FormsStaffEnrollment → Health Screenings

Health Screenings

Student Record Card 5 (SR-5)

About this Form

Form number: SR-5

Audience:  Students

Last revised: December 2019


This is a sample of the SR-5, Health Screenings card, and is for reference only.  Schools should complete a SR-5 card for each student on the yellow card stock version of this form ordered through the Department of Materials Management.  

Student Record Card 5 (SR-5) is used for recording health information concerning a student. 

Adobe PDF Health Screenings *
Student Record Card 5 (SR-5)
440 KEnglish

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat