Health Forms Information Letter

Spring 2013 Health Forms Information Letter All completed health forms must be returned to the division Health Office. Each form has division mailing address and fax number (if available). Completed, signed forms may be scanned and emailed to: healthforms@ecfs.org Dear Parents, Ethical Culture Fieldston School requires every student to have an annual physical. Please review the following school policies: 1. A completed physical form signed by a parent and physician, and a current immunization record must be on file in order for your child to attend school, participate in athletics, and/or go on a class trip. 2. In order for the nurse or designee to administer prescription medication during the school day a Prescription Medication Form accompanied by a prescription (original or photocopy) from a licensed prescriber. The form must include the following: a. Medication, dose, and diagnosis or reason for the medication b. Dose and time to be administered c. Dates to be dispensed 3. Students are not permitted to carry controlled substances at any time; these medications must be stored and administered in the nursing office. All students may carry current prescription epi-pens and/or inhalers upon instruction from a physician. Parents must also supply a second epi-pen or inhaler to be stored in the nursing office. 4. If your child requires medication on a class trip (Middle and Upper School only), the Class Trip Medication Form signed by the parent must be filed with the division health office. 5. If applicable, an Allergy Form must be completed for all children with allergies and signed by a physician. 6. If applicable, an Asthma Form must be completed for all children with asthma and signed by a physician. 7. All Kindergarten students and new students in Grades 1-5 must have an eye examination signed by an optometrist or ophthalmologist. Thank you for your cooperation in this matter. Sincerely, 2013 PHYSICAL FORMS ARE DUE BEFORE AUGUST 12, 2013 Eileen M. Coogan, RN, BSN, MSN, NSNC Amy McNamara, RN, BA, BSN, NSNC Susan Gower, RN BSN, MSPH Stacey Husted, RN, BSN Please contact your division health office with any questions: ETHICAL CULTURE: Sue Gower, RN, BSN, MSPH 33 Central Park West, New York, NY 10023 Tel (212) 712-6265 Faxes not accepted for EC student health forms FIELDSTON LOWER: Stacey Husted, RN, BSN 3901 Fieldston Road, Bronx, NY 10471 Tel (718) 329-7292 Fax (718) 329-7304 FIELDSTON MIDDLE/UPPER: Eileen Coogan, RN, BSN, MSN, NSNC Amy McNamara, RN, BA, BSN, NSNC 3901 Fieldston Road, Bronx, NY 10471 Tel (718) 329-7276 Fax (718) 329-7346

HEALTH FORMS CHECKLIST March 2013 Please print each applicable form, complete, sign and return to the appropriate ECFS division health office as indicated. Please read the Health Forms Information Letter ALL STUDENTS must submit a physical annually, signed by parent and physician DUE 8/12/13 ECFS Physical and Immunization Form (2 pages)... must be signed by parent & physician Additional Health Forms: (please submit if applicable) Prescription Medication Form... must be signed by parent & physician Allergy Form... must be signed by parent & physician Asthma Form... must be signed by parent & physician Class Trip Medication Form (middle/upper school students only)... must be signed by parent Forms for New Students: Eye Examination Form... must be signed by Optometrist/Ophthalmologist (for all Kindergarten students and new students Grades 1-5) Health Forms Packet: This file includes all individual forms plus the health forms information letter. PLEASE CONTACT YOUR DIVISION HEALTH OFFICE WITH ANY QUESTIONS: ETHICAL CULTURE: Sue Gower, RN, BSN, MSPH 33 Central Park West, New York, NY 10023 Tel (212) 712-6265 Faxes not accepted for EC health forms FIELDSTON LOWER: Stacey Husted, RN, BSN 3901 Fieldston Road, Bronx, NY 10471 Tel (718) 329-7292 Fax (718) 329-7304 FIELDSTON MIDDLE/UPPER: Eileen Coogan, RN, BSN, MSN, NSNC Amy McNamara, RN, BA, BSN, NSNC 3901 Fieldston Road, Bronx, NY 10471 Tel (718) 329-7276 Fax (718) 329-7346 Email address for all health forms: healthforms@ecfs.org

physical Form All completed medical forms must be returned to the Nurse s office before 8/12/13 check the division your child is attending and Send completed & signed form to ECFS o ethical culture 33 Central Park West, New York, NY 10023 Faxes not accepted for EC students o fieldston lower 3901 Fieldston Road, Bronx, NY 10471 fax (718) 329-7304 o fieldston middle/upper 3901 Fieldston Road, Bronx, NY 10471 FAX (718) 329-7346 E-mail: healthforms@ecfs.org Student s Name_ Grade Sex Date of Birth All Parents/Guardians should be listed below. Student lives with Parent Both Parents Guardian Parent s Name_ Parent s Address City, State, Zip_ Parent s Name Parent s Address City, State, Zip Parent s Home phone ( ) Parent s Home phone Parent s Business phone ( ) Parent s Business phone ( ) Parent s Cell phone ( ) Parent s Cell phone ( ) Physician s/pediatrician s Name Physician s Telephone ( ) Medical Information School nurse may administer the following as needed: May substitute generic for below. Please check choice(s). Lower Schools (EC, FL) Cough drops/lozenges Advil Tylenol Benadryl Antacid Antibiotic Ointment I do not give permission for my child to receive any OTC medications. Daily Medications TAKEN AT HOME Allergies - Describe Medication Seasonal Food Stinging Insects Attached Allergy Form Completed Cardiac Arrhythmias Heart Murmur Endocrine Diabetes type Insulin Hypoglycemia Thyroid Hypothyroid Hyperthyroid Heart Disease Gastro-Intestinal Crohn s Disease Celiac Disease Eating Disorders Anorexia Binge eating Bulimia Food Intolerance Genito-Urinary/Gynecological Dysmenorrhea Urinary Tract Infections Musculoskeletal Injuries Osgood Schlatters Scoliosis Neurological/ Psychological ADD/ ADHD Anxiety Depression Migraines OCD Tourettes Seizure Disorder Pulmonary Asthma Attached Asthma Form Completed Positive Mantoux mm Treatment Surgery Emergency Contact (if Parent/Guardian cannot be reached) PLEASE PRINT Name Tel ( ) Cell ( ) RELATIONSHIP Consent for Medical Treatment & Release of Medical Information I give my permission for the School Nurse to administer first-aid as needed. I give my permission for the School Nurse to release medical information as appropriate, to involved school staff/faculty and to medical personnel on school related activities. In an urgent situation, every effort will be made to contact the parent and family physician IMMEDIATELY. In the event that neither can be reached promptly, I hereby give authority to the school to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. Signature of Parent/Legal Guardian Date Page 1 of 2

physical Form All completed medical forms must be returned to the Nurse s office before 8/12/13 To be completed by Physician Significant past illness or injury including allergies, surgery, and chronic conditions: Current Medical Problems: Significant Family History: Height Weight Blood Pressure Pulse NL AB NL AB NL AB HEENT Lungs Extremities Dental Status Cardiovascular Back Neck Abdomen Skin Lymph Genito Urinary Neuro Gyn: onset of menses Vision Screening: Rt. Lt. ; Age Hearing: Rt. Lt. ; Scoliosis (required by law) IMMUNIZATIONS & TESTS (Series and most recent booster) Need Dates for all vaccines VACCINE & TYPE Date Date Date Date Date VACCINE & TYPE Date Date Date DTP, Dtap, DT Hep A Tdap Hep B Polio IPV Varicella Disease OPV Vaccine Pneumococcal PCV 7 PCV 13 MMR Hib Measles Typhoid Mumps HPV (Gardasil) Rubella Meningococcal Menveo Menomune MCV4 Menactra TEST Date RESULT Other HCT/Hgb** Lead** **Required for Pre-K, K only. ACTIVITY: Full Limited (If limited, please explain with covering letter to P.E. Department and Nurse.) I have examined this student and have found his/her physical exam within normal limits. (If not, please explain.) He/she is physically fit to participate in Physical Education and/or sports. I give my permission for the school nurse to administer the medications indicated by the parents. (See reverse side.) Signature of Examining Physician Date SIGNATURE REQUIRED Page 2

ALLERGY FORM IF APPLICABLE ALL COMPLETED MEDICAL FORMS MUST BE RETURNED TO THE HEALTH OFFICE BEFORE 8/12/13 CHECK THE DIVISION YOUR CHILD IS ATTENDING AND RETURN COMPLETED & SIGNED FORM TO ECFS ETHICAL CULTURE 33 Central Park West, New York, NY 10023 Faxes not accepted for EC health forms FIELDSTON LOWER 3901 Fieldston Road, Bronx, NY 10471 Fax (718) 329-7304 FIELDSTON MIDDLE/UPPER 3901 Fieldston Road, Bronx, NY 10471 Fax (718) 329-7346 Student s Name Date of Birth Allergy to Weight: lbs. Asthma: YES (higher risk for a severe reaction) NO Extremely reactive to the following foods: THEREFORE: If checked, give epinephrine immediately for ANY symptoms if the allergen was likely eaten. If checked, give epinephrine immediately if the allergen was definitely eaten, even if no symptoms are noted. Place Student s Photo Here MEDICATIONS/DOSES Epinephrine (brand and dose): Antihistamine (brand and dose): Other (e.g., inhaler/bronchodilator if asthmatic): Parent/Guardian signature Date Physician/Healthcare Provider signature Date Home phone Cell phone Work phone Telephone Emergency contact/relationship to student Contact number Any SEVERE SYMPTONS after suspected or known ingestion: One or more of the following: LUNG: Short of breath, wheeze, repetitive cough HEART: Pale, blue, faint, weak pulse, dizzy, confused THROAT: Tight, hoarse, trouble breathing/swallowing MOUTH: Obstructive swelling (tongue and/or lips) SKIN: Many hives over body Combination of symptoms from different body areas: SKIN: Hives, itchy rashes, swelling (e.g., eyes, lips) GUT: Vomiting, crampy pain MILD SYMPTOMS ONLY: MOUTH: Itchy Mouth SKIN: A few hives around mouth/face, mild itch GUT: Mild nausea/discomfort Combination of symptoms from different body areas: SKIN: Hives, itchy rashes, swelling (e.g., eyes, lips) GUT: Vomiting, crampy pain 1. 1. INJECT EPINEPHRINE IMMEDIATELY 2. Call 911 3. Begin monitoring (see box below) 4. Give additional medications:* Antihistamine Inhaler (bronchodilator) if asthma *Antihistamines & inhalers/bronchodilators are not to be depended upon to treat a severe reaction (anaphylaxis). USE EPINEPHRINE. GIVE ANTIHISTAMINE 2. Stay with student; alert healthcare professional and parent 3. If symptoms progress (see above), USE EPINEPHRINE 4. Begin monitoring (see box below) MONITORING: Stay with student; alert healthcare professional and parent. Tell rescue squad epinephrine was given; request an ambulance with epinephrine. Note time when epinephrine was administered. A second dose of epinephrine can be given 5 minutes or more after the first if symptoms persist or recur. For a severe reaction, consider keeping student lying on back with legs raised. Treat student even if parents cannot be reached. Form adapted from FAAN (www.foodallergy.org) July 2010

ASTHMA FORM IF APPLICABLE TO BE COMPLETED BY AUTHORIZED HEALTH CARE PROVIDER, SIGNED BY PARENT AND RETURNED TO ECFS. ALL COMPLETED FORMS MUST BE RETURNED TO THE HEALTH OFFICE BEFORE BEFORE 8/12/13 CHECK THE DIVISION YOUR CHILD IS ATTENDING AND RETURN COMPLETED & SIGNED FORM TO ECFS ETHICAL CULTURE 33 Central Park West, New York, NY 10023 Faxes not accepted for EC health forms FIELDSTON LOWER 3901 Fieldston Road, Bronx, NY 10471 Fax (718) 329-7304 FIELDSTON MIDDLE/UPPER 3901 Fieldston Road, Bronx, NY 10471 Fax (718) 329-7346 Student s Name Grade Sex Date of Birth MEDICATIONS TO BE GIVEN AT SCHOOL: PLEASE CHECK ALL BOXES THAT APPLY Quick Relief: Albuterol HFA: Levobuterol (Xopenex) HFA: 2 puffs every four hours as needed for cough, wheezing or shortness of breath Repeat if not improved in 20 minutes 2 puffs every four hours as needed for cough, wheezing or shortness of breath Albuterol or Xopenex 0.63mg 1.25mg via nebulizer as needed for cough, wheezing or shortness of breath Use 15-30 minutes before exercise School to keep medication in health office Repeat if not improved in 20 minutes May substitute school stock Albuterol or Xopenex as needed Physician Authorization My signature below provides authorization for the above orders. All procedures will be implemented in accordance with state laws and regulations. This authorization is valid for the duration of this school year. Physician or Authorized Name/Title Health Care Provider Signature Date Parental Consent for Asthma Management in School As the parent(s) or guardian(s) of the above named student, I (we) hereby authorized the school nurse (or designee) to dispense the listed medication to my child. The school may communicate with the above health care provider about this student when necessary. Parent/Guardian Name Signature Date Parental Consent for Student Medication Self-Administration Student has permission to carry and self-administer. The health care provider has confirmed that the student is capable of appropriate self-administration of the above medication. If student is younger than 18, the parent/guardian assumes all liability related to this patient s use, timing and technique in self-administering this medication. Ethical Culture & Fieldston Lower: Elementary students are not permitted to carry prescribed inhalers until determined self-directed by parents, physician and school nurse. Student must have an Asthma Plan on file, and a second inhaler must be supplied to the appropriate division health office. Parent/Guardian Name Signature Date Parents/guardians must: Provide the necessary equipment (inhalers, spacers, etc.) Notify the school nurse of any changes in student health or medical plan Notify the school nurse immediately of any change in health care provider authorization Medication must be in the original pharmacy-labeled container

CLASS TRIP MEDICATIONS Fieldston Middle & Upper Schools ONLY FORM SUMMARY: OTC Yes No Rx Yes No ALL COMPLETED MEDICAL FORMS MUST BE RETURNED TO THE HEALTH OFFICE RETURN COMPLETED & SIGNED FORM TO: FIELDSTON MIDDLE/UPPER 3901 Fieldston Road, Bronx, NY 10471 Fax (718) 329-7346 Student s Name Grade Sex Date of Birth INSTRUCTIONS FOR STUDENTS NEEDING OVER-THE-COUNTER (OTC) AND/OR PRESCRIPTION MEDICATION ON A CLASS TRIP Please be advised students are not permitted to carry over the counter (OTC) or prescription medications (Rx) on a class trip. Chaperones will have on hand the OTC medications listed below. Please check off the medications your child may be given if needed. MEDICATION Acetaminophen [i.e., Tylenol] for pain or fever Benadryl tablets for rash or allergy Antacid [i.e., Tums] Cough drops I do not give permission for my child to receive any OTC medications. If you want your child to have any other OTC medication, please use the space below to indicate the product(s), dosage and time(s) to administer. The medication must be in its original packaging. Medication Dose Time(s) Medication Dose Time(s) If applicable, indicate any prescription (Rx) medications you are sending for your child. Legally, the school requires a written prescription (original or photocopy) for the medication from a licensed prescriber stating the student s name, medication, dosage and approximate time to be given. All medication must be in its original pharmacy container. Medication Dose Time(s) Medication Dose Time(s) Medication Dose Time(s) Prescribing physician s name & phone # I hereby authorize the school nurse, her designee or chaperone, to dispense as needed the above indicated prescription medication(s) to my child: Parent/Guardian Signature Date signed ALL MEDICATIONS MUST BE BROUGHT INTO THE HEALTH OFFICE AT LEAST ONE DAY PRIOR TO THE TRIP.

PRESCRIPTION MEDICATION FORM IF APPLICABLE ALL COMPLETED MEDICAL FORMS MUST BE RETURNED TO THE HEALTH OFFICE CHECK THE DIVISION YOUR CHILD ATTENDS AND RETURN COMPLETED & SIGNED FORM TO ECFS ETHICAL CULTURE 33 Central Park West, New York, NY 10023 Faxes not accepted for EC health forms FIELDSTON LOWER 3901 Fieldston Road, Bronx, NY 10471 Fax (718) 329-7304 FIELDSTON MIDDLE/UPPER 3901 Fieldston Road, Bronx, NY 10471 Fax (718) 329-7346 Student s Name Grade Sex Date of Birth THIS FORM IS FOR PRESCRIPTION MEDICATION ON CAMPUS DURING THE SCHOOL DAY. THERE IS A SEPARATE CLASS TRIP MEDICATIONS FORM FOR FIELDSTON MIDDLE/UPPER. ETHICAL CULTURE & FIELDSTON LOWER Elementary students are not permitted to carry prescribed epi-pens or inhalers until determined self-directed by parents, physician and division health office. They must have an Allergy and/or Asthma Plan on file, and a second pen or inhaler must be supplied to the health office. FIELDSTON MIDDLE & UPPER SCHOOL Students may carry prescribed epi-pens and/or asthma inhalers, but must have an Allergy and/or Asthma Plan on file in the health office. A second pen or inhaler must be supplied to the health office. STUDENTS ARE NOT PERMITTED TO CARRY CONTROLLED SUBSTANCES IN SCHOOL The legal requirements listed below for the administration of prescription medication to students by the school nurse or designee must be followed. 1. A prescription form (original or photocopy) for medication from a licensed prescriber stating the student s name, medication, dosage and approximate time to be given. 2. The medication must be in the original pharmacy labeled container. 3. Written permission by the parents or legal guardian for the administration of the medication. I hereby authorize the school nurse (or her designee) to dispense medication to my child as follows: PLEASE PRINT ALL INFORMATION Student s Name PLEASE INDICATE THE GRADE/FORM YOUR CHILD IS ENTERING AS OF SEPTEMBER 2013: Name of Medication and Dosage Dose to be given Time Dates when to dispense: From To Prescribing Physician s Name Prescribing Physician s Phone Number ( ) Parent s Signature Date signed THIS FORM MUST BE ACCOMPANIED BY A PRESCRIPTION FORM (ORIGINAL OR PHOTOCOPY) FROM A LICENSED PRESCRIBER.

EYE EXAMINATION FORM ALL KINDERGARTEN & NEW EC/FL STUDENTS ALL COMPLETED MEDICAL FORMS MUST BE RETURNED TO THE HEALTH OFFICE BEFORE 8/12/13 CHECK THE DIVISION YOUR CHILD IS ATTENDING AND RETURN COMPLETED & SIGNED FORM TO ECFS ETHICAL CULTURE 33 Central Park West, New York, NY 10023 Faxes not accepted for EC health forms FIELDSTON LOWER 3901 Fieldston Road, Bronx, NY 10471 Fax (718) 329-7304 Student s Name Grade Sex Date of Birth THIS FORM IS FOR ALL KINDERGARTEN STUDENTS AND NEW STUDENTS (GRADES 1-5) Because determination of visual acuity only is not completely adequate to uncover various eye problems that may interfere with the child s optimum handling of school curriculum, a complete eye examination by an ophthalmologist or optometrist is required for all new elementary students (Pre-K through 5 th Grade). Visual Acuity: Uncorrected Corrected Right Eye Left Eye Cycloplegic Refraction: Right Eye Left Eye Muscle Balance Depth Perception Color Based on the above, would you kindly make any recommendations that could be helpful to us in this child s classroom or extracurricular activities? Recommendation: Note: If this child wears glasses, please indicate by checking: Worn at all times Worn only for reading and close work Worn only for distance and board work Worn as child desires Name of Examiner: (please print) Signature of Examiner: