Content Overview
The Pennsylvania Health form, officially known as the School Personnel Health Record, is a vital document designed to ensure the health and safety of school personnel. This form collects essential patient information, including personal details such as name, date of birth, and contact information, alongside the individual's usual source of medical care. Immunization history is a significant section, where records of vaccinations like Diphtheria, Tetanus, Hepatitis B, and Measles, Mumps, and Rubella must be documented. Tuberculosis test results are also mandatory, requiring specific details about the testing method, results, and any necessary follow-up actions. The form further addresses significant medical conditions, allowing for transparency regarding allergies, chronic illnesses, and other health concerns that may impact an individual's ability to perform their duties. A thorough physical examination report is included, which assesses various health metrics and identifies any special medical issues that could necessitate activity restrictions. Completing this form accurately is crucial, as it not only affects employment eligibility but also plays a role in maintaining a healthy school environment.
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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 Address Telephone
II. Immunization History
VACCINE
Enter Month, Day, and Year Each Immunization was Given
DOSES
BOOSTERS & DATES
Diphtheria and Tetanus*
1.
2.
3.
4.
5.
Hepatitis B
1.
2.
3.
Measles, Mumps, Rubella
1.
2.
Other ________________
1.
Other _____________________
1.
* 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)
SIGNATURE
For previously known/new positive reactors: _______________________________________________________________________
Chest X-ray: Date: ____________ Results: _____________ Other: Date: _____________ Results: _______________
(Attach a copy of the report.) (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
EXAMINED
COMMENTS
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 Date
Form Specifications
| Fact Name | Description |
|---|---|
| Governing Law | The Pennsylvania Health Form is governed by the Pennsylvania Department of Health regulations. |
| Form Version | This form is identified as H511.340 and was last updated in August 2011. |
| Purpose | The form serves as a health record for school personnel in Pennsylvania. |
| Patient Information | It collects essential personal details such as name, date of birth, and contact information. |
| Immunization History | The form requires a detailed record of immunizations, including vaccines and booster dates. |
| Tuberculosis Testing | Results of tuberculosis tests must be documented as per the Department of Health regulations. |
| Medical Conditions | It includes a section for reporting significant medical conditions and allergies. |
| Physical Examination Report | A physical examination section records various health metrics and observations. |
Pennsylvania Health: Usage Guidelines
Completing the Pennsylvania Health form requires careful attention to detail. Each section must be filled out accurately to ensure that all necessary information is provided. Once you have completed the form, you will need to submit it to the appropriate authority as part of your health record requirements.
- Begin with the Patient Information section. Fill in your last name, first name, middle initial, sex, date of birth, and social security number.
- Provide your home and work telephone numbers, along with your mailing address, including street, city, state, and zip code.
- Identify your usual source of medical care by entering your physician’s name, address, and telephone number.
- List an emergency contact by providing their name, relationship to you, address, and telephone number.
- Move to the Immunization History section. Enter the month, day, and year for each immunization given, including Diphtheria and Tetanus, Hepatitis B, and Measles, Mumps, Rubella.
- Document any other vaccines you have received in the designated spaces.
- Complete the Required Tuberculosis Test Results section. Note the date applied, method, antigen manufacturer, and signature of the administering physician.
- Record the date read and the results in millimeters (mm). If applicable, include information about chest X-ray results and other tests.
- Indicate whether preventive anti-tuberculosis chemotherapy was ordered and provide the date if applicable.
- In the Significant Medical Conditions section, check "Yes" or "No" for each condition listed. If you answer "Yes," provide an explanation.
- Proceed to the Report of Physical Examination section. Mark whether each item is normal or abnormal, and provide comments where necessary.
- Ensure to include your height, weight, pulse, and blood pressure measurements.
- Identify any special medical problems or chronic diseases that may require activity restrictions or medication.
- Have the examining physician print their name, sign the form, and date it.
- Finally, sign and date the statement affirming that all provided information is true and complete to the best of your knowledge.
Your Questions, Answered
What is the purpose of the Pennsylvania Health Form?
The Pennsylvania Health Form is designed to collect essential health information about school personnel. This information helps ensure that employees are physically capable of performing their job duties and that any health issues are documented. It includes sections on immunization history, tuberculosis test results, significant medical conditions, and a report of physical examination. Completing this form accurately is crucial for maintaining a safe and healthy school environment.
Who is required to complete the Pennsylvania Health Form?
All school personnel in Pennsylvania, including teachers, administrators, and support staff, must complete the Pennsylvania Health Form. This requirement is in place to comply with state health regulations and to promote the well-being of both employees and students. New hires typically need to submit this form before starting work, while current employees may be asked to update their information periodically.
What should I do if I have a significant medical condition?
If you have a significant medical condition, it is important to disclose this information on the Pennsylvania Health Form. The form includes a section where you can indicate any allergies, chronic illnesses, or other health issues that may affect your work. Being transparent about your health helps ensure that appropriate accommodations can be made if necessary. If you have concerns about privacy, rest assured that this information is handled confidentially and is only shared with authorized personnel.
What happens if I do not complete the Pennsylvania Health Form?
Failure to complete the Pennsylvania Health Form may result in delays in your employment process or even termination of your employment. The form is a crucial part of ensuring that all school personnel meet health and safety standards. It is advisable to fill out the form thoroughly and return it promptly to avoid any issues. If you have questions or need assistance, reach out to your employer for guidance.
Common mistakes
-
Missing Personal Information: Not providing complete personal details like last name, first name, or date of birth can lead to processing delays.
-
Incorrect Social Security Number: Entering an incorrect Social Security number can create significant issues with identification and benefits.
-
Incomplete Immunization History: Failing to list all vaccinations or not including the dates can result in non-compliance with health regulations.
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Skipping Tuberculosis Test Details: Not providing the date applied, method, or results of the tuberculosis test can lead to rejection of the form.
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Omitting Significant Medical Conditions: Not disclosing allergies or other medical conditions can affect job performance and safety.
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Not Signing the Form: Forgetting to sign the form at the end can render it invalid.
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Ignoring Required Attachments: Failing to attach necessary reports, such as chest X-ray results, can delay processing.
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Inaccurate Emergency Contact Information: Providing incorrect contact details can hinder communication in case of an emergency.
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Neglecting to Update Information: Not updating any changes in health status or personal information can lead to complications later.
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Forgetting to Review the Form: Not double-checking for errors or omissions before submission can cause unnecessary delays and issues.
Documents used along the form
When completing the Pennsylvania Health form, you may also need to gather additional documents to ensure a comprehensive health record. Here are some commonly used forms that can complement the Pennsylvania Health form:
- Immunization Records: This document provides a detailed history of all vaccinations received. It typically includes dates, types of vaccines, and any booster shots. Schools and employers often require this to verify compliance with health regulations.
- Tuberculosis (TB) Test Results: This report details the results of a TB skin test or blood test. It indicates whether the individual has been exposed to TB and may include recommendations for further testing or treatment if necessary.
- Physical Examination Report: A thorough examination by a healthcare provider is documented here. This report assesses the individual's overall health, highlighting any significant medical conditions that could impact their ability to work or attend school.
- Emergency Contact Form: This form lists individuals to be contacted in case of an emergency. It typically includes names, relationships, and contact information, ensuring that the necessary parties can be reached quickly if needed.
Gathering these documents alongside the Pennsylvania Health form can help create a complete health profile. This ensures that all necessary information is readily available for schools or employers, streamlining the process and enhancing safety and compliance.
Similar forms
The Pennsylvania Health form is an essential document for school personnel, ensuring that health information is accurately recorded and accessible. Several other documents serve similar purposes in various contexts, focusing on health history, immunizations, and medical evaluations. Here are five documents that share similarities with the Pennsylvania Health form:
- School Immunization Record: This document tracks the immunizations a student has received. Like the Pennsylvania Health form, it requires specific details about each vaccine, including dates and types, to ensure compliance with state health regulations.
- Employee Health History Questionnaire: Often used by employers, this questionnaire collects information about an employee's medical history. Similar to the Pennsylvania Health form, it includes sections for allergies, chronic conditions, and any significant medical issues that may affect job performance.
- Physical Examination Report: This report is typically required for sports participation or employment. It assesses an individual's overall health and includes findings similar to those on the Pennsylvania Health form, such as height, weight, and vital signs, ensuring that the individual is fit for their activities.
- Immunization Exemption Form: In some cases, individuals may be exempt from certain vaccinations for medical, religious, or philosophical reasons. This form requires documentation and justification, paralleling the Pennsylvania Health form's focus on immunization history and health assessments.
- Health Insurance Portability and Accountability Act (HIPAA) Authorization Form: This document allows healthcare providers to share an individual's medical information with designated parties. While it serves a different purpose, it emphasizes the importance of consent and transparency regarding health information, much like the Pennsylvania Health form, which requires employee acknowledgment of health disclosures.
Each of these documents plays a vital role in maintaining health records, ensuring safety, and promoting well-being in various environments. Understanding their similarities can help individuals navigate health-related requirements more effectively.
Dos and Don'ts
When filling out the Pennsylvania Health form, it’s important to approach the task with care and attention to detail. Here’s a list of ten things you should and shouldn’t do to ensure your submission is accurate and complete.
- Do read the entire form carefully before starting. Understanding what information is required will help you fill it out correctly.
- Do provide accurate personal information. Ensure that your name, address, and contact details are correct.
- Do include all relevant medical history. If you have allergies or medical conditions, be honest and thorough.
- Do list all immunizations with the exact dates. This includes any boosters received.
- Do have your physician sign and date the form. Their signature is often required for the submission to be valid.
- Don’t leave any sections blank. If a question does not apply to you, indicate that clearly.
- Don’t use abbreviations or shorthand. Write out all information fully to avoid confusion.
- Don’t provide false information. Misleading statements can lead to serious consequences, including job termination.
- Don’t forget to attach any required documents. If reports or additional information are needed, include them with your submission.
- Don’t submit the form without reviewing it. A final check can catch errors that might have been overlooked.
By following these guidelines, you can help ensure that your Pennsylvania Health form is completed correctly, making the process smoother for everyone involved.
Misconceptions
Understanding the Pennsylvania Health form is crucial for compliance and proper documentation. However, several misconceptions can lead to confusion. Here are four common misconceptions:
- Misconception 1: The form is only for school personnel.
- Misconception 2: Immunization records are optional.
- Misconception 3: Tuberculosis testing is not necessary if there are no symptoms.
- Misconception 4: Only a physician can complete the form.
While the form is titled "School Personnel Health Record," it is applicable to various roles within educational settings. Any employee or volunteer who interacts with students may need to complete this form to ensure health and safety standards are met.
Immunization history is a required section of the form. Accurate documentation of vaccinations is essential for preventing outbreaks of contagious diseases in schools and ensuring the health of all students and staff.
The form mandates tuberculosis testing regardless of symptom presence. This requirement is in place to safeguard public health, especially in environments where individuals are in close contact.
While a physician must review and sign the form, other qualified health professionals, such as nurse practitioners or physician assistants, may also complete the examination and documentation. This flexibility can streamline the process for employees.
Key takeaways
Ensure all patient information is filled out accurately. This includes your name, date of birth, and contact details.
List your usual source of medical care, including the physician’s name and contact information.
Document your immunization history clearly. Provide the dates for each vaccine received.
Complete the Tuberculosis test results section as required. Include the date applied and the results.
Indicate any significant medical conditions by checking the appropriate boxes. Provide explanations where necessary.
Ensure the physical examination report is filled out completely. This includes height, weight, and any abnormalities.
Read through the form carefully before submission to ensure all sections are complete and accurate.
Sign and date the form at the bottom to confirm that all information is true to the best of your knowledge.
Keep a copy of the completed form for your records after submission.