Address: 150 West Madison Street, Lombard, Illinois Telephone: FAX:

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Address: 150 West Madison Street, Lombard, Illinois 60148-3317 Telephone: 630.827.4400 FAX: 630.620.

1 Address: 150 West Madison Street, Lombard, Illinois Telephone: FAX: Kindergarten and New Student Registration Health and Immunization Information Complete and return forms below, as necessary, for the enrollment of your student. Health Requirements and Immunizations... page 2 Illinois Certificate of Religious Exemption... pages 3-4 State of Illinois Health Exam Form... pages 5-6 Physical exams are required for all students entering preschool, kindergarten and 6 th grades, all children entering school for the first time, and all students new to Illinois schools. This documentation is due at registration or on the first day of school or your child may be excluded. State of Illinois Eye Exam Form... pages 7-8 All kindergarten students and all students new to Illinois schools shall have an eye examination before October 15 of the year of the required exam or within 30 days of enrollment for new students from out of state. State of Illinois Dental Exam Form... page 9 All kindergarten, 2 nd and 6 th grade students must have an oral health examination performed by a licensed dentist. The exam is due no later than May 15 of the year of the required exam. If your child has a specific health concern and/or requires medication, please contact your school nurse. Revised 5/15, 1/16, 5/16 Our Mission: The mission of Lombard School District 44, working in partnership with students, families, and community members, is to educate the whole child in order to achieve personal excellence.

2 Our Mission: The mission of Lombard School District 44, working in partnership with students, families, and community members, is to educate the whole child in order to achieve personal excellence Health Examination and Immunization Requirements The following, completed documentation is due in your school office on or before the first day of school. Certificate of Child Health Examination: Parent/guardian completes: Page 1 - Student name and information Page 2 - Student name and information; Health History; Health History signature Physicians office(s) to complete: Page 1 Immunizations and Screenings with signatures Page 2 Physical Exam Requirements and Screenings with signature including Diabetes Screening, BMI, Lead Screening for Early Childhood and Kindergarten, Physical Education checked yes or no Religious Exemption Form, if applicable Health Requirements Early Childhood Kindergarten Grade 6 Dtap Vaccine Tdap Booster Polio Vaccine HIB Vaccine Hepatitis B Vaccine Varicella Vaccine MMR Vaccine - Measles, Mumps, Rubella Early Childhood: 4 doses at correct intervals Early Childhood: 3 doses at correct intervals Early Childhood: 3 doses at...correct intervals Early Childhood: 3 doses at correct intervals Early Childhood: 1 dose on or...after 1 st birthday Early Childhood: 1 dose on or after 1 st birthday Kindergarten: 4 or more doses at correct intervals Kindergarten: 4 or more doses at correct intervals All students grade 6: one Tdap booster All students grade 6:.three doses at.correct intervals Kindergarten, grades 2,6,7 and 8: proof of two doses at correct intervals All other grades proof of 1 dose Kindergarten: 2 doses at correct intervals Pneumococcal Vaccine Meningococcal Vaccine Early Childhood All students grade 6 and 7: one dose on.or after 10 th birthday Child Health Exam Due in office by 1 st day of school Dental Examination Due in office by May 15, 2017 Eye Examination Due in office by October 15, 2016 Early Childhood Kindergarten Grade 6 Kindergarten AND Grade 2 Kindergarten Grade 6 If you have any questions please call your school s nurse. Eileen Bell - RN, PEL-CSN Glenn Westlake Middle School Eileen Rydel-Boesso - RN, PEL-CSN Butterfield & Madison School Beth Lyons - RN, PEL-CSN Manor Hill School Jenn Kurtz - RN, PEL-CSN Hammerschmidt, Park View & Pleasant Lane Health Requirements Rev 2/14, 1/15, 2/16 Address: 150 West Madison Street, Lombard, Illinois Telephone: FAX:

3 INSTRUCTIONS FOR COMPLETING ILLINOIS CERTIFICATE OF RELIGIOUS EXEMPTION TO REQUIRED IMMUNIZATIONS AND/OR EXAMINATIONS FORM Who may use the Certificate of Religious Exemption to Required Immunizations and/or Examinations Form: Parents or legal guardians who are requesting a religious exemption to immunizations or examinations must use this form for students entering kindergarten, sixth, or ninth grades. A separate form must be used for each child with a religious exemption enrolled to enter any public, charter, private or parochial preschool, kindergarten, elementary or secondary school. This form may not be used for exemptions from immunizations and/or examination for personal or philosophical reasons. Illinois law does not allow for such exemptions. (See excerpts below from Public Act enacted August 3, 2015 at page bottom.) When use of this form becomes required: October 16, 2015 How to complete the Certificate of Religious Exemption to Required Immunizations and/or Examinations Form: Complete the Parent/Guardian sections, which include key information about the student and the school the student will be entering, and the immunizations or examinations for which religious exemption is being requested. Provide a statement of religious belief(s) for each vaccination/examination requested. The form must be signed by the child s parent or legal guardian AND the child s health care provider* responsible for performing the child s health examination. Submit the completed form to local school authority on or before October 15th of the school year, or by an earlier enrollment date established by a school district. Religious Exemption from Immunizations and/or Examination Form Process: The local school authority is responsible for determining whether the information supplied on the Certificate of Religious Exemption to Required Immunizations and/or Examinations Form constitutes a valid religious objection. The local school authority shall inform the parent or legal guardian, at the time that the exemption is presented, of exclusion procedures, should there be an outbreak of one or more diseases from which the student is not protected, in accordance with the Illinois Department of Public Health (IDPH) rules, Control of Communicable Diseases Code (77 Ill. Adm. Code 690). Exempting a child from health, dental, or eye examination does not exempt the child from participation in the program of physical education training provided in Section 27-5 through 27-7 of the Illinois School Code [105 ILCS 5/27-5 through 105 ILCS 5/27-7]. A separate request for exemption from physical education, if desired, would need to be presented. Excerpt from Public Act enacted August 3, 2015: Children of parents or legal guardians who object to health, dental, or eye examinations or any part thereof, or to immunizations or to vision and hearing screening tests on religious grounds shall not be required to undergo the examinations or immunizations if the parents or legal guardians present to the appropriate local school authority a signed Certificate of Religious Exemption detailing the grounds for objection and the specific immunizations and/or examinations to which they object. The grounds for objection must set forth the specific religious belief(s) that conflict with the examination, immunization, or other medical intervention. The certificate will be signed by the parent or legal guardian to confirm their awareness of the school s exclusion policies in the case of a vaccine preventable disease outbreak or exposure. The certificate must also be signed by the child s health care provider responsible for performing the child s examination for entry into kindergarten, sixth or ninth grade. This signature affirms that the provider educated the parent or legal guardian about the benefits of immunization and the health risks to the student and to the community from the communicable diseases for which immunization is required in Illinois. The religious objection provided need not be directed by the tenets of an established religious organization. However, general philosophical or moral reluctance CERTIFICATE to allow physical examinations, OF RELIGIOUS eye examinations, EXEMPTION immunizations, vision and hearing screening or dental examinations will not provide a sufficient basis for an exception to statutory requirements. The local school authority is responsible for determining if the content of the Certificate of Religious Exemption constitutes a valid religious objection. The local school authority shall inform the parent or legal guardian of exclusion procedures in accordance with IDPH s rules, Control of Communicable Diseases Code (77 Ill. Adm. Code 690) at the time the objection is presented.

4 ILLINOIS CERTIFICATE OF RELIGIOUS EXEMPTION TO REQUIRED IMMUNIZATIONS AND/OR EXAMINATIONS FORM PARENT OR LEGAL GUARDIAN - COMPLETE THIS SECTION te: This form is required for all students entering kindergarten, sixth or ninth grades when parent(s) or legal guardian(s) is requesting a religious exemption on or after October 16, This form also must be submitted to request religious exemption for any student enrolling to enter any public, charter, private or parochial preschool, kindergarten, elementary or secondary school on or after October 16, This form may NOT Student Name:(last, first, middle) Parent/Guardian Name: Address: be used for personal or philosophical reasons. Illinois law does not allow for such exemptions. Student Date of Birth: School Name: Month Day Year Gender: M F Telephone Number(s): City: Grade: Exemption requested for (mark all that apply): Hepatitis B DTaP Polio Hib Pneumococcal MMR Varicella Td/Tdap Meningococcal Health Exam Eye Exam Dental Exam Vision/Hearing Tests Other (indicate below) To receive an exemption to vaccination/examination, a parent or legal guardian must provide a statement detailing the religious beliefs that prevent the child from receiving each required school vaccinations/examination being requested. In the space provided below, state each vaccination or examination exemption requested and state the religious grounds for each request. If additional space is needed, attach additional page(s). Religious Exemption tice: student is required to have an immunization/examination that is contrary to the religious beliefs of his/her parent or legal guardian. However, not following vaccination recommendations may endanger the health or life of the unvaccinated student, others with whom they come in contact, and individuals in the community. In a disease outbreak, or after exposure to any of the diseases for which immunization is required, schools may exclude children who are not vaccinated in order to protect all students. I have read the Religious Exemption tice (above) and have provided requested information for each vaccination/examination being requested for religious exemption. Signature of parent or legal guardian (required) Date HEALTH CARE PROVIDER* COMPLETE THIS SECTION Provision of information: I have provided the parent or legal guardian of the student named above, with information regarding 1) the required examinations, 2) the benefits of immunization, and 3) the health risks to the student and to the community from the communicable diseases for which immunization is required in Illinois. I understand that my signature only reflects that this information was provided; I am not affirming the parent or legal guardian s religious beliefs regarding any examination, immunization or immunizing agent. Health Care Provider Name: Signature of health care provider* Date: (Must be within 1 year prior to school entry) Address: Telephone #: *Health care provider responsible for performing child s health examination includes physicians licensed to practice medicine in all of its branches, advanced practice nurses, or physician assistants.

State of Illinois Certificate of Child Health Examination Student s Name Last First Middle Birth Date Month/Day/Year Sex Race/Ethnicity School /Grade Level/ID# Address Street City Zip Code

5 State of Illinois Certificate of Child Health Examination Student s Name Last First Middle Birth Date Month/Day/Year Sex Race/Ethnicity School /Grade Level/ID# Address Street City Zip Code Parent/Guardian Telephone # Home Work IMMUNIZATIONS: To be completed by health care provider. The mo/da/yr for every dose administered is required. If a specific vaccine is medically contraindicated, a separate written statement must be attached by the health care provider responsible for completing the health examination explaining the medical reason for the contraindication. REQUIRED Vaccine / Dose DOSE 1 DOSE 2 DOSE 3 DOSE 4 DOSE 5 DOSE 6 DTP or DTaP Tdap; Td or Pediatric DT (Check specific type) Polio (Check specific type) Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV Hib Haemophilus influenza type b Pneumococcal Conjugate Hepatitis B MMR Measles Mumps. Rubella Varicella (Chickenpox) Meningococcal conjugate (MCV4) RECOMMENDED, BUT NOT REQUIRED Vaccine / Dose Hepatitis A Comments: HPV Influenza Other: Specify Immunization Administered/Dates Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here. Signature Title Date Signature Title Date ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis (measles, mumps, hepatitis B) is allowed when verified by physician and supported with lab confirmation. Attach copy of lab result. *MEASLES (Rubeola) **MUMPS HEPATITIS B VARICELLA 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below verifies that the parent/guardian s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title 3. Laboratory Evidence of Immunity (check one) Measles* Mumps** Rubella Varicella Attach copy of lab result. *All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence. **All mumps cases diagnosed on or after July 1, 2013, must be confirmed by laboratory evidence. Completion of Alternatives 1 or 3 MUST be accompanied by Labs & Physician Signature: Physician Statements of Immunity MUST be submitted to IDPH for review. Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and Maintained by the School Authority. 11/2015 (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois

6 Last First Middle Month/Day/ Year HEALTH HISTORY ALLERGIES (Food, drug, insect, other) Birth Date Sex School Grade Level/ ID TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER List: Diagnosis of asthma? Child wakes during night coughing? MEDICATION (Prescribed or taken on a regular basis.) Loss of function of one of paired organs? (eye/ear/kidney/testicle) Birth defects? Hospitalizations? Developmental delay? When? What for? List: Blood disorders? Hemophilia, Surgery? (List all.) Sickle Cell, Other? Explain. When? What for? Diabetes? Serious injury or illness? Head injury/concussion/passed out? TB skin test positive (past/present)? * *If yes, refer to local health department. Seizures? What are they like? TB disease (past or present)? * Heart problem/shortness of breath? Tobacco use (type, frequency)? Heart murmur/high blood pressure? Alcohol/Drug use? Dizziness or chest pain with exercise? Family history of sudden death before age 50? (Cause?) Eye/Vision problems? Glasses Contacts Last exam by eye doctor Dental Braces Bridge Plate Other Other concerns? (crossed eye, drooping lids, squinting, difficulty reading) Ear/Hearing problems? Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Bone/Joint problem/injury/scoliosis? Signature Date PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA HEAD CIRCUMFERENCE if < 2-3 years old HEIGHT WEIGHT BMI B/P DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI 85% age/sex And any two of the following: Family History Ethnic Minority Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) At Risk LEAD RISK QUESTIONNAIRE: Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.) Questionnaire Administered? Blood Test Indicated? Blood Test Date Result TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. test needed Test performed Skin Test: Date Read / / Result: Positive Negative mm Blood Test: Date Reported / / Result: Positive Negative Value LAB TESTS (Recommended) Date Results Date Results Hemoglobin or Hematocrit Urinalysis SYSTEM REVIEW rmal Comments/Follow-up/Needs Skin Sickle Cell (when indicated) Developmental Screening Tool Endocrine Ears Screening Result: Gastrointestinal rmal Comments/Follow-up/Needs Eyes Screening Result: Genito-Urinary LMP se Throat Mouth/Dental Cardiovascular/HTN Neurological Musculoskeletal Spinal Exam Nutritional status Respiratory Diagnosis of Asthma Mental Health Currently Prescribed Asthma Medication: Quick-relief medication (e.g. Short Acting Beta Agonist) Controller medication (e.g. inhaled corticosteroid) NEEDS/MODIFICATIONS required in the school setting Other DIETARY Needs/Restrictions SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If you would like to discuss this student s health with school or school health personnel, check title: Nurse Teacher Counselor Principal EMERGENCY ACTION needed while at school due to child s health condition (e.g., seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? If yes, please describe. On the basis of the examination on this day, I approve this child s participation in (If or Modified please attach explanation.) PHYSICAL EDUCATION Modified INTERSCHOLASTIC SPORTS Modified Print Name (MD,DO, APN, PA) Signature Date Address Phone

7 State of Illinois Eye Examination Report Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides eye examinations be submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school for other children. The examination must be completed within one year prior to the first day of the school year the child enters the Illinois school system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school. Student Name (Last) (First) (Middle Initial) Birth Date Gender Grade (Month/Day/Year) Parent or Guardian (Last) (First) Phone (Area Code) Address (Number) (Street) (City) (ZIP Code) County To Be Completed By Examining Doctor Case History Date of exam Ocular history: rmal or Positive for Medical history: rmal or Positive for Drug allergies: NKDA or Allergic to Other information Examination Distance Near Right Left Both Both Uncorrected visual acuity 20/ 20/ 20/ 20/ Best corrected visual acuity 20/ 20/ 20/ 20/ Was refraction performed with dilation? rmal Abnormal t Able to Assess Comments External exam (lids, lashes, cornea, etc.) Internal exam (vitreous, lens, fundus, etc.) Pupillary reflex (pupils) Binocular function (stereopsis) Accommodation and vergence Color vision Glaucoma evaluation Oculomotor assessment Other NOTE: "t Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test. Diagnosis rmal Myopia Hyperopia Astigmatism Strabismus Amblyopia Other Page 1 Continued on back

State of Illinois Eye Examination Report Recommendations 1. Corrective lenses:, glasses or contacts should be worn for: Constant wear Near vision Far vision May be removed for physical education 2.

8 State of Illinois Eye Examination Report Recommendations 1. Corrective lenses:, glasses or contacts should be worn for: Constant wear Near vision Far vision May be removed for physical education 2. Preferential seating recommended: Comments 3. Recommend re-examination: 3 months 6 months 12 months Other Print name Optometrist or physician (such as an ophthalmologist) who provided the eye examination MD OD DO Address License Number Consent of Parent or Guardian I agree to release the above information on my child or ward to appropriate school or health authorities. (Parent or Guardian s Signature) Phone (Date) Signature Date (Source: Amended at 32 Ill. Reg., effective ) Page 2 Printed by Authority of the State of Illinois 6/09 IOCI

9 State of Illinois Illinois Department of Public Health To be completed by the parent (please print): PROOF OF SCHOOL DENTAL EXAMINATION FORM Student s Name: Last First Middle Birth Date: / / Address: Street City ZIP Code Telephone: (Month/Day/Year) Name of School: Grade Level: Gender: Male Female Parent or Guardian: Address (of parent/guardian): To be completed by dentist: Oral Health Status (check all that apply) Dental Sealants Present Caries Experience / Restoration History A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1 st molars. Untreated Caries At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present. Soft Tissue Pathology Malocclusion Treatment Needs (check all that apply) Urgent Treatment abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling Restorative Care amalgams, composites, crowns, etc. Preventive Care sealants, fluoride treatment, prophylaxis Other periodontal, orthodontic Please note Signature of Dentist Date of Exam Address Street City ZIP Code Telephone Illinois Department of Public Health, Division of Oral Health TTY (hearing impaired use only) IOCI Printed by Authority of the State of Illinois

Health Requirements from the Illinois State Board of Education Health requirements for the students of Illinois are summarized below.

Health Requirements from the Illinois State Board of Education 2014-2015 Health requirements for the students of Illinois are summarized below. ALL Illinois State Board of Education health requirements