CONSENT FORM FOR LEARNERS’ HEALTH
ASSESSMENT AND SCREENING
Date: _______________________
I.Data Privacy Notice other oral tissues to identify dental and other oral
health concerns.
The Department of Education (DepEd) shall engage Universal mental health and psychosocial
in the collection of health/medical information for the screening and assessment
purposes of tracking, provision of necessary In compliance with “Republic Act (RA) 11036 or the
health/medical interventions, and educational “Mental Health Act”, Universal mental health
purposes. This information shall be processed in screening refers to the systematic assessment of
accordance with the provisions of the Data Privacy learners based on their school performance,
Act and the Data Privacy Policies of the Department. behaviors, and social-emotional functioning.
Psychosocial screening aims to identify risk factors
This information shall be stored and held that may affect a learner’s mental health, emotions,
confidentially in accordance with the provisions of or interactions with other people. It is intended to
prevent the learner’s condition from worsening and
the Basic Education Act and may only be shared with
to provide immediate intervention if necessary. The
other government agencies or third parties subject to
purpose of screening is not to provide clinical
Data sharing agreements and data privacy diagnosis of mental disorders, but to identify at-risk
requirements for legitimate purposes only. learners and provide early intervention and support,
or referral for specialized help if needed.
For inquiries, requests and concerns regarding your Psychosocial assessment is a guided, semi-structured
data privacy rights, please contact the data privacy interview conducted by the School Counselors and/or
compliance officer, team of the school, schools other trained personnel on learners who will be
division office or regional office concerned. identified as “at-risk.”
III.Consent to Health Assessment and
By affixing my signature at the end of this document, Screening
I hereby consent and authorize the Department of (Full Name)
Education to use, collect, and process the information I,
for the purposes of the above stated. ______________________________________________________
_____, the parent/ parent
Full Name - substitute/ legal guardian
of Learner
II.Components of Learner Health Assessment of ________________________________________________,
Grade level Name of
School
and Screening (LHAS) ______ years old, Male/Female, __________ learner in
__________________________ have been properly and
Nutritional Assessment fully informed about the details of the learners’
Determining the height and weight of Kinder to health assessment and screening. I understand that
Grade 6 learners to get their nutritional status as participation is voluntary and choosing whether to
basis for inclusion to the School-Based Feeding participate or not will have no effect on the grade,
Program (SBFP). treatment, or care of my child/ward. I am aware that
non-participation may lead to my child/ward being
Health history intake and general head-to-toe
unable to join certain programs and services that
assessment
require the information collected in the procedures
Recording of past medical history (allergies, ongoing listed above.
medical conditions, past surgeries/hospitalization),
family medical history, smoking/vaping history, By affixing my signature below, I hereby state that:
handedness, immunization status, and other relevant
Please mark the space with a (✓) and place your signature at the end of this
information. document.
General head-to-toe assessment is a thorough I CONSENT for my
child/ward to undergo
I DO NOT CONSENT for
my child/ward to
overall examination performed by health personnel the following undergo the following
assessments/screening: assessments/screening:
to detect signs and symptoms of illness, physical or
behavioral defects or abnormality, monitor hygiene Nutritional Assessment
practices, and provide health education. Health history intake and general
head-to-toe assessment
Vision screening
Vision screening
A non-diagnostic procedure aimed at early detection
Hearing screening
and management of vision problems among learners. Oral health assessment
This may be done by teachers (for Kindergarten Universal mental health and
learners and non-readers) and non-teaching psychosocial screening and
assessment
personnel (for Grades 1 and 7) who have received
appropriate training, school health personnel, or local
partners.
Hearing screening
A non-diagnostic procedure intended to identify
Signature above Printed Name Date
learners who may require further evaluation and (Parent/parent-substitute/legal guardian)
management by appropriate healthcare
professionals. LEARNER’S ASSENT FORM FOR HEALTH ASSESSMENT AND
Oral health assessment SCREENING
Evaluation of the oral cavity, conducted by licensed
I have been informed of the details of the Learner Health
dentists, including inspection of the teeth, gums, and Assessment and Screening and that my parent/parent-
substitute/guardian has given permission for me to
participate. My participation is voluntary and I have been
told that I may stop my participation at any time. I
understand that If I choose to participate or not, will not
affect my grade, treatment, or care in any way, except in Signature above Printed Name Date
activities that require the information collected in the (Learner)
procedures listed above.
