Annual CHDP Health Examination Report
This form is to be completed by the school nurse. Please count the total number of first grade students from your school and fill in the appropriate field. If you have any questions, please call the Child Health and Disability Prevention (CHDP) Health Promotion Program at (619) 692-8808.
School Name: *
Your answer
School Address:
Your answer
School District:
Your answer
School Year:
CHDP Health Examination data submitted is usually for the current school year
Your answer
Name of Person Completing Report:
Your answer
Phone Number:
Your answer
Email Address:
Your answer
Total number of students enrolled in first grade: *
Your answer
Total number of students who submitted documentation of completed health exam: *
Your answer
Total number of students who submitted waiver and checked 'Parent does not want': *
Your answer
Total number of students who submitted waiver and checked 'Parent unable to obtain exam' *
Your answer
Total number of students who submitted waiver but did not provide reason *
Your answer
Total number of students who did not submit documentation of completed health exam or waiver of health exam *
Students who did not respond/submit any forms
Your answer
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