DC Health | 899 North Capitol Street, N.E., Washington, DC 20002 | 202.442.5925 | dchealth.dc.gov version 04.02.19 pg1
Universal Health Certificate
Use this form to report your child’s physical health to their school/child care facility. This is required by DC Official Code §38-602. Have a licensed medical professional
complete part 2 - 4. Access health insurance programs at https://dchealthlink.com
. You may contact the Health Suite Personnel through the main office at your child’s school.
Part 1: Child Personal Information | To be completed by parent/guardian.
Child Last Name: Child First Name: Date of Birth:
School or Child Care Facility Name: Gender:
Home Address: Apt: City: State: ZIP:
(check all that apply)
Non-Hispanic/Non-Latino
(check all that apply)
American Indian/
Asian
Native Hawaiian/
Black/African
White
Prefer not to
Parent/Guardian Name: Parent/Guardian Phone:
Emergency Contact Name: Emergency Contact Phone:
Insurance Type:
Medicaid
Private
None
Insurance Name/ID #:
Has the child seen a dentist/dental provider within the last year?
I give permission to the signing health examiner/facility to share the health information on this form with my child’s school, child care, camp, or
appropriate DC Government agency. In addition, I hereby acknowledge and agree that the District, the school, its employees and agents shall be immune
from civil liability for acts or omissions under DC Law 17-107, except for criminal acts, intentional wrongdoing, gross negligence, or willful misconduct. I
understand that this form should be completed and returned to my child’s school every year.
Parent/Guardian Signature: _______________________________________________ Date: ____________________
Part 2: Child’s Health History, Exam, and Recommendations |
To be completed by licensed health care provider.
____ /_____
NML
Percentile:
Vision
Screening:
Left eye: 20/________ Right eye: 20/________
Corrected
Wears glasses Referred Not tested
Hearing Screening: (check all that apply)
Does the child have any of the following health concerns? (check all that apply and provide details below)
Asthma
Autism
Behavioral
Cancer
Cerebral palsy
Developmental
Failure to thrive
Heart failure
Kidney failure
Language/Speech
Obesity
Scoliosis
Sickle cell
Significant food/medication/environmental allergies that may require emergency medical care.
Details provided below.
Long-term medications, over-the-counter-drugs (OTC) or special care requirements.
Details provided below.
Significant health history, condition, communicable illness, or restrictions.
Details provided below.
Other:_________________________________________________________________
Provide details. If the child has Rx/treatment, please attach a complete Medication/Medical Treatment Plan form; and if the child was referred, please
note. _______________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
TB Assessment | Positive TST should be referred to Primary Care Physician for evaluation. For questions call T.B. Control at 202-698-4040.
What is the child’s risk level for TB?
High complete skin test
and/or Quantiferon test
Low
Negative Positive Positive, Treated
Additional notes on TB test:
Lead Exposure Risk Screening | All lead levels must be reported to DC Childhood Lead Poisoning Prevention. Call 202-654-6002 or fax 202-535-2607.
ONLY FOR CHILDREN
UNDER AGE 6 YEARS
Every child must have
2 lead tests by age 2
Normal
Abnormal,
Developmental Screening Date:
Stick Lead Level:
Normal
Abnormal,
Developmental Screening Date:
Stick Lead Level:
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