Form 3300: Georgia Certificate of Vision, Hearing, Dental, and Nutrition Screening

Enter the child's name (First, Middle, Last) and the Parent/Guardian name (First, Middle, Last).

Enter the Date of Birth and check Male or Female for Gender.

Under Parent/Guardian Contact Information, enter the Home Address (Street, City, State, Zip Code), the Primary Phone# and the Secondary Phone#.

Under Vision, check Uses corrective lenses, Worn for testing, or Not worn for testing, as they apply.

For Screening Method (Select one) under Vision, check Distance visual acuity chart; 20/50 age 3, 20/40 age 4 and 5, 20/32 age 6+ (Primary method: Required when developmentally appropriate), or Instrument-based/Photoscreener (Alternative method: Use only if primary method is not developmentally appropriate; document reason in comments).

Under Results, check Passed both eyes, Failed one or both eyes; Needs further evaluation (explain in comments), Under professional care (explain in comments) or Unable to complete screening (explain in comments).

Under Screened by, check Physician, Optometrist, Local Health Department, Prevent Blindness Georgia Employee or School Registered Nurse.

Under Hearing, check Uses hearing aid / assistive device (do not screen), as it applies.

For Screening Method (Select one) under Hearing, check Pure tone audiometry; 1000, 2000, and 4000 Hz at 20 dBHL (Primary method: Required when developmentally appropriate), or Automated Otoacoustic Emissions (Alternative method: Use only if primary method is not developmentally appropriate; document reason in comments).

Under Results, check Passed both ears, Failed one or both ears; Needs further evaluation (explain in comments), Under professional care (explain in comments) or Unable to complete screening (explain in comments).

Under Screened by, check Physician, Audiologist, Local Health Department, Speech-Language Pathologist or School Registered Nurse.

Under Dental Results, check Normal appearance, Needs further evaluation, Emergency problem observed, Under professional care (explain in comments) or Unable to complete screening (explain in comments).

Under Screened by, check Physician, Dentist, Local Health Department Registered Nurse, Registered Dental Hygienist or School Registered Nurse.

Under Nutrition Results, enter Height, Weight, BMI and BMI%.

BMI means body mass index, 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.

Check 5th to 84th percentile (Appropriate for age), <5th percentile or ≥85th percentile (Needs further evaluation), Under professional care (explain in comments), or Unable to complete screening (explain in comments).

Under Screened by, check Physician, Registered Dietician, Local Health Department or School Registered Nurse.

Under each screening, the screener signs on the Screener's Signature line and enters the Date, to certify that the screening was completed or attempted for this child.

Under each screening, enter the screener's Contact Information. Screener contact information is required.

Use Comments to explain any box marked (explain in comments).

If 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, the original school is required to forward the Form 3300 to the new school.

Form 3300 is the Certificate of Vision, Hearing, Dental, and Nutrition Screening, which makes 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.

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.

The screener signs and dates each screening. It is not necessary that the same person conduct all four 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.

File this form with the school when your child is first enrolled in a Georgia public school.