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The Mdch Bcal 3305 form serves as a vital tool for schools and parents, ensuring that a child’s health needs are accurately assessed and addressed. It gathers comprehensive information regarding the child's physical, intellectual, and emotional well-being. Parents or guardians must provide essential details in Section I, which includes the child's health history and any existing medical conditions. For immunization records, Section III requires specific dates and types of vaccinations administered, and parents must ensure the child’s immunization records are available for examination. Further evaluation is needed for physical examinations, tests, and any health concerns, as documented in Sections II and IV. Notably, certain exemptions for vaccinations might apply, but these must be correctly documented and submitted. Dentists may also contribute recommendations in Section V to complete the health appraisal process. This holistic approach not only fulfills school requirements but also helps foster a supportive environment that prioritizes a child's health and development.

Mdch Bcal 3305 Example

HEALTH APPRAISAL

Dear Parent or Guardian:  The following information is requested so that the school can work with the parent to meet the physical, intellectual and emotional needs of the child. Fill out the information requested in Section I. Section III may be certified by the transcription of information from the certificate of immunization. The remaining sections are to be completed by a doctor, nurse and dentist. (BE SURE TO BRING YOUR CHILD’S IMMUNIZATION RECORDS TO THE EXAMINATION.)

PERSONAL

CHILD’S NAME (Last, First, Middle)

 

 

DATE OF BIRTH (mm/dd/yy)

 

 

 

 

/

/

 

 

 

 

ADDRESS (Number & Street)

(City)

(ZIP Code)

TODAY’S DATE (mm/dd/yy)

 

MI

 

 

/

/

 

 

 

 

PARENT/GUARDIAN (Last, First, Middle)

 

 

HOME TELEPHONE NUMBER

 

 

 

(

)

 

 

 

 

 

ADDRESS (Number & Street)

(City)

(ZIP Code)

WORK TELEPHONE NUMBER

 

MI

 

(

)

 

 

 

 

 

 

 

SECTION I - HEALTH HISTORY

Yes

No

Resolved

  # Is your child having any of the problems listed below?

Birth History:

hh h 1 Allergies or Reactions (for example, food, medication or other)

hh h 2 Hay Fever, Asthma, or Wheezing

hh h 3 Eczema or Frequent Skin Rashes

hh h 4 Convulsions/Seizures

hh h 5 Heart Trouble

hh h 6 Diabetes

h h h

7

Frequent Colds, Sore Throats, Earaches (4 or more per year)

 

Are there any current or past diagnosis(es) h  Yes    h  No

h h h

8

Trouble with Passing Urine or Bowel Movements

 

If yes, please describe:

h h h

9

Shortness of Breath

 

 

hh h 10 Speech Problems

hh h 11 Menstrual Problems

h

h

h

12 Dental Problems:  Date of Last Exam

/

/

 

h

h

h

Other (please describe):

 

 

 

 

 

 

 

 

 

 

 

 

h h

Does your child take any medication(s) regularly?

 

 

[

If yes, list medications:

 

 

 

 

Reason for Medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

Was the health history reviewed by a health professional?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent/Guardian Signature

Date

 

h  Yes    h  No

Examiner’s Initials:

 

 

SECTION II - PHYSICAL EXAMINATION, INSPECTION, TESTS AND MEASUREMENTS

Required for Child Care and Head Start / Early Head Start

Tests and Measurements

No Yes

Was child tested for:

Test results:

 

VISION

 

h h

 

 

 

Date:

 

/

/

Other:

HEARING

 

 

 

h h

 

 

Other:

 

 

 

Date:

 

/

/

 

URINALYSIS

 

 

 

h h

 

 

 

Date:

 

/

/

 

BLOOD LEAD LEVEL

 

 

h h

 

 

Level

 

 

 

Date:

 

/

/

 

  Essential Findings Deviating from Normal:

 

Normal

Referred

Under Care

No

Yes

Was child tested for:

 

Test results:

 

 

 

 

Normal

Referred

Under Care

Visual Acuity

 

 

 

h

h

HEIGHT & WEIGHT

 

 

 

Height

 

 

 

 

 

 

 

Muscle Imbalance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weight

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h

h

Other:

 

 

 

 

 

Other

 

 

 

 

 

 

 

Audiometer

 

 

 

h

h

HEMOGLOBIN / HEMATOCRIT

 

 

 

 

]

 

 

 

 

 

 

Sugar

 

 

 

h

h

BLOOD PRESSURE

 

 

 

Reading:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TUBERCULIN

 

 

 

 

Type:

 

 

 

 

 

 

 

 

Albumin

 

 

 

h

h

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Microscopic

 

 

 

 

 

Date:

/

/

 

 

Neg.:  h    Pos.:  h

 

 

mm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[

NOTE:  Blood lead level required for all children enrolled in Medicaid must be tested

ug/dl

at one and two years of age, or once between three and six years of age if not

 

 

 

 

previously tested. All children under age six living in high-risk areas should be tested

 

 

 

 

at the same intervals as listed above.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Examinations and/or Inspections

Exam Date: 

/ 

/

HHS/BCAL-3305 (formerly OCAL 3305/BRS-3305)

Page 1 of 2

Rev. July 2015

SECTION III - IMMUNIZATIONS

Statements such as “UP-TO-DATE” or “COMPLETE” will not be accepted. Admission to school may be denied on the basis of this information.*

VACCINES (Circle Type)

 

DATE ADMINISTERED

 

 

VACCINES (Circle Type)

DATE ADMINISTERED

 

 

 

MM/DD/YYYY

 

 

 

 

MM/DD/YYYY

 

 

 

Hepatitis B

1

 

3

 

 

Hepatitis A (HepA)

1

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(HepB)

2

 

 

 

 

Influenza (IIV/LAIV)

1

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

4

 

 

2

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DTaP/DTP/DT/Td

2

 

5

 

 

Meningococcal (MCV4 / MPSV4)

1

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

6

 

 

Human Papillomavirus

1

 

 

3

 

 

 

 

 

 

 

 

 

(HPV9/HPV4/HPV2)

 

 

 

 

 

 

 

Tdap

1

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Haemophilus Influenzae

1

 

3

 

 

 

Type of Vaccine(s)

Date of Vaccine(s)

 

 

 

 

 

 

 

OTHER Vaccines

 

 

 

 

 

 

 

type b (HIB)

2

 

4

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

Specify Date & Type

 

 

 

 

 

 

 

Polio

1

 

3

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(IPV/OPV)

2

 

4

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal Conjugate

1

 

3

 

Indicate and attach physician diagnosis or laboratory evidence of immunity as applicable

 

(PCV7/PCV13)

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

4

 

*NOTE: According to Public Act 368 of 1978, any child enrolling in a Michigan school for

 

 

 

 

 

 

 

Rotavirus (RV1/RV5)

1

 

3

 

 

the first time must be adequately immunized, vision tested and hearing tested.

 

 

 

 

 

 

 

Exemptions to these requirements are granted for medical, religious and other

 

 

2

 

 

 

 

 

 

 

 

objections, provided that the waiver forms are properly prepared, signed and

 

 

 

 

 

 

 

Measles,Mumps, Rubella (MMR)

1

 

2

 

 

delivered to school administrators. Forms for these exemptions are available

 

 

 

 

 

 

 

at your provider office for medical waiver forms and through your local health

 

Varicella (Chickenpox)

1

 

2

 

 

 

 

department for nonmedical waiver forms.

 

 

 

 

 

 

 

 

 

 

 

 

 

History of Chickenpox Disease?    h  Yes    h  No      If yes, date:

 

Parent/Guardian refused immunizations:  h

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I certify that the immunization dates are true to the best of my knowledge

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/ 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Professional’s Signature

 

Title

 

 

 

Date

 

 

No Yes

h h

h h

SECTION IV - RECOMMENDATIONS

(Required for Child Care and Head Start/Early Head Start)

Is there any defect of vision, hearing or other condition for which the school could help by seating or other actions? If yes, please explain:

Should the child’s activity be restricted because of any physical defect or illness?

If yes, check and explain degree of restriction(s): h  Classroom    h  Playground    h  Gymnasium    h  Swimming Pool    h  Competitive Sports    h  Other

Other Recommendations

SECTION V - DENTAL EXAMINATION AND RECOMMENDATIONS (OPTIONAL)

 

I have examined

 

’s teeth. As a result of this examination, my recommendation for treatment is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

child’s name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

  /

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dentist’s Signature

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN’S SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Examiner’s Signature

 

 

 

Date

Examiner’s Name (Print or Type)

 

 

 

 

 

 

 

Degree or License

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MI

 

 

(

 

 

   

)

 

 

 

 

 

 

 

 

Number & Street

 

 

City

 

 

 

ZIP Code

 

 

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Information required for:

Early On - Hearing and Vision Status; Diagnosis; Health Status Child Care Licensing - Physical Exam, Restrictions, Immunizations

Head Start/Early Head Start - Determination that child is up-to-date on a schedule of age-appropriate preventive and primary health care, including medical, dental, and mental health. The schedule must incorporate the well-child care visit required by EPSDT and the latest immunizations schedule recommended by the Centers for Disease Control and Prevention, State, tribal, and local authorities. An EPSDT well-child exam includes height, weight, and blood tests for anemia at regular intervals based on age.

**************

Developed in Cooperation with the Department of Health and Human Services, Education, Michigan American Association of Pediatrics, Early Childhood Investment Corporation, Child Care Licensing, Head Start, Michigan State Medical Society, Michigan Association of Osteopathic Physicians and Surgeons.

DHHS/BCAL 3305 (formerly OCAL 3305/BRS-3305)

Page 2 of 2

Rev. July 2015

Form Characteristics

Fact Name Description
Purpose The Mdch Bcal 3305 form is designed to collect health information about a child to help schools meet their physical, intellectual, and emotional needs.
Sections The form consists of several sections, including health history, physical examination, immunization status, and recommendations for care.
Immunization Record Parents must bring their child's immunization records to the examination to complete Section III of the form.
Health Professional Review A health professional must review the health history section to ensure accuracy before submission.
Governing Law According to Public Act 368 of 1978, children enrolling in Michigan schools for the first time must be adequately immunized and tested.
Exemption Policy Exemptions from immunizations are granted for medical, religious, or other objections but require proper documentation to be submitted.

Guidelines on Utilizing Mdch Bcal 3305

Completing the Mdch Bcal 3305 form involves providing necessary information about the child’s health and immunization history. This form must be filled out correctly to ensure that the school can adequately address the physical, intellectual, and emotional needs of the child. Information gathered includes personal details, health history, immunization records, and required examinations by medical professionals.

  1. Begin by entering the personal details of the child in Section I. Provide the child's name (last, first, middle), date of birth (mm/dd/yy), address including number and street, city, and ZIP code. Also, state today's date.
  2. Supply the information for the parent/guardian including their name (last, first, middle), home and work telephone numbers, and address.
  3. In Section I, answer the health history questions by marking 'Yes' or 'No' for each item listed. Include additional information if applicable.
  4. If your child takes any medications regularly, list the medications and the reason for taking them.
  5. Ensure the health history section has been reviewed by a health professional and provide their initials.
  6. Move to Section II to document the results from the required physical examinations and tests. Fill out relevant data including vision, hearing, urinalysis, and blood lead level.
  7. Provide any abnormal findings along with actions taken, if necessary.
  8. In Section III, fill out the immunization records. Record the type of vaccines administered along with the specific dates.
  9. Do not use phrases like "UP-TO-DATE" or "COMPLETE" for the immunization status. Instead, list each vaccine and its administration date.
  10. If applicable, note if your child has a history of chickenpox disease and provide the date.
  11. Confirm the immunization information with the health professional's signature and their title.
  12. Move to Section IV to specify any recommendations regarding the child’s physical activity based on their health status.
  13. If a dental examination was conducted, complete Section V with the recommendations or treatment ideas provided by the dentist, along with their signature.
  14. Finally, ensure the entire form is signed and dated by the examiner.

After filling out the Mdch Bcal 3305 form, make sure to gather all relevant medical records and immunization documentation to take to the designated healthcare appointments. This will aid in ensuring a smooth completion and submission process for your child’s health appraisal requirements.

What You Should Know About This Form

What is the purpose of the Mdch Bcal 3305 form?

The Mdch Bcal 3305 form, also known as the Health Appraisal, is primarily designed to gather critical information about a child's health. This includes details about their physical, intellectual, and emotional needs. Schools require this information to ensure that they can adequately support the child throughout their educational journey. The form helps facilitate communication between parents, guardians, and school health professionals.

What sections need to be completed by a healthcare professional?

Sections II, III, and V of the Mdch Bcal 3305 form are to be completed by a healthcare professional, such as a doctor, nurse, or dentist. These sections include the physical examination results, immunization records, and dental examination outcomes. The contributions from these professionals ensure that the child's health status is accurately assessed and documented.

What information should I provide in the health history section?

In the health history section, parents or guardians are asked to describe any past or current health issues the child may have experienced. This includes allergies, chronic illnesses, and frequent medical concerns. Information about medications the child is taking should also be provided. It's crucial for care providers at school to have a full understanding of the child's health background to tailor their support appropriately.

Are immunization records necessary when filling out this form?

Yes, immunization records are essential when completing the Mdch Bcal 3305 form. Section III requires detailed documentation of the child's vaccinations, including the dates and types of vaccines they have received. Statements like "up-to-date" or "complete" are not acceptable; specific dates must be provided to ensure compliance with state laws regarding school enrollment and health safety.

How can exemptions to vaccination requirements be obtained?

Exemptions to vaccination requirements can be granted for medical, religious, or other reasons. To obtain an exemption, specific waiver forms must be properly filled out, signed, and submitted to school administrators. Medical waiver forms are usually available at the child’s healthcare provider's office, while non-medical waivers can be obtained from local health departments. This process ensures that parents seeking exemptions do so in accordance with state policy.

What is the significance of the physical examination?

The physical examination outlined in Section II of the Mdch Bcal 3305 form plays a critical role in assessing the child's overall health. It includes tests for vision, hearing, and other essential health metrics. These evaluations help identify any conditions that may affect the child's learning or participation in school activities and ensure that they receive necessary interventions early on.

What if my child has special health needs?

If your child has special health needs, it is important to indicate this on the form, especially in the recommendations section. This section allows parents to communicate any specific accommodations or restrictions that might be necessary for the child’s learning environment. Providing this information ensures that the school understands how best to support your child's unique health requirements.

Common mistakes

Filling out the Mdch Bcal 3305 form can be straightforward, but many people make common mistakes that can lead to complications. One frequent error is leaving out the child's full name or date of birth. Ensuring these details are complete and accurate is crucial. If this information is missing, it could delay the processing and might require additional steps for verification.

Another common mistake is failing to provide accurate immunization dates. Some parents may write “up-to-date” or “complete” instead of listing specific dates. It's essential to remember that schools need precise records for each vaccination administered. Without exact dates, the child's enrollment could be jeopardized, as the school may deem the immunization record insufficient.

Omitting critical health history information is also a mistake many make. For instance, if a child has allergies or previous health issues, not answering these questions could impact their care at school. It's important to communicate any past or present health concerns clearly. Not doing so could place the child at risk without appropriate accommodations.

Lastly, incorrect signatures or missing initials from health professionals can create problems. Each section requires verification by the relevant medical provider, whether it's a doctor, nurse, or dentist. Skipping this step means the form may not be accepted, and parents might find themselves having to restart the process entirely. Double-checking for all necessary signatures can save time and ensure that everything is in good order.

Documents used along the form

The Mdch Bcal 3305 form, commonly used for health assessments, often requires several other documents to ensure that a child's health needs are thoroughly addressed. Here is a list of related forms and documents that might be required alongside it.

  • Immunization Records: This document outlines all vaccinations a child has received. It's essential for verifying compliance with health requirements for school entry.
  • Health History Questionnaire: Parents typically fill out this form before health exams to provide background information about the child's medical history.
  • Consent for Treatment: This form authorizes health care providers to perform necessary treatments during a child's medical examination.
  • Vision Screening Report: A separate record of a child's vision tests. It may indicate whether a child needs corrective lenses or further evaluation.
  • Hearing Screening Report: Similar to the vision report, this document records hearing tests and identifies any potential hearing loss in a child.
  • Dental Examination Form: This form captures information from a child's dental check-up, detailing recommended treatments and care.
  • Medication Administration Form: If a child requires medication during school hours, this form provides details on what, when, and how to administer medications.
  • Emergency Contact Form: This form lists contacts in case of health emergencies, ensuring that caregivers can quickly reach someone familiar with the child.
  • Physical Fitness Assessment: Used to document a child's physical capabilities, this assessment can help in screening for any needs for modifications in physical activities.

Gathering these documents helps create a comprehensive health profile for a child, ensuring their well-being is properly addressed in educational settings. By being proactive, parents and guardians can support their child's health and educational needs effectively.

Similar forms

  • Medical History Form: Similar to the Mdch Bcal 3305 form, this document collects comprehensive health information about a patient. It typically includes sections for past medical history, current illnesses, and medication usage, helping healthcare providers understand the patient's overall health.
  • Immunization Record: Like the immunization section of the Mdch Bcal 3305 form, this document tracks the vaccines a child has received. It serves as proof of vaccination status, ensuring that schools and childcare facilities can verify compliance with immunization requirements.
  • Physical Examination Report: This report documents the results of a physical examination, similar to Section II of the Mdch Bcal 3305. It includes vital statistics, health measurements, and may indicate any abnormalities detected during the exam.
  • Dental Examination Record: This document is aligned with the optional dental section in the Mdch Bcal 3305 form. It summarizes findings from a dental check-up and outlines any recommended treatments, allowing for better coordination of a child's oral health care.

Dos and Don'ts

When completing the Mdch Bcal 3305 form, careful attention to detail is essential. Here are some important guidelines to follow:

  • Do ensure all sections are completed accurately. Missing information can lead to delays in processing.
  • Don't use vague statements like “UP-TO-DATE” for immunizations. Provide specific dates of administration instead.
  • Do bring your child’s immunization records to the examination. These documents are crucial for confirming vaccination status.
  • Don't forget to sign and date the form. Your signature indicates all information provided is accurate to the best of your knowledge.

Misconceptions

Misconceptions about the Mdch Bcal 3305 form can lead to confusion for parents and guardians. Here are ten common misconceptions explained:

  1. All sections of the form need to be filled by the parent. Many believe they can complete the entire form themselves. However, parts of the form require the professional input of a doctor, nurse, or dentist.
  2. The immunization section is optional. Some parents think they can skip or simply state "up-to-date". This is not true; specific immunization details must be provided to ensure school admission.
  3. A parent’s signature is the only requirement for validation. Parents are often unaware that a health professional’s signature and initial are also necessary to validate the health history and exam results.
  4. Completing the form is a one-time task. In reality, annual updates may be required, especially if the child’s health status changes or if new immunizations are administered.
  5. It only reflects physical health. Many think the form only covers physical health; however, it also addresses emotional and intellectual needs to ensure a child’s holistic development.
  6. Current medications don’t need to be listed if they are minor. Regardless of the nature of the medications, all regular medications should be disclosed to provide a complete health history.
  7. A health professional can sign without seeing the child. This is a misconception. Health professionals need to personally examine and review the child's health to provide an accurate certification.
  8. Vaccinations from any source are acceptable. Parents often assume that any document showing vaccinations is sufficient. Only specific formats and declarations noted on the form will be accepted.
  9. There are no exemptions to the immunization requirements. While most children must be vaccinated, medical and religious exemptions do exist, but proper documentation must be submitted for these cases.
  10. The Health History Section is optional. Some assume this section can be skipped, but it is critical for assessing any ongoing or past health issues the child may have.

Key takeaways

Filling out the Mdch Bcal 3305 form is an essential step in ensuring a child's health and readiness for school. Here are some key takeaways:

  • Complete all sections carefully. Make sure to fill out Section I with the child's health history, and Sections II and III must be completed by qualified health professionals.
  • Immunization records are crucial. Bring your child’s immunization records to the examination, as only certified details will be accepted. Statements like "up-to-date" will not suffice.
  • Consult with health professionals. It's important that the health history is reviewed by a doctor, nurse, or dentist for accurate assessment and care recommendations.
  • Understand the requirements and deadlines. Keep in mind that certain immunizations and health evaluations are mandatory for school enrollment in Michigan.