!!!!!!!!!!!!!!!PORTLAND!PUBLIC!SCHOOLS!
Office:!File!in!Student!Cumulative!Record!and!Enter!into!Synergy!
PPS!Vision!and!Dental!Certification!02/2018!
Vision and Dental Screening Certification Form
Student Name: ________________________________ Date of Birth: _________________ Grade: ________
(Please print: Last Name, First Name)
Student ID: ____________
Oregon Law now requires a child who is 7 years of age or younger to have dental and vision screenings
before entering school for the first time. For information about vision requirements see 2013 Oregon HB3000
Section 1: (2)(a) through (3)(b) For information about dental requirements see 2015 Oregon HB2972 Section 1:
(2)(a) through (3)(c)
Parents/Guardians please complete and sign both Vision and Dental Screening Certifications.
VISION SCREENING CERTIFICATION (Please check the appropriate box)
My Child has received a vision screening.
Most recent screening or eye exam date: ___________ Was a follow-up recommended? (circle) Yes or No
Name of provider: _________________________________________________
I have previously submitted certification to the school office at _____________________________________
I am not providing certification of vision screening/exam due to my religious beliefs.
_____________________________________________ _______________________
Parent/Guardian Signature Date
DENTAL SCREENING CERTIFICATION (Please check the appropriate box)
My Child has received a dental screening within the last 12 months.
Most recent screening or dental exam date: ___________ Was a follow-up recommended? (circle) Yes or No
Name of provider: _________________________________________________
I have previously submitted certification to the school office at _____________________________________
I am not providing certification of vision screening/exam due to my religious beliefs.
The dental screening is a burden because:
(A) The cost of obtaining the dental screening is
too high;
(B) The student does not have access to a screener or;
(C) The student was unable to obtain an appointment with a screener
_____________________________________________
_______________________
Parent/Guardian Signature Date
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