Pm 171 A Form PDF Details

Ensuring the well-being of children as they enter school is a priority that the State of California takes seriously, which is where the PM 171 A form comes into play. This essential document, provided by the Department of Health Care Services and the Child Health and Disability Prevention (CHDP) Program, serves as a thorough report of a health examination for school entry. For all children about to step into their educational journey, California law mandates this health check to shield them from potential health issues. The process involves a detailed completion of the form by both a parent or guardian and a qualified health examiner, covering every aspect of the child's health—from immunization records to various vital health screenings such as vision, hearing, dental, and nutritional assessments, among others. Additionally, this form acts as a confidential bridge between the health examiner and the school, ensuring that any health conditions that could affect the child's educational activities are communicated effectively, all while maintaining the privacy of the child's health information. Also, it acknowledges the parents' right to either consent to or waive this health examination, illustrating the blend of care and autonomy that the state promotes for its young residents' health and education.

QuestionAnswer
Form NamePm 171 A Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesreport entry, how to 171 a, pm 171 a, pm 171 a form

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State of CaliforniaHealth and Human Services Agency

Department of Health Care Services

 

Child Health and Disability Prevention (CHDP) Program

REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY

To protect the health of children, California law requires a health examination on school entry. Please have this report filled out by a health examiner and return it to the school. The school will keep and maintain it as confidential information.

PART I TO BE FILLED OUT BY A PARENT OR GUARDIAN

CHILD’S NAME—Last

First

Middle

BIRTH DATEMonth/Day/Year

ADDRESSNumber, Street

City

ZIP code

SCHOOL

PART II TO BE FILLED OUT BY HEALTH EXAMINER

HEALTH EXAMINATION

NOTE: All tests and evaluations except the blood lead test must be done after the child is 4 years and 3 months of age.

IMMUNIZATION RECORD

Note to Examiner: Please give the family a completed or updated yellow California Immunization Record.

Note to School: Please record immunization dates on the blue California School Immunization Record (PM 286).

REQUIRED TESTS/EVALUATIONS

DATE (mm/dd/yy)

Health History

______/______/______

Physical Examination

______/______/______

Dental Assessment

______/______/______

Nutritional Assessment

______/______/______

Developmental Assessment

______/______/______

Vision Screening

______/______/______

Audiometric (hearing) Screening

______/______/______

TB Risk Assessment and Test, if indicated

______/______/______

Blood Test (for anemia)

______/______/______

Urine Test

______/______/______

Blood Lead Test

______/______/______

Other

______/______/______

DATE EACH DOSE WAS GIVEN

VACCINE

First

Second

Third

Fourth

Fifth

POLIO (OPV or IPV)

DtaP/DTP/DT/Td (diphtheria, tetanus, and [acellular] pertussis) OR (tetanus and diphtheria only)

MMR (measles, mumps, and rubella)

HIB MENINGITIS (Haemophilus Influenzae B) (Required for child care/preschool only)

HEPATITIS B

VARICELLA (Chickenpox)

OTHER (e.g., TB Test, if indicated)

OTHER

PART III ADDITIONAL INFORMATION FROM HEALTH EXAMINER (optional)

and

RELEASE OF HEALTH INFORMATION BY PARENT OR GUARDIAN

RESULTS AND RECOMMENDATIONS

Fill out if patient or guardian has signed the release of health information.

Examination shows no condition of concern to school program activities.

Conditions found in the examination or after further evaluation that are of importance to schooling or physical activity are: (please explain)

I give permission for the health examiner to share the additional information about the health check-up with the school as explained in Part III.

Please check this box if you do not want the health examiner to fill out Part III.

Signature of parent or guardian

Date

Name, address, and telephone number of health examiner

Signature of health examiner

Date

PM 171 A (09/07) (Bilingual)

If your child is unable to get the school health check-up, call the Child Health and Disability Prevention (CHDP) Program in your local health department. If you do not want your child to have a health check-up, you may sign the waiver form (PM 171 B) found at your child’s school.

CHDP website: www.dhcs.ca.gov/services/chdp

State of CaliforniaHealth and Human Services Agency

Department of Health Services

 

Child Health and Disability Prevention (CHDP) Program

INFORME DEL EXAMEN DE SALUD PARA EL INGRESO A LA ESCUELA

Para proteger la salud de los niños, la ley de California exige que antes de ingresar a la escuela todos los niños tengan un examen médico de salud. Por favor, pidale al examinador de salud que llene este informe y entregelo a la escuelaeste informe sera archivado por la escuela en forma confidencial.

PARTE I PARA SER LLENADO POR EL PADRE/LA MADRE O EL GUARDIÁN

NOMBRE DEL NIÑO/NIÑAApellido

Primer Nombre

Segundo Nombre

FECHA DE NACIMIENTOMes/Día/Año

DOMICILIONúmero y Calle

Ciudad

Zona Postal

Escuela

PARTE II PARA SER LLENADO POR EL EXAMINADOR DE SALUD

EXAMEN DE SALUD

AVISO: Todas las pruebas y evaluaciones excepto el análisis de sangre para el plomo deben ser hechas después de la edad de 4 años y 3 meses.

PRUEBAS Y EVALUACIONES REQUERIDAS FECHA(mm/dd/aa)

Historia de Salud

______/______/______

Examen Físico

______/______/______

Evaluación de Dientes

______/______/______

Evaluación de Nutrición

______/______/______

Evaluación del Desarrollo

______/______/______

Pruebas Visuales

______/______/______

Pruebas con Audiómetro (auditivas)

______/______/______

Evaluacion de Riesgo y prueba Tuberculosis* ______/______/______

Análisis de Sangre (para anemia)

______/______/______

Análisis de Orina

______/______/______

Análisis de Sangre para el plomo

______/______/______

Otra

______/______/______

REGISTRO DE INMUNIZACIONES

Aviso al Examinador: Por favor dé a la familia, una vez completado, o a la fecha, el Registro de Inmunización de California en papel amarillo.

Aviso a la Escuela: Por favor apunte las fechas de inmunización sobre el Registro de Inmunización de la escuela de California en papel azul.

FECHA EN QUE CADA DOSIS FUE DADA

VACUNA

Primero Segundo Tercero

Quarto

Quinto

POLIO (OPV o IPV)

DTaP/DTP/DT/Td (difteria, tétano y [acellular] pertusis [tos ferina]) O (tétano y difteria solamente)

MMR (sarampión, paperas, rubéola)

HIB MENINGITIS (Hemófilo, Tipo B)

(Requerida para centros de cuidado para niños y centros preescolares solamente)

HEPATITIS B

VARICELLA (Viruelas locas)

OTRA (e.g. prueba TB, de ser indicado)

OTRA

PARTE III INFORMACIÓN ADICIONAL DEL EXAMINADOR DE SALUD (optional)

y

PERMISO PARA DIVULGAR (DISTRIBUIR) EL INFORME DE SALUD

RESULTADOS Y RECOMENDACIONES

Llene esta parte si el padre/la madre o el guardián ha firmado el consentimiento para divulgar (distribuir) la información de salud de su niño/niña.

El examen reveló que no hay condiciones que conciernen las actividades de los programas escolares.

Las condiciones encontradas en el examen o después de una evaluación posterior que son de importancia para la actividad escolar o física son: (por favor explique)

Yo le doy permiso al examinador de salud para que comparta con la escuela la información adicional de este examen como es explicado en la Parte III.

Por favor marque esta caja si Ud. no desea que el examinador llene la Parte III.

Firma del padre/madre o guardián

Fecha

*de ser indicado

Firma del examinador de salud

Fecha

Si su niño o niña no puede obtener el examen de salud llame al Programa de Salud para la Prevención de Incapacidades de Niños y Jovenes (Child Health and Disability Prevention Program)

en su departamento de salud local. Si Ud. no desea que su niño(a) tenga un examen de salud, puede firmar la orden (PM 171 B), formulario que se consigue en la escuela de su niño(a).

CHDP website: www.dhcs.ca.gov/services/chdp

PM 171 A (3/03) (Bilingual)

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