About this Form
Form number: DHMH 4620
Audience: Parents/Guardians, School Staff
Last revised: May 2016
Reference Montgomery County Public Schools (MCPS) Regulation JPA-RB, Screening Programs: Lead, Hearing, and Vision.
Maryland Department of Health and Mental Hygiene Form 4620 Instructions: Use this form when enrolling a child in child care, pre-kindergarten, kindergarten or first grade. BOX A is to be completed by the parent or guardian. BOX B, also completed by parent/guardian, is for a child born before January 1, 2015 who does not need a lead test (children must meet all conditions in Box B). BOX C should be completed by the health care provider for any child born on or after January 1, 2015, and any child born before January 1, 2015 who does not meet all the conditions in Box B. BOX D is for children who are not tested due to religious objection (must be completed by health care provider).
Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat
* This form is not a fill-in form.