SCHOOL HEALTH PROGRAM

SCREENING REPORT

District_____________ Tehsil ______________ U.C.______________ BHU______________

School.__________________________________Total Teachers_________Trained Teachers_______

Screening of students was performed on ___________________.

SCREENING SUMMARY

Total No. of No. with No. with No. with No. with No. with No. with No. with Total
Students students Eye Vision Ear Hearing Dental Skin any referral
screened problems problems problems problems Problems problems other slips
problems issued

FEED BACK REPORT AFTER TREATMENT

No. of Eye No. of No. of Ear No. of No. of No. of Skin No. of any Total
Problems Vision problems Hearing Dental problems other students
treated problems treated problems Problems treated problems treated
treated treated treated treated

Name of Head Teacher _______________ Signature___________________ Date ________

Name of SH & NS____________________ Signature___________________ Date ________

Note:

1. SH & NS will prepare each report after screening process.

2. Feed back screening report will be prepared by SH & NS after one month on visit to the school
again.
3. SH & NS will submit screening report after completion along with the comments and
signatures of MO, BHU, to the Program Director DHDC.

Punjab Health Sectors Reforms Program