
State of California Health and Human Services Agency Primary Care and Family Health Division Department of Health Services Children s Medical Services Branch Child Health and Disability Prevention CHDP Program REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY To protect the health of children California law requires a health examination on school entry. Please have this report filled out by a health examiner and return it to the school* The school will keep and maintain it as confidential information* PART I TO BE FILLED OUT BY A PARENT OR GUARDIAN CHILD S NAME Last First ADDRESS Number/Street City Middle BIRTHDATE Month/Day/Year ZIP Code SCHOOL HEALTH EXAMINATION IMMUNIZATION RECORD NOTE 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....
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How to fill out the CA PM 171 A online
The CA PM 171 A form is essential for ensuring that children receive the necessary health examination before entering school. This guide provides clear, step-by-step instructions on how to complete the form online, ensuring that users can easily navigate through each section.
Follow the steps to complete the CA PM 171 A online.
- Click the ‘Get Form’ button to access the online version of the CA PM 171 A form and open it for editing.
- In Part I, enter the child's legal name by filling in the last name, first name, and middle name where indicated. Provide the full address, including the number, street, city, and ZIP code.
- Still in Part I, fill in the child's birthdate using the format of month, day, and year. Be sure to select the correct school that the child will be attending.
- In Part II, the health examiner will complete several sections including the health examination results and immunization record. Ensure that the examiner details all required tests and evaluations conducted for the child.
- Provide the dates when each vaccination dose was administered in Part III. This includes filling out the dates for vaccines such as polio, DTaP, MMR, and others listed.
- After all necessary fields are filled out, review the additional information section from the health examiner if available. Check the box if the health examiner should not fill out Part III.
- Both the parent or guardian and the health examiner must sign the form where indicated, noting the date of signature. Ensure that the examiner also includes their contact information.
- Once you have completed all sections of the form, review it for accuracy. You may then choose to save changes, download, print, or share the completed form as required.
Complete the CA PM 171 A online to ensure your child's health examination is recorded properly for school entry.
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