Certificate of Scoliosis Screening

Form #4400

Required for students entering 6

and 8

grade

Form must be completed in its entirety and returned within 90 days of school start

Student name: ________________________________________________________________________

First Middle Last

Date of Birth: _ _ /_ _ /_ _ _ _ Gender: Male___ Female___ Grade: _____

Student Address: __________________________________________________________________

Street City

_________________________________________________________________

Zip code County State

Name of School: _______________________________________________________________________

Parent/Guardian Contact information:

Name: _______________________________________________________________________________

Phone number: ________________________________________________________________________

Email: _____________________________________@_________________________________________

Scoliosis Screening (Adams Forward Bend Test) Results:

Negative screen: _______

Needs further evaluation: ______

Referred to provider: ______

Screener’s Comments:

Screening completed by:

Physician Practice: _____ County Health Department: _____

Licensed School Nurse: _____

Screener Information:

Name: ___________________________ Office Address: ______________________________________

Signature: ______________________________________________________ Date: _ _ / _ _ / _ _ _ _

Parent/Guardian – Complete This Portion Only if Student Will Not Be Screened

Opt-out

_____I do not want my student to be screened for scoliosis at this time.

_____The student listed above is currently under professional care for scoliosis.

Parent/Guardian’s Signature: ___________________________________________Date: _ _ / _ _ / _ _ _

Georgia Department of Public Health

Form #4400

Certificate of Scoliosis Screening

What is scoliosis?

Scoliosis is an abnormal curvature of the spine. If detected early in a child’s life, it may be possible to treat the condition

and prevent it from becoming more serious.

Who is required to file this Form #4400?

The parent or guardian of a student entering the 6

grade shall furnish to school authority a properly executed DPH

Form #4400, Certificate of Scoliosis screening, as early as the first day of 5

and no later than 90 days after the student

begins 6

grade. The parent or guardian of a student entering the 8

grade shall furnish to school authority a properly

executed Form #4400, Certificate of Scoliosis screening, as early as the first day of 7

and no later than 90 days after the

student begins 8

grade.

These time periods were chosen because these are the years when rapid growth occurs, and scoliosis is most likely to

become observable.

What is the purpose of Form #4400?

Form #4400 is intended to ensure every child in Georgia public schools is screened for spinal deformities. The earlier

these problems are detected the earlier parents/guardians can seek professional help for their student.

What screenings are required?

The “Adams Forward Bend Test” is required, and the results must be documented on the Form #4400 before it is filed

with the school. The Adams Forward Bend test is a simple painless observation of the child’s back as he or she stands

and bends over.

Who can conduct the screenings?

The test can be conducted by a physician with an active GA license or person working under the supervision of a

physician with an active GA license, the local health department, and licensed school nurses.

What should a parent do if the “Needs further evaluation” box is checked?

If the “Needs further evaluation” box is checked, then the parent/guardian should take the student to a medical

provider for a more detailed evaluation. Your physician or local health department may be able to help or recommend

someone who can help.

What if a Form #4400 was previously filed for the child at another school?

Form #4400 should become part of the student’s permanent record. If a student transfers schools, the school where the

form was filed is required to forward Form #4400 to the new school.

What happens if Form #4400 is not completed for students in 6

and 8

grades?

Students without Form #4400 on file will be screened by school staff during a mass scoliosis screening event during the

school year.