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North Carolina Health Assessment Transmittal Form

North Carolina requires a health assessment within 12 months before a child first enters public school. After the exam, the provider completes this two-page transmittal so the school receives what it needs: medications, allergies and required responses, diet instructions, vision and hearing results, follow-up needs and attached care plans, kept confidential in the student's school file.

Who completes it

The parent completes the student and parent section and lists health concerns to share. A physician, physician assistant, nurse practitioner or local health department completes the provider section and signs the certification.

Submitting and payment

How to submit it
The completed form is given to the parent, who delivers it to the school principal by the first day of attendance.
Who pays
The form sets no fee and does not address payment for the health assessment.

Good to know

  • The certification states the assessment followed G.S. 130A-440(b), including medical history and physical exam with vision and hearing screening and, if appropriate, anemia and tuberculosis testing.
  • Checkboxes prompt the provider to attach the immunization record, school medication authorization, diabetes care plan, asthma action plan and other condition plans.
  • The form is maintained in the school the student attends and is confidential, not a public record.
  • It was approved by the Department of Public Instruction and DHHS; the current version is the January 2016 revision, with a Spanish edition available.

Get the official form

Download the current version from the source each time; forms change without notice.

North Carolina Health Assessment Transmittal Form

Formulario de Evaluación de Salud y Transmisión de Carolina del Norte

Official pagePDFVersión en español

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

When is the North Carolina school health assessment required?

The health assessment must be done within the 12 months before a child first enters a North Carolina public school, under G.S. 130A-440, and the transmittal form is delivered to the principal by the first day of attendance.

Is the North Carolina transmittal form available in Spanish?

Yes. NCDHHS posts a Spanish version, Formulario de Evaluación de Salud y Transmisión de Carolina del Norte, alongside the English form on its public school health assessment page. Both versions carry the same parent and provider sections and the same certification under G.S. 130A-440.

What screening results go on the North Carolina transmittal form?

The provider records whether the student passed vision screening and hearing screening, with concerns for each, then notes recommendations and whether school follow-up is needed. Anemia and tuberculosis testing are covered in the certification when appropriate.