PHYSICAL EXAMINATION and IMMUNIZATION RECORD ARE DUE AT THE TIME OF REGISTRATION

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HEALTH REQUIREMENTS FOR KINDERGARTEN ENTRY 2015-2016 PHYSICAL EXAMINATION and IMMUNIZATION RECORD ARE DUE AT THE TIME OF REGISTRATION 1.

1 HEALTH REQUIREMENTS FOR KINDERGARTEN ENTRY PHYSICAL EXAMINATION and IMMUNIZATION RECORD ARE DUE AT THE TIME OF REGISTRATION 1. THE MOST RECENT PHYSICAL AND IMMUNIZATION RECORD is required for registration. This may be your child s 3 year, 4 year or 5 year physical examination. 2. KINDERGARTEN EXAMINATIONS (dated on or after August 25, 2014) ARE DUE PRIOR TO THE FIRST DAY OF SCHOOL. Only the DHS examination form R will be accepted. Both sides must be completed. Parent signature required. 3. IMMUNIZATIONS: Month/day/year and correct number of doses at the correct intervals must be verified by a health care provider. Please see the back for immunization details. 4. EMERGENCY HEALTH CARD: List of emergency contacts and their phone numbers in the event the parent/guardian cannot be reached regarding student illness, accident, or injury. EYE EXAMINATION - DUE ON or BEFORE OCTOBER 15, Eye examinations dated on or after October 15, 2014 will be accepted. 2. Must be on the eye examination form attached. 3. The State has developed a waiver for children who show an undue burden or a lack of access for an eye examination. Please contact the nurse in your child s school if assistance is needed. DENTAL EXAMINATION - DUE ON or BEFORE MAY 15, Dental examinations dated after November 15, 2014 will be accepted. 2. The State has developed a waiver for children who show an undue burden or a lack of access to a dentist. Please contact the nurse in your child s school if assistance is needed. Most tooth decay can be prevented with appropriate amounts of fluoride and with the use of dental sealants applied when the first permanent molars erupt at about age 6 years and second permanent molars erupt at about age 12 years. Parents or guardians who object to examination(s) or immunization(s) on religious grounds are not required to submit their child or wards to either, provided they present a signed statement to that effect. The statement must set forth the specific religious belief which conflicts with the examination(s) and / or immunization(s). over Barrington 220 / / 310 James St., Barrington, IL 60010

2 Per School Board Policy 7:100 - Students not meeting the physical examination and immunization requirements PRIOR to the first day of school will not be allowed to start classes. MANDATORY IMMUNIZATIONS FOR KINDERGARTEN ENTRY 1. POLIOMYELITIS: Three or more doses of polio (IPV or OPV), at the appropriate intervals, with the last dose being a booster and having been received on or after the 4 th birthday. 2. DIPTHERIA, TETANUS, PERTUSSIS (DTaP): Four or more doses of DTaP, at appropriate intervals, with the last dose being a booster and having been received on or after the 4 th birthday. 3. MEASLES (rubeola): TWO DOSES of measles vaccine, the first being on or after 12 months of age and the second dose no less than 1 month after the first. 4. MUMPS: TWO DOSES mumps vaccine at 12 months of age or older age and the second dose no less than 1 month after the first. 5. RUBELLA (3 day measles): TWO DOSES of rubella vaccine at 12 months of age or older and the second dose no less than 1 month after the first. 6. VARICELLA (chicken pox): TWO DOSES on or after 12 months of age or older and the second dose no less than 1 month after the first OR laboratory evidence of varicella immunity. Barrington 220 / / 310 James St., Barrington, IL 60010

Must be completed and returned to Barrington 220 before August 20, 2015 State of Illinois Certificate of Child Health Examination FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 2/2013

3 Must be completed and returned to Barrington 220 before August 20, 2015 State of Illinois Certificate of Child Health Examination FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 2/2013 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. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication. Vaccine / Dose 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 Hepatitis B (HB) Varicella (Chickenpox) COMMENTS: MMR Combined Measles Mumps. Rubella Single Antigen Vaccines Measles Rubella Mumps Pneumococcal Conjugate Other/Specify Meningococcal, Hepatitis A, HPV, Influenza 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 is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.) *MEASLES (Rubeola) MUMPS VARICELLA Physician s Signature 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below is verifying 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 Date 3. Laboratory confirmation (check one) Measles Mumps Rubella Hepatitis B Varicella Lab Results Date (Attach copy of lab result) VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN Date Age/ Grade Vision Hearing R L R L R L R L R L R L R L R L R L Code: P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/Contacts IL (R-02-13) (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois Physical must be dated on or after August 25, 2014

4 Birth Date Sex School Grade Level/ ID # Last First Middle Month/Day/ Year HEALTH HISTORY ALLERGIES (Food, drug, insect, other) Diagnosis of asthma? Child wakes during night coughing? TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER Yes Yes No No MEDICATION (List all prescribed or taken on a regular basis.) Loss of function of one of paired organs? (eye/ear/kidney/testicle) Birth defects? Yes No Hospitalizations? Developmental delay? Yes No When? What for? Blood disorders? Hemophilia, Yes No Surgery? (List all.) Yes No Sickle Cell, Other? Explain. When? What for? Diabetes? Yes No Serious injury or illness? Yes No Head injury/concussion/passed out? Yes No TB skin test positive (past/present)? Yes* No *If yes, refer to local health department. Seizures? What are they like? Yes No TB disease (past or present)? Yes* No Heart problem/shortness of breath? Yes No Tobacco use (type, frequency)? Yes No Heart murmur/high blood pressure? Yes No Alcohol/Drug use? Yes No Dizziness or chest pain with exercise? Yes No Family history of sudden death before age 50? (Cause?) Yes No 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? Yes No Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Bone/Joint problem/injury/scoliosis? Yes No 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 Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No 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? Yes No Blood Test Indicated? Yes No 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. No 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 Sickle Cell (when indicated) Developmental Screening Tool SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs Skin Ears Endocrine Gastrointestinal Eyes Amblyopia Yes No Genito-Urinary LMP Nose 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)? Yes No If yes, please describe. On the basis of the examination on this day, I approve this child s participation in Yes Yes No No (If No or Modified please attach explanation.) PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS Yes No Limited Print Name (MD,DO, APN, PA) Signature Date Address Phone (Complete Both Sides)

5 Complete and return to your school nurse's office on or before October 15, 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: Normal or Positive for Medical history: Normal 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? Yes No Normal Abnormal Not 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: "Not 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 Normal Myopia Hyperopia Astigmatism Strabismus Amblyopia Other Page 1 Continued on back

6 State of Illinois Eye Examination Report Recommendations 1. Corrective lenses: No Yes, glasses or contacts should be worn for: Constant wear Near vision Far vision May be removed for physical education 2. Preferential seating recommended: No Yes 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

7 Complete and return to your school nurse's office on or before October 15, 2015 To be completed by the parent (please print): Illinois Department of Public Health 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) Yes No Yes No Yes No Yes No Yes No 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 Address Street City ZIP Code Telephone Illinois Department of Public Health, Division of Oral Health, 535 W. Jefferson St., Springfield, IL TTY (hearing impaired use only) Printed by Authority of the State of Illinois P.O.# M 10/05

9 Welcome to Kindergarten Frequently Asked Questions WHEN DO I KEEP MY CHILD HOME FROM SCHOOL? FEVER: Keep your child home for a period of 24 hours after the fever has passed, without fever reducing medications. VOMITING or DIARRHEA: Keep your child home for 24 hours after the symptoms have stopped. COMMUNICABLE DISEASE: Keep your child home for a period of 24 hours of antibiotic treatment or after the contagious period for the illness is over. This time frame may be longer for more serious communicable diseases. REPORT ILLNESS SYMPTOMS COMPLETELY on the attendance line at school. WHAT IF MY CHILD HAS A COMMUNICABLE DISEASE? Please report all communicable diseases to the school health office. For example: chicken pox, strep throat, scarlet fever, pink eye, impetigo, fifth s disease, ring worm, whooping cough, measles, mumps, other. Notification enables us to alert other parents of the possible exposure and help prevent further spread of the illness in the classroom. Children should remain at home until the contagious period has passed. WHEN WILL MY CHILD BE SENT HOME FROM SCHOOL? Fever of 100 degrees or greater Vomiting or Diarrhea Unidentified skin rash Communicable illness suspected: pink eye, strep throat, chicken pox, impetigo, whooping cough, or other. Injury and/or illness requiring medical attention Other as decided upon by the nurse and parent/guardian WHAT ABOUT HEAD LICE? Pediculosis is ever present in our society. Although not a serious medical condition, it can cause an interruption in children s education and is a source of anxiety for families. Therefore the school requires the following: Please report all cases of head lice to the school health office. Visit our website to learn more: and select "Parent Resources" then "Health Office". Parent/Guardian will be contacted if their child is suspected of having a lice infestation. Nurse will provide evidence based guidelines and information regarding the elimination of head lice. Parents are strongly urged to notify their child's close contacts regarding the possibility of head lice transmission. Siblings and close contacts will be inspected and referred for treatment if needed. On return to school, the nurse will inspect the child s head, monitor regularly, and advise if follow-up is needed. IF MY CHILD TAKES MEDICATION, WHAT DO I DO? CUSD #220 believes that prescription and nonprescription medication should be administered in the home. However, if it is in the best educational and health interest of the child to take prescribed medication during the school day, then a Medication Authorization Form must be completed. This pertains to all medications (prescription, over the counter, and emergency). You may obtain the medication form at the district website or in the school nurse office. Medication must be brought to the school by the parent or guardian in the original container. HOW DO I MAKE CHANGES FOR EMERGENCY CONTACTS and HEALTH INFORMATION? Emergency contacts and parent phone numbers can be changed through the parent portal of Infinite Campus. It is frightening for an ill or injured child when we are unable to reach a parent or guardian. Also, please notify the health office regarding changes in your child s health condition or medication, so that we can best meet his/her health needs at school over

THINGS TO KEEP IN MIND 1. Having head lice is common. It is estimated that there are 6-12 million infestations annually. 2. Head lice do not carry or transmit any disease process. 3.

10 THINGS TO KEEP IN MIND 1. Having head lice is common. It is estimated that there are 6-12 million infestations annually. 2. Head lice do not carry or transmit any disease process. 3. Personal hygiene or cleanliness in the home or school has nothing to do with getting head lice. 4. Head lice are transferred most often through direct head to head contact and less often through indirect contact via the environment. 5. Because of the unpredictability of possible exposure (especially among younger children who play closely together), we recommend periodic inspection of your child s head throughout the year. 6. Because of misunderstandings about head lice, there is much embarrassment, anxiety, and many unnecessary days lost from school and work. 7. An Internet search for head lice yielded almost 4 million resources! For up-to-date information visit our website at Default.aspx?PageID= Please report suspect or confirmed cases to the school nurse. The school nurse can provide you with more detailed information regarding treatment of the infestation, treatment of the environment, and prevention of re-infestation. Head Lice Head lice are parasitic insects known by the scientific name of pediculosis. They have been around since the dawn of man, and have been found in the Egyptian mummies. They do not infest dogs or other animals and only live on human heads. Head lice spend their entire short life (about 30 days) in one place. They crawl, but don t jump or fly, and carry no disease they cannot make you sick. They are a nuisance but not life threatening in any way. After lice hatch from an egg, the human head keeps them warm and nourished. It takes about 7-10 days to mature and start reproducing. They lay eggs (nits) on the hair shaft, close to the scalp, so they will incubate. A female louse lays up to 10 nits per day. When two or more people put their heads together, the lice s odds of populating improve. Sleeping together, playing with each other s hair or wrestling are common ways for lice to move from one head to another. Without another human host, lice will starve in two days. While it's harder to find other living quarters without direct head to head contact, it is possible. Lice can survive on clothing, upholstered furniture, carpeting, combs and brushes, or stuffed animals for two whole days. Vacuums, really hot water, washing machines, and dryers are their environmental enemies. These practices further reduce their chances of survival. Lice are good at hiding. They may live on a head for weeks before being discovered. You may notice your head itches more, or may see nits in your hair. Nits are tiny, yellowish or grayish-white, and oval in shape. They are glued to the side of a hair shaft, about 1/8 to 1/4 inch from the scalp. As a full grown adult, they are still only the size of a sesame seed. The color can be translucent, grey-brown or reddishbrown after feeding. They are adept at hiding and will quickly move away from the light when hair is parted. If you search, you may find them on the scalp or clinging to a hair shaft. Applying medicated shampoos or cream rinses will generally get rid of lice. Unfortunately, sometimes nits have been left behind, and they still have a small chance for survival. These can be eliminated by using nit-picking combs. The teeth are very fine so that they damage and rip the eggs right off the hair shaft. There is still a chance that a few of the nits will survive and will need further treatment. In seven to ten days, any nits that have survived will hatch, starting the whole cycle of life over again. Lice outbreaks are most prevalent in the summertime and during winter breaks. WEBSITES (Centers for Disease Control) (American Academy of Pediatrics) (Illinois Department of Public Health) (Harvard School of Public Health)

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