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The HAR 3 Connecticut form is a crucial document designed to ensure that students receive appropriate health assessments before entering school. It plays a significant role in gathering essential health information from parents or guardians, which is vital for school personnel to understand each child's unique health needs. The form consists of two main parts: Part I, where parents provide detailed health history about their child, and Part II, which is completed by a qualified health care provider following a medical evaluation. Connecticut law mandates that students have complete primary immunizations and a health assessment conducted by a licensed medical professional before starting school. Additionally, updates to immunizations and health assessments are required at specific grade levels, including the 6th or 7th grade and again in the 9th or 10th grade. This form is also applicable for students participating in sports, ensuring they meet health requirements for physical activities. By collecting comprehensive health data, the HAR 3 form supports schools in promoting a safe and healthy environment for all students.

Har 3 Connecticut Example

State of Connecticut Department of Education

Health Assessment Record

To Parent or Guardian:

In order to provide the best educational experience, school personnel must understand your child’s health needs. This form requests information from you (Part I) which will also be helpful to the health care provider when he or she completes the medical evaluation (Part II).

State law requires complete primary immunizations and a health assessment by a legally qualiied practitioner of medicine, an advanced

practice registered nurse or registered nurse, a physician assistant or the school medical advisor prior to school entrance in Connecticut (C.G.S.

Secs. 10-204a and 10-206). An immunization update and additional health assessments are required in the 6th or 7th grade and in the 9th or 10th grade. Speciic grade level will be determined by the local board of education. This form may also be used for health assessments required

every year for students participating on sports teams.

Please print

Student Name (Last, First, Middle)

Birth Date

 

❑ Male ❑ Female

 

 

 

 

 

Address (Street, Town and ZIP code)

 

 

 

 

 

 

 

 

 

Parent/Guardian Name (Last, First, Middle)

Home Phone

 

Cell Phone

 

 

 

School/Grade

Race/Ethnicity

❑ Black, not of Hispanic origin

 

❑ American Indian/

❑ White, not of Hispanic origin

 

Alaskan Native

❑ Asian/Paciic Islander

Primary Care Provider

 

❑ Hispanic/Latino

❑ Other

 

 

 

 

 

Health Insurance Company/Number* or Medicaid/Number*

Does your child have health insurance?

Y

N

If your child does not have health insurance, call 1-877-CT-HUSKY

Does your child have dental insurance?

Y

N

 

 

 

 

 

* If applicable

 

 

 

Part I — To be completed by parent/guardian.

Please answer these health history questions about your child before the physical examination.

Please circle Y if “yes” or N if “no.” Explain all “yes” answers in the space provided below.

Any health concerns

Y

N

Hospitalization or Emergency Room visit Y

N

Concussion

Y

N

Allergies to food or bee stings

Y

N

Any broken bones or dislocations

Y

N

Fainting or blacking out

Y

N

Allergies to medication

Y

N

Any muscle or joint injuries

Y

N

Chest pain

Y

N

Any other allergies

Y

N

Any neck or back injuries

Y

N

Heart problems

Y

N

Any daily medications

Y

N

Problems running

Y

N

High blood pressure

Y

N

Any problems with vision

Y

N

“Mono” (past 1 year)

Y

N

Bleeding more than expected

Y

N

Uses contacts or glasses

Y

N

Has only 1 kidney or testicle

Y

N

Problems breathing or coughing

Y

N

 

 

 

 

 

 

 

 

 

Any problems hearing

Y

N

Excessive weight gain/loss

Y

N

Any smoking

Y

N

Any problems with speech

Y

N

Dental braces, caps, or bridges

Y

N

Asthma treatment (past 3 years)

Y

N

 

 

 

 

 

 

 

 

 

Family History

 

 

 

 

 

Seizure treatment (past 2 years)

Y

N

Any relative ever have a sudden unexplained death (less than 50 years old)

Y

N

Diabetes

Y

N

 

 

 

 

 

 

Any immediate family members have high cholesterol

Y

N

ADHD/ADD

Y

N

 

 

 

 

 

 

 

 

 

Please explain all “yes” answers here. For illnesses/injuries/etc., include the year and/or your child’s age at the time.

Is there anything you want to discuss with the school nurse? Y N If yes, explain:

Please list any medications your child will need to take in school:

All medications taken in school require a separate Medication Authorization Form signed by a health care provider and parent/guardian.

I give permission for release and exchange of information on this form between the school nurse and health care provider for conidential

use in meeting my child’s health and educational needs in school. Signature of Parent/Guardian

Date

 

 

HAR-3 REV. 4/2011

TO BE MAINTAINED IN THE STUDENT’S CUMULATIVE SCHOOL HEALTH RECORD

Part II — Medical Evaluation

HAR-3 REV. 4/2011

Health Care Provider must complete and sign the medical evaluation and physical examination

Student Name

 

Birth Date

 

Date of Exam

❑I have reviewed the health history information provided in Part I of this form

Physical Exam

Note: *Mandated Screening/Test to be completed by provider under Connecticut State Law

*Height _____ in. / _____% *Weight _____ lbs. / _____%

BMI _____ / _____% Pulse _____

*Blood Pressure _____ / _____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Normal

 

Describe Abnormal

 

 

Ortho

 

 

Normal

 

Describe Abnormal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neurologic

 

 

 

 

 

 

Neck

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEENT

 

 

 

 

 

 

Shoulders

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Gross Dental

 

 

 

 

 

 

Arms/Hands

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lymphatic

 

 

 

 

 

 

Hips

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart

 

 

 

 

 

 

Knees

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lungs

 

 

 

 

 

 

Feet/Ankles

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abdomen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Postural

❑ No spinal

❑ Spine abnormality:

 

 

 

 

 

 

 

 

Genitalia/ hernia

 

 

 

 

 

 

 

 

abnormality

 

❑ Mild

❑ Moderate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

❑ Marked ❑ Referral made

Skin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Screenings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Vision Screening

 

 

 

*Auditory Screening

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

Type:

Right

Left

 

Type:

Right

Left

 

 

Lead:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

❑ Pass

❑ Pass

 

 

 

 

 

 

 

With glasses

20/

20/

 

 

 

 

*HCT/HGB:

 

 

 

 

 

 

 

 

 

 

❑ Fail

❑ Fail

 

 

 

 

 

 

 

 

 

Without glasses

20/

20/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Speech (school entry only)

 

 

 

 

 

 

 

 

 

 

 

 

 

❑ Referral made

 

 

 

❑ Referral made

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TB: High-risk group?

❑ No

❑ Yes

 

PPD date read:

 

 

Results:

 

 

 

Treatment:

 

 

 

*IMMUNIZATIONS

❑Up to Date or ❑ Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED

*Chronic Disease Assessment:

Asthma

❑ No

❑ Yes:

❑ Intermittent ❑ Mild Persistent ❑ Moderate Persistent ❑ Severe Persistent ❑ Exercise induced

 

If yes, please provide a copy of the Asthma Action Plan to School

 

Anaphylaxis ❑ No

❑ Yes:

❑ Food

❑ Insects

❑ Latex

❑ Unknown source

 

Allergies

If yes, please provide a copy of the Emergency Allergy Plan to School

 

 

History of Anaphylaxis

❑ No

❑ Yes

Epi Pen required ❑ No

❑ Yes

Diabetes

❑ No

❑ Yes:

❑ Type I

❑ Type II

Other Chronic Disease:

 

Seizures

❑ No

❑ Yes, type:

 

 

 

 

❑This student has a developmental, emotional, behavioral or psychiatric condition that may affect his or her educational experience. Explain: ____________________________________________________________________________________________________

Daily Medications (specify): ____________________________________________________________________________________

This student may: ❑ participate fully in the school program

❑participate in the school program with the following restriction/adaptation: _____________________________

___________________________________________________________________________________________________________

This student may: ❑ participate fully in athletic activities and competitive sports

❑participate in athletic activities and competitive sports with the following restriction/adaptation: ____________

___________________________________________________________________________________________________________

❑Yes ❑ No Based on this comprehensive health history and physical examination, this student has maintained his/her level of wellness.

Is this the student’s medical home? ❑ Yes ❑ No ❑ I would like to discuss information in this report with the school nurse.

 

 

 

 

 

 

Signature of health care provider MD / DO / APRN / PA

Date Signed

Printed/Stamped Provider Name and Phone Number

 

 

 

 

 

Student Name: ______________________________________ Birth Date: ___________________

Immunization Record

To the Health Care Provider: Please complete and initial below.

HAR-3 REV. 4/2011

Vaccine (Month/Day/Year) Note: *Minimum requirements prior to school enrollment. At subsequent exams, note booster shots only.

 

Dose 1

Dose 2

 

Dose 3

 

Dose 4

 

Dose 5

 

Dose 6

 

 

 

 

 

 

 

 

 

 

 

 

 

DTP/DTaP

*

*

 

*

 

*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DT/Td

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tdap

*

 

 

 

 

 

 

Required for 7th grade entry

 

 

 

 

 

 

 

 

 

 

 

 

 

IPV/OPV

*

*

 

*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMR

*

*

 

 

 

 

 

Required K-12th grade

 

 

 

 

 

 

 

 

 

 

 

Measles

*

*

 

 

 

 

 

Required K-12th grade

 

 

 

 

 

 

 

 

 

 

 

Mumps

*

*

 

 

 

 

 

Required K-12th grade

 

 

 

 

 

 

 

 

 

 

 

Rubella

*

*

 

 

 

 

 

Required K-12th grade

 

 

 

 

 

 

 

 

 

 

 

HIB

*

 

 

 

 

 

 

PK and K (Students under age 5)

 

 

 

 

 

 

 

 

 

 

 

Hep A

*

*

 

 

 

 

 

PK and K (born 1/1/2007 or later)

 

 

 

 

 

 

 

 

 

 

 

Hep B

*

*

 

*

 

 

 

Required PK-12th grade

 

 

 

 

 

 

 

 

 

 

 

Varicella

*

*

 

 

 

 

 

2 doses required for K & 7th grade as of 8/1/2011

 

 

 

 

 

 

 

 

 

 

 

 

PCV

*

 

 

 

 

 

 

PK and K (born 1/1/2007 or later)

 

 

 

 

 

 

 

 

 

 

 

Meningococcal

*

 

 

 

 

 

 

Required for 7th grade entry

 

 

 

 

 

 

 

 

 

 

 

 

 

HPV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Flu

*

 

 

 

 

 

 

PK students 24-59 months old – given annually

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disease Hx ________________________________

________________________________

________________________________

 

 

of above

(Specify)

 

 

(Date)

 

 

 

(Conirmed by)

 

 

 

 

 

 

 

Exemption

 

 

 

 

 

 

 

 

 

Religious _____ Medical: Permanent _____

Temporary _____ Date _____

 

 

 

 

Recertify Date _________

Recertify Date _________ Recertify Date ________

 

 

 

Immunization Requirements for Newly Enrolled Students at Connecticut Schools

KINDERGARTEN

•DTaP: At least 4 doses. The last dose must be given on or after 4th birthday.

•Polio: At least 3 doses. The last dose must be given on or after 4th birthday.

•MMR: 2 doses given at least 28 day apart – 1st dose on or after the 1st birthday.

•Hib: 1 dose on or after 1st birthday (Children 5 years and older do not need proof of Hib vaccination).

•Pneumococcal: 1 dose on or after 1st birthday (born 1/1/2007 or later and less than 5 years old).

•Hep A: 2 doses given six months apart-1st dose on or after 1st birthday.

•Hep B: 3 doses-the last dose on or after 24 weeks of age.

•Varicella: For students enrolled before August 1, 2011, 1 dose given on or after 1st birthday; for students enrolled on or after August 1, 2011

2 doses given 3 months apart – 1st dose on or after 1st birthday or veriication of disease*.

GRADES 1-6

•DTaP /Td/Tdap: At least 4 doses. The last dose must be given on or after 4th birthday;

students who start the series at age 7 or older only need a total of 3 doses of tetanus-diphtheria containing vaccine.

•Polio: At least 3 doses. The last dose must be given on or after 4th birthday.

•MMR: 2 doses given at least 28 days apart- 1st dose on or after the 1st birthday.

•Hep B: 3 doses – the last dose on or after 24 weeks of age.

•Varicella: 1 dose on or after the 1st birthday or veriication of disease*.

GRADE 7

•Tdap/Td: 1 dose of Tdap for students 11 yrs. or older enrolled in 7th grade who completed their primary DTaP series; For those students who start the series at age 7 or older a total of 3 doses of tetanus-diphtheria containing vac- cines are needed, one of which must be Tdap.

•Polio: At least 3 doses. The last dose must be given on or after 4th birthday.

•MMR: 2 doses given at least 28 days apart – 1st dose on or after the 1st birthday.

•Meningococcal: one dose for students enrolled in 7th grade.

•Hep B: 3 doses-the last dose on or after 24 weeks of age.

•Varicella: 2 doses given 3 months apart – 1st dose on or after 1st birthday or veriication of

disease*.

GRADES 8-12

•Td: At least 3 doses. Students who start the series at age 7 or older only need a total of 3 doses of tetanus-diphtheria containing vaccine one of which should be Tdap.

•Polio: At least 3 doses. The last dose must be given on or after 4th birthday.

•MMR: 2 doses given at least 28 days apart- 1st dose on or after the 1st birthday.

•Hep B: 3 doses-the last dose on or after 24 weeks of age.

•Varicella: For students <13 years of age, 1 dose given on or after the 1st birthday. For

students 13 years of age or older, 2 doses given at least 4 weeks apart or veriication of

disease*.

*Veriicationofdisease:Conirmation in writ- ing by a MD, PA, or APRN that the child has a previous history of disease, based on family or medical history.

 

 

 

 

 

 

Initial/Signature of health care provider MD / DO / APRN / PA

Date Signed

Printed/Stamped Provider Name and Phone Number

 

 

 

 

 
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Document Specifications

Fact Name Details
Purpose of the Form The HAR-3 form is designed to gather essential health information about a student to ensure their health needs are met in the educational environment.
Part I and Part II Part I is completed by the parent or guardian, providing health history. Part II is filled out by a healthcare provider during a medical evaluation.
Immunization Requirements Connecticut law mandates that students must have complete primary immunizations before entering school, as outlined in C.G.S. Secs. 10-204a and 10-206.
Grade-Specific Assessments Additional health assessments are required for students in the 6th or 7th grade and again in the 9th or 10th grade, as determined by local education boards.
Sports Participation This form can also be used for annual health assessments required for students participating in sports teams.
Health Insurance Inquiry The form includes questions about the student's health and dental insurance status, ensuring that all health needs can be addressed.
Confidentiality Agreement Parents or guardians must sign a permission statement allowing the exchange of information between the school nurse and healthcare provider.
Completion Date The HAR-3 form was last revised in April 2011, ensuring that it reflects current health assessment requirements.
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