To fill out the New Jersey Universal Child Health Record, known as Form CH-14, you complete Section I with your child’s identifying and health history information, then your child’s licensed physician, advanced practice nurse, or physician assistant completes Section II during a physical exam, recording measurements, required screenings, immunization dates, and a signed, stamped certification that the child is medically cleared for school and childcare activities.1New Jersey Department of Health. Universal Child Health Record CH-14 The blank form is a free two-page PDF at nj.gov/health/forms/ch-14.pdf, and most school nurses and pediatric offices in New Jersey keep copies on hand.
Every child enrolling in a licensed childcare center, preschool, or any public, private, or parochial school in New Jersey needs a completed CH-14 on file.2Legal Information Institute. New Jersey Administrative Code 6A:16-2.4 – Required Student Health Records Districts also prompt parents to get updated exams at three developmental stages: early childhood through third grade, fourth through sixth grade, and seventh through twelfth grade.3Legal Information Institute. New Jersey Administrative Code 6A:16-2.2 – Required Health Services Younger children in childcare and preschool usually need an updated form yearly.
Section I: What You Fill In
Section I is the parent portion. Start at the top with your child’s full legal name, date of birth, and gender. Then enter your contact information, an emergency contact, and the name and phone number of your child’s primary healthcare provider.1New Jersey Department of Health. Universal Child Health Record CH-14
Below that sits a health history section covering past illnesses, surgeries, allergies, and current medications. Be thorough. Your provider uses what you write here to guide the physical exam in Section II, and a missing allergy or an overlooked medication can create real problems once your child is in a classroom. If your child has asthma, a severe food allergy, diabetes, seizures, or another condition that calls for action during the school day, flag it clearly. The provider will need to note it in the clinical section and may need to attach a separate care plan.
Section II: What the Provider Fills In
Section II must be completed by a licensed physician, advanced practice nurse, or physician assistant during an in-person physical examination. Bring the blank form to a scheduled well-child visit, or call the office ahead of time to confirm they have copies.1New Jersey Department of Health. Universal Child Health Record CH-14
Physical Exam and Measurements
The provider records the date of the exam and marks whether findings are normal or abnormal, noting anything that needs attention. Standard measurements include height, weight, and blood pressure for children over three. For children under two, head circumference is also recorded. For children enrolled in WIC, height and weight must be taken within 30 days.
Required Screenings
The screening grid has fields for the date performed and the result of each item:
- Vision and hearing, with any abnormality that could affect learning flagged.
- Blood lead testing. New Jersey requires it at both 12 and 24 months, and for any untested child between 25 and 72 months. The provider records whether the test was capillary or venous and enters the result value.4New Jersey Department of Health. Universal Blood Lead Testing
- Hemoglobin or hematocrit to check for anemia.
- Dental, developmental, and scoliosis screenings, each with the date and whether an abnormality was found.
- Tuberculosis testing, required only for students entering a New Jersey school for the first time from a country with elevated TB rates. A positive interferon gamma release assay, or a Mantoux skin test showing more than 10mm of induration, counts as a significant reaction.5New Jersey Department of Health. Recommended Tuberculosis Testing in New Jersey Schools
Immunization Dates
The immunization section has rows for every required vaccine, and the provider fills in the date each dose was administered. For childcare and preschool entry, New Jersey requires DTaP, IPV, Hib, PCV, influenza, MMR, and varicella, with the number of doses rising as the child ages.6New Jersey Department of Health. New Jersey School Vaccine Requirements for Child Care and Preschool By 19 months, for example, a child needs four doses of DTaP, three of IPV, and at least one each of MMR and varicella. Influenza vaccine is due annually by November 30 for all children six months and older in childcare or preschool settings. K-12 students face additional requirements that shift with grade level, including Tdap and meningococcal vaccines for middle and high school entry. If your child is behind on any doses, ask the provider about a catch-up schedule before the enrollment deadline.
Limitations and the Provider’s Signature
If the provider identifies any restriction, such as no running because of a heart condition, it goes in the “Limitations to Physical Activity” area. At the bottom of Section II, the provider prints their name, signs, dates the form, and applies an official office stamp. The certification states that the child has been examined and is medically cleared to participate in all school and childcare activities, including physical education and competitive contact sports, unless limitations are noted above.7New Jersey Department of Health. Universal Child Health Record CH-14 A missing signature or stamp is one of the most common reasons school nurses send forms back, so check both before leaving the office.
Attach a CH-15 if Your Child Has a Special Health Need
The CH-14 is deliberately concise and does not leave room for detailed instructions on managing a complex condition. If your child has asthma, a life-threatening allergy, diabetes, seizures, or another condition requiring specific action during the school day, the healthcare provider should complete a CH-15 Care Plan and attach it to the CH-14.8New Jersey Department of Health. Instructions for Completing the CH-15, Care Plan for Children with Special Health Needs Check the “Special Care Plan Attached” box on the CH-14 so the school nurse knows to look for it.1New Jersey Department of Health. Universal Child Health Record CH-14
The CH-15 prompts the provider to list the diagnosis, daily medications, emergency procedures, and any equipment the school needs to keep on hand, such as nebulizers, EpiPens, or glucometers. It also spells out which symptoms call for contacting a parent and which warrant calling 911. For asthma, a pediatric asthma action plan from the Pediatric Asthma Coalition of New Jersey (pacnj.org) can be used alongside or in place of the generic CH-15. The CH-15 is available at nj.gov/health/forms/ch-15.pdf, or by calling the Division of Family Health Services at 609-292-5666 for a hard copy.
Submitting the Form and Avoiding Rejection
Once both sections are finished, signed, and stamped, deliver the original to the school nurse or childcare administrator. Most facilities want a physical copy, though some districts now accept scanned uploads through a secure parent portal. Keep a copy for yourself. You will need it if your child changes schools or enrolls in a summer program that requires health documentation.
The school nurse reviews the form to confirm every required immunization and screening is documented. During the late-summer enrollment rush, this review can take several business days. If anything is incomplete, such as a missing vaccine date, an unsigned provider section, or a lead screening with no result value, the nurse will contact you to correct it. Submitting the form well before the first day of school gives you time to fix problems without disrupting your child’s start date. A child whose required immunizations are not documented, and who has not been granted provisional admission or an exemption, can be kept out of attendance until the paperwork is provided.9Legal Information Institute. New Jersey Administrative Code 8:57-4.5 – Provisional Admission
What the CH-14 Does Not Cover: Student Athletes
The CH-14 clears your child for physical education and competitive contact sports at the general school level. It does not clear a student in grades six through twelve for a school-sponsored interscholastic or intramural athletic team. For that, New Jersey requires a separate Preparticipation Physical Evaluation, or PPE.10State of New Jersey. Scholastic Student-Athlete Safety Act Frequently Asked Questions and Answers
The PPE exam must be conducted within 365 days before the first day of official practice in an athletic season, and the examining provider must first complete a Student-Athlete Cardiac Screening professional development module.3Legal Information Institute. New Jersey Administrative Code 6A:16-2.2 – Required Health Services The PPE has three parts: a health history questionnaire, a physical examination form, and a medical eligibility form. Only the medical eligibility form goes to the school, and the school physician must review and approve it in writing before practice begins.10State of New Jersey. Scholastic Student-Athlete Safety Act Frequently Asked Questions and Answers If the exam was more than 90 days before the first practice, you also need to complete a health history update questionnaire.