North Carolina Health Assessment Transmittal Form
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1
2January 2016
NORTH CAROLINA HEALTH ASSESSMENT TRANSMITTAL FORM
This form and the information on this form will be maintained on file in the school attended by the student named herein
and is confidential and not a public record.
(Approved by North Carolina Department of Public Instruction and Department of Health and Human Services)
PARENT to COMPLETE THIS SECTION
Student Name:
M
F
(Last)
(First)
(Middle)
Birthdate
School Name:
(M/D/YYYY):
1 Other Non-White
2 White
3 Black
4 American Indian
5 Chinese
Hispanic of Latino Origin:
Race:
1 Yes
2 No
6 Japanese
7 Hawaiian
8 Filipino
9 Other Asian
10 Unknown
Home Address:
City:
State:
County:
Parent Information: Name of Parent, Guardian, or person standing in
Telephone(s)
loco parentis:
Home:
Work:
Cell Phone:
Health Concerns to be shared with authorized persons (school administrators, teachers, and other school personnel who require such
information to perform their assigned duties):
HEALTH CARE PROVIDER TO COMPLETE THIS SECTION
Medications prescribed for student:
Student’s allergies, type, and response required:
Special diet instructions:
Health-related recommendations to enhance the student’s school performance:
Vision screening information:
Passed vision screening:
Yes
No
Concerns related to student’s vision:
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