Form 581-3417 "Oregon School Health Screening Record" - Oregon

What Is Form 581-3417?

This is a legal form that was released by the Oregon Department of Education - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2010;
  • The latest edition provided by the Oregon Department of Education;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 581-3417 by clicking the link below or browse more documents and templates provided by the Oregon Department of Education.

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Download Form 581-3417 "Oregon School Health Screening Record" - Oregon

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________________________ ____________________
_______
OREGON SCHOOL HEALTH SCREENING RECORD
Last Name
First
MI
This file shall not include medical or nursing records (ORS 192.525 et seq.)
Health Alert 
DOB ______________________ Gender: M _______ F _______
Health Management Plan 
ID Number _____________________________
HMP located at ___________________________________________
School District ___________________________________________
Medical/Nursing Records (confidential health information) located
at _______________________________________________________
(requires parent/guardian consent to release)
Demographic Information (may attach label)
REQUIRED
OPTIONAL
School
Gr.
School/City/State
VISION
Hearing*
Height
Weight
Blood
Scoliosis*
Dental*
Screening
Year
Pressure
Comments
Right
Left
Corrective
Lenses
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
*Codes:
N–Normal
R–Referred
UT–Under Treatment
D–Deferred—no referral
See guidelines for screening and referral criteria in Health Services for the School Community (ODE 2010)
OREGON DEPARTMENT OF EDUCATION, Salem, Oregon 97310-1300
Form 581-3417 (11/10)
________________________ ____________________
_______
OREGON SCHOOL HEALTH SCREENING RECORD
Last Name
First
MI
This file shall not include medical or nursing records (ORS 192.525 et seq.)
Health Alert 
DOB ______________________ Gender: M _______ F _______
Health Management Plan 
ID Number _____________________________
HMP located at ___________________________________________
School District ___________________________________________
Medical/Nursing Records (confidential health information) located
at _______________________________________________________
(requires parent/guardian consent to release)
Demographic Information (may attach label)
REQUIRED
OPTIONAL
School
Gr.
School/City/State
VISION
Hearing*
Height
Weight
Blood
Scoliosis*
Dental*
Screening
Year
Pressure
Comments
Right
Left
Corrective
Lenses
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
20/
20/
Y
N
R
R
L
L
*Codes:
N–Normal
R–Referred
UT–Under Treatment
D–Deferred—no referral
See guidelines for screening and referral criteria in Health Services for the School Community (ODE 2010)
OREGON DEPARTMENT OF EDUCATION, Salem, Oregon 97310-1300
Form 581-3417 (11/10)
THIS FILE SHALL NOT INCLUDE MEDICAL OR NURSING RECORDS (ORS 192.525 et seq.)
Refer to the School Nurse*
Child has a health condition which is chronic or may become life threatening (for example, insect or food allergy, seizure disorder, cancer,
cystic fibrosis, spina bifida, asthma, diabetes)
Child has an untreated medical condition
Unexplained injuries or neglect**
Contents of this folder may include:
Document
Requirements
Archival
Send with Record
3 years Regular Education
(In or Out-of-District)
7 years Special Education
CIS–Certificate of Immunization Status
Required
X
X
Tuberculosis Clearance Certificate
If required
X
X
Medication Record
If related to IEP
X If related to IEP
X If related to IEP
Health Management Plan
Most recent version
X
X If related to IEP
Records of Health Room Visits for First Aid
Optional
Communications from Parent or Physicians
X If related to IEP
Additional Screening Results:
Date
Screening Results
Date
Screening Results
* See guidelines in Health Services for the School Community
** All school employees are mandatory reporters under ORS 146.710
Guidelines for Recording on Oregon School Health Screening Record
[Form 581-3417 (11/10)
Demographic Information
Contents of Health Screening Record
Only the results of health screenings shall be recorded/stored in this Health
Name and Student Number: Use pen or type
Screening Record. Other health information shall be kept separately from
Space is provided for a demographics label; re-label as necessary
health screening information to protect confidentiality. Contents:
Health Alert: Check box if student has a health condition which may
Certificate of Immunization Status (CIS) form
affect him/her during the school day
Tuberculosis Clearance Certificate, if the child has one
Health Management Plan: Check box if student has a health
Records of medications given the child in the school setting, if
condition which is serious enough to require an individualized
related to the IEP
Health Management Plan. Note location of the health plan
A current copy of the Health Management Plan
Records of first aid health room visits and the instructions sent to the
Screening Results
parent, according to district policy
Follow screening procedures in manual, Health Services for the School
Communications related to health and safety and directed to
Community. Screening comments should address results of screening. Other
information should be documented in the medical/nursing file to preserve
the school from the parent or health care provider
confidentiality of health information.
Record date by month/year
Archival Data
Vision: Record results of vision screening. Document rechecks under
Retain the following with the education record for three years after
―Additional Screening Results‖; check if the student is wearing
graduation:
corrective lenses
Certificate of Immunization Status (CIS) form
Hearing, Scoliosis, Dental: Use provided code
Tuberculosis Clearance Certificate
Height: Record to the nearest one-fourth inch
Retain the following with the special education record for seven years after
Weight: Record to the nearest one-half pound
graduation:
Blood Pressure: Note arm on which blood pressure was taken
Health Management Plan, if it is an addendum to the IEP
Height and weight charts are included in the manual
Medication record, if medication administration is addressed in the
TB Clearance Certificate—See back of Health Screening Record for
IEP
list of birth countries which necessitate a clearance certificate
Certificate of Immunization Status (CIS)—See back of Health
Transfer of Records
Screening Record for directions
Transfer the following with the educational record:
Certificate of Immunization Status (CIS) form
Tuberculosis Clearance Certificate
Health plan, if related to the IEP
Medication records, if related to the IEP
Uncleared exclusion orders for Immunization/Tuberculosis
Transfer the following with the educational record if it is significant in
maintaining the child safely in the school setting:
Communications from parents and health care providers
directed to the school
Records of first aid provided and instructions given to the parent
Immunization Requirements for School/Children’s Facilities
Tuberculosis
http://www.oregon.gov/DHS/ph/b/oars.shtml
ORS 433.235.433.284
―NOTE: School Rule OAR 333-019-0041 (3) has been dropped
1. All students in the following categories entering Oregon
from the Administrative Rules (since summer 2005). Public
schools for the first time must provide a signed Certificate of
schools are no longer required to do Tuberculosis screening on
Immunization Status form documenting either evidence of
selected foreign-born students entering Oregon schools under state
immunization or a religious and/or medical exemption prior to
law. However, each local health authority may elect to mandate
initial attendance:
targeted Tuberculosis testing on populations within their
Students transferring from a school outside the U.S.
jurisdiction whom they determine are at high risk for Tuberculosis.
Students initially attending at the entry level (pre-
Please consult your local health authority prior to any Tuberculosis
kindergarten/kindergarten, or the first grade)
school screening,‖
Students initially attending from a home-study setting at
any grade
If age appropriate and the child has not claimed an exemption,
a minimum of one dose of each of the following vaccines must
be received prior to attendance: polio, measles, mumps,
rubella, varicella, Hepatitis B, Hepatitis A (if currently required
for the student’s grade) and diphtheria/tetanus/pertussis
containing vaccine. Haemophilus influenzae type B is required
for students less than 5 years of age. The Hepatitis A vaccine
requirement is being phased in for all grades by school year
2014-2015, starting with kindergarten in school year 2008-
2009. See OAR 333-050-0120 for more details, including the
complete phase-in schedule for Hepatitis A vaccine and
vaccines required for specific ages/grades.
2. A student transferring from a school inside of the U.S. must be
given at least 30 days for transfer immunizations records to
arrive from the previous school.
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