Pm 171 A Form – Fill Out and Use This PDF

Part I is filled out by a parent or guardian: enter the child's name (last, first, middle), the birth date (month, day, year), the address (number, street, city, ZIP code) and the school.

Part II is filled out by the health examiner.

For the required tests/evaluations, enter the date (mm/dd/yy) for 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 and Other.

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

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).

Under DATE EACH DOSE WAS GIVEN, enter the date each dose was given (First to Fifth) for each VACCINE: 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) and OTHER (e.g., TB Test, if indicated).

Part III, Additional Information From Health Examiner (optional), Results and Recommendations: Fill out if patient or guardian has signed the release of health information.

Check either: Examination shows no condition of concern to school program activities, or: 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.

The parent or guardian signs Signature of parent or guardian and enters the Date.

The health examiner signs Signature of health examiner and enters the Date, with the Name, address, and telephone number of health examiner.

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.

Please have this report filled out by a health examiner and return it to the school.