Harrison Central School District Harrison, New York

Transcription

1 Harrison Central School District Harrison, New York Dear Parents and Guardians of Returning Students: Attached are health forms to be completed by you and your pediatrician and returned to the school nurse. The PHYSICAL EXAM FORM is for the convenience of your physician. The physical exam will be acceptable if performed within the 12 months prior to the start of the current school year. If the exam form is not received before December 31 st your child will automatically be scheduled for a health inspection by the School Doctor. No diagnostic testing, and no immunizations are given in school. Please note that children entering Kindergarten, 2 nd, 4 th, 7 th and 10 th grades are required by the State of New York to have a physical examination including Body Mass Index (BMI) and Weight Class Status The DENTAL EXAM FORM should be completed and returned before the end of the school year. The REFERENCE SHEET lists health policies. Parents and students are urged to fully acquaint themselves with these policies. The Harrison Central School District is required by the NYSDOH and CDC to provide families with information regarding influenza disease and the benefits of influenza immunizations. Attached is the Seasonal Flu Guide for Parents for your review. It is our goal to provide a healthy and safe environment for your child. Your attention to these forms is appreciated. Sincerely, School Nurse

2 HEALTH CERTIFICATE / APPRAISAL FORM NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits and triennially for the Committee on Special Education (CSE). Page 1 of 2 Name: Date of Birth: / / Gender: M F Grade: IMMUNIZATIONS / HEALTH HISTORY Tuberculosis Screening - NEW ENTRANTS ONLY - (complete back of this form) No immunizations given today Immunizations given since last Health Appraisal (list below): Immunization record attached (or completed back of this form) Dental Referral: Yes No Not done Date: Comments: Significant Medical/Surgical History: See attached Allergies: LIFE THREATENING Food: Insect: Other: Seasonal Medication: PHYSICAL EXAM Date of Exam: Height: Weight: Blood Pressure: Pulse: Referral Body Mass Index:. Vision - without glasses/contact lenses R L Weight Status Category (BMI Percentile): Vision - with glasses/contact lenses R L less than 5 th 5 th through 49 th 50 th through 84 th Vision - Near Point R L 85 th through 94 th 95 th through 98 th 99 th and higher Hearing Pass 20 db sc both ears or: R L General Appearance: Skin: Head: Eyes, Ears, Nose, Throat, Teeth: Lungs: Heart: Abdomen: Tanner: I. II. III. IV. V. Scoliosis: Negative Positive: EXAM ENTIRELY NORMAL Specify any abnormality (attach additional pages as needed): MEDICATIONS Medications (list all): None Additional medications listed separately attached physician s orders Name: Dosage/Time: Name: Dosage/Time: If AM dose is missed at home: I assess this student to be self-directed Yes No Student may self carry and self administer medication Yes No Note: Nurse will also assess self-direction for the school setting. Please advise parent to send in additional medication in the event that emergency sheltering is necessary at school or if the morning medication has not been given. PHYSICAL EDUCATION / SPORTS / PLAYGROUND / WORK QUALIFICATION / CSE CONSIDERATION Free from contagions & physically qualified for all physical education, sports, playground, work & school activities OR only as checked: Limited contact: cheerlead, gymnastics, ski, volleyball, cross-country, handball, fence, baseball, floor hockey, softball. Non-contact: badminton, bowl, golf, swim, table tennis, tennis, archery, weight train, crew, dance, track, run, walk, rope jump. Specify medical accommodations needed for school (provide supporting documentation): Known or suspected disability: Restrictions: Protective equipment required: Athletic Cup Sport goggles/impact resistant eyewear Other: OTHER MEDICAL INFORMATION & AUTHORIZING SIGNATURES None Please monitor Please monitor Specify current diseases: Asthma Diabetes: Type 1 Type 2 Hyperlipidemia Hypertension Other: Physician s Signature: Date: Phone: (Physician s Stamp below) Physician s Name/Address: Fax: Parent Signature: Date: Phone 5/26/11 This health appraisal complies with NYSED requirements above and is valid for twelve months, with the exception of any illness or injury lasting more than five days that will require review by private healthcare provider and the school physician. Go to page 2

3 HEALTH CERTIFICATE / APPRAISAL FORM NYSED requires an annual physical exam for new entrants, students in Grades K, 2, 4, 7 and 10, sports, working permits and triennially for the Committee on Special Education (CSE). Page 2 of 2 IMMUNIZATION HISTORY DTaP/DT/Td Tdap Polio IPV Live Measles Vaccine #1 #2 Disease Live Mumps Vaccine #1 #2 Disease Live Rubella Vaccine #1 #2 Disease (Not acceptable without serology) Varicella #1 #2 Hepatitis B Vaccine #1 #2 #3 Hepatitis A #1 #2 #3 TUBERCULIN SKIN TEST *** If the student has had a medically documented, positive TST in the past, the test need not be repeated. Go to Section B below. A. Tuberculin Skin Test (Mantoux/Intermediate PPD) WITHIN 12 MONTHS OF ENTRY Test must be read by a health care provider hours after administration. If there is no induration, indicate 0 under results. Tine or Mono-Vac tests are not accepted. Date test administered: / / Date test read: / / Result: mm induration Test interpretation (refer to table below): Negative Positive Risk Factor Close contact with case of TB/is immunocompromised Born in country with a high rate of tuberculosis Traveled or lived for a month or more in a country with a high rate of tuberculosis No risk factors (PPD should not be performed) Positive Result 5 mm or more 10 mm or more 10 mm or more 15 mm or more (if PPD done) B. If Tuberculin Skin Test is Positive, now or previously, the following are required: 1. Date of Positive PPD: / / 2. Chest X-ray: (please attach copy of report) / / Normal Abnormal If Abnormal, describe: 3. Clinical Evaluation: Normal Abnormal If Abnormal, describe: 4. Treatment: No (please explain): Yes (Drug, Dose, Frequency, Dates): C. Tuberculin Skin Test screening not indicated (Student has none of the above risk factors): (Physician s Signature Required) Physician s Signature: Phone: (Physician s Stamp below) Physician s Name/Address: Fax: 5/26/11 This health appraisal complies with NYSED requirements above and is valid for twelve months, with the exception of any illness or injury lasting more than five days that will require review by private healthcare provider and the school physician.

4 HARRISON CENTRAL SCHOOL DISTRICT 50 Union Avenue Harrison, NY Dentist Certificate Dear Parents: You are encouraged to have your child s teeth examined by a dentist at least once a year. If, for any reason, you are unable to provide this care for your child, please advise the school nurse, who may be able to assist you. Please return this completed Dentist Certificate to your school nurse. Student Name: Address: School Year: School: Teacher: Home Phone: Grade Level: To be completed by dentist Date of examination: Please check to indicate what was done during this examination: Inspection Cleaning Repair No treatment needed Comments: Print Name of Dentist: (Dentist s Stamp below) Address: Telephone:

5 HARRISON CENTRAL SCHOOL DISTRICT 50 Union Avenue Harrison, NY REFERENCE SHEET COLDS, FEVER, RASH, SORE THROAT OR OTHER SIGNS OF ILLNESS Children with colds, fever, rash, sore throats awaiting throat culture results and other signs of illness SHOULD BE KEPT AT HOME. It is wise to check with your doctor regarding care and treatment of illness. Students who are absent for a period of more than two weeks are required to present a doctor s statement regarding the nature of illness and any necessary modifications in the school program. RASHES AND SKIN LESIONS Children with rashes and skin lesions are excluded from school pending diagnosis. A written statement from the doctor is required upon return to school. INTERNAL MEDICATIONS (No medicines are to be given to children in school.) NO internal medication is dispensed by school personnel. School authorities are not engaged in the practice of medicine, but are responsible for administering first aid and then placing the child under jurisdiction of his/her parents for any further medical care. Under certain unusual conditions, when it is necessary for the child to take internal medication during school hours, the nurse may cooperate with the family physician and the parents. If the parent submits (1) a written request from the physician and (2) a parental request to the school authorities, then the nurse may administer this medication during school hours. Also, the physician must indicate frequency and dosage of the prescribed medication, as well as the name of the medication and the nature of illness for which the medication is prescribed. NOTICES REGARDING CONDITIONS FOUND AFTER SCREENING TESTS Any child found to have a condition needing further evaluation following any of the screening procedures performed in school, is recommended for further professional evaluation. The notice form should be completed by the evaluating person and returned to the school nurse. MODIFIED ACTIVITY IN PHYSICAL EDUCATION (Gym Excuses) A note from a parent or guardian will excuse a child from PE Class and/or related physical activities for up to two (2) consecutive PE Classes. A physician s note may be requested for repeated absence from PE and related activities at the discretion of the school physician. If a child is excused from PE following treatment from a private physician, a note is needed by that physician for the child to resume PE, sports, and physical activities associated with recess. FIRST AID (For illness or injury as applied to schools) The responsibility of the school is limited to first aid first treatment of a child until that child can be turned over to the parent, guardian, or person designated by the parent. When a child has had an injury out of school, the school nurse cannot accept responsibility for taking care of the wound, nor is she permitted to change the dressing.