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
School/ Community Name
School Nurse/ Contact Person Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
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
Select Screening Date
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
Requested Grade Level
Separate with a Comma(,) e.g. PreK, K, 1, 2,4
Approximate Total Number of students
Comments or any specific request (i.e. Be there 15 minutes early)
Note:

After submitting the screening request form, you will receive a confirmation email containing a secure link to upload your student screening roster. The completed roster must be uploaded at least two weeks before the scheduled screening date.

Submitting the roster on time allows Healthy Learners to prepare effectively, coordinate with school personnel, and ensure timely follow-up services for students. Please check your email for the upload link and follow the instructions provided.

Please ensure that an appropriately sized room is available for the screening and that the room’s lighting can be dimmed. Having a school representative available to assist with student flow is also greatly appreciated and helps the screening process run smoothly.

All student roster uploads are completed through a secure, HIPAA-compliant process.
Signature

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: