Health Forms

Published: 10/25/2013 2:49 PM

 

Documents on this web page are updated per statute and regulation and are intended for district/school use in fulfilling the requirements for school entry.

702 KAR 1:160 - School Health Regulation (2012)
 
Link to: Kentucky Immunization Program
Link to: KHSAA Sports Physical Form

 

 

 
Click on an icon to download a form.​
Dental Screening/Exam Form  
 
KDESHS004_EyeExam.pdf    KDESHS005_DSF.doc

Kentucky law in KRS 156.160 (j) requires proof of a dental screening or examination by a dentist, dental hygienist, physician, registered nurse, nurse practitioner, or physician assistant to be presented to the school no later than January 1 of the first year that a five (5) or six (6) year old child is enrolled in public school.

 

Immunization Certificate and Related Forms
 
KDESHS004_EyeExam.pdfStandard Immunization Form KDESHS004_EyeExam.pdfMedical Exemption KDESHS004_EyeExam.pdfReligious Exemption KDESHS004_EyeExam.pdfProvisional Form
KRS 214. 034 requires any child enrolled as a regular attendee in all public or private primary or secondary schools, and preschool programs shall have a current immunization certificate and be on file within two weeks of the child’s attendance. Information including school immunization legislation and regulations, school immunization schedules, school immunization reporting forms and requirements can be found at the Kentucky Immunization Program Web site.

 

Medical Examination of School Employees
 

Exam       Exam

Per KRS 161.145, as a condition of employment all classified employees including substitute employees shall have a medical examination

 

Preventative Health Care Examination Form
 
Exam       Exam
 
702 KAR 1:160 requires each child first entering a Kentucky public school or entering Grade 6 to present a Kentucky Preventative Health Care Examination Form.  This exam may be completed up to one year prior to initial entry. 
 
Vision Exam Form

 KDESHS004_EyeExam.pdf   KDESHS004_EyeExam.doc

KRS 156.160 (1)(i) requires proof of a vision examination by an optometrist or ophthalmologist.  This evidence shall be submitted to the school no later than January 1 of the first year that a three (3), four (4), five (5) or six (6) year old is enrolled in public school, public preschool, or Head Start program. 
Karen Erwin 
Office of Administration and Support
Division of District Support
500 Mero Street, 15th Floor CPT
Frankfort, KY 40601
(502) 564-5279
Fax (502) 564-6771