The PM 171 B form is a critical document from the State of California—Health and Human Services Agency, Department of Health Care Services, associated with the Child Health and Disability Prevention (CHDP) Program. It serves as a waiver for the health examination required for school entry in California. This form is specifically designed for parents or guardians who choose to excuse their child from the mandatory health examination while still acknowledging the importance of the immunizations required by the state for school attendance. Unlike excusing the child from the health exam, the waiver does not exempt the child from receiving necessary vision and hearing tests provided by schools. The form contains sections for the child's basic information, including name, date of birth, address, and school information, and requires the signature of a parent or guardian to be valid. It advises parents about their rights, the recommended health examinations, and provides guidance on how to access these health examinations at no cost based on income levels. Additionally, the document is bilingual, ensuring broader access and understanding across California’s diverse population. This waiver upholds the state’s commitment to child health while respecting parental rights and circumstances that may prevent the completion of a health examination.
| Question | Answer |
|---|---|
| Form Name | Form Pm 171 B |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | NOMBRE, pm 171 a, CHDP, INGRESAR |
State of |
Department of Health Care Services |
|
Child Health and Disability Prevention (CHDP) Program |
WAIVER OF HEALTH EXAMINATION FOR SCHOOL ENTRY
CHILD’S |
First |
Middle |
DATE OF |
City |
ZIP Code |
SCHOOL |
Teacher |
PARENT OR GUARDIAN:
Please fill out this form if you want to excuse your child from the health examination required by California law for school entry. SIGN AND RETURN THIS FORM TO THE SCHOOL where it will be maintained as confidential information.
NOTE: SIGNING THIS WAIVER DOES NOT EXCUSE YOUR CHILD FROM RECEIVING THE IMMUNIZATIONS REQUIRED BY CALIFORNIA LAW FOR CHILDREN IN SCHOOL. ALSO, SIGNING THIS WAIVER WILL NOT DENY YOUR CHILD THE VISION AND HEARING TESTS DONE BY THE SCHOOL.
I have been informed about the health examination recommended by health professionals and required by state law. I have been informed about where my child can receive a health examination and about the income levels for receiving it at no cost to me.
Please check one of the following:
I choose not to have my child receive a health examination as part of the school entry requirement.
I would like my child to receive a health examination, but I am unable to obtain it.
Reason (see Health and Safety Code, Section 124085):
Signature of parent or guardian |
Date |
INQUIRE AT THE SCHOOL OFFICE OR YOUR LOCAL HEALTH DEPARTMENT IF YOU WANT MORE INFORMATION.
CHDP website: www.dhcs.ca.gov/services/chdp
PM 171 B (Bilingual) (09/07)
State of |
Department of Health Care Services |
|
Child Health and Disability Prevention (CHDP) Program |
RENUNCIA VOLUNTARIA PARA RECIBIR UN EXAMEN DE SALUD PARA INGRESAR A LA ESCUELA
NOMBRE DEL NIÑO/DE LA |
Primer Nombre |
Segundo Nombre |
FECHA DE |
Ciudad |
Zona Postal |
ESCUELA |
Maestro(a) |
PADRE/MADRE O GUARDIÁN:
Si desea que su niño(a) no reciba el examen de salud requerido por la ley de California antes de ingresar a la escuela, por favor llene este formulario. FIRMELO Y DEVUELVALO A LA ESCUELA donde será guardado en forma confidencial.
AVISO: EL FIRMAR ESTA RENUNCIA VOLUNTARIA NO DISPENSA PARA QUE EL NIÑO/LA NIÑA RECIBA LAS INMUNIZACIONES REQUERIDAS POR LA LEY DE CALIFORNIA PARA LOS NIÑOS EN LA ESCUELA. TAMBIÉN, EL FIRMAR ESTE FORMULARIO NO LE NEGARÁ A SU NIÑO(A) EL DERECHO A RECIBIR LOS EXÁMENES DE LA VISTA Y EL OÍDO HECHOS POR LA ESCUELA.
Se me ha informado acerca del examen de salud recomendado por los respectivos profesionales y requerido por la ley del estado. Se me ha informado también acerca de los lugares donde mi niño(a) puede recibir un examen de salud y sobre los diferentes niveles de ingresos para recibirlo sin costo alguno.
Por favor marque uno de los siguientes casilleros:
Escojo que mi niño(a) no reciba el examen de salud que es uno de los requisitos para ingresar a la escuela.
Me gustaría que mi niño(a) reciba un examen de salud, pero estoy incapacitado(a) para obtenerlo.
Razón (vea Health and Safety Code, Sección 124085):
Firma del padre/madre o guardián |
Fecha |
SI DESEA MÁS INFORMACIÓN CONSIGALA EN LA ESCUELA O EN SU DEPARTAMENTO LOCAL DE SALUD.
CHDP website: www.dhcs.ca.gov/services/chdp
PM 171 B (Bilingual) (09/07)