Georgia Department of Public Health
Form 3300
Certiicate of Vision, Hearing, Dental, and Nutrition Screening
PLEASE SEE THE INSTRUCTIONS
ON THE BACK OF THIS FORM
FILE THIS FORM WITH THE SCHOOL WHEN YOUR CHILD IS FIRST ENROLLED IN A GEORGIA PUBLIC SCHOOL
SCREENER CONTACT INFORMATION IS REQUIRED
Parent/ Guardian Name:_______________________________________
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middle |
last |
Parent/ Guardian Contact Information: |
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Daytime phone number:_____________________________________________________________
Evening phone number:_____________________________________________________________
Cell phone number:_________________________________________________________________
Child’s Name:__________________________________________________
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middle |
last |
Date of Birth: _____/_____/_____ |
Gender: Male Female |
Child’s Home Address:
____________________________________________________________________________________
street |
city |
state |
zip code |
county |
VISION
Unable to screen (explain why below)
Uses corrective lenses
Worn for testing
Passed (20/30 in each eye for age 6 and above, 20/40 in each eye for below age 6)
Needs further evaluation
Under professional care (explain below)
Screening completed by:
Physician
Local Health Department
Optometrist
“Prevent Blindness Georgia” employee
School Registered Nurse
___________________________________
Screener’s Signature Date
I certify that this child has received the above screening.
Contact Information:
HEARING
Unable to screen (explain why below)
Uses hearing aid / assistive device
Passed at 500, 1000, 2000, and 4000 Hz with audiometer at 20 or 25 dB
Needs further evaluation
Under professional care (explain below)
Screening completed by:
Physician
Local Health Department
Audiologist
Speech-Language Pathologist
School Registered Nurse
___________________________________
Screener’s Signature Date
I certify that this child has received the above screening.
Contact Information:
DENTAL
Unable to screen (explain why below)
Normal appearance
Needs further evaluation
Emergency problem observed
Under professional care (explain below)
Screening completed by:
Physician
Dentist
Local Health Department Registered Nurse
Registered Dental Hygienist
School Registered Nurse
___________________________________
Screener’s Signature Date
I certify that this child has received the above screening.
Contact Information:
NUTRITION
Unable to screen (explain why below)
Height: ___________ |
Weight: ___________ |
BMI: _____________ |
BMI%: ___________ |
5th to 84th percentile - Appropriate for age
< 5th percentile - Needs further evaluation
≥ 85th percentile - Needs further evaluation
Under professional care (explain below)
Screening completed by:
Physician
Local Health Department
Registered Dietician
School Registered Nurse
___________________________________
Screener’s Signature Date
I certify that this child has received the above screening.
Contact Information:
FOR SCHOOL SYSTEM ONLY |
Follow up for further evaluation |
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2nd attempt |
Actions reported (if any) |
Vision |
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Hearing |
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Dental |
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Nutrition |
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Student support services initiated on:
Screeners’ Comments:
DPH FORM 3300 REV. 2013
Georgia Department of Public Health Form 3300
Certificate of Vision, Hearing, Dental, and Nutrition Screening
Who is required to file this Form 3300? The parent or guardian of a child who is being admitted for the first time to a public school in Georgia must file a completed Form 3300 with the school when the child is enrolled.
What is the purpose of Form 3300? Form 3300 is intended to make sure that every child in Georgia is screened for possible problems with their vision, hearing, teeth and nutrition. The earlier these problems are detected, the earlier parents can seek professional help for the child.
What screenings are required? Four different screenings are required: vision, hearing, dental, and nutrition. All four screenings must be conducted and reported on the form before it can be filed with the school.
Who can conduct the screenings? Your child’s doctor is authorized to conduct all four screenings, as is your local health department. In addition, the vision screening can be conducted by a Georgia licensed optometrist, an employee of Prevent Blindness Georgia trained to conduct vision screening, or a school registered nurse; the hearing screening can be conducted by a Georgia licensed speech-language pathologist or audiologist, or a school registered nurse; the dental screening can be conducted by a Georgia licensed dentist, dental hygienist, or a school registered nurse; and the nutrition screening can be conducted by a Georgia licensed dietician or a school registered nurse. It is not necessary that the same person conduct all four screenings.
What does “BMI” and “BMI%” mean? “BMI” means “body mass index.” BMI is a way to describe how
much a child weighs in relation to height. “BMI percentile” is a way to compare the child’s body mass index to the body mass index of a healthy child. If the child’s BMI is less than 5% or more than 84% of what is appropriate for his or her age
and height, then the child should be taken to a doctor or dietician for a more detailed evaluation. For more information, visit
the Centers for Disease Control and Prevention website on child and teen BMI at: http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html
What should a parent do if the “needs further evaluation” box is checked? “Needs further evaluation”
means that the child may have a problem. If the “needs further evaluation” box is checked, then the parent should
take the child to a professional for a more detailed evaluation. Your doctor or local health department may be able to help, or recommend someone who can help.
What if a Form 3300 was previously filed for the child at another school? It is only necessary to file the Form 3300 once. If the Form 3300 is filed at the child’s first school, and the child later transfers to another school, then the original school is
required to forward the Form 3300 to the new school.
