Screening Request Form

Screening Request Form

By completing this form, the organization grants permission for student health screenings and data collection, in compliance with HIPAA and related guidelines.
Select Program*

Midlands (Richland; Lexington; Newberry; Fairfield)Lowcountry (Allendale; Barnwell; Bamberg; Hampton)Pee Dee (Dillon; Marion; Marlboro; Georgetown; Williamsburg; Chesterfield; Darlington)Upstate (Greenwood; Laurens; Spartanburg; Abbeville)
School/ Community Name*
School Nurse/ Contact Person Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address*
Screening Roster Upload Link will be sent in this email address.
Screening Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred date & time to conduct screening*

MonthDayYear
Date
Hour MinutesAM/PM Option
Any other specific date and time, if the above selection is not suitable.*

MonthDayYear
Date
Hour MinutesAM/PM Option
Type of Screenings to Be Conducted*

VisionDentalHearing
Requested Grade Level*
Separate with a Comma(,) e.g. PreK, K, 1, 2,4
Comments or any specific request (i.e. Be there 15 minutes early)
Note:

After your screening request is confirmed, Healthy Learners prefers that your organization upload a student screening roster to help us prepare for and deliver effective services.

A secure, HIPAA-compliant upload link will be sent to you via email in response to this request. While submitting a roster is optional, it greatly supports our ability to follow up with school personnel and ensure timely services for students. Please check your email for the link and follow the instructions if you choose to upload a roster.
Signature*

Clear
By signing above, I confirm that the above-stated organization gives consent to Healthy Learners to conduct health screenings and collect relevant screening data for students, in accordance with HIPAA guidelines. This data will be used solely to support follow-up services for students who do not pass initial screenings.
Should be Empty:

Screening Request Form

Note: