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Blank Har 3 Connecticut Form

The HAR-3 Connecticut form is a crucial document used by schools to gather essential health information about students. This form is designed to help school personnel understand each child's health needs, ensuring that they receive the appropriate care and support during their educational journey. Parents or guardians are required to complete this form, which includes sections for health history and medical evaluations, before their child can enter school in Connecticut.

Outline

The HAR 3 Connecticut form is an essential document designed to ensure that school personnel are well-informed about a child's health needs. This form is divided into two parts. Part I is completed by the parent or guardian, gathering vital information about the child's medical history, including any allergies, medications, and previous health concerns. It also asks about family health history, which can be crucial for understanding potential risks. Part II is filled out by a qualified healthcare provider after a physical examination. This section includes a detailed medical evaluation, covering vital signs, growth measurements, and mandated screenings. State law mandates that children must have up-to-date immunizations and a comprehensive health assessment before entering school. Additionally, the HAR 3 form is required for students participating in sports, ensuring that their health is monitored throughout their school years. Overall, this form plays a pivotal role in promoting the well-being of students and facilitating communication between families and schools.

Sample - Har 3 Connecticut Form

State of Connecticut Department of Education

Health Assessment Record

To Parent or Guardian:

In order to provide the best educational experience, school personnel must understand your child’s health needs. This form requests information from you (Part I) which will also be helpful to the health care provider when he or she completes the medical evaluation (Part II).

State law requires complete primary immunizations and a health assessment by a legally qualiied practitioner of medicine, an advanced

practice registered nurse or registered nurse, a physician assistant or the school medical advisor prior to school entrance in Connecticut (C.G.S.

Secs. 10-204a and 10-206). An immunization update and additional health assessments are required in the 6th or 7th grade and in the 9th or 10th grade. Speciic grade level will be determined by the local board of education. This form may also be used for health assessments required

every year for students participating on sports teams.

Please print

Student Name (Last, First, Middle)	Birth Date		❑ Male ❑ Female

Address (Street, Town and ZIP code)

Parent/Guardian Name (Last, First, Middle)	Home Phone		Cell Phone

School/Grade	Race/Ethnicity	❑ Black, not of Hispanic origin
	❑ American Indian/	❑ White, not of Hispanic origin
	Alaskan Native	❑ Asian/Paciic Islander
Primary Care Provider	Alaskan Native	❑ Asian/Paciic Islander
	❑ Hispanic/Latino	❑ Other

Health Insurance Company/Number* or Medicaid/Number*

Does your child have health insurance?	Y	N	If your child does not have health insurance, call 1-877-CT-HUSKY
Does your child have dental insurance?	Y	N
Does your child have dental insurance?	Y	N

* If applicable

Part I — To be completed by parent/guardian.

Please answer these health history questions about your child before the physical examination.

Please circle Y if “yes” or N if “no.” Explain all “yes” answers in the space provided below.

Any health concerns	Y	N	Hospitalization or Emergency Room visit Y		N	Concussion	Y	N
Allergies to food or bee stings	Y	N	Any broken bones or dislocations	Y	N	Fainting or blacking out	Y	N
Allergies to medication	Y	N	Any muscle or joint injuries	Y	N	Chest pain	Y	N
Any other allergies	Y	N	Any neck or back injuries	Y	N	Heart problems	Y	N
Any daily medications	Y	N	Problems running	Y	N	High blood pressure	Y	N
Any problems with vision	Y	N	“Mono” (past 1 year)	Y	N	Bleeding more than expected	Y	N
Uses contacts or glasses	Y	N	Has only 1 kidney or testicle	Y	N	Problems breathing or coughing	Y	N

Any problems hearing	Y	N	Excessive weight gain/loss	Y	N	Any smoking	Y	N
Any problems with speech	Y	N	Dental braces, caps, or bridges	Y	N	Asthma treatment (past 3 years)	Y	N

Family History						Seizure treatment (past 2 years)	Y	N
Any relative ever have a sudden unexplained death (less than 50 years old)				Y	N	Diabetes	Y	N

Any immediate family members have high cholesterol				Y	N	ADHD/ADD	Y	N

Please explain all “yes” answers here. For illnesses/injuries/etc., include the year and/or your child’s age at the time.

Is there anything you want to discuss with the school nurse? Y N If yes, explain:

Please list any medications your child will need to take in school:

All medications taken in school require a separate Medication Authorization Form signed by a health care provider and parent/guardian.

I give permission for release and exchange of information on this form between the school nurse and health care provider for conidential


use in meeting my child’s health and educational needs in school. Signature of Parent/Guardian		Date

HAR-3 REV. 4/2011	TO BE MAINTAINED IN THE STUDENT’S CUMULATIVE SCHOOL HEALTH RECORD

Part II — Medical Evaluation

HAR-3 REV. 4/2011

Health Care Provider must complete and sign the medical evaluation and physical examination

Student Name

Birth Date

Date of Exam

❑I have reviewed the health history information provided in Part I of this form

Physical Exam

Note: *Mandated Screening/Test to be completed by provider under Connecticut State Law

*Height _____ in. / _____% *Weight _____ lbs. / _____%

BMI _____ / _____% Pulse _____

*Blood Pressure _____ / _____

Normal

Describe Abnormal

Ortho

Normal

Describe Abnormal

Neurologic

Neck

HEENT

Shoulders

*Gross Dental

Arms/Hands

Lymphatic

Hips

Heart

Knees

Lungs

Feet/Ankles

Abdomen

*Postural

❑ No spinal

❑ Spine abnormality:

Genitalia/ hernia

abnormality

❑ Mild

❑ Moderate

❑ Marked ❑ Referral made

Skin

Screenings

*Vision Screening

*Auditory Screening

Date

Type:

Right

Left

Type:

Right

Left

Lead:

❑ Pass

With glasses

20/

*HCT/HGB:

❑ Fail

Without glasses

20/

*Speech (school entry only)

❑ Referral made

Other:

TB: High-risk group?

❑ No

❑ Yes

PPD date read:

Results:

Treatment:

*IMMUNIZATIONS

❑Up to Date or ❑ Catch-up Schedule: MUST HAVE IMMUNIZATION RECORD ATTACHED

*Chronic Disease Assessment:

Asthma	❑ No	❑ Yes:	❑ Intermittent ❑ Mild Persistent ❑ Moderate Persistent ❑ Severe Persistent ❑ Exercise induced
	If yes, please provide a copy of the Asthma Action Plan to School
Anaphylaxis ❑ No		❑ Yes:	❑ Food	❑ Insects	❑ Latex	❑ Unknown source
Allergies	If yes, please provide a copy of the Emergency Allergy Plan to School
	History of Anaphylaxis			❑ No	❑ Yes	Epi Pen required ❑ No	❑ Yes
Diabetes	❑ No	❑ Yes:	❑ Type I	❑ Type II		Other Chronic Disease:
Seizures	❑ No	❑ Yes, type:

❑This student has a developmental, emotional, behavioral or psychiatric condition that may affect his or her educational experience. Explain: ____________________________________________________________________________________________________

Daily Medications (specify): ____________________________________________________________________________________

This student may: ❑ participate fully in the school program

❑participate in the school program with the following restriction/adaptation: _____________________________

___________________________________________________________________________________________________________

This student may: ❑ participate fully in athletic activities and competitive sports

❑participate in athletic activities and competitive sports with the following restriction/adaptation: ____________

___________________________________________________________________________________________________________

❑Yes ❑ No Based on this comprehensive health history and physical examination, this student has maintained his/her level of wellness.

Is this the student’s medical home? ❑ Yes ❑ No ❑ I would like to discuss information in this report with the school nurse.


Signature of health care provider MD / DO / APRN / PA	Date Signed	Printed/Stamped Provider Name and Phone Number

Student Name: ______________________________________ Birth Date: ___________________

Immunization Record

To the Health Care Provider: Please complete and initial below.

HAR-3 REV. 4/2011

Vaccine (Month/Day/Year) Note: *Minimum requirements prior to school enrollment. At subsequent exams, note booster shots only.

Dose 1

Dose 2

Dose 3

Dose 4

Dose 5

Dose 6

DTP/DTaP

DT/Td

Tdap

Required for 7th grade entry

IPV/OPV

MMR

Required K-12th grade

Measles

Required K-12th grade

Mumps

Required K-12th grade

Rubella

Required K-12th grade

HIB

PK and K (Students under age 5)

Hep A

PK and K (born 1/1/2007 or later)

Hep B

Required PK-12th grade

Varicella

2 doses required for K & 7th grade as of 8/1/2011

PCV

PK and K (born 1/1/2007 or later)

Meningococcal

Required for 7th grade entry

HPV

Flu

PK students 24-59 months old – given annually

Other

Disease Hx ________________________________

________________________________

of above

(Specify)

(Date)

(Conirmed by)

Exemption

Religious _____ Medical: Permanent _____

Temporary _____ Date _____

Recertify Date _________

Recertify Date _________ Recertify Date ________

Immunization Requirements for Newly Enrolled Students at Connecticut Schools

KINDERGARTEN

•DTaP: At least 4 doses. The last dose must be given on or after 4th birthday.

•Polio: At least 3 doses. The last dose must be given on or after 4th birthday.

•MMR: 2 doses given at least 28 day apart – 1st dose on or after the 1st birthday.

•Hib: 1 dose on or after 1st birthday (Children 5 years and older do not need proof of Hib vaccination).

•Pneumococcal: 1 dose on or after 1st birthday (born 1/1/2007 or later and less than 5 years old).

•Hep A: 2 doses given six months apart-1st dose on or after 1st birthday.

•Hep B: 3 doses-the last dose on or after 24 weeks of age.

•Varicella: For students enrolled before August 1, 2011, 1 dose given on or after 1st birthday; for students enrolled on or after August 1, 2011

2 doses given 3 months apart – 1st dose on or after 1st birthday or veriication of disease*.

GRADES 1-6

•DTaP /Td/Tdap: At least 4 doses. The last dose must be given on or after 4th birthday;

students who start the series at age 7 or older only need a total of 3 doses of tetanus-diphtheria containing vaccine.

•Polio: At least 3 doses. The last dose must be given on or after 4th birthday.

•MMR: 2 doses given at least 28 days apart- 1st dose on or after the 1st birthday.

•Hep B: 3 doses – the last dose on or after 24 weeks of age.

•Varicella: 1 dose on or after the 1st birthday or veriication of disease*.

GRADE 7

•Tdap/Td: 1 dose of Tdap for students 11 yrs. or older enrolled in 7th grade who completed their primary DTaP series; For those students who start the series at age 7 or older a total of 3 doses of tetanus-diphtheria containing vac- cines are needed, one of which must be Tdap.

•Polio: At least 3 doses. The last dose must be given on or after 4th birthday.

•MMR: 2 doses given at least 28 days apart – 1st dose on or after the 1st birthday.

•Meningococcal: one dose for students enrolled in 7th grade.

•Hep B: 3 doses-the last dose on or after 24 weeks of age.

•Varicella: 2 doses given 3 months apart – 1st dose on or after 1st birthday or veriication of

disease*.

GRADES 8-12

•Td: At least 3 doses. Students who start the series at age 7 or older only need a total of 3 doses of tetanus-diphtheria containing vaccine one of which should be Tdap.

•Polio: At least 3 doses. The last dose must be given on or after 4th birthday.

•MMR: 2 doses given at least 28 days apart- 1st dose on or after the 1st birthday.

•Hep B: 3 doses-the last dose on or after 24 weeks of age.

•Varicella: For students <13 years of age, 1 dose given on or after the 1st birthday. For

students 13 years of age or older, 2 doses given at least 4 weeks apart or veriication of

disease*.

*Veriicationofdisease:Conirmation in writ- ing by a MD, PA, or APRN that the child has a previous history of disease, based on family or medical history.


Initial/Signature of health care provider MD / DO / APRN / PA	Date Signed	Printed/Stamped Provider Name and Phone Number

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Form Information

Fact Name	Fact Description
Governing Laws	The HAR 3 form is governed by Connecticut General Statutes Sections 10-204a and 10-206.
Purpose	This form collects health information from parents or guardians to assist school personnel in understanding a child's health needs.
Immunization Requirements	State law mandates complete primary immunizations before school entrance in Connecticut.
Health Assessment	A health assessment by a qualified medical practitioner is required prior to school entry.
Grade-Specific Assessments	Additional health assessments are required for students in 6th or 7th grade and 9th or 10th grade.
Sports Participation	This form can also be used for annual health assessments for students participating in sports.
Completion Requirement	Part I must be completed by the parent or guardian before the physical examination.
Confidentiality	Parents give permission for the exchange of information between the school nurse and the healthcare provider.

Detailed Guide for Filling Out Har 3 Connecticut

Completing the HAR-3 form is an important step in ensuring your child’s health needs are understood by school personnel. This form collects essential health information that will be used by both the school and healthcare provider. Follow these steps carefully to fill out the form accurately.

Begin by printing your child's full name in the designated area (Last, First, Middle).
Fill in your child's birth date.
Select your child's gender by checking the appropriate box: Male or Female.
Provide your child's home address, including street, town, and ZIP code.
Enter your name as the parent or guardian (Last, First, Middle).
List your home phone number and cell phone number.
Indicate your child's school and grade.
Select your child's race/ethnicity by checking the appropriate box.
Provide the name of your child's primary care provider.
Indicate whether your child has health insurance by checking Yes or No.
If applicable, provide the health insurance company name and number or Medicaid number.
Answer whether your child has dental insurance by checking Yes or No.
In Part I, answer the health history questions by circling Yes (Y) or No (N). Provide explanations for any "yes" answers in the space provided.
List any medications your child will need to take in school. Remember that a separate Medication Authorization Form is required for medications taken at school.
Sign and date the form to give permission for the release and exchange of information between the school nurse and healthcare provider.
Ensure that Part II is completed by the healthcare provider during the medical evaluation and physical examination.
Make sure the healthcare provider completes the immunization record section, attaching any necessary documents.

After filling out the HAR-3 form, submit it to the school along with any required immunization records. This will help ensure that your child is prepared for a successful school experience.

Obtain Answers on Har 3 Connecticut

What is the purpose of the HAR 3 Connecticut form?
The HAR 3 form, officially known as the Health Assessment Record, is designed to gather important health information about students entering school in Connecticut. This form serves two main purposes: it helps school personnel understand a child's health needs and provides essential information to healthcare providers during medical evaluations. By collecting this information, schools can ensure that they meet each child's unique health requirements, which is crucial for creating a safe and supportive educational environment.
Who is required to complete the HAR 3 form?
Both parents and guardians are responsible for completing Part I of the HAR 3 form. This section requires them to provide detailed health history information about their child. Additionally, a legally qualified healthcare provider, such as a physician, advanced practice registered nurse, or physician assistant, must complete Part II, which includes a medical evaluation and physical examination. This two-part process ensures that both the family and medical professionals contribute to the child's health record.
What are the immunization requirements outlined in the HAR 3 form?
The HAR 3 form outlines specific immunization requirements that must be met before a child can enter school in Connecticut. These requirements vary by grade level. For example, kindergarten students must have a minimum of four doses of DTaP, three doses of polio, and two doses of MMR, among others. As students progress to higher grades, additional vaccinations, such as the meningococcal vaccine for seventh graders, are required. It is essential for parents to ensure that their child's immunizations are up to date to comply with state laws.
What should parents do if their child does not have health insurance?
If a child does not have health insurance, parents can contact 1-877-CT-HUSKY for assistance. The state of Connecticut provides options for families to obtain health coverage for their children. It is important for parents to explore these resources to ensure their child has access to necessary medical care, which is vital for their overall health and well-being.
How often must the HAR 3 form be updated?
The HAR 3 form must be updated periodically to reflect the child's health status accurately. Specifically, it is required to be completed before a child enters school and again during the sixth or seventh grade, as well as in the ninth or tenth grade. Additionally, for students participating in sports teams, annual health assessments are necessary. Keeping this form updated helps schools monitor and address any health issues that may arise throughout the child's educational journey.

Common mistakes

Filling out the HAR 3 Connecticut form can seem straightforward, but many people make common mistakes that can lead to delays or issues with their child's school health records. One frequent error is failing to provide complete and accurate information about the child’s health history. Parents often overlook important health concerns or recent medical events, such as hospital visits or allergies. This information is crucial for the school nurse and health care provider to ensure the child’s well-being at school.

Another mistake is not properly answering the health history questions. Parents may circle “Y” for “yes” or “N” for “no” without thoroughly considering each question. For example, if a child has had a concussion or any significant health issue, it’s vital to circle “Y” and provide an explanation. Omitting details can lead to misunderstandings about the child’s health needs.

Some parents forget to include emergency contact information or fail to update it when it changes. This information is essential for school personnel to reach someone quickly in case of an emergency. If the contact numbers are incorrect or outdated, it can cause unnecessary stress during urgent situations.

Additionally, parents sometimes neglect to sign and date the form. A signature is not just a formality; it confirms that the information provided is accurate and complete. Without a signature, the form may not be accepted by the school.

Lastly, many parents overlook the immunization section. They might not attach the required immunization record or fail to check if the child’s vaccinations are up to date. This can lead to complications with school enrollment and participation in sports. Ensuring that this section is complete and accurate is vital for compliance with state law.

Documents used along the form

The HAR 3 Connecticut form is an essential document used to gather important health information about students before they enter school. Along with this form, several other documents may be required to ensure a comprehensive understanding of a child's health needs. Below is a list of related forms and documents that are often used in conjunction with the HAR 3.

Immunization Record: This document provides a detailed account of the vaccinations a child has received. It is crucial for verifying that a student meets the state’s immunization requirements before attending school.
Medication Authorization Form: Required for students who need to take medication during school hours, this form must be signed by both a parent or guardian and a healthcare provider. It ensures that school staff can administer the necessary medications safely.
Emergency Contact Form: This form lists individuals who can be contacted in case of an emergency. It is vital for schools to have up-to-date information about who to reach if a child requires immediate assistance.
Physical Examination Form: Often required for sports participation, this document confirms that a child has undergone a recent physical examination and is fit to participate in athletic activities.
Dental Health Form: Some schools request this form to ensure that a child has received necessary dental care. It may include information about dental check-ups and any treatments received.
Health History Questionnaire: This document gathers information about a child’s past medical history, including any chronic conditions or allergies. It helps school nurses provide appropriate care.
Vision and Hearing Screening Form: Schools may require this form to document the results of vision and hearing tests. Early detection of issues in these areas is crucial for a child’s learning experience.
Sports Physical Examination Form: Specifically for students participating in sports, this form verifies that a child has been cleared by a healthcare provider to engage in physical activities.
Special Education Needs Assessment: For children who may require additional support, this assessment outlines any special education needs and accommodations that may be necessary for the student’s success.
Emergency Allergy Plan: If a child has known allergies, this plan details how to manage allergic reactions and includes information about medications like EpiPens.

These documents work together to create a comprehensive health profile for students, ensuring that their health needs are met while they are in school. It is important for parents and guardians to keep these forms updated and readily available to support their child's educational journey.

Similar forms

Health History Questionnaire: Similar to the Har 3 form, this document collects comprehensive health information from parents or guardians about their child's medical history and any ongoing health concerns.
Immunization Record: Like the Har 3 form, this document tracks the immunizations a child has received, ensuring compliance with state vaccination requirements for school attendance.
Physical Examination Report: This report is comparable to Part II of the Har 3 form, as it requires a licensed healthcare provider to conduct a physical exam and document findings, including any necessary screenings.
Medication Authorization Form: This form is related to the Har 3 form as it requires parental consent for any medications a child needs to take during school hours, ensuring proper management of health needs.
Emergency Contact Form: Similar in purpose, this document gathers essential contact information for parents or guardians in case of medical emergencies, ensuring quick access to support.
Sports Physical Form: This form parallels the Har 3 in that it assesses a child's physical ability to participate in sports, requiring a healthcare provider's evaluation and approval.
Health Insurance Information Form: Just like the Har 3 form, this document collects information about a child's health insurance coverage, which can be critical for medical care access.
Dental Health Assessment: Similar to the Har 3 form, this assessment collects information about a child's dental health history and current status, often required before school entry.
Special Education Health Assessment: This document is akin to the Har 3 form, as it gathers health-related information to support students with special educational needs, ensuring appropriate accommodations.

Dos and Don'ts

When filling out the HAR 3 Connecticut form, there are several important dos and don'ts to keep in mind. Following these guidelines can help ensure that your child's health information is accurately reported and processed.

Do provide complete and accurate information about your child's health history.
Do ensure that all required immunization records are attached.
Do answer all health history questions honestly, especially those regarding serious conditions.
Do include contact information for your child's primary care provider.
Do sign and date the form to authorize the release of health information.

Don't leave any sections blank, as this may delay processing.
Don't omit any medications your child takes, even if they seem minor.
Don't provide outdated immunization records; ensure they are current.
Don't forget to explain any "yes" answers in the designated area.
Don't ignore instructions regarding the completion of the medical evaluation by a healthcare provider.

Misconceptions

Misconception 1: The HAR-3 form is optional for school enrollment.

This is not true. The HAR-3 form is required by Connecticut state law for students entering school. It ensures that school personnel understand a child’s health needs.

Misconception 2: Only new students need to complete the HAR-3 form.

In fact, returning students may also need to submit updated health assessments, especially when they reach certain grades, such as 6th or 9th grade.

Misconception 3: Parents do not need to provide any information about their child’s health history.

This is incorrect. Parents must fill out Part I of the HAR-3 form, which includes crucial health history questions that help guide the medical evaluation.

Misconception 4: The HAR-3 form is only for physical health assessments.

The form also addresses mental health and developmental concerns, ensuring a comprehensive view of a child's well-being.

Misconception 5: Immunization records are not necessary if the child has health insurance.

This is misleading. Regardless of insurance status, parents must provide immunization records to demonstrate compliance with state requirements.

Misconception 6: The HAR-3 form can be filled out by anyone.

Only a legally qualified health care provider can complete and sign Part II of the form, which includes the medical evaluation.

Misconception 7: Completing the HAR-3 form is a quick process that requires no preparation.

On the contrary, parents should gather relevant health information and records beforehand to ensure accuracy and completeness when filling out the form.

Misconception 8: The HAR-3 form is only relevant for physical education or sports participation.

This is not accurate. The HAR-3 form is essential for overall school health and is required for all students, not just those involved in athletics.

Key takeaways

The HAR 3 form is essential for understanding your child's health needs before they start school in Connecticut.
Part I of the form must be filled out by a parent or guardian, providing crucial health history information.
State law mandates that children have complete immunizations and a health assessment before entering school.
Health assessments are also required for students entering 6th or 7th grade and 9th or 10th grade.
This form can be used for health assessments needed for students participating in sports.
Parents should explain any "yes" answers in detail to ensure the school understands their child's health concerns.
It’s important to list any medications your child needs to take during school hours, as a separate authorization form is required.
The health care provider must complete Part II of the form, which includes a physical examination and medical evaluation.
Always attach an immunization record to the HAR 3 form, as it's a requirement for school enrollment.