Student Health Information Packet. Grades Lyndhurst Campus. Requirements. Table of Contents. Student Grade 11-12

Transcription

1 Lyndhurst Campus Completed packets are due by June 3, Student Health Information Packet Grades 7-8 Student Grade Last Name First Dear Lyndhurst Parents, It is our responsibility to plan for the health and safety of each Hawken Student during the times he/she is under school authority. We also hope to simplify the parents role in the gathering of school health information. In so planning, we have compiled this Health Information Packet, containing all required student health forms. We are relying on the expedient cooperation of Hawken parents in the completion of those portions of the packet that apply to each of your children, including the acquisition of physician signatures when indicated. We ask that you return one completed health packet for each Hawken child. Packets should be returned to the Clinic by June 3, The well being of each of our students is of the utmost importance to us. Planning for their health and safety necessitates that we allow time for organizing and processing all of this very important information before students return to school in the fall. Thank you for your cooperation with procedures that assist us in offering your children the very best in health services. Requirements All 7th and 8th grade students must submit the following forms: 1. Emergency Medical Authorization (page 2) 2. Annual Health Update (page 3) 3. Administraton of Medication (only if needed) (page 4) 4. Ohio High School Athletic Association (OHSAA) Preparticipation Physical Exam New 7th and 8th grade students must submit the Immunization Requirements form (page 5) in addition to the forms listed above. 7th and 8th grade students must have one dose of Td / Tdap. Table of Contents Emergency Medical Authorization... 2 Annual Health Update... 3 Administration of Medication... 4 Immunization Requirements... 5 OHSSA Athletic Forms... Included

2 Emergency Medical Authorization Student Name Grade Date of Birth Phone: Home Cell Address _ City State Zip Residential Parent(s) or Guardian(s) Father/Guardian 1 Name Social Security Address (if different from above) ) City State Zip Phone: Home Work Cell Mother/Guardian 2 Name Social Security Address (if different from above) City State Zip Phone: Home Work Cell Name of Insurance Company Primary Policy # Policy Holder Secondary Policy # Policy Holder Persons to contact if unable to reach parent/guardian (please give the name of one relative or child-care provider plus one additional person): Must have two listed. Name 1 Relationship to Student Phone: Home Work Cell Address Name 2 Relationship to Student Phone: Home Work Cell Address _ I hereby give consent for the use of the following medical care providers and local hospital to be called: Physician Phone Specialist Phone Dentist Phone Preferred Hospital (Emergency transport is always to Hillcrest Meridia until patients are stabilizedfor transport to the preferred hospital.) Parts 1 or 2 of the next section must be completed. Part 1: To Grant Consent In the event reasonable attempts to contact me at (phone 1) or (phone 2) or other parent/guardian at (phone 1) or (phone 2) have been unsuccessful, I hereby give consent for the administration of any treatment deemed necessary by Dr. (preferred doctor) or Dr. (preferred dentist), or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and the transfer of the child to hospital This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concurring in the necessity for such surgery is performed. Signature of Parent/Guardian Date Part 2: Refusal to Consent I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish for school authorities to take the following action: Signature of Parent/Guardian Date Witnessed by Name 1 Date Name 2 Date 2

3 Annual Health Update The following information is needed by any hospital or practitioner not having access to the student s medical history. Please include all information to which an emergency physician or the school nurse would need to best meet the student s health care needs. Student Name Medication Allergies (list): Other Allergies (list): History of serious illnesses/fractures/surgery: Chronic conditions: Physical limitations: Pertinent facts for physician alert: Special instructions for emergency care: Last Diphtheria/Tetanus Booster / / Immunizations Received This Year (MMR, Hepatitis, etc.): *Please indicate name of immunization and date received (day/date/year). 1 / / 3 / / 2 / / 4 / / Family History Serious illness in the immediate family (indicate family member): Diabetes Tuberculosis Heart Disease High Blood Pressure Cancer Any additional information: 3

4 Administration of Medication Medication Procedures Hawken School urges you to schedule, to the extent possible, medication of a student outside of school hours. When that is not possible, medication will be permitted, insofar as feasible, during school hours. The following requirements must be met in order to ensure our students safety, and in order to comply with current State recommendations: All requests for medications to be administered during school or on school trips must include WRITTEN INSTRUCTIONS, including purpose of medication, dosage, route, timing, and side effects to be reported, and must be submitted for each new school year (see below). Medical needs may arise during the course of the school year for which additional medication forms will be required. These are available from the school clinic; however, a signed (faxed) request from your physician and a parent that includes all of the written instructions (see above) is all that is required. Requests to administer ANY medication (including non-prescription medications purchased over the counter) will require the signature of the physician and the parent. (Please note that this is a change from the past when only prescriptions required a physician s signature. We are hopeful that parents will find it easy to comply with this current State recommendation by anticipating students needs [for Tylenol and allergy medication, for example] when they meet with their physicians in the spring preceding the following school year). Prescription medication in its original prescription bottle, labeled with the appropriate date, student s name, and exact dosage will be given when accompanied by the written instructions signed by the parent and physician. (Pharmacists may be asked to divide prescriptions into two bottles in order that the home and the school each have properly labeled medications). Non-prescription medications will be given only when they come to school in their original sealed container accompanied by the written instructions signed by the parent and the physician. (Sealed sample size medications are ideal, as are labeled, sealed, foil-wrapped tablets or pills). Tylenol (or generic Acetaminophen) and Motrin (Ibuprofn) is stocked in the Lyndhurst school clinic, and may be given at the nurse s discretion if the parent and physician signify in writing that they authorize the nurse to do so (see below). Students may only carry emergency medications in school and on the bus (i.e. asthma inhalers) if the proper forms are filled out. All other medications must be brought into the school by an adult and given to the school health nurse. The first dose of a new medication may not be administered at school. Parents must pick up unused medication. We will dispose of it 30 days after it is discontinued or on June 30 of each school year. Administration of Medication While Under School Authority Complete and submit the following information only if you anticipate that your child will need to take medication during school. We ask that students taking medication at school or on school trips, as either daily or as needed medication, do so under the school nurse s supervision. In exceptional circumstances when the school nurse is not immediately available, such as school trips, a teacher or administrator may be requested by the school to administer medication. If you can anticipate that you ll want medicine to be administered to your child at school and/or on trips during the 2011/12 school year, please complete theinformation below as indicated, and give all medicines to the school nurse (in their original containers) at the beginning of the school year. Tylenol and Motrin are the only in-stock medications available from the school clinic. Parents must supply all other medications in their original (sealed) containers. Student Name Grade Level Medication Name Dosage & Route Purpose Time/Frequency Side Effects to be Reported Special Instructions: Parent/Guardian Signature Date Phone Physician s signature Date _ Phone *Must have both signatures for all medication even over the counter. It is understood that Hawken School and its school personnel, its agents and nurses are absolved from any responsibility which might be associated with the administration of such medication. 4

5 Immunization Requirements This page must be completed for all new Hawken students. Returning students should record vaccines received since April, 2010 on page 3 of this booklet. Immunization requirements are as follows: DPT (Diphtheria, Pertussis, Tetanus) Four (4) doses are required *5 *Fifth dose required if fourth dose was given prior to fourth birthday. Td/Tdap (Tetanus) one dose required prior to 7th and 8th grade. 1 2 Polio (Poliomyelitis) Oral. Three (3) doses are required *Fourth dose required if third dose was given prior to fourth birthday. *Incoming Kindergartners final dose must be administered after the fourth birthday MMR (Measles, Mumps, Rubella) One (1) dose is required on or after the first birthday. A second dose is required for all students. 1 2 TB ( Tuberculosisis) Skin Test Used to determine if your child has been exposed to TB and is highly recommended but not required. Tes Date Type Test Results (check one): Positive Negative Hepatitis B Series (required for all students) Hib (H. Influenza) Varicella (Chicken Pox) One dose required for 2nd through 5th graders, and two doses for incoming Kindergarten and 1st grade students. 1 2 *Exceptions are provided for under law. They may be discussed with the school nurse. OHSAA Athletic Form Attention Parents: The State of Ohio mandates medical clearance annually before students may participate in athletics. Students entering grades seven and eight next fall will not be allowed to participate in any athletic practice or event (beginning August 2011) until the completed Ohio High School Athletic Association Preparticipation Physical Exam Form and the OHSAA Authorization Form, both attached, have been received and reviewed by our staff. Hawken School encourages its students to seek a comprehensive athletic health screening with a strong health promotion component. Should you wish to use your private physician for this service, we ask that you arrange for an appointment at this time. This is because we are asking that all health forms be completed and returned with this booklet before the last day of school on June 3, This allows for processing of records before students return next fall. Physicals are good for one calendar year. Thank you for your expedient compliance with this State mandate! Sincerely, Cyril Nalty Lyndhurst Athletic Director Vicki L. Goodrich, R.N., B.S.N. Lyndhurst School Nurse Note: Athletes will be unable to participate in sports/practice/activities without filling out pages 2, 3, the two OHSAA forms referred to above. 5

6 x Ohio High School Athletic Association Preparticipation Physical Evaluation DATE OF EXAM: Page 1 of 4 Name Sex Age Date of Birth Grade School Sport(s) Address Phone Personal Physician In case of emergency, contact: Name Relationship Phone (H) (W) (Cell) (Cell) History This section is to be carefully completed by the student and his/her parent(s) or legal guardian(s) before participation in interscholastic athletics in order to help detect possible risks. Explain "YES" answers in the space provided. Circle Yes No questions you don't know the answer to. 25. Do you cough, wheeze, or have difficulty breathing during or after exercise? 26. Is there anyone in your family who has asthma? 1. Has a doctor ever denied or restricted you participation in sports for any reason? Yes No 27. Have you ever used an inhaler or taken asthma medicine? 28. Were you born without or are you missing a kidney, an eye, a testicle, or 2. Do you have an ongoing medical condition (like diabetes or asthma)? 3. Are you currently taking any prescription or nonprescription (over-the-counter) medicines or pills? any other organ? 29. Have you had infectious mononucleosis (mono) within the last month? 30. Do you have any rashes, pressure sores, or other skin problems? 4. Do you have allergies to medicines, pollens, foods, or stinging insects? 31. Have you had a herpes skin infection? 5. Do you think you are in good health? 32. Have you ever had a head injury or concussion? 6. Have you ever passed out or nearly passed out DURING exercise? 33. Have you been hit in the head and been confused or lost your memory? 7. Have you ever passed out or nearly passed out AFTER exercise? 34. Have you ever had a seizure? 8. Have you ever had discomfort, pain, or pressure in your chest during exercise? 35. Do you have headaches with exercise? 36. Have you ever had numbness, tingling, or weakness in your arms or 9. Does your heart race or skip beats during exercise? 10. Has a doctor ever told you that you have (check all that apply): legs after being hit or falling? 37. Have you ever been unable to move your arms or legs after being hit or High Blood Pressure A heart murmur falling? High Cholesterol A heart infection 38. When exercising in the heat, do you have severe muscle cramps or 11. Has a doctor ever ordered a test for your heart? (for example, ECG, echocardiogram) become ill? 39. Has a doctor told you that you or someone in your family has sickle cell 12. Has anyone in your family died for no apparent reason? 13. Does anyone in your family have a heart problem? trait or sickle cell disease? 40. Have you had any problems with your eyes or vision? 14. Has any family member or relative died of heart problems or of sudden death before age 50? 41. Do you wear glasses or contact lenses? 42. Do you wear protective eyewear, such as goggles or a face shield? 15. Does anyone in your family have Marfan syndrome? 43. Are you happy with your weight? 16. Have you ever spent the night in a hospital? 44. Are you trying to gain or lose weight? 17. Have you ever had surgery? 45. Has anyone recommended you change your weight or eating habits? 18. Have you ever had an injury, like a sprain, muscle or ligament tear, or tendinitis, that caused you to miss a practice or game? If yes, circle affected area below: 46. Do you limit or carefully control what you eat? 47. Do you have any concerns that you would like to discuss with a doctor? 48. Record the dates of your most recent immunizations (shots) 19. Have you had any broken or fractured bones or dislocated Tdap MMR Hepatitis B joints? If yes, circle below: Chicken Pox Meningococcal 20. Have you had a bone or joint injury that required x-rays, MRI, CT, surgery, injections, rehabilitation, physical therapy, a FEMALES ONLY brace, a cast, or crutches? If yes, circle below: 49. Have you ever had a menstrual period? Head Neck Shoulder Upper Arm Elbow Forearm Hand / Fingers Chest 50. How old were you when you had your first menstrual period? Upper Lower Foot / back back Hip Thigh Knee Calf/shin Ankle Toes 51. How many periods have you had in the last 12 months? 21. Have you ever had a stress fracture? 22. Have you been told that you have or have you had an x-ray for atlantoaxial (neck) instability? 23. Do you regularly use a brace or assistive device? 24. Has a doctor ever told you that you have asthma or allergies? Explain "Yes" Answers Here: (Attach additional sheets as needed) I (we) hereby state, to the best of my (our) knowledge, my (our) answers to the above questions are complete and correct. Signature: Signature: Athlete Parent or Guardian (If athlete is under 18) Date: The student has family insurance Yes No; If yes, family insurance company name and policy number: Rev. 2/11 NOTE: CONSENT AND HIPAA RELEASE FORMS THAT MUST BE SIGNED BY BOTH THE PARENT AND THE STUDENT ARE ON A SEPARATE SHEET. NOTE: HISTORY AND ALL CONSENT FORMS MUST BE COMPLETED PRIOR TO PHYSICAL EXAMINATION Modified from American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine, Rev. 03/10

7 Physical Examination Form The section below is to be completed by physician or staff after history and consent forms are completed. Page 2 of 4 Students Name Birth Date Height Weight % Body Fat (optional) Pulse BP /, /, / Vision R 20/ L 20/ Corrected: Y N Pupils: Equal Unequal Follow-Up Questions on More Sensitive Issues (Optional) 1. Do you feel stressed out or under a lot of pressure? 2. Do you ever feel so sad or hopeless that you stop doing some of your usual activities for more than a few days? 3. Do you feel safe? 4. Have you ever tried cigarette smoking, even 1 or 2 puffs? Do you currently smoke? 5. During the past 30 days, did you use chewing tobacco, snuff, or dip? 6. During the past 30 days, have you had at least 1 drink of alcohol? 7. Have you ever taken steroid pills or shots without a doctor's prescription? 8. Have you ever taken any supplements to help you gain or lose weight or improve your performance? 9. Questions from the Youth Risk Behavior Survey ( on guns, seatbelts, unprotected sex, domestic violence, drugs, etc. Notes: MEDICAL Appearance Eyes/ears/nose/throat Hearing Lymph nodes Heart Murmurs Pulses Lungs Abdomen Genitalia (males only) Skin MUSCULOSKELETAL Neck Back Shoulder/arm Elbow/forearm Wrist/hand/fingers Hip/thigh Knee Leg/ankle Foot/toes *Multiple-examiner set-up only. Notes: Normal Abnormal findings Initials* Clearance Cleared without restriction Cleared, with recommendations for further evaluation or treatment for: Not cleared for: All Sports Certain sports: Reason: Recommendations: Emergency Information: Allergies: Other Information: Name of Physician: (print/type/stamp) (M.D., D.O., D.C.) Date: If the Physician's Assistant (P.A.) or Advanced Nurse Practitioner (A.N.P.) performed the exam, name and address of collaborating physician or physician group: Address: Phone: Signature of Physician: Date:

8 Page 3 of 4 OHSAA AUTHORIZATION FORM I hereby authorize the release and disclosure of the personal health information of ("Student"), as described below, to ("School"). The information described below may be released to the School principal or assistant principal, athletic director, coach, athletic trainer, physical education teacher, school nurse or other member of the School's administrative staff as necessary to evaluate the Student's eligibility to participate in school sponsored activities, including but not limited to interscholastic sports programs, physical education classes or other classroom activities. Personal health information of the Student which may be released and disclosed includes records of physical examinations performed to determine the Student's eligibility to participate in school sponsored activities, including but not limited to the Pre-participation Evaluation form or other similar document required by the School prior to determining eligibility of the Student to participate in classroom or other School sponsored activities; records of the evaluation, diagnosis and treatment of injuries which the Student incurred while engaging in school sponsored activities, including but not limited to practice sessions, training and competition; and other records as necessary to determine the Student's physical fitness to participate in school sponsored activities. The personal health information described above may be released or disclosed to the School by the Student's personal physician or physicians; a physician or other health care professional retained by the School to perform physical examinations to determine the Student's eligibility to participate in certain school sponsored activities or to provide treatment to students injured while participating in such activities, whether or not such physicians or other health care professionals are paid for their services or volunteer their time to the School; or any other EMT, hospital, physician or other health care professional who evaluates, diagnoses or treats an injury or other condition incurred by the student while participating in school sponsored activities. I understand that the School has requested this authorization to release or disclose the personal health information described above to make certain decisions about the Student's health and ability to participate in certain school sponsored and classroom activities, and that the School is a not a health care provider or health plan covered by federal HIPAA privacy regulations, and the information described below may be redisclosed and may not continue to be protected by the federal HIPAA privacy regulations. I also understand that the School is covered under the federal regulations that govern the privacy of educational records, and that the personal health information disclosed under this authorization may be protected by those regulations. I also understand that health care providers and health plans may not condition the provision of treatment or payment on the signing of this authorization; however, the Student's participation in certain school sponsored activities may be conditioned on the signing of this authorization. I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken by a health care provider in reliance on this authorization, by sending a written revocation to the school principal (or designee) whose name and address appears below. Name of Principal: School Address: This authorization will expire when the student is no longer enrolled as a student at the school. NOTE: IF THE STUDENT IS UNDER 18 YEARS OF AGE, THIS AUTHORIZATION MUST BE SIGNED BY A PARENT OR LEGAL GUARDIAN TO BE VALID. IF THE STUDENT IS 18 YEARS OF AGE OR OVER, THE STUDENT MUST SIGN THIS AUTHORIZATION PERSONALLY. Student s Signature Birth date of Student, including year Name of Student's personal representative, if applicable I am the Student's (check one): Parent Legal Guardian (documentation must be provided) Signature of Student's personal representative, if applicable Date A copy of this signed form has been provided to the student or his/her personal representative THE STUDENT SHALL NOT BE CLEARED TO PARTICIPATE IN INTERSCHOLASTIC ATHLETICS UNTIL THIS FORM HAS BEEN SIGNED AND RETURNED TO THE SCHOOL

9 Rev. 2/11 Page 4 of Ohio High School Athletic Association Eligibility and Authorization Statement This document is to be signed by the participant from an OHSAA member school and by the participant s parent. I have read, understand and acknowledge receipt of the OHSAA brochure entitled Your Athletic Eligibility, which contains a summary of the eligibility rules of the Ohio High School Athletic Association. I understand that a copy of the OHSAA Handbook is on file with the principal and athletic administrator and that I may review it, in its entirety, if I so choose. All OHSAA bylaws and regulations from the Handbook are also posted on the OHSAA web site at I understand that an OHSAA member school must adhere to all rules and regulations that pertain to the interscholastic athletics programs that the school sponsors, but that local rules may be more stringent than OHSAA rules. I understand that participation in interscholastic athletics is a privilege not a right. Student Code of Responsibility As a student athlete, I understand and accept the following responsibilities: I will respect the rights and beliefs of others and will treat others with courtesy and consideration I will be fully responsible for my own actions and the consequences of my actions I will respect the property of others I will respect and obey the rules of my school and laws of my community, state and country I will show respect to those who are responsible for enforcing the rules of my school and the laws of my community, state and country I understand that a student whose character or conduct violates the school s Athletic Code or School Code of Responsibility is not in good standing and is ineligible for a period of time as determined by the principal Informed Consent By its nature, participation in interscholastic athletics includes risk of injury and transmission of infectious disease such as HIV and Hepatitis B. Although serious injuries are not common and the risk of HIV transmission is almost nonexistent in supervised school athletic programs, it is impossible to eliminate all risk. Participants have a responsibility to help reduce that risk. Participants must obey all safety rules, report all physical and hygiene problems to their coaches, follow a proper conditioning program, and inspect their own equipment daily. PARENTS, GUARDIANS OR STUDENTS WHO MAY NOT WISH TO ACCEPT RISK DESCRIBED IN THIS WARNING SHOULD NOT SIGN THIS FORM. STUDENTS MAY NOT PARTICIPATE IN AN OHSAA-SPONSORED SPORT WITHOUT THE STUDENT S AND PARENT S/GUARDIAN S SIGNATURE. I understand that in the case of injury or illness requiring transportation to a health care facility, that a reasonable attempt will be made to contact the parent or guardian in the case of the student-athlete being a minor, but that, if necessary, the student-athlete will be transported via ambulance to the nearest hospital. To enable the OHSAA to determine whether the herein named student is eligible to participate in interscholastic athletics in an OHSAA member school I consent to the release to the OHSAA any and all portions of school record files, beginning with seventh grade, of the herein named student, specifically including, without limiting the generality of the foregoing, birth and age records, name and residence address of parent(s)or guardian(s), residence address of the student, academic work completed, grades received and attendance data. I consent to the OHSAA s use of the herein named student s name, likeness, and athletic-related information in reports of contests, promotional literature of the Association and other materials and releases related to interscholastic athletics. I understand that if I drop a class, take course work through Post Secondary Enrollment Option, Credit Flexibility or other educational options, this action could affect compliance with OHSAA academic standards and my eligibility. I understand all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. Further I understand that if my student is removed from a competition due to a suspected concussion, he or she will be unable to return to competition that day without the written authorization from a physician (M.D. or D.O.) or an athletic trainer which indicates that the student has not been concussed.. By signing this we acknowledge that we have read the above information and that we consent to the herein named student s participation. *Must Be Signed Before Physical Examination Student s Signature Birth date Grade in School Date Parent s or Guardian s Signature Date

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