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Pennsylvania Health Form

The Pennsylvania Health Form is a crucial document required for school personnel, ensuring that all health information is accurately recorded and maintained. This form collects essential data, including immunization history, tuberculosis test results, and significant medical conditions. Completing this form is vital for compliance with health regulations and safeguarding the well-being of students and staff alike.

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Common mistakes

Filling out the Pennsylvania Health form can be straightforward, but many make critical mistakes that can lead to delays or complications. One common error is failing to provide complete patient information. Each section requires specific details, including the full name, date of birth, and social security number. Omitting any of this information can result in significant delays in processing.

Another frequent mistake is neglecting to accurately record immunization history. Individuals often forget to include the exact dates for each vaccine received. This is essential, as incomplete immunization records can lead to questions about compliance with health regulations. Be meticulous when entering this information.

Inaccurate reporting of tuberculosis test results is also a serious issue. Many individuals either misread the results or fail to include necessary details such as the method of testing and the signature of the healthcare provider. This section is crucial for ensuring that the applicant is free from tuberculosis, so it must be filled out correctly.

Additionally, people often overlook the section on significant medical conditions. If any condition applies, it must be marked and explained clearly. Failing to disclose important health issues can have severe implications for employment, as it may affect the individual's ability to perform their job safely.

Another mistake is not attaching required documents, such as chest X-ray reports or other significant medical records. These attachments are necessary to provide a complete picture of the applicant's health status. Without them, the form may be deemed incomplete.

Furthermore, individuals frequently forget to sign and date the form. This may seem minor, but without a signature, the form is not valid. The statement confirming that the information is true and complete is crucial for both legal and medical reasons.

Lastly, failing to keep a copy of the completed form for personal records is a mistake that can lead to confusion later. Having a copy can help clarify any discrepancies that may arise during the employment process. Always retain a copy for your records to ensure you have access to the information you provided.

Dos and Don'ts

When completing the Pennsylvania Health form, it is important to follow specific guidelines to ensure accuracy and compliance. Below is a list of things to do and not to do.

Do provide accurate personal information, including your full name, date of birth, and social security number.
Do ensure that all immunization dates are entered clearly and correctly.
Do sign and date the form at the end to validate the information provided.
Do attach any required reports, such as chest X-ray results, if applicable.
Don’t leave any sections blank; if a question does not apply, indicate that appropriately.
Don’t provide incomplete or vague explanations for any significant medical conditions.

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Similar forms

The Pennsylvania Health form shares similarities with the Employee Health History form often required by employers. Both documents collect essential health information from individuals, ensuring that employers are aware of any medical conditions that could impact job performance. They include sections for personal information, medical history, and specific health evaluations. This ensures that employers can make informed decisions regarding workplace safety and employee well-being.

The Ohio Motor Vehicle Bill of Sale is an essential document used in the sale and transfer of ownership of a vehicle in Ohio. This form provides a written record of the transaction, detailing important information about the buyer, seller, and the vehicle itself. Understanding how to properly complete this form can ensure a smooth transfer process and protect both parties' interests. For more information, visit https://topformsonline.com/ohio-motor-vehicle-bill-of-sale.

Another document that resembles the Pennsylvania Health form is the Immunization Record. This record specifically tracks an individual's vaccination history, including dates and types of vaccines received. Just like the Pennsylvania Health form, it emphasizes the importance of immunizations in maintaining public health. Both documents require detailed information about vaccines, thereby helping to prevent the spread of contagious diseases in schools and workplaces.

The School Physical Examination form is also comparable to the Pennsylvania Health form. This document serves as a comprehensive health assessment for students before they participate in school activities. It includes sections on physical examinations, medical history, and any significant health conditions. Both forms aim to ensure that individuals are fit for their respective environments, whether it be a school or workplace, and prioritize the health and safety of all involved.

Finally, the Medical Release form shares similarities with the Pennsylvania Health form. This document allows healthcare providers to share medical information with employers or schools, ensuring that necessary accommodations can be made for individuals with specific health needs. Like the Pennsylvania Health form, it requires consent from the individual to disclose health information, highlighting the importance of privacy while facilitating necessary communication about health matters.

Guidelines on How to Fill Out Pennsylvania Health

Completing the Pennsylvania Health form requires careful attention to detail. This form gathers essential information regarding health history and immunization records. Once filled out, it will need to be submitted to the appropriate authority as part of the employment process.

Begin with Section I, Patient Information. Fill in your Last Name, First Name, and Middle Initial.
Provide your Sex, Date of Birth, and Social Security Number.
Enter your Home Telephone and Work Telephone.
Complete your Mailing Address, including Street, City, State, and Zip Code.
List your usual source of medical care, including the Physician’s Name, Address, and Telephone.
Identify an Emergency Contact by providing their Name, Relationship, Address, and Telephone.
Proceed to Section II, Immunization History. Record the Month, Day, and Year for each vaccine received.
For each vaccine listed, fill in the number of doses and any boosters, including Diphtheria and Tetanus, Hepatitis B, and Measles, Mumps, Rubella.
In Section III, Required Tuberculosis Test Results, enter the DATE APPLIED, ARM METHOD, and ANTIGEN MANUFACTURER.
Document the DATE READ and RESULTS (in mm) of the tuberculosis test.
If applicable, provide details for any significant reactions, including a chest X-ray date and results.
In Section IV, indicate any significant medical conditions by marking Yes or No for each condition listed.
If you marked Yes, provide explanations for each condition.
Move to Section V, Report of Physical Examination. Fill in the Height, Weight, Pulse, and Blood Pressure.
Complete the examination findings for Hair/Scalp, Skin, Eyes, Ears, Nose and Throat, Teeth, Lymph Glands, Heart, Lungs, Abdomen, Genitourinary, Neuromuscular System, and Extremities.
If there are any special medical problems or chronic diseases, specify them in the provided space.
Finally, sign and date the form at the bottom, ensuring that all information is accurate and complete.

Form Preview Example

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


		Enter Month, Day, and Year Each Immunization was Given
VACCINE			DOSES				BOOSTERS & DATES
Diphtheria and Tetanus*	1.		2.		3.	4.		5.

Hepatitis B	1.		2.		3.
Measles, Mumps, Rubella	1.		2.
Measles, Mumps, Rubella	1.		2.
Other ________________	1.		Other _____________________			1.
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	COMMENTS
	NORMAL	ABNORMAL	EXAMINED	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	Date

Form Information

Fact Name	Description
Purpose of the Form	The Pennsylvania Health Form is used to collect essential health information from school personnel. This includes immunization history, tuberculosis test results, and significant medical conditions that may affect their ability to perform their job duties.
Governing Laws	This form is governed by the Pennsylvania Department of Health regulations, which require school personnel to provide proof of immunizations and undergo health examinations to ensure public health and safety in educational settings.
Immunization Requirements	Individuals filling out the form must document their immunization history, including vaccines such as Diphtheria, Tetanus, Hepatitis B, and Measles, Mumps, and Rubella. This information is critical for preventing outbreaks in schools.
Physical Examination	A physical examination is a key component of the form. It assesses various health indicators, such as height, weight, blood pressure, and the presence of any significant medical conditions that could affect the individual's work role.