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The Health For Florida form, specifically the School Entry Health Exam (DH 3040), plays a crucial role in ensuring that children meet health requirements before entering Florida public and private schools from Pre-Kindergarten through 12th grade. This form is mandated by state law and is designed to gather essential health and screening information that supports school health personnel in addressing each child's needs effectively. A licensed health care provider, whether based in Florida or the state where the child previously resided, must certify the completion of the health examination. The examination must be conducted within one year prior to school enrollment, with specific provisions for homeless children who receive a temporary exemption. Parents or guardians may also request exemptions on religious grounds. The form requires detailed child identification information and a comprehensive medical history, which parents must complete before the examination. Additionally, it includes recommendations for further assessments, such as vision and dental exams, and mandates that providers document screening results and any health conditions that could affect a child's participation in school activities. Proper completion and submission of the DH 3040 form are essential for compliance with state regulations and for the well-being of the child in the educational environment.
Form Example
Guide for Completing the School Entry Health Exam (DH 3040 Form)
DH 3040, 6/02, Stock Number:
General Information
Purpose: The School Entry Health Exam has been designed to meet the requirements for the school entry health examination, as mandated by s.1003.22, F.S. (formerly s. 232.0315, F.S.) for student entry into Florida public and private schools, grades
Health Care Provider: A health professional who is licensed in Florida or in the state where the student resided at the time of the health examination, and who is authorized to perform a general health examination under such licensure shall certify that the health examination has been completed.
Time Limits: The child’s health examination must be completed within one year prior to enrollment in school. A homeless child shall be given a temporary exemption for 30 school days.
Exemptions: A child shall be exempt from this requirement upon written request from parent or guardian on religious grounds.
Copies: A copy of the front and back of the completed form may be retained in the child’s medical file kept by the health care provider. The original completed DH 3040 Form should be given to the parent to take to the school to provide information and to document that this requirement is met.
Directions for completing the School Entry Health Exam Form
Page 1: The health history is to be filled in by the parent or interviewer in the provider’s office. If the parent seeks the exams recommended by the Partnership for School Readiness, the appropriate provider will fill in the information regarding the exam results.
1.Child Identifying Information: Fill in all of the information requested, including child’s middle name and parent’s complete names. This information is critical for distinguishing between children with the same or similar name.
2.PART
3.Partnership for School Readiness Recommendations for
Page 2: This page is to be completed by the health care provider only.
1.Fill in the complete name and birth date of the child, as it appears on page 1.
2.PART
3.Screening Results: Perform the indicated screenings and fill in the results of each of the indicated screenings, including vision and hearing information.
4.Exam Components: Indicate whether the results of the exam are normal or abnormal and any actions taken by the provider.
5.TB Risk Assessment: See guidelines on the bottom of the page for TB risk assessment. The screening and results should not be recorded on the school health form. If a test is given, arrangements should be made with the parent/guardian for follow up.
6.If the child has any physical or behavioral problem that may adversely affect the educational experience, check the appropriate box and explain the impairment or restrictions. Because the record will not be subject to the strict protection of medical records, providers are asked to refrain from including information of a confidential nature such as child abuse and HIV/AIDS.
7.Participation in Activities: Indicate whether the child has health or physical conditions that would prevent participation in normal school activities such as physical activities in recess, physical education or other physical activities during the school day.
8.Provider information: Fill out or stamp the form to provide information that identifies the provider and their address.
Revised 7/02
Document Breakdown
| Fact Name | Description |
|---|---|
| Purpose of the Form | The School Entry Health Exam (DH 3040) is designed to fulfill the requirements for health examinations mandated by Florida law for students entering public and private schools from Pre-Kindergarten to 12th grade. |
| Governing Law | This form is governed by Florida Statutes s.1003.22, which outlines the health examination requirements for school entry. |
| Health Care Provider Requirements | A licensed health professional in Florida must certify the completion of the health examination. This professional may also be from the state where the student resided during the examination. |
| Exemptions | Parents or guardians may request an exemption from the health examination requirement on religious grounds. Additionally, homeless children are granted a temporary exemption for 30 school days. |
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