About this Form
Form number: SR-5
Last revised: February 2017
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.
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* This form is not a fill-in form.