Georgia DPH Form 4400: Scoliosis Screening Submission and Opt-Out

Georgia DPH Form 4400 is the Certificate of Scoliosis Screening that public schools in Georgia use to document whether a student between the ages of 10 and 15 has been screened for scoliosis. You can download the blank form from the Georgia Department of Public Health website,¹ have an authorized provider complete it, and return it to your child’s school, or let the school handle the screening on-site through the local health authority.

Where to Get the Form

The Department of Public Health posts Form 4400 as a downloadable PDF.¹ The school nurse or front office can also hand you a paper copy. If your district runs on-site screenings with the county health department, the school typically supplies the form and routes it through the screening event, so you may never need to download anything yourself.

Who the Form Is For

Georgia Administrative Code 511-5-8 defines the at-risk population as children aged 10 through 15 and requires schools to screen at least two grade levels within that range each year.² In practice, most districts screen in sixth and eighth grade. The authority for the program comes from O.C.G.A. § 20-2-772, which directs the Department of Public Health to set the rules together with the State Board of Education.³

If your child has already been screened privately, you do not need to repeat the exam at school. A screening done by a licensed physician, someone working under a physician’s supervision, a local health department, or a licensed school nurse all count. The completed Form 4400 still has to be on file with the school, though, so the private screener needs to sign and date it.

Filling Out the Form

The form has a parent-facing section at the top and a provider section below it. You handle the top; the screener handles the rest.

Student and Parent Information

Fill in your child’s first, middle, and last name, date of birth, gender, and current grade. Add the student’s street address, city, zip code, county, and state, along with the name of the school. In the parent or guardian block, put your name, phone number, and email address so the health authority can reach you if any follow-up is needed.¹

Screening Results and Provider Section

After performing the exam, the screener marks one of three outcomes: negative screen, needs further evaluation, or referred to a provider. There is a comments field, a line for the screener to identify whether the screening was done at a physician’s practice, a county health department, or by a licensed school nurse, and spaces for the signature and date.¹

The following people are authorized to perform the screening and sign Form 4400:

A physician with an active Georgia license
A physician assistant
A nurse practitioner
A registered nurse
A licensed practical nurse
Other staff working under a licensed physician’s supervision
Nurses at a local health department
Licensed school nurses¹

What the Screening Involves

The exam is the Adams Forward Bend Test and takes only a few minutes. Your child removes any top covering the back, stands with feet together and knees straight, and bends forward at the waist until the back is roughly horizontal, with arms hanging down and palms together. The screener stands behind the child and looks along the plane of the spine for asymmetry: one side of the back higher than the other, uneven shoulders, a shoulder blade sticking out more on one side, uneven hips, or a visible rib hump.⁴

The test is painless and non-invasive, and it is not a diagnosis. A finding of “needs further evaluation” or “referred to provider” means the screener saw something that warrants a closer look from a pediatrician or orthopedic specialist, not that your child has scoliosis.

Opting Out

Georgia law lets a parent or legal guardian exempt a child from the screening by objecting.³ You have to notify the school in writing within five days of receiving the screening notification.²

Form 4400 has a parent opt-out section at the bottom to make this easy. You can check a box stating you do not want your child screened at this time, or indicate that your child is already under professional care for scoliosis. Sign, date, and return the form to the school.¹ You do not have to give a reason.

Submitting the Form

Return the completed form to the school nurse or the administrative office. Schools get written notice of screening dates at least two weeks ahead from the health authority, which gives you lead time to arrange a private screening or file an opt-out if you want to.²

A negative result ends the matter until the next required screening year, and the form stays in your child’s school health record. If the screening flags a possible spinal deformity, the health authority — not the school — contacts you directly, with a recommendation to seek further professional attention.² When a volunteer did the initial screening and flagged something, the health authority rescreens your child before any notification goes out.

If the Result Is Not Negative

A referral on Form 4400 is a prompt to schedule an appointment, not a diagnosis. Your child’s pediatrician or a pediatric orthopedic specialist is the usual next stop, and they will typically order a standing X-ray to measure the Cobb angle of any curve. Most health plans that comply with the Affordable Care Act cover preventive screenings at no cost when performed in-network, though coverage for follow-up care like bracing varies by plan.⁵ The point of catching a curve early is simple: bracing works best while a child is still growing.

1
Georgia Department of Public Health. Form 4400 – Scoliosis Screening
2
Georgia Secretary of State. Georgia Administrative Code 511-5-8 – Screening of Public School Children for Scoliosis
3
Justia. Georgia Code 20-2-772 – Rules and Regulations for Screening of Students for Scoliosis
4
Georgia Department of Public Health. Certificate of Scoliosis Screening Form 4400
5
HealthCare.gov. Preventive Health Services