New York's Education Law requires a health certificate for new entrants and students in grades Pre-K or K, 1, 3, 5, 7, 9 and 11, every year for interscholastic sports, for working papers, and when the CSE or CPSE requests one. A private provider or the school medical director records history, exam, screenings, activity clearance and immunization status on this NYSED form. The school health office keeps it in the student's cumulative health record.
A physician, nurse practitioner or physician assistant authorized to practice in New York, or the school's medical director, completes and signs the whole form. Parents have no section on it; for sports seasons they complete NYSED's separate Interval Health History.
Enter the student's name, affirmed name if applicable, date of birth, sex assigned at birth, gender identity (female, male, nonbinary or X), school, grade and exam date. NYSED's instructions require the exam date on the form and say it may be no more than 12 months before the start of the school year. The student's name, affirmed name and DOB repeat at the top of page 2.
Check allergies, asthma, seizures or diabetes when diagnosed and give the type, for example intermittent or persistent asthma, type 1 or 2 diabetes, or the date of the last seizure. Each comes with checkboxes for an attached medication or treatment order and care plan. The instructions require a separate care plan for each: an anaphylaxis plan, asthma action plan, seizure plan or Diabetes Medical Management Plan. List all allergies, including medication, food, insects and latex.
Record BMI in kg/m2 and check the percentile category: under 5th, 5th to 49th, 50th to 84th, 85th to 94th, 95th to 98th, or 99th and above. The form suggests considering type 2 diabetes screening when BMI percentile exceeds 85% with two or more risk factors such as family history, ethnicity, signs of insulin resistance, maternal gestational diabetes or pre-diabetes. Then mark hyperlipidemia and hypertension.
Enter height, weight, BP, pulse and respirations; NYSED asks for pulse and respiratory rate for students with respiratory or cardiac conditions whose baseline is outside the normal range. Check system review within normal limits or list abnormal findings by system, from HEENT and dental through mental health and musculoskeletal. List diagnoses and problems, with ICD-10 codes only for students with an IEP who receive Medicaid, and note any unpaired eye, kidney or testicle.
TB and sickle cell screening are marked PRN, with positive or negative and a date. Lead level is required for PreK and K: check that the test was done and whether lead was elevated at 5 micrograms per deciliter or higher, with the date. The instructions ask for the TB test type (PPD or interferon-gamma release assay) and say sickle cell screening is at the provider's discretion.
Vision and hearing are required for new entrants and grades PreK or K, 1, 3, 5, 7 and 11. Record distance and near acuity for each eye, with or without correction, color perception, and any referral; NYSED's pass is 20/30 or better for distance and 20/40 or better for near. Hearing passes at 20 dB from 500 to 4000 Hz, adding 6000 and 8000 Hz in grades 7 and 11. Scoliosis screening covers girls in grades 5 and 7 and boys in grade 9.
Check that the family cardiac history was reviewed, which the form marks as required for sports under the Dominic Murray Sudden Cardiac Arrest Prevention Act. Then either clear the student for all activities without restrictions or restrict participation in contact, limited contact or non-contact sports, each listed by name, or describe other restrictions. Note accommodations such as a brace, insulin pump, prosthetic or sports goggles, and check with the athletic governing body about device approval.
Check that an order form for medications needed at school is attached; NYSED's instructions ask for strength or concentration, formulation, dose, frequency and timing for chronic medications, or a separate order. Confirm the student was free of communicable disease during the exam. For immunizations, attach the record or check that it is reported in NYSIIS, the state immunization registry.
Sign the form and print your name, address, phone and fax. The form closes with 'Please Return This Form to Your Child's School Health Office When Completed.' NYSED's guidelines add that a school with questions about a certificate's authenticity should verify it with the provider who signed, so a legible name and contact details help.
Download the current version from the source each time; forms change without notice.
Required NYS School Health Examination Form
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NYSED's guidelines say each health certificate must be signed by a duly licensed physician, physician assistant or nurse practitioner authorized to practice in New York. Some providers exempt under Education Law 6526 may also sign, such as a physician licensed in a bordering state who lives near the border and limits practice here to that vicinity.
NYSED's instructions say the exam date must be noted on the form and be no more than 12 months before the start of the school year. For athletics, the exam is valid for 12 continuous months, through the last day of the month it was done, and through the entire sports season even if it expires mid-season.
Yes, if it is NYSED's approved EHR-compatible equivalent. NYSED publishes instructions that must be followed so the EHR form carries the same information in relatively the same order as the required form, completed in its entirety with tests or screenings marked not done or not applicable where that applies.
If no certificate arrives within the first 30 days of attendance, the school must notify the parent in writing. If the parent still does not provide one within 30 days of that notice, the district medical director examines the student at school, and NYSED notes parental consent is not required for that exam.