HEALTH INFORMATION FORM

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1 St. Michael Albertville STUDENT INFORMATION Name: School: HEALTH INFORMATION FORM Grade: DOB: HEALTH INFORMATION Does your child have any health problems (i.e. Asthma, Diabetes, ADHD, Heart Condition, Seizures, Depression, Handicaps, etc.)? If yes, describe. Is your child taking any medication at home? If yes, what medication(s)? Will your child be taking any medication at school? If yes, complete and sign a Medication Authorization form (available on web site) or call the school nurse. Does your child require any special healthcare procedures? If yes, list procedures. If at school, call the school nurse. Does your child have any allergies? If yes, list non-food allergies. If yes, list food allergies. Has an EpiPen been prescribed for your child s allergy? If your child has a food allergy that is life threatening/requires an EpiPen, you must call Food Services at prior to your child eating school /hot lunch. ADDITIONAL HEALTH INFORMATION Has your child been hospitalized, had any operations, and/or had any serious injuries in the past year? If yes, list the date(s) and reason(s)/injuries. In case of serious accident or illness and I cannot be reached, I authorize the doctor listed below to give necessary treatment. The school may call him/her or an ambulance if necessary. Doctor Name: Phone: Clinic Name/Location: Hospital Preference: I give the school nurse permission to contact the above named doctor should the need arise. Are there any other general concerns, health concerns, or considerations not listed on this page that you feel the School District should be aware of? Are there any other general concerns, health concerns, or considerations not listed on this page that you feel the school should be aware of? If yes, describe. The welfare of your child is our first consideration. Unless your child has an Emergency Care Plan in place or you indicate otherwise, this procedure will be followed in case of serious medical emergency: will be called immediately. You will be informed as soon as possible. 2. A copy of this Health Information Form will be given to the ambulance attendant. 3. The school will call the authorized physician, if you cannot be reached. 4. If you or your physician cannot be reached, the school will make arrangements as necessary. Parent or Guardian Signature: Date: Page 1 Revised

2 St. Michael Albertville HEALTH INFORMATION FORM ANAPHYLAXIS TREATMENT NOTIFICATION TO PARENTS Name: School: Grade: DOB: Minnesota statute 121A.2207 permits school districts to possess epinephrine auto-injectors (EpiPens) for a student or other individual experiencing anaphylaxis regardless of whether the student or individual has a prescription for an EpiPen. Therefore, St. Michael-Albertville School District has adopted a policy allowing the school nurse or health paraprofessional to administer epinephrine for a severe, life-threatening allergic reaction. The emergency epinephrine will be kept in the school health office and accessible during school hours. It will not be sent on school-based field trips or available before or after the instructional day. This anaphylaxis protocol is not intended to replace student specific orders or parent/guardian provided individual medications for students with known allergies. If your child has a known allergy and has an EpiPen prescribed for him/her, you still need to provide the health office one (or preferably two) EpiPens with a pharmacy label. Medication authorization forms or an Anaphylaxis Action Plan signed by you and your child s physician are required annually for your child s specific orders. The child-specific EpiPens will be sent on school-based field trips. Anaphylaxis is a rapid, life-threatening allergic response triggered by insect stings, foods, medications, latex, exercise, or in rare cases by unknown causes. Anaphylaxis is a life-threatening allergic condition requiring immediate treatment; death has been reported within minutes. It is well documented that it is safer to administer epinephrine than to delay treatment for anaphylaxis. The epinephrine auto-injector rapidly delivers a pre-measured, single dose of epinephrine by direct injection through the skin. If your son/daughter has a life-threatening allergic reaction at school requiring EpiPen administration, Emergency Medical Services, parents, and the school nurse (if administered by the health paraprofessional) will be called immediately. If you do not want your child to receive a life-saving injection of epinephrine if he/she is experiencing a lifethreatening allergic reaction, please send a letter to the school health office. Otherwise, parental consent is implied for all students. If your child has a heart condition, please talk with his/her health care provider about the safety of administration of epinephrine in the event of a life-threatening anaphylaxis and contact the school health office. Parent or Guardian Signature: Date: Page 2 Revised

3 Student Immunization Form Student Name Birthdate Student Number Minnesota law requires children enrolled in school to be immunized against certain diseases or file a legal medical or conscientious exemption. FOR SCHOOL USE ONLY ( ) Complete; booster required in ( ) In process; 8 mos. expires ( ) Medical exemption for ( ) Conscientious objection for ( ) Parental/guardian consent Parent/Guardian: You may attach a copy of the child s immunization history to this form OR enter the MONTH, DAY, and YEAR for all vaccines your child received. Enter MED to indicate vaccines that are medically contraindicated including a history of disease, or laboratory evidence of immunity and CO for vaccines that are contrary to parent or guardian s conscientiously held beliefs. Sign or obtain appropriate signatures on reverse. Complete section 1A or 1B to certify immunization status and section 2A to document medical exemptions (including a history of varicella disease) and 2B to document a conscientious exemption. Additionally, if a parent or guardian would like to give permission to the school to share their child s immunization record with Minnesota s immunization information system, they may sign section 3 (optional). For updated copies of your child s vaccination history, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at or School Personnel: Be sure to initial and date any new information that you add to this form after the parent/guardian submits it. Also, record combination vaccines (e.g., DTaP+HepB+IPV, Hib+HepB) in each applicable space. Type of Vaccine DO NOT USE ( ) or ( ) 1st Dose 2nd Dose 3rd Dose 4th Dose 5th Dose Required (The shaded boxes indicate doses that are not routinely given; however, if your child has received them, please write the date in the shaded box.) Diphtheria, Tetanus, and Pertussis (DTaP, DTP, DT) for children age 6 years and younger final dose on or after age 4 years Tetanus and Diphtheria (Td) for children age 7 years and older 3 doses of Td required for children not up to date with DTaP, DTP, or DT series above Tetanus, Diphtheria and Pertussis (Tdap) for children in 7th - 12th grade Polio (IPV, OPV) final dose on or after age 4 years Measles, Mumps, and Rubella (MMR) minimum age: on or after 1st birthday Hepatitis B (hep B) Varicella (chickenpox) minimum age: on or after 1st birthday vaccine or disease history required Meningococcal (MCV, MPSV) for children in 7th - 12th grade booster given at age 16 years Recommended Human Papillomavirus (HPV) Hepatitis A (hep A) Influenza (annually for children 6 months and older) 4th dose not required if 3rd dose was given on or after the 4th birthday 5th dose not required if 4th dose was given on or after the 4th birthday Additional exemptions: Children 7 years of age and older: A history of 3 doses of DTaP/DTP/DT/Td/Tdap and 3 doses of polio vaccine meets the minimum requirements of the law. Students in grades 7-12: A Tdap at age 11 years or later is required for students in grades If a child received Tdap at age 7-10 years another dose is not needed at age years. However, if it was only a Td, a Tdap dose at age years is required. Students years of age: A 3rd dose of hepatitis B vaccine is not required for students who provide documentation of the alternative 2-dose schedule. Students 18 years of age or older: Do not need polio vaccine. Developed by the Minnesota Department of Health - Immunization Program (12/13)

4 Student Name Instructions, please complete: Box 1 to certify the child s immunization status Box 2 to file an exemption (medical or concientious) Box 3 to provide consent to share immunization information (optional) 1. Certify Immunization Status. Complete A or B to indicate child s immunization status. A. Received all required immunizations: I certify that this student has received all immunizations required by law. Signature of Parent / Guardian OR Physician / Public Clinic B. Will complete required immunizations within the next 8 months: I certify that this student has received at least one dose of vaccine for diphtheria, tetanus, and pertussis (if age-appropriate), polio, hepatitis B, varicella, measles, mumps, and rubella and will complete his/her diphtheria, tetanus, pertussis, hepatitis B, and/or polio vaccine series within the next 8 months. The dates on which the remaining doses are to be given are: Signature of Physician / Public Clinic 2. Exemptions to School Immunization Law. Complete A and/or B to indicate type of exemption. A. Medical exemption: No student is required to receive an immunization if they have a medical contraindication, history of disease, or laboratory evidence of immunity. For a student to receive a medical exemption, a physician, nurse practitioner, or physician assistant must sign this statement: I certify the immunization(s) listed below are contraindicated for medical reasons, laboratory evidence of immunity, or that adequate immunity exists due to a history of disease that was laboratory confirmed (for varicella disease see * below). List exempted immunization(s): B. Conscientious exemption: No student is required to have an immunization that is contrary to the conscientiously held beliefs of his/ her parent or guardian. However, not following vaccine recommendations may endanger the health or life of the student or others they come in contact with. In a disease outbreak schools may exclude children who are not vaccinated in order to protect them and others. To receive an exemption to vaccination, a parent or legal guardian must complete and sign the following statement and have it notarized: I certify by notarization that it is contrary to my conscientiously held beliefs for my child to receive the following vaccine(s): Signature of physician/nurse practitioner/physician assistant *History of varicella disease only. In the case of varicella disease, it was medically diagnosed or adequately described to me by the parent to indicate past varicella infection in (year) Signature of physician/nurse practitioner/physician assistant (If disease occured before September 2010, a parent can sign.) Signature of parent or legal guardian Subscribed and sworn to before me this: day of 20 Signature of notary 3. Parental/Guardian Consent to Share Immunization Information (optional): Your child s school is asking your permission to share your child s immunization documentation with MIIC, Minnesota s immunization information system, to help better protect students from disease and allow easier access for you to retrieve your child s immunization record. You are not required to sign this consent; it is voluntary. In addition, all the information you provide is legally classified as private data and can only be released to those legally authorized to receive it under Minnesota law. I agree to allow school personnel to share my student s immunization documentation with Minnesota s immunization information system: Signature of parent or legal guardian Date Developed by the Minnesota Department of Health - Immunization Program (12/13)

5 Revised 11/20/2017 St. Michael Albertville POTASSIUM IODINE FORM Potassium Iodide Administration Parent/Guardian Informed Consent Form Please complete if your student(s) will attend Fieldstone Elementary or St. Michael-Albertville High School Reason for Taking Potassium Iodide In the event of a major incident at the nuclear power plant or what is also known as a radiological emergency, radioactive iodine will be released into the air. This material may be inhaled or ingested and enter the thyroid gland where it can cause cancer and/or disease. Children and infants are the most vulnerable to this occurrence. When taken by pill or liquid, potassium iodide (KI) floods the thyroid with non-radioactive iodine and prevents the thyroid from absorbing the radioactive material. Potassium iodide needs to be given before or shortly after exposure to radiation. Potassium iodide works only to prevent the thyroid from absorbing radioactive iodine. Potential Side Effects of Potassium Iodide It is possible to experience any or all of the following side effects when taking Potassium Iodide: Upset Stomach Rash Allergic Reaction Risks of Taking Potassium Iodide Taking Potassium Iodide is safe for most people. Potassium Iodide should not be taken if someone: Is allergic to iodine Has Graves Disease Has any other thyroid illness Takes thyroid medication CONSULT WITH YOUR PHYSICIAN IF YOU HAVE QUESTIONS OR CONCERNS ABOUT TAKING KI More Information Additional information can be found on the St. Michael-Albertville school district s website Administration of Potassium Iodide Potassium Iodide will only be given: In the case of a radiological emergency If it is recommended by public health officials If a parent/guardian signs a consent form for a child Informed Consent Please Check the Appropriate Box I do not consent to have the school nurse or his/her designee administer Potassium Iodide to my child. I consent to have the school nurse or his/her designee administer Potassium Iodide to my child. This consent, unless the school is notified by the parent/guardian to the contrary, is good for the duration your child is a student of St. Michael-Albertville Public Schools. Student s Full Name School Printed Name of Legal Parent/Guardian Signature of Legal Parent/Guardian Date Birthdate Grade Return this form to the appropriate school by fax, , USPS, or in-person. Fieldstone Elementary 5255 Jansen Ave NE, St. Michael, MN 55376, Fax: , or High School 5800 Jamison Avenue NE, St. Michael, MN 55376, Fax: (763) , or

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