotional needs of students. By requiring completion by parents or guardians, and certification by healthcare professionals, this form encompasses a child's health history, including allergies, chronic conditions, and medication needs, and specifies requirements for physical examinations, immunization records, and dental assessments. Crucially, the form facilitates the transcription of immunization information, underlining the importance of vaccination in school admission processes, while also addressing accommodations needed within the school environment to support the child's health and participation in various activities. Developed with input from an array of health and education stakeholders, the Mdch Bcal 3305 embodies a proactive approach to ensuring that children receive the necessary health checks, vaccinations, and care recommendations tailored to support their success in the educational setting.

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Form NameForm Mdch Bcal 3305
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesHealth Appraisal 1f18s4s webadvisor ohlone form

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HEALTH APPRAISAL

Dear Parent or Guardian:  The following information is requested so that the school can work with the parent to meet the physical, intellectual and emotional needs of the child. Fill out the information requested in Section I. Section III may be certified by the transcription of information from the certificate of immunization. The remaining sections are to be completed by a doctor, nurse and dentist. (BE SURE TO BRING YOUR CHILD’S IMMUNIZATION RECORDS TO THE EXAMINATION.)

PERSONAL

CHILD’S NAME (Last, First, Middle)

 

 

DATE OF BIRTH (mm/dd/yy)

 

 

 

 

/

/

 

 

 

 

ADDRESS (Number & Street)

(City)

(ZIP Code)

TODAY’S DATE (mm/dd/yy)

 

MI

 

 

/

/

 

 

 

 

PARENT/GUARDIAN (Last, First, Middle)

 

 

HOME TELEPHONE NUMBER

 

 

 

(

)

 

 

 

 

 

ADDRESS (Number & Street)

(City)

(ZIP Code)

WORK TELEPHONE NUMBER

 

MI

 

(

)

 

 

 

 

 

 

 

SECTION I - HEALTH HISTORY

Yes

No

Resolved

  # Is your child having any of the problems listed below?

Birth History:

hh h 1 Allergies or Reactions (for example, food, medication or other)

hh h 2 Hay Fever, Asthma, or Wheezing

hh h 3 Eczema or Frequent Skin Rashes

hh h 4 Convulsions/Seizures

hh h 5 Heart Trouble

hh h 6 Diabetes

h h h

7

Frequent Colds, Sore Throats, Earaches (4 or more per year)

 

Are there any current or past diagnosis(es) h  Yes    h  No

h h h

8

Trouble with Passing Urine or Bowel Movements

 

If yes, please describe:

h h h

9

Shortness of Breath

 

 

hh h 10 Speech Problems

hh h 11 Menstrual Problems

h

h

h

12 Dental Problems:  Date of Last Exam

/

/

 

h

h

h

Other (please describe):

 

 

 

 

 

 

 

 

 

 

 

 

h h

Does your child take any medication(s) regularly?

 

 

[

If yes, list medications:

 

 

 

 

Reason for Medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

Was the health history reviewed by a health professional?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent/Guardian Signature

Date

 

h  Yes    h  No

Examiner’s Initials:

 

 

SECTION II - PHYSICAL EXAMINATION, INSPECTION, TESTS AND MEASUREMENTS

Required for Child Care and Head Start / Early Head Start

Tests and Measurements

No Yes

Was child tested for:

Test results:

 

VISION

 

h h

 

 

 

Date:

 

/

/

Other:

HEARING

 

 

 

h h

 

 

Other:

 

 

 

Date:

 

/

/

 

URINALYSIS

 

 

 

h h

 

 

 

Date:

 

/

/

 

BLOOD LEAD LEVEL

 

 

h h

 

 

Level

 

 

 

Date:

 

/

/

 

  Essential Findings Deviating from Normal:

 

Normal

Referred

Under Care

No

Yes

Was child tested for:

 

Test results:

 

 

 

 

Normal

Referred

Under Care

Visual Acuity

 

 

 

h

h

HEIGHT & WEIGHT

 

 

 

Height

 

 

 

 

 

 

 

Muscle Imbalance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weight

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h

h

Other:

 

 

 

 

 

Other

 

 

 

 

 

 

 

Audiometer

 

 

 

h

h

HEMOGLOBIN / HEMATOCRIT

 

 

 

 

]

 

 

 

 

 

 

Sugar

 

 

 

h

h

BLOOD PRESSURE

 

 

 

Reading:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TUBERCULIN

 

 

 

 

Type:

 

 

 

 

 

 

 

 

Albumin

 

 

 

h

h

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Microscopic

 

 

 

 

 

Date:

/

/

 

 

Neg.:  h    Pos.:  h

 

 

mm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[

NOTE:  Blood lead level required for all children enrolled in Medicaid must be tested

ug/dl

at one and two years of age, or once between three and six years of age if not

 

 

 

 

previously tested. All children under age six living in high-risk areas should be tested

 

 

 

 

at the same intervals as listed above.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Examinations and/or Inspections

Exam Date: 

/ 

/

HHS/BCAL-3305 (formerly OCAL 3305/BRS-3305)

Page 1 of 2

Rev. July 2015

SECTION III - IMMUNIZATIONS

Statements such as “UP-TO-DATE” or “COMPLETE” will not be accepted. Admission to school may be denied on the basis of this information.*

VACCINES (Circle Type)

 

DATE ADMINISTERED

 

 

VACCINES (Circle Type)

DATE ADMINISTERED

 

 

 

MM/DD/YYYY

 

 

 

 

MM/DD/YYYY

 

 

 

Hepatitis B

1

 

3

 

 

Hepatitis A (HepA)

1

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(HepB)

2

 

 

 

 

Influenza (IIV/LAIV)

1

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

4

 

 

2

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DTaP/DTP/DT/Td

2

 

5

 

 

Meningococcal (MCV4 / MPSV4)

1

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

6

 

 

Human Papillomavirus

1

 

 

3

 

 

 

 

 

 

 

 

 

(HPV9/HPV4/HPV2)

 

 

 

 

 

 

 

Tdap

1

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Haemophilus Influenzae

1

 

3

 

 

 

Type of Vaccine(s)

Date of Vaccine(s)

 

 

 

 

 

 

 

OTHER Vaccines

 

 

 

 

 

 

 

type b (HIB)

2

 

4

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

Specify Date & Type

 

 

 

 

 

 

 

Polio

1

 

3

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(IPV/OPV)

2

 

4

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal Conjugate

1

 

3

 

Indicate and attach physician diagnosis or laboratory evidence of immunity as applicable

 

(PCV7/PCV13)

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

4

 

*NOTE: According to Public Act 368 of 1978, any child enrolling in a Michigan school for

 

 

 

 

 

 

 

Rotavirus (RV1/RV5)

1

 

3

 

 

the first time must be adequately immunized, vision tested and hearing tested.

 

 

 

 

 

 

 

Exemptions to these requirements are granted for medical, religious and other

 

 

2

 

 

 

 

 

 

 

 

objections, provided that the waiver forms are properly prepared, signed and

 

 

 

 

 

 

 

Measles,Mumps, Rubella (MMR)

1

 

2

 

 

delivered to school administrators. Forms for these exemptions are available

 

 

 

 

 

 

 

at your provider office for medical waiver forms and through your local health

 

Varicella (Chickenpox)

1

 

2

 

 

 

 

department for nonmedical waiver forms.

 

 

 

 

 

 

 

 

 

 

 

 

 

History of Chickenpox Disease?    h  Yes    h  No      If yes, date:

 

Parent/Guardian refused immunizations:  h

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I certify that the immunization dates are true to the best of my knowledge

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/ 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Professional’s Signature

 

Title

 

 

 

Date

 

 

No Yes

h h

h h

SECTION IV - RECOMMENDATIONS

(Required for Child Care and Head Start/Early Head Start)

Is there any defect of vision, hearing or other condition for which the school could help by seating or other actions? If yes, please explain:

Should the child’s activity be restricted because of any physical defect or illness?

If yes, check and explain degree of restriction(s): h  Classroom    h  Playground    h  Gymnasium    h  Swimming Pool    h  Competitive Sports    h  Other

Other Recommendations

SECTION V - DENTAL EXAMINATION AND RECOMMENDATIONS (OPTIONAL)

 

I have examined

 

’s teeth. As a result of this examination, my recommendation for treatment is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

child’s name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

  /

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dentist’s Signature

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN’S SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Examiner’s Signature

 

 

 

Date

Examiner’s Name (Print or Type)

 

 

 

 

 

 

 

Degree or License

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MI

 

 

(

 

 

   

)

 

 

 

 

 

 

 

 

Number & Street

 

 

City

 

 

 

ZIP Code

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Information required for:

Early On - Hearing and Vision Status; Diagnosis; Health Status Child Care Licensing - Physical Exam, Restrictions, Immunizations

Head Start/Early Head Start - Determination that child is up-to-date on a schedule of age-appropriate preventive and primary health care, including medical, dental, and mental health. The schedule must incorporate the well-child care visit required by EPSDT and the latest immunizations schedule recommended by the Centers for Disease Control and Prevention, State, tribal, and local authorities. An EPSDT well-child exam includes height, weight, and blood tests for anemia at regular intervals based on age.

**************

Developed in Cooperation with the Department of Health and Human Services, Education, Michigan American Association of Pediatrics, Early Childhood Investment Corporation, Child Care Licensing, Head Start, Michigan State Medical Society, Michigan Association of Osteopathic Physicians and Surgeons.

DHHS/BCAL 3305 (formerly OCAL 3305/BRS-3305)

Page 2 of 2

Rev. July 2015

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entering details in Form Mdch Bcal 3305 part 1

In the h h h Allergies or Reactions for, h h, Does your child take any, If yes list medications, Reason for Medication, ParentGuardian Signature, Date, Was the health history reviewed by, h Yes h No, Examiners Initials, SECTION II PHYSICAL EXAMINATION, Tests and Measurements, o N, s e Y, and Was child tested for area, put in writing your details.

stage 2 to finishing Form Mdch Bcal 3305

The application will require for more info as a way to effortlessly fill out the part URINALYSIS, h h, Date, BLOOD LEAD LEVEL, h h, Date, Type, TUBERCULIN, h h, Date, Neg h Pos h, NOTE Blood lead level required for, Sugar, Albumin, and Microscopic.

Filling in Form Mdch Bcal 3305 stage 3

You need to define the rights and responsibilities of all parties in box VACCINES Circle Type, DATE ADMINISTERED MMDDYYYY, Hepatitis B, HepB, DTaPDTPDTTd, Tdap, Haemophilus Influenzae, type b HIB, Polio, IPVOPV, Pneumococcal Conjugate, PCVPCV, Rotavirus RVRV, MeaslesMumps Rubella MMR, and Varicella Chickenpox.

Form Mdch Bcal 3305 VACCINES Circle Type, DATE ADMINISTERED MMDDYYYY, Hepatitis B, HepB, DTaPDTPDTTd, Tdap, Haemophilus Influenzae, type b HIB, Polio, IPVOPV, Pneumococcal Conjugate, PCVPCV, Rotavirus RVRV, MeaslesMumps Rubella MMR, and Varicella Chickenpox blanks to insert

End by checking the following sections and filling them in as needed: Is there any defect of vision, Should the childs activity be, h Classroom h Playground h, h h, h h, Other Recommendations, I have examined, s teeth As a result of this, childs name, SECTION V DENTAL EXAMINATION AND, Dentists Signature, Date, PHYSICIANS SIGNATURE, Examiners Signature, and Date.

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