Adopted: April 1994
Revised: December 2023
Download 501.3.2.1P - Child History Questionnaire
Click above link to download and review complete form -
Dear Parent/Guardian:
To help ensure success in school, the State of Minnesota requires all children entering public school be screened before entering kindergarten (or before entering first grade, if your child did not attend kindergarten). The law encourages parents/guardians to have their child screened prior to their fourth birthday. The screening may be done by District 196, another school district or by a public or private health care provider or organization. Your child need not be screened by District 196 if the child has received comparable screening by another provider or organization within the preceding year and those records are submitted to the District 196 not later than 30 days after your child first attends public school.
To make sure your child is screened, District 196 will mail your family a postcard letting you know it is time to schedule an appointment. All children residing in the district are welcome to come through screening even if they will attend a nonpublic school. There is no charge for Early Childhood Screening.
Early Childhood Screening is a careful review and check of your child’s health, well-being and development. Together parents and professionals identify strengths and areas that may require special attention before your child enters school. The screeners do not recommend whether your child is ready for kindergarten. At the end of the screening, a staff person will conduct a summary interview and address any concerns you have regarding your child’s health or development. You will have the opportunity to be with your child the entire time and you will receive a copy of the screening results. All information will remain private. The screening process takes approximately 60 minutes.
You have scheduled the following appointment for your child to attend the district's screening. Please call to reschedule if this time no longer works for you.
Day ________ Date________ Time________
Place - Independent School District 196 - District Service Center
14301 Diamond Path, Apple Valley, MN 55124
To cancel or change your appointment, contact the Early Childhood Screening Office at 651-423-7899. Please reschedule your appointment if your child has a communicable disease such as chicken pox, “pink-eye,” strep-throat, impetigo, etc.
We suggest that you do not bring other children with you to the screening appointment.
NOTE TO PARENTS: Please complete the remainder of this form and bring it with you to your child’s appointment. The information will help us provide your child with a comprehensive health and developmental screening. Completion of this form is optional. You may also decline to answer questions or provide information about family circumstances that might affect development and identification of risk factors that may influence learning. Declining to answer such questions or provide such information will not prevent your child from enrolling in school if all other screening components are met. The information collected on this form and in the screening will be used for screening purposes by District 196 employees and agents with responsibilities related to the screening program. It may also be shared with the Department of Education, or as otherwise authorized by law. You are not required to provide requested information, however your refusal may prevent the district from completing the mandatory screening. Early Childhood Screening is not a substitute for ongoing health care from your family physician, dentist or other health care providers.