The Pennsylvania Health Form is a crucial document used to collect and verify health information for school personnel within the state. This form ensures that educators and staff meet health requirements and are fit for their roles in educational settings. It includes sections for personal information, immunization history, tuberculosis test results, and a report of physical examination.
The Pennsylvania Health form, officially known as the School Personnel Health Record, serves as a crucial tool for ensuring the health and safety of school personnel in the Commonwealth of Pennsylvania. This comprehensive document collects vital patient information, including personal details such as name, date of birth, and contact information, alongside the individual’s usual source of medical care. One of the most significant sections of the form is the immunization history, where specific vaccines like Diphtheria, Tetanus, and Hepatitis B are documented, along with the dates they were administered. Another critical component involves tuberculosis testing, which mandates a detailed record of test results, including the method of testing and any necessary follow-up actions, such as chest X-rays. Additionally, the form addresses significant medical conditions by prompting individuals to disclose any allergies, chronic illnesses, or disabilities that could impact their job performance. A thorough physical examination section further evaluates the overall health of the individual, capturing essential metrics like height, weight, and blood pressure. This form not only safeguards the health of school personnel but also ensures that they are fit for their roles, contributing to a healthier school environment for both staff and students.
H511.340 (8/2011)
Position ____________________________
COMMONWEALTH OF PENNSYLVANIA
PENNSYLVANIA DEPARTMENT OF HEALTH
SCHOOL PERSONNEL HEALTH RECORD
I. Patient Information
Last Name
First
MI
Sex
Date of Birth
Social Security Number
Home Telephone
Work Telephone
Mailing Address
Street
City
State
Zip
Usual Source of Medical Care
Physician’s Name
Address
Telephone
Emergency Contact – Name
Relationship
II. Immunization History
Enter Month, Day, and Year Each Immunization was Given
VACCINE
DOSES
BOOSTERS & DATES
Diphtheria and Tetanus*
1.
2.
3.
4.
5.
Hepatitis B
Measles, Mumps, Rubella
Other ________________
Other _____________________
*Tetanus and Diphtheria are usually received in combined vaccines such as DTP, DtaP, DT, or Td
III. Required Tuberculosis Test Results (as per Regulations of the Department of Health
DATE APPLIED
ARM
METHOD
ANTIGEN
MANUFACTURER
SIGNATURE
DATE READ
RESULTS (mm)
For previously known/new positive reactors: _______________________________________________________________________
Chest X-ray:
Date: ____________ Results: _____________
Other: Date: _____________ Results: _______________
(Attach a copy of the report.)
Preventive Anti-Tuberculosis Chemotherapy ordered:
No
Yes
Date: ______________
IF SIGNIFICANT REACTION WAS REPORTED, THE PHYSICIAN REPORT MUST STATE THAT THE APPLICANT IS FREE FROM CURRENT TUBERCULOSIS DISEASE OR IS UNDER ADEQUATE CHEMOTHERAPY FOR TUBERCULOSIS DISEASE:
___________________________________________________________________________________________________________________
IV. Significant Medical Conditions ()
Yes
No
If Yes, Explain:
Allergies
___________________________________________________________________
Asthma
Cardiac
Chemical Dependency
Drugs
Alcohol
Diabetes Mellitus
Gastrointestinal Disorder
Hearing Disorder
Hypertension
Neuromuscular Disorder
Orthopedic Condition
Respiratory Illness
Seizure Disorder
Skin Disorder
Vision Disorder
Other (Specify)
V. Report of Physical Examination ()
NORMAL
ABNORMAL
NOT
COMMENTS
EXAMINED
Height (inches) ______________
Weight (pounds) ______________
Pulse _____________
Blood Pressure ______________
Hair/Scalp
Skin
Eyes – Visual Acuity: R _____ L _____
Eyes – Color Vision
Ears – Hearing (dB) R _____ L _____
Nose and Throat
Teeth and Gingiva
Lymph Glands
Heart – Murmur, etc…
Lungs – Adventitous Findings
Abdomen
Genitourinary
Neuromuscular System
Extremities
Are there any special medical problems or chronic diseases which require restriction of activity, medication or which might affect his/her work role? If so, specify __________________________________________________________________________________
____________________________________________
__________________________________________________
___________________
Physician Name (Print)
Signature of Examiner
Date
______________________________________________________________________________________________________________________________
Physician Address
The statements and answers as recorded above are full, complete and true to the best of my knowledge and belief. I understand that any false or misleading statements may cause termination of my employment.
I authorize the physician or other person to disclose any knowledge or information pertaining to my health to the employing authority for whom this examination is performed.
_________________________________________
_____________________
Signature of Employee
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