Staunton City Schools Health Screening Form
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1
2STAUNTON CITY SCHOOLS HEALTH SCREENING FORM
8/2009
(Students new to division plus in grades K, 3, 7, 10)
Name
____________________________
Date _________________
School
_____________
Grade_______
Homeroom __________________
Observation Results
1. Vision
2. Hearing
st
st
(School Nurse within 60 days of the 1
day of school
(School Nurse within 60 days of the 1
day of school
st
st
OR medical form 60 days prior to the 1
day of school, K, 3, 7,
OR medical form 60 days prior to the 1
day of school, K, 3, 7, 10,
10, new to division)
new to division)
____ Normal Acuity
____ Normal Pure-Tone Acuity
____ Failed Screening
____ Failed initial screening
(attach documentation)
____ Re-Screening Date
Follow-up:
____ Second screening date
____ Pass/Fail
____ Pass/Fail
________ Date of Referral
____ Referral
________ ENT report received
Signature ____________________________________
Signature ______________________________________
Title _______________________ Date __________
Title ________________________ Date ___________
3. Speech, Voice, & Language
4. Fine & Gross Motor Skills
(K-3 only--Classroom
(K- 3 only--Classroom
st
st
Teacher within 60 days of the 1
day of school OR medical
Teacher or Physical Education Teacher within 60 days of the 1
st
st
form 60 days prior to the 1
day of school –
day of school OR medical form 60 days prior to the 1
day of
complete chart on reverse side)
school – complete chart on reverse side)
____ Fine motor skills appropriate for
____ Normal Skills
developmental age
(Classroom Teacher)
____ Normal skills with developmental errors
____ Individual screening by speech pathologist
____ Gross motor skills appropriate for
developmental age
(P.E. Teacher)
Recommendations by Speech Pathologist
____ Referral to Child Study Team
____ Refer to CST
Signature ______________________________________
____ See Cumulative File
(Classroom Teacher)
Date _______________
____ Normal
Signature ____________________________________
Signature ______________________________________
(P.E. Teacher)
Title ________________________ Date _________
Date _______________
Results of these observations: (check one)
____ No evidence of referral needed at this time
____ A referral to Child Study Committee is in order
____ See Cumulative File
Other comments or recommendations _______________________________________________________________
Principal’s Signature __________________________________________________ Date __________________________
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