North Carolina Health Assessment Transmittal Form Page 2
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1
2January 2016
Hearing screening information:
Passed hearing screening:
Yes
No
Concerns related to student’s hearing:
Recommendations, concerns, or needs related to student’s health and required school follow-up:
School follow-up needed:
Yes
No
Medical Provider Comments:
Please attach other applicable school health forms:
Immunization record attached:
School medication authorization form attached:
Diabetes care plan attached:
Asthma action plan attached:
Health care plans for other conditions attached:
Health Care Professional’s Certification
I certify that I performed, on the student named above, a health assessment in accordance with G.S. 130A-440(b) that included a medical history and
physical examination with screening for vision and hearing, and if appropriate, testing for anemia and tuberculosis. I certify that the information on this
form is accurate and complete to the best of my knowledge.
Name:
Title:
Signature: _________________________________________________________
Date (m/d/yyyy):
Practice/Clinic Name:
Practice/Clinic Address:
Practice/Clinic City:
State:
Zip:
Phone:
Fax:
Provider Stamp Here:
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