TS puauc scuooLs oF NORTH CAROLINA a ‘State Board of Education | Deperiment of Pubic Instruction | NORTH CAROLINA HEALTH ASSESSMENT TRANSMITTAL FORM “This frm andthe ifermation on thi form wl be manaied on fle the chon attended by the siden raed herein ‘hd confer apd nota pub aco sproved by Nort Caretna Degartmart of Pu nsructen ard Department of Heath and Human Sarvs) PARENT to COMPLETE THIS SECTION SudentName NERALLA ANISH ey —(las) et ___ (Mate) aes S Birthdate verve. School Nome: (2/24) 2015 __ Jones DARY ELEMENTARY _Scricol Mepmicoatno Orgs 1Yer ave [Rew C4 Sense” Ginn ona «(Bam fan a Home Address: ‘chy: - ras "Countye 4220 Fawn LLY DR, WAKE FoRESsT, No, WAKE a said - rent information: Name of Parent, Guardian or person aig in Telephones) Toco parents woe BBG SAB ETH Work: qiq- B65 — BECO IO! cite BSS-SB1- F544 SUPHEER NeERALA ANNAPORNA NERALLA Health Concerns to be shared with authorized persons (schoo! Information to perferm their asigned duties): None iu HEALTH CARE PROVIDER TO COMPLETE THIS SECTION Tor student: ‘Student alersles ype, and response required ‘Health rfatad recommendations to eniance the student's shoal performance! ‘Vision screening information: awed von screening: Yes No Concer rete 0 Sus SE Page tot? NOae PUBLIC SCHOOLS OF NORTH CAROLINA Sanaa 2016 FAP? sae sont usin |Oeprnettebo heron Hearing screening information: Passed hearing screening: 1 Yes No ‘Cneers elt to sents erg Recommendations, concerns or need related to students heath and required schoo! follow-op Schoo follow-up neaded: (Yes ON Wedical Provider Commenter lease attach other appileable school health forma: lanai record atch o ‘Scho medissenauthorztan fom aszenes: Dabetes care pln tached g ‘Aste acto pan attach eal care plans or cher eondtions aces: carsy Wat {prereset SDE re above, 2 Neath ascsoner In acrdance wth GS 30h-+40(8) tht Ince a matical ior and physeal examination wth soeorng fer vison and Rearing, ard approarite, eng franc and tuberculss. Tear that he nermaton on is form's accurate ard came to th best of my knowlege. tame: es: Sete se Date (vr Praca hae Peele Ress Pracca/Gre Or sae sz rane Fa Provider tame Were: Page 202