Georgia Department of Public Health Form 3300.pdf

Georgia Department of Public Health

Form 3300

Certicate of Vision, Hearing, Dental, and Nutrition Screening

FILE THIS FORM WITH THE SCHOOL WHEN YOUR CHILD IS FIRST ENROLLED IN A GEORGIA PUBLIC SCHOOL

SCREENER CONTACT INFORMATION IS REQUIRED

Child’s Name:__________________________________________________

 rst middle last

Date of Birth: _____/_____/_____ Gender: Male Female

Child’s Home Address:

____________________________________________________________________________________

street city state zipcode county

Parent/ Guardian Name:_______________________________________

 rst middle last

Parent/ Guardian Contact Information:

Daytimephonenumber:_____________________________________________________________

Eveningphonenumber:_____________________________________________________________

Cellphonenumber:_________________________________________________________________

VISION

Unabletoscreen(explainwhybelow)

Usescorrectivelenses

Wornfortesting

Passed(20/30ineacheyeforage6and

above,20/40ineacheyeforbelowage6)

Needsfurtherevaluation

Underprofessionalcare(explainbelow)

Screening completed by:

Physician

LocalHealthDepartment

Optometrist

“PreventBlindnessGeorgia”employee

SchoolRegisteredNurse

___________________________________

Screener’s Signature Date

I certify that this child has received the

above screening.

Contact Information:

HEARING

Unabletoscreen(explainwhybelow)

Useshearingaid/assistivedevice

Passedat500,1000,2000,and4000Hzwith

audiometerat20or25dB

Needsfurtherevaluation

Underprofessionalcare(explainbelow)

Screening completed by:

Physician

LocalHealthDepartment

Audiologist

Speech-LanguagePathologist

SchoolRegisteredNurse

___________________________________

Screener’s Signature Date

I certify that this child has received the

above screening.

Contact Information:

DENTAL

Unabletoscreen(explainwhybelow)

Normalappearance

Needsfurtherevaluation

Emergencyproblemobserved

Underprofessionalcare(explainbelow)

Screening completed by:

Physician

Dentist

LocalHealthDepartmentRegisteredNurse

RegisteredDentalHygienist

SchoolRegisteredNurse

___________________________________

Screener’s Signature Date

I certify that this child has received the

above screening.

Contact Information:

NUTRITION

Unabletoscreen(explainwhybelow)

Height:___________ Weight:___________

BMI:_____________BMI%:___________

5

to84thpercentile-Appropriateforage

<5

percentile-Needsfurtherevaluation

≥85

percentile-Needsfurtherevaluation

Underprofessionalcare(explainbelow)

Screening completed by:

Physician

LocalHealthDepartment

RegisteredDietician

SchoolRegisteredNurse

___________________________________

Screener’s Signature Date

I certify that this child has received the

above screening.

Contact Information:

FOR SCHOOL SYSTEM ONLY Follow up for further evaluation

attempt 2

attempt Actions reported (if any)

Vision

Hearing

Dental

Nutrition

Student support services initiated on:

Screeners’ Comments:

DPH Form 3300 Rev. 2013

PLEASE SEE THE INSTRUCTIONS

ON THE BACK OF THIS FORM

Georgia Department of Public Health Form 3300

Certificate of Vision, Hearing, Dental, and Nutrition Screening

Who is required to file this Form 3300? The parent or guardian of a child who is being admitted for the first time to a public

school in Georgia must file a completed Form 3300 with the school when the child is enrolled.

What is the purpose of Form 3300? Form 3300 is intended to make sure that every child in Georgia is screened for

possible problems with their vision, hearing, teeth and nutrition. The earlier these problems are detected, the earlier

parents can seek professional help for the child.

What screenings are required? Four different screenings are required: vision, hearing, dental, and nutrition. All four

screenings must be conducted and reported on the form before it can be filed with the school.

Who can conduct the screenings? Your child’s doctor is authorized to conduct all four screenings, as is your local health

department. In addition, the vision screening can be conducted by a Georgia licensed optometrist, an employee of Prevent

Blindness Georgia trained to conduct vision screening, or a school registered nurse; the hearing screening can be

conducted by a Georgia licensed speech-language pathologist or audiologist, or a school registered nurse; the dental

screening can be conducted by a Georgia licensed dentist, dental hygienist, or a school registered nurse; and the nutrition

screening can be conducted by a Georgia licensed dietician or a school registered nurse. It is not necessary that the same

person conduct all four screenings.

What does “BMI” and “BMI%” mean? “BMI” means “body mass index.” BMI is a way to describe how

much a child weighs in relation to height. “BMI percentile” is a way to compare the child’s body mass index to the body

mass index of a healthy child. If the child’s BMI is less than 5% or more than 84% of what is appropriate for his or her age

and height, then the child should be taken to a doctor or dietician for a more detailed evaluation. For more information, visit

the Centers for Disease Control and Prevention website on child and teen BMI at:

http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html

What should a parent do if the “needs further evaluation” box is checked? “Needs further evaluation”

means that the child may have a problem. If the “needs further evaluation” box is checked, then the parent should

take the child to a professional for a more detailed evaluation. Your doctor or local health department may be able to help,

or recommend someone who can help.

What if a Form 3300 was previously filed for the child at another school? It is only necessary to file the Form 3300 once.

If the Form 3300 is filed at the child’s first school, and the child later transfers to another school, then the original school is

required to forward the Form 3300 to the new school.