Health Office STUDENT HEALTH RECORD

Transcription

1 STUDENT HEALTH RECORD PARENTS: PLEASE LIST Allegies: Dietay Restictions: Please fill out the following fom completely. This fom includes a pemission statement that MUST be signed by a paent o guadian. Pe Massachusetts law, students will not be allowed to attend Fay School without completely updating all health foms and immunization ecods. The completed fom must be etuned to the Health Office by June 1, THESE FORMS MUST BE COMPLETED IN ENGLISH. Student s Name Bith date Enteing gade male female Student cell numbe Home Addess numbe and steet city state zip code Student esides with both paents fathe mothe othe Paent/Guadian full name Home Phone ( ) Addess Cell Phone ( ) Wok Phone ( ) Fax ( ) Paent/Guadian full name Home Phone ( ) Addess Cell Phone ( ) Wok Phone ( ) Fax ( ) Altenate esponsible peson (not a paent) to be eached in case of emegency, if paent o guadian is unavailable: Home Phone ( ) Addess Cell Phone ( ) INSURANCE: MANDATORY FOR ENROLLMENT If you have hospital o health insuance fo you child, please list the infomation below. A copy of you insuance cad (font and back) is also equied. Intenational Students do NOT need to supply insuance infomation as insuance is included with tuition. Name and addess of insuance plan Policy o Goup # Subscibe Name Date of bith

2 PERMISSION TO TREAT AUTHORIZATION TO USE & DISCLOSE HEALTH INFORMATION Please ead and sign the pemissions listed below. Pe Massachusetts law, childen will not be allowed to attend Fay School without completely updating all health foms and immunization ecods. The completed fom must be etuned to the Health Office by June 1, Student s Name Enteing gade Bith date PaRent PeRmIssIon/PeRmIssIon to treat I heeby give consent to the Fay School Health Office, o designated health cae povides, to cay out accepted pocedues fo diagnosis and teatment of medical conditions, athletic injuies, dental injuies, counseling sevices and medication administation fo my daughte/son, (student name). Futhemoe, I undestand that the exchange of petinent medical, psychological, and health insuance infomation may be necessay when poviding cae with an outside povide o though an off- campus facility. Faculty and othe school pesonnel will be infomed of any life theatening allegies, medical conditions, and psychological issues which may equie teatment as deemed necessay by the Wellness Cente staff. USE/ DISCLOSURE INFORMATION This fom authoizes Fay School s Health Office staff, Counseling Sevices staff, and community health cae povides to whom the student is efeed fo health cae, to use the student s health infomation and disclose the student s health infomation to each othe fo the following puposes: To evaluate whethe accommodations at school ae ecommended o necessay in ode to addess the student s health elated condition To povide the student s health infomation with school administation and the head of school to the extent necessay to make thei above mentioned ecommendation. The Health Insuance Potability and Accountability Act of 1996 (HIPPA) equies that you be infomed that by signing this fom you authoize the use/disclosue of the students health infomation as descibed above. This authoization shall become effective immediately and emain fo one yea following the child s last day of attendance. You have the ight to evoke this authoization at any time. Revocation must be in witing, signed by a paent/guadian and deliveed to the Health Office. I undestand that Fay School will potect the student s health infomation as pescibed by the Family Educational Rights and Pivacy Act (FERPA) and that the infomation becomes pat of the student s health ecod. The infomation will be shaed with individuals woking at o with Fay School fo the pupose of poviding safe and appopiate health sevices.

3 HEALTH & WELLNESS POLICIES Please ead and sign that you have ead the policies listed below. Pe Massachusetts law, students will not be allowed to attend Fay School without completely updating all health foms and immunization ecods. The completed fom must be etuned to the Health Office by June 1, Student s Name Enteing gade Bith date medical ReGIstRatIon PolICY Yealy updated medical egistation foms, including signed pemission to teat, ae equied befoe students ae allowed to egiste o paticipate in FaySumme activities. These ecods ae kept confidential and ae pohibited fom elease unless specific witten pemission is given. Paents should infom the Health Office pomptly of any new o changed medical teatment at home duing the academic yea, paticulaly if such teatment includes pescibed medications. ImmunIZatIon PolICY Unde the Massachusetts Depatment of Public Health statutes and Fay School s equiements, all students ae equied to have a completed ecod of immunizations against cetain vaccine-peventable diseases as a condition of enollment. If documentation is not available, e-immunization o blood tite immunity detemination will be equied. This is the esponsibility of the paent. Students may not paticipate in FaySumme activities unless immunizations ae complete. HealtH InsuRanCe PolICY All students must have health insuance while in attendance at Fay School. A copy of cuent medical insuance and, if applicable, a pesciption cad must be kept on file in the Health Office. Changes in medical insuance infomation must be updated immediately by contacting the Health Office o via notification in witing o fax medication PolICY Fay may not give medications without a signed docto s ode and paental consent. Docto s odes, theefoe, must be povided (in English) any time a medication is stated, anytime thee is a dose change, o anytime a medication is discontinued. Ove-the-counte medications may be dispensed as appopiate only if paents o guadians have submitted a signed and authoized ove-the-counte consent fom. School nuses will supevise the stoage and administation of all medications and follow Massachusetts Depatment of Public Health guidelines fo delegating medication administation to non-nusing pesonnel (e.g. administatos, teaches, house paents, coaches). Paents and guadians ae esponsible fo keeping tack of when medications need to be efilled o mailed. School nuses may make coutesy calls in some instances, but these calls will not be outine. I have ead and undestand the policies listed above.

4 CERTIFICATE OF IMMUNIZATION This fom must be completed in English. See Massachusetts School Immunizations page fo equied vaccines. Student s Name Bith date / / female male day boading month day yea If combination vaccine is administeed, please indicated vaccine type (e.g. DTaP-Hib, etc.) Vaccine Date/Vaccine Type Vaccine Date/Vaccine Type Hepatitis B (e.g. HepB, HepB-Hib, DTaP-HepB-IPV) Diptheia, Tetanus, Petussis (e.g. DTaP, DT, DTaP-Hib, DTaP-HepB-IPV, Td) Polio (e.g. IPV, DTaP-HepB-IPV) Pneumococcal Conjugate (PCV7) 1 Haemophilus 1 2 influenzae type b 2 (e.g. Hib, HepB-Hib, 3 DTaP-Hib) Measles, Mumps, 1 3 Rubella (MMR) 2 4 Vaicella 1 5 (Va) 2 6 Hepatitis A 1 7 (HepA) 2 1 Pneumococcal 1 2 Polysacchaide (PPV23) 2 3 Influenza 1 4 inactivated (Intamuscula) 2 o Live (Intanasal) Othe: 3 4 Seologic Poof of Immunity Check One Chickenpox Histoy Test (if done) Date of Test Positive Negative Measles / / Check the box if this peson has a physician-cetified eliable histoy of chickenpox. Mumps / / Date of disease: Rubella / / Reliable histoy may be based on: Vaicella* / / physician intepetation of paent/guadian desciption of chickenpox Hepatitis B / / physical diagnosis of chickenpox, o * must also check Chickenpox Histoy box seologic poof of immunity I cetify that this immunization infomation was tansfeed fom the above-named individual s medical ecods. Docto o nuse s name (please pint) Date: / / Signatue Facility name

5 Student s Name female male Bith date Medical histoy Petinent family histoy Cuent health issues Y N Allegies: Please list: Medications Food Othe Histoy of Anaphylaxis to EpiPen: yes no (Please attach) Asthma: asthma action plan yes no (Please attach) Diabetes: Type I Type II Seizue disode: Othe (please specify): Cuent medications (if elevant to the student s health and safety) Please cicle those administeed in school; a sepaate medication ode fom is equied fo each medication administeed in school. Physical Examination: Date of examination Height ( %) Weight ( %) BMI ( %) BP (Check = Nomal/If abonomal, please descibe) Geneal Lungs Extemities Skin Heat Neuologic HEENT Abdomen Othe Dental/Oal Genitalia Pass Fail Pass Fail Pass Fail Sceening Vision: Right Eye Heaing: Right Ea Postual Sceening: Left Eye Left Ea (Scoliosis/Kyphosis/Lodosis) Steeopsis Laboatoy Results The entie examination was nomal MASSACHUSETTS SCHOOL HEALTH RECORD Health Cae Povide s Examination healthfoms@fayschool.og Lead Date Othe Tageted TB Skin Testing Med-to-high isk (exposue to TB; bon, lived, tavel to TB endemic counties; medical isk factos): Date of PPD ; Results mm Refeed fo evaluation to Low isk (no PPD done) This student has the following poblems that may impact his/he educational expeience: Vision Heaing Speech/Language Fine/Goss Moto Deficit Emotional/Social Behavio Othe Comments/Recommendations Y N Y N This student may paticipate fully in the school pogam, including physical education and competitive spots. If no, please list estictions: Immunizations ae complete: If no, give eason: Please attach Massachusetts Immunization Infomation System Cetificate o othe complete immunization ecod. Signatue of examine Pint name of examine Goup pactice Telephone Steet City State Zip Code Please attach additional infomation as needed fo the health and safety of the student.

6 PERMISSION TO DISPENSE OVER-THE-COUNTER MEDICINES Due to guidelines set foth by the Massachusetts Depatment of Public Health, no ove-the-counte medicines can be dispensed in school without paental consent. Please complete this fom and etun it to the Health Office. Student s Name Enteing gade Bith date Please check all medicine the school nuse may dispense: Acetaminophen (Tylenol) Antacids (Tums/Mylanta) Cough Lozenges/ dops Loatidine (Claitin/ Zytec) Mialax/ Imodium/ PeptoBismol Calamine lotion Topical antifungal (Lotimin/Lamisil) Ibupofen (Advil/Motin) Polyspoin/ Neospoin ointment Cough/Cold Medicine 1% Hydocotisone ceam Multi Vitamins/ Mineals Bacitacin ointment Dipenhydamine (Benadyl) Eye dops/wash Allegies to medication OR: I do NOT want Student name (please pint) to eceive any ove-the-counte medication. for BoaRDInG students only: Would you like you child to eceive the flu vaccine? yes no

7 MEDICATION ORDER All medications must be checked into the Fay School Health Office. Fay School does not allow students to keep any medicine, including vitamins o supplements, in the domitoy. A paent, guadian o esponsible adult shall delive all pesciption medication and ove the counte medication to the school nuse. The pesciption medication must be in a phamacy o manufactue labeled containe (105. CMR ) and must be in English. Additionally, the following documents must be on file in the Health Office befoe we can administe any medication to you child (105.CMR: Massachusetts Depatment of Public Health): Medication Ode (This fom is fo any student taking pesciption medication) Pemission to Dispense Ove the Counte Medicines/Supplements (Must be etuned by ALL students) This fom is to be completed if you child is taking any pesciption medication(s) and MUST be completed by a Licensed Pescibe, Nuse Pactitione, o othes authoized by Massachusetts Geneal Laws, Chapte 94C. Student s Name Enteing gade Bith date Name of Licensed Pescibe Addess of Pescibe Business Phone Signatue Fax Date Medication Date of Ode Dosage Stength Fequency Route Medication Date of Ode Dosage Stength Fequency Route Medication Date of Ode Dosage Stength Fequency Route Medication Date of Ode Dosage Stength Fequency Route **PLEASE INCLUDE EPI-PEN ORDER**

8 INFORMATION ABOUT MENINGOCOCCAL DISEASE AND VACCINATION WAIVER FOR STUDENTS AT RESIDENTIAL SCHOOLS AND COLLEGES Revised legislation in Massachusetts now equies all newly enolled full-time students attending a seconday school (e.g., boading schools) o postseconday institution (e.g., colleges) who will be living in a domitoy o othe congegate housing licensed o appoved by the seconday school o institution to: 1. eceive meningococcal vaccine; o 2. fall within one of the exemptions in the law, which ae discussed on the evese side of this sheet. The law povides an exemption fo students signing a waive that eviews the danges of meningococcal disease and indicates that the vaccination has been declined. To qualify fo this exemption, you ae equied to eview the infomation below and sign the waive at the end of this document. Please note, if a student is unde 18 yeas of age, a paent o legal guadian must be given a copy of this document and must sign the waive. What is meningococcal disease? Meningococcal disease is caused by infection with bacteia called Neisseia meningitidis. These bacteia can infect the tissue that suounds the bain and spinal cod called the meninges and cause meningitis, o they can infect the blood o othe body ogans. In the US, about 1,000-3,000 people get meningococcal disease each yea and 10-15% die despite eceiving antibiotic teatment. Of those who live, anothe 11-19% lose thei ams o legs, become deaf, have poblems with thei nevous systems, become mentally etaded, o suffe seizues o stokes. How is meningococcal disease spead? These bacteia ae passed fom peson-to-peson though saliva (spit). You must be in close contact with an infected peson s saliva in ode fo the bacteia to spead. Close contact includes activities such as kissing, shaing wate bottles, shaing eating/dinking utensils o shaing cigaettes with someone who is infected; o being within 3-6 feet of someone who is infected and is coughing o sneezing. Who is at most isk fo getting meningococcal disease? People who tavel to cetain pats of the wold whee the disease is vey common ae at isk, as ae militay ecuits who live in close quates. Childen and adults with damaged o emoved spleens o an inheited disode called teminal complement component deficiency ae at highe isk. People who live in settings such as college domitoies ae also at geate isk of infection. Ae some students in college and seconday schools at isk fo meningococcal disease? College feshmen living in esidence halls o domitoies ae at an inceased isk fo meningococcal disease as compaed to individuals of the same age not attending college. The setting, combined with isk behavios (such as alcohol consumption, exposue to cigaette smoke, shaing food o beveages, and activities involving the exchange of saliva), may be what puts college students at a geate isk fo infection. Thee is insufficient infomation about whethe new students in othe congegate living situations (e.g., esidential schools) may also be at inceased isk fo meningococcal disease. But, the similaity in thei envionments and some behavios may incease thei isk. The isk of meningococcal disease fo othe college students, in paticula olde students and students who do not live in congegate housing, is not inceased. Howeve, meningococcal vaccine is a safe and efficacious way to educe thei isk of contacting this disease. Is thee a vaccine against meningococcal disease? Yes, thee ae cuently 2 vaccines available that potect against 4 of the most common of the 13 seogoups (subgoups) of N. meningitidis that cause seious disease. Meningococcal polysacchaide vaccine is appoved fo use in those 2 yeas of age and olde and meningococcal conjugate vaccine is appoved fo use in those 2-55 yeas of age. Both of the vaccines povide potection against fou seogoups of the bacteia, called goups A, C, Y and W-135. These fou seogoups account fo appoximately two-thids of the cases that occu in the U.S. each yea. Most of the emaining one- thid of the cases ae caused by seogoup B, which is not contained in eithe vaccine. Potection with the meningococcal polysacchaide vaccine is not lifelong; it lasts about 3 to 5 yeas in healthy adults (some people may be potected longe.) The meningococcal conjugate vaccine is expected to help decease disease tansmission and povide moe long-tem potection. Is the meningococcal vaccine safe? A vaccine, like any medicine, is capable of causing seious poblems such as sevee allegic eactions. Getting meningococcal vaccine is much safe than getting the disease. Some people who get meningococcal vaccine have mild side effects, such as edness o pain whee the shot was given. These symptoms usually last fo 1-2 days. A small pecentage of people who eceive the vaccine develop a feve. The vaccine can be given to pegnant women. A few cases of Guillain-Baé syndome (GBS), a ae but seious nevous system disode, have been epoted among people who eceived meningococcal conjugate vaccine. This infomation is still being evaluated by health officials. An ongoing isk of seious meningococcal disease exists. At this time, expets continue to ecommend vaccination fo those at inceased isk of acquiing meningococcal disease. Howeve, pesons who have had GBS should geneally not eceive meningococcal conjugate vaccine, and should talk to thei docto about thei othe options fo vaccination.

9 MENINGOCOCCAL VACCINATION WAIVER, page 2 Is it mandatoy fo students to eceive meningococcal vaccine fo enty into seconday schools o colleges that povide o license housing? Massachusetts law (MGL Ch. 76, s.15d) equies newly enolled full-time students attending a seconday school (those schools with gades 9-12) o postseconday institution (e.g., colleges) who will be living in a domitoy o othe congegate housing licensed o appoved by the seconday school o institution to eceive meningococcal vaccine. At affected seconday schools, the equiements apply to all new full-time esidential students, egadless of gade (including gades pe-k though 8) and yea of study. All students coveed by the egulations must povide documentation of having eceived a dose of meningococcal polysacchaide vaccine within the last 5 yeas (o a dose of meningococcal conjugate vaccine at any time in the past), unless they qualify fo one of the exemptions allowed by the law. Wheneve possible, immunizations should be obtained pio to enollment o egistation. Howeve, students may be enolled o egisteed povided that the equied immunizations ae obtained within 30 days of egistation. Students may begin classes without a cetificate of immunization against meningococcal disease if: 1) the student has a lette fom a physician stating that thee is a medical eason why he/she can t eceive the vaccine; 2) the student (o the student s paent o legal guadian, if the student is a mino) pesents a statement in witing that such vaccination is against his/he sincee eligious belief; o 3) the student (o the student s paent o legal guadian, if the student is a mino) signs the waive below stating that the student has eceived infomation about the danges of meningococcal disease, eviewed the infomation povided elected to decline the vaccine. Whee can a student get vaccinated? Students and thei paents should contact thei healthcae povide and make an appointment to discuss meningococcal disease, the benefits and isks of vaccination, and the availability of this vaccine. Schools and college health sevices ae not equied to povide you with this vaccine. Whee can I get moe infomation? You healthcae povide The Massachusetts Depatment of Public Health, Division of Epidemiology and Immunization at (617) o dph/imm and You local health depatment (listed in the phone book unde govenment) WAIVER FOR MENINGOCOCCAL VACCINATION REQUIREMENT: BOARDING STUDENTS ONLY I have eceived and eviewed the infomation povided on the isks of meningococcal disease and the isks and benefits of meningococcal vaccine. I undestand that Massachusetts law equies newly enolled full-time students at seconday schools, colleges and univesities who ae living in a domitoy o congegate living aangement licensed o appoved by the seconday school o postseconday institution to eceive meningococcal vaccinations, unless the students povide a signed waive of the vaccination o othewise qualify fo one of the exemptions specified in the law. Afte eviewing the mateials above on the danges of meningococcal disease, I choose to waive eceipt of meningococcal vaccine. Student s Name Enteing gade Bith date Student ID o SSN Pinted Name Relationship to Patient/Student

10 Massachusetts School Immunization Requiements fo School Yea * Child Cae/Peschool 1 Kindegaten Gades 1-6 Gades 7-12 College 2 Hepatitis B 3 3 doses 3 doses 3 doses 3 doses 3 doses fo students and fulltime undegaduate and gaduate students >4 doses DTaP/DTP 5 doses DTaP/DTP/DT/ Td/Tdap 4 DTaP/DTP >4 doses DTaP/DTP o > 3 doses Td 4 doses DTaP/DTP o >3 doses Td; plus 1 dose Tdap (See Phase-In Schedule) Polio 5 >3 doses 4 doses >3 doses >3 doses Hib 6 1 to 4 doses 6 1 dose 2 doses Gades 1-4: 2 doses 7 NA NA NA NA NA MMR 7 Gades 5-6: 2 doses measles, 1 mumps, 1 ubella (See Phase-In Schedule) Gades 7-11: 2 doses Gade 12: 2 doses measles, 1 mumps, 1 ubella (See Phase-In Schedule) 1 dose 2 doses Gades 1-4: 2 doses Gades 7-11: 2 doses Vaicella 8 Gades 5-6: 1 dose Gade 12: 1 dose (See Phase-In Schedule) (See Phase-In Schedule) Meningococcal 9,10 NA NA NA 10 1 dose fo new full-time esidential *These equiements also apply to all new entees. NA = no vaccine equiement fo the gades indicated. All health science students and full-time undegaduate and gaduate students: 1 dose Tdap All health science students and full-time undegaduate and gaduate students: 2 doses All health science students and full-time undegaduate and gaduate students: 2 doses students 9 1 dose fo full-time esidential students 9 1 Child Cae/Peschool: Minimum equiements by 24 months; immunize younge childen accoding to thei age. 2 College: Requiements apply to: 1) all full-time undegaduate and gaduate students; 2) all full-time and pat-time health science students; and 3) any full-time o pat-time student attending any postseconday institution while on a student o othe visa, including foeign students attending o visiting classes as pat of a fomal academic visitation o exchange pogam. 3 Hepatitis B: 3 doses equied fo child cae attendance and peschool enty, kindegaten-12 th gade, and college (see footnote 2 above). Laboatoy poof of immunity is acceptable. 4 DTaP/DTP/DT/Td/Tdap: >4 doses equied fo child cae attendance and peschool enty; 5 doses of DTaP/DTP equied fo school enty unless the 4th dose is given > the 4th bithday. DT is only acceptable with a lette stating a medical containdication to DTaP/DTP. One dose of Tdap is equied fo all students enteing gade 7-11, full-time college feshmen-gaduates and all health science students. If it has been <5 yeas since the last dose of DTaP/DTP/DT/Td, Tdap is not equied but is ecommended egadless of the inteval since the last tetanus-containing vaccine. See Phase-In Schedule below. 5 Polio: >3 doses equied fo child cae attendance and enty into peschool. 4 doses equied fo school enty, unless the 3d dose is given on o afte the 4th bithday, and > 6 months following the pevious dose, in which case only 3 doses ae needed. Administe the final dose in the seies on o afte the 4th bithday and > 6 months following the pevious dose. If 4 doses ae administeed befoe age 4 yeas, a 5th dose is ecommended at age 4-6 yeas. 6 Hib: Requied fo child cae attendance and peschool enty. The numbe of doses is detemined by vaccine poduct and age the seies begins. Phase-In Schedule fo MMR, Vaicella, and Tdap Vaccines MMR and 2 Vaicella 7 MMR: 1 dose of MMR is equied fo child cae attendance and peschool enty; 2 doses ae equied fo kindegaten-gade 4, gade 7-11, full-time undegaduate and gaduate students and all health science students. Laboatoy poof of immunity is acceptable. Fo college students, except health science students, bith befoe 1957 in the U.S. is also acceptable. See Phase-In Schedule below. 8 Vaicella: 1 dose equied fo child cae attendance and peschool enty; 2 doses equied fo kindegaten-gade 4, gade 7-11, full-time undegaduate and gaduate students and all health science students, unless they have a eliable histoy of chickenpox. A eliable histoy includes a diagnosis of chickenpox, o intepetation of paent/guadian desciption of chickenpox, by a physician, nuse pactitione, physician assistant o designee; o 2) laboatoy poof of immunity. Bith befoe 1980 in U.S. is acceptable fo college students, except health science students. See Phase-In Schedule below. 9 Meningococcal: 1 dose MCV4, o a dose of MPSV4 in the last 5 yeas, is equied fo 1) newly enolled full-time students attending a seconday school with gades 9-12 (in ungaded classooms, those with students > 13 yeas) who will live in a domitoy o compaable congegate living aangement appoved by the seconday school; and 2) newly enolled full-time undegaduate and gaduate students in a degee pogam at a postseconday institution (e.g., college) who will live in a domitoy o compaable congegate living aangement appoved by the institution. Students may decline the vaccine afte they have ead and signed the MDPH Meningococcal Infomation and Waive Fom povided by thei institution. These equiements apply to newly- enolled full-time esidential students, egadless of gade and yea of study. 10 At esidential schools with lowe gades: The equiements apply to esidential students in gades pe-k though 8 only if the school combines these gades in the same school with students in gades K-4 and 7-11 feshmen-gaduates; Tdap Gades 7-11 feshmen-gaduates; K-5 and 7-12 feshmen-gaduates; Gades 7-12 feshmen-gaduates; K-12 feshmen-gaduates; Gades 7-12 feshmen-gaduates; Massachusetts Depatment of Public Health Immunization Pogam 2015