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Fill Your Har 3 Connecticut Form

The HAR 3 Connecticut form is a Health Assessment Record required by the State of Connecticut Department of Education. This form gathers essential health information from parents or guardians to ensure that school personnel can address their child's health needs effectively. Completing this form is crucial for compliance with state law before your child enters school, and it also aids in ongoing health assessments throughout their education.

To ensure your child’s health needs are met, please fill out the HAR 3 form by clicking the button below.

Prepare Har 3 Connecticut Here

Prepare Har 3 Connecticut Here

Article Structure

The HAR 3 Connecticut form is a crucial document designed to ensure that students receive the necessary health assessments before entering school. This form is divided into two parts: the first part must be completed by a parent or guardian, while the second part requires a licensed health care provider's evaluation. Parents are asked to provide essential information regarding their child's health history, including any allergies, previous hospitalizations, and current medications. This information is vital for school personnel to understand each child's unique health needs and to facilitate effective communication with health care providers. Connecticut state law mandates that children must have a complete health assessment and up-to-date immunizations before starting school. Additionally, updates are required for students entering the 6th or 7th grade and again for those in the 9th or 10th grade. The HAR 3 form also serves as a health assessment for students participating in sports, highlighting its versatility and importance in maintaining student wellness. Accurate completion of this form is essential for ensuring that children are healthy and ready to learn.

Documents used along the form

The HAR 3 Connecticut form is essential for documenting a student's health assessment and immunization records before school entry. Several other forms and documents complement the HAR 3, ensuring that schools have a comprehensive understanding of a student's health needs. Below is a list of commonly used forms that may accompany the HAR 3.

Medication Authorization Form: This form allows parents or guardians to authorize school personnel to administer specific medications to their child during school hours. It requires signatures from both a healthcare provider and a parent or guardian.
Power of Attorney Form: To navigate legal decisions on behalf of others, consider the Colorado Power of Attorney document guide for detailed instructions and requirements.
Emergency Contact Form: This document provides the school with vital information about who to contact in case of an emergency. It typically includes names, phone numbers, and relationships of individuals authorized to pick up the child.
Physical Examination Form: Often required for sports participation, this form documents a student's physical fitness and any medical concerns identified during a physical exam by a healthcare provider.
Immunization Record: This record details all vaccinations a student has received, including dates and types of vaccines. It is crucial for ensuring compliance with school immunization requirements.
Health History Form: This form collects detailed information about a child's past medical history, including allergies, chronic conditions, and any significant illnesses. It helps healthcare providers understand the student's health background.
Sports Physical Form: Required for students participating in school sports, this form confirms that a student has been evaluated by a healthcare provider and is cleared to participate in athletic activities.
Special Health Care Needs Form: This document outlines any specific health care needs or accommodations a student may require at school. It helps ensure that the school can provide appropriate support.
Dental Health Assessment Form: This form is often required to assess a student's dental health status. It provides information on dental visits and any ongoing dental issues that may affect the child's overall health.
Consent for Release of Information Form: This form allows parents to authorize the sharing of their child's health information between the school and healthcare providers. It is essential for coordinated care.

These forms work together to create a comprehensive health profile for each student, ensuring that schools can effectively meet their health and educational needs. Proper documentation is vital for the safety and well-being of students as they navigate their educational journey.

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Preview - 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

Common Questions

What is the HAR 3 form and why is it important?

The HAR 3 form, or Health Assessment Record, is a document required by the State of Connecticut for students entering school. It gathers essential health information from parents or guardians, which is crucial for understanding a child's health needs. This information helps school personnel and healthcare providers ensure that students receive appropriate care and support throughout their educational experience.

Who needs to fill out the HAR 3 form?

The HAR 3 form must be completed by the parent or guardian of the student. It requires personal and health history information about the child, including details about immunizations and any medical conditions. Additionally, this form is necessary for students entering kindergarten, as well as those in 6th or 7th grade, and 9th or 10th grade, or those participating in school sports.

What information is required in Part I of the HAR 3 form?

Part I of the HAR 3 form asks for various health history questions about the child. Parents or guardians must indicate whether the child has experienced certain health issues, such as allergies, hospitalizations, or chronic conditions. This section also includes a space for parents to explain any "yes" answers, providing further context for the healthcare provider during the medical evaluation.

What happens in Part II of the HAR 3 form?

Part II of the HAR 3 form is completed by a healthcare provider. This section includes a physical examination and a review of the health history provided in Part I. The healthcare provider will assess the child's overall health, document any findings, and ensure that all required immunizations are up to date. This part must be signed by the provider to validate the medical evaluation.

What are the immunization requirements associated with the HAR 3 form?

Immunization requirements vary by grade level and are outlined in the HAR 3 form. For example, kindergarten students need several vaccinations, including DTaP, MMR, and polio, among others. Students in 7th grade have additional requirements, such as a Tdap booster and a meningococcal vaccine. Parents should ensure that the child's immunization record is attached to the HAR 3 form to meet state regulations before school enrollment.

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Guide to Filling Out Har 3 Connecticut

Filling out the HAR 3 Connecticut form is an important step in ensuring your child’s health needs are properly documented for their educational experience. This form consists of two parts: one for the parent or guardian to complete and another for the healthcare provider. Follow these steps carefully to ensure all necessary information is accurately recorded.

Print the student’s full name (Last, First, Middle) in the designated space.
Enter the student’s birth date.
Select the student’s gender by checking the appropriate box (Male or Female).
Fill in the address, including street, town, and ZIP code.
Provide the parent or guardian’s full name (Last, First, Middle).
List the home phone and cell phone numbers.
Indicate the school and grade the student is in.
Select the student’s race/ethnicity from the options provided.
Enter the primary care provider’s name.
Fill in the health insurance company and number or Medicaid number, if applicable.
Answer whether your child has health insurance by checking Yes or No.
Answer whether your child has dental insurance by checking Yes or No.
Answer the health history questions by circling Y for yes or N for no.
For any “yes” answers, provide explanations in the space provided.
Indicate if there are any health concerns to discuss with the school nurse.
List any medications your child will need to take in school.
Sign and date the form at the bottom of Part I.

Once Part I is completed, it will be necessary for a healthcare provider to fill out Part II. This section includes the medical evaluation and physical examination details. Ensure that the provider signs and dates this part, and provides any required immunization records. After both parts are completed, submit the form to the school.

Dos and Don'ts

When filling out the HAR 3 Connecticut form, it's essential to follow certain guidelines to ensure accuracy and compliance. Here are four things you should and shouldn't do:

Do: Provide complete and accurate information about your child's health history.
Do: Answer all health history questions honestly, marking "yes" or "no" as appropriate.
Do: Include any medications your child will need to take during school hours.
Do: Sign and date the form to authorize the release of information between the school nurse and health care provider.

Don't: Leave any sections blank; incomplete forms may delay processing.
Don't: Provide false information; this can lead to serious consequences for your child’s health care.
Don't: Forget to attach the immunization record, as it is mandatory for school enrollment.
Don't: Ignore the instructions regarding the completion of the medical evaluation by a health care provider.