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501.3.2P - Parental Consent Early Childhood Health and Developmental Screening (ECS)

501.3.2P - Parental Consent Early Childhood Health and Developmental Screening (ECS)

Adopted: April 1994
Revised: November 2023

Download 501.3.2p - Parental Consent - Early Childhood Health and Developmental Screening (ECS)

1.  Description of Program

     1.1  Required Early Childhood Screening (ECS) components are:

1.1.1   Immunization assessment;

1.1.2 Developmental screening to assess development of cognitive, fine and gross motor skills;     speech and language; social-emotional behavior, and self-help skills;

1.1.3 Hearing and vision screening;

1.1.4   Height and weight;

1.1.5   Health history, and

1.1.6   A summary interview.

1.2  A discussion of family circumstances which might affect the child’s learning readiness is recommended.

2.  Participant’s Rights, Obligations and Assurances

2.1  The standards for the program are the same for everyone regardless of race, color, creed, religion, national origin, sex, marital status, familial status, disability, status with regard to public assistance, sexual orientation, gender identity, genetic information or age.

2.2  The parent or guardian has the right to refuse participation for their child in any or all components of the screening program by submitting a statement of the parent’s or guardian’s conscientiously held beliefs (District Procedure 501.3P, Conscientious Objection to Early Childhood Screening).

2.3 The parent or guardian has the right to refuse referral for evaluation, diagnosis and possible treatment for their child.

3.  Required Notice To Parent/Guardian: Your child does not need to submit to screening by District 196 if your child has received comparable screening by another school district or by a private or public health care provider or organization within the preceding year. Records of that screening must be submitted to District 196 no later than 30 days after your child first attends public school. You may decline to answer questions or provide information about family circumstances that might affect development and identification of risk factors that may influence learning. Your failure to provide such information will not prevent your child from enrolling in school if all other components of the screening are met. Information collected from the screening will be used for the purposes described below by employees and agents of the School District. You are not required to provide requested information, but your refusal may prevent District 196 from completing the mandatory screening.


Summary data or individual data collected through screening may be used by District 196 to:

1.    Facilitate counseling or other follow-up services which the parent or guardian may wish to obtain after the screening;

2.    Transmit helpful information to District 196 or another provider of services if a referral is made for further evaluation;

3.    Permit evaluation of the screening program by the local school district, the Minnesota Department of Education or the Minnesota Department of Health (for evaluation by a state department, the child’s identity remains anonymous);

4.    Provide access to and accountability for government funds paid to the local school district for providing the required Early Childhood Screening services, and/or

5.    Plan for early childhood education programs and school entry.

By giving permission below, I authorize Independent School District 196 to conduct screening to be used for permanent school health and development records in addition to the above-stated purposes. I understand that screening results are classified as private data. Please provide the name of your child who is being considered for early childhood screening:

first                                                     middle                                     last

             I authorize the entire screening package indicated above for my child


             I authorize the screening package indicated above for my child


             with the exception of the following components(s):                                                                  
              (submit completed Procedure 501.3P, Conscientious Objection of Early Childhood Screening)                                                                                    

           I refuse participation for my child
            (submit completed Procedure 501.3P, Conscientious Objection of Early Childhood Screening)   

In addition, I authorize release of Early Childhood Screening information to the following sources for purposes of evaluation, diagnosis, treatment and/or programming. (Check and specify any persons or agencies that you wish to receive information about your child's screening; include name and address.) I understand this specific authorization expires one year from the date of my signature.

_______ Physician                                                                                          

_______ Daycare center                                                                                  

_______ Dakota County Public Health Nursing                                                

_______ Dakota County Social Service Agency                                                 

_______ Other                                                                                                


Signature                                    Relationship to child                                  Date