5/2023
(if applicable)
Vision & Hearing Screenings Required for PreK or K, 1, 3, 5, 7, & 11
With Correction ☐Yes ☐ No
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Color Perception Screening ☐
Pass ☐
Fail ☐
Hearing Passing indicates student can hear 20dB at all frequencies: 500, 1000, 2000, 3000, 4000 Hz;
for grades 7 & 11 also test at 6000 & 8000 Hz.
Not Done
Pure Tone Screening
Right ☐ Pass ☐ Fail Left ☐ Pass ☐ Fail Referral ☐ Yes ☐
Scoliosis Screening: Boys grade 9, Girls grades 5 & 7
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FOR PARTICIPATION IN PHYSICAL EDUCATION/SPORTS*/PLAYGROUND/WORK
☐ *Family cardiac history reviewed – required for Dominic Murray Sudden Cardiac Arrest Prevention Act
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Student may participate in all activities without restrictions.
If Restrictions Apply – Complete the information below
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Student is restricted from participation in:
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Contact Sports: Basketball, Competitive Cheerleading, Diving, Downhill Skiing, Field Hockey, Football, Gymnastics, Ice
Hockey, Lacrosse, Soccer, and Wrestling.
☐ Limited Contact Sports: Baseball, Fencing, Softball, and Volleyball.
☐ Non-Contact Sports: Archery, Badminton, Bowling, Cross-Country, Golf, Riflery, Swimming, Tennis, and Track & Field.
☐ Other Restrictions:
Developmental Stage for Athletic Placement Process ONLY required for students in Grades 7 & 8 who wish to play at the
high school interscholastic sports level OR Grades 9-12 who wish to play at the modified interscholastic sports level.
Tanner Stage: ☐ I ☐ II ☐ III ☐ IV ☐ V
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Other Accommodations*: (e.g., brace, orthotics, insulin pump, prosthetic, sports goggles, etc.) Use additional space
below to explain.
*Check with the athletic governing body if prior approval/form completion is required for use of the device at athletic competitions.
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Order Form for medication(s) needed at school attached
☐ Confirmed free of communicable disease during exam ☐ Record Attached ☐ Reported in NYSIIS
Healthcare Provider Signature:
Provider Name: (please print)
Please Return This Form to Your Child’s School Health Office When Completed.