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Oregon SBHC Standards for Certification

Oregon's SBHC standards for certification were developed in partnership with the Oregon School-Based Health Alliance, Conference of Local Health Officials, and the SBHC State Program Office (SPO).  Oregon's certification process was implemented on July 1, 2000. In 2014, Oregon Administrative Rules 333-028-0200 through 333-028-0250 were adopted to establish the procedures and criteria the Oregon Health Authority shall us to certify, suspend and decertify SBHCs. Certification of a SBHC by the SPO is voluntary; an operating clinic is free to operate without participating in SPO certification. However, only certified SBHCs are eligible for funding from the Oregon Health Authority.

Reference to certification requirements can be found OARS 333-028-0200 through 333-028-0250 and in the Local County Health Department contracts under Program Element 44: School-Based Health Centers.


SPO Standards for Certification (pdf)


The goals of standardization are to:

  • Establish clearly-defined SBHC model for Oregon;
  • Reduce site-to-site variability; and
  • Increase evidence-based practice and quality improvement, particularly among adolescent and child populations.

Benefits of certification:

  • Inclusion in the SPO funding formula; 
  • Access to grant projects and funding through the SPO; 
  • Access to technical assistance through the SPO; 
  • Increased capacity to leverage money from other sources (such as federal grants); 
  • Access to statewide network of SBHC; and 
  • Representation of data in SPO materials and access to SBHC data by request.



SBHC Certification Process


For SBHCs applying for certification for the first time:

Initial Certification Application (website link)




Confirm Date of Site Visit
Notify Partners 
One Month Prior to Site Visit
Update Operational Profile (website link)
Operational Profile User's Guide (pdf)
Day of Site Visit
Schedule 2 primary care
(well child exam, complete physical exam) visits
*Verification review CAN NOT be completed without these appointments
Have updated certification binder on site


  • A lack of signage directing students and visitors to SBHCs location
  • Missing exit and emergency exit signage
  • Missing policies and procedures
  • Missing signatures on policies and procedures
  • Outdated policies and procedures
  • Policies and procedures that are not inclusive of all SBHC partners (e.g., school, medical sponsor, etc.)
  • Lack of evidence of medical director involvement
  • Patient confidentiality concerns
  • Suppression of EOB/billing issues
  • Not meeting SPO annual key performance measure requirements
  • Not meeting patient satisfaction survey requirements


  • Sponsoring agency: Person(s) or entity(ies) that provides a SBHC or contracts with another entity to provide funding, staffing, medical oversight, liability insurance, and billing support. SBHCs may have more than one sponsor, but at least one of the sponsors must meet the definition of a medical sponsor. (Standards B.1(a)(b))
  • Medical sponsor: Person(s) or entity(ies) that provide medical liability coverage, ownership of medical records, and designation of SBHC medical director. (Standards B.1(c))
  • Medical Director:  A health care provider with a license to practice independently with the population being served and who has prescriptive authority. The Medical Director may be employed by the Medical Sponsor or the Medical Sponsor may enter into a contract with a licensed health care provider to provide the required services. The Medical Director is actively involved in the SBHC through clinical oversight, chart reviews and policy/procedure development. The Medical Director must be accessible to the SBHC staff by phone to discuss clinical issues and available to provide clinical assistance as needed. (Standards B.1(c))
  • ​SBHC Administrator: An identified person with administrative duties who is employed by at least one of the sponsoring agencies of the SBHC. The SBHC Administrator is the primary contact for the SBHCs administrative functions. The SBHC Administrator may share duties with the SBHC Site Coordinator.
  • SBHC Site Coordinator: An identified person with administrative duties who is employed by at least one of the sponsoring agencies of the SBHC. The Site Coordinator is the primary contact and liaison between the SBHC, SPO, Local Public Health Authority (LPHA) and other SBHC community partners. The SBHC Site Coordinator is responsible for attending SPO meetings and verification site visits. (Standard C.2(c))
  • Privacy Official: The individual responsible for health information privacy including HIPAA and Oregon Privacy laws. The Privacy Official is responsible for the SBHC’s privacy policies and procedures and ensuring all staff have completed privacy training.
  • Laboratory Coordinator: The individual assigned as liaison to the entity that holds the CLIA license for the SBHC’s lab (“CLIA License Holder”). Responsible for maintaining current CLIA licensure, documenting laboratory competency training for staff, on-site lab QA, and ensuring the CLIA License Holder provides the SBHC ongoing oversight for complying with CLIA requirements (lab policies/procedures, quality control, instrument maintenance, proficiency testing, etc.). (Standards D)
  • Immunization Coordinator: The individual responsible for oversight of immunizations and compliance with all the requirements of the Oregon Vaccines for Children (VFC) program. The Immunization Coordinator oversees the vaccine ordering, storage, temperature monitoring and handling) within the SBHC, acts as the SBHC’s liaison to Oregon Immunization Program and LPHA immunization coordinator. (Standards D)
  • Quality Assurance Coordinator: The person designated to oversee the SBHC’s quality improvement processes, including conducting the annual chart reviews and reporting of the SPO’s Key Performance Measures.