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Oregon SBHC Certification Standards
Oregon SBHC Logo

Oregon's SBHC certification standards were developed in partnership with the Oregon School-Based Health Care Network, Conference of Local Health Officials, and the SBHC State Program Office.  Oregon's certification process was implemented on July 1, 2000. The standards outline a voluntary certification process rather than licensing. However, all SBHCs receiving state funds are required to be certified. Reference to certification requirements can be found in the Local County Health Department contracts under Program Element 44: School-Based Health Centers.

The goals of standardization are to:

  • Increase emphasis on Best Practices,
  • Reduce site-to-site variability,
  • Increase the ability to study clinical outcomes, and
  • Increase the potential for insurance reimbursement.

The standards address the following:

  • Facilities,
  • Operations and staffing,
  • Laboratory services,
  • Clinical services,
  • Data collection and reporting,
  • Quality assurance activities, and
  • Administrative procedures for certification. 


Initial Certification Application- for SBHCs applying for certification for the first

Click HERE for the application

Recertification Process - for SBHCs currently certified, seeking renewal


Standards for Certification.


2014 Certification Standards 


Preparing for Certification

Confirm Date of Site Visit
Notify Partners
One Month Prior to Site Visit
Complete Readiness Assessment
Day of Site Visit
Schedule 2 primary care
(well child exam, complete physical exam) visits
*Verification review CAN NOT be completed without these appointments
Provide copy of completed readiness assessment
Have updated certification binder on site



Supplemental documents

Most common findings  (pdf)

  • 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  • Outdated policies and procedures
  • Lack of evidence of medical director involvement
  • Unlocked medication cabinets


Roles description (pdf)

      • Medical Sponsor: person(s) or entity(ies) that oversees the day-to-day operation of the SBHC through funding, staffing, designation of the medical director,  ownership of medical records and liability insurance. (Standards B.1 & B.2)
      • Medical Director:  a  health care provider with a license to practice independently 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 provides ongoing oversight of the SBHC, at least quarterly, 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.2.a, C.3.b, C.5.d)
      • SBHC Administrator: An identified person with administrative duties who is employed by at least one of the sponsoring agencies of the SBHC.  The Site 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, State Program Office ( SPO), Local Public Health Authority (LPHA) and other SBHC community partners.  The SBHC Site Coordinator is responsible for attending SPO meetings and Certification site visits.  (Standard C.5.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.. (Standard C.5.h)
      • 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.  (Standard G.1.a)