Health Forms

Published: 8/4/2017 11:54 AM

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.

Link to: School Health Regulation 702 KAR 1:160
Link to: Kentucky Immunization Program


Click on an icon to download a form.​
Dental Screening/Exam Form 

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
Immunization Form
 Religious Exemption Declination 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


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
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



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 Finance and Operations
Division of District Support
300 Sower Blvd., 4th Floor
Frankfort, KY 40601
(502) 564-5279
Fax (502) 564-6771