Early Childhood Screening Consent

Early Childhood Screening Consent Child s Name: (For office use only) MARSS other ID: Parent/Guardian Name(s): Birthdate: Early childhood developmental screening helps a school district identify children who may benefit from district and community resources available to help in their development. Early childhood developmental screening includes a vision screening that helps detect potential eye problems, but is not a substitute for a comprehensive eye exam. This screening does not replace on-going care from your health care provider or dentist. A. This Screening includes: Review of your child s immunization record Check of your child s growth, such as height and weight Tests for possible hearing problems Tests for eye health, including how well your child can see Review of any other factors that might interfere with your child s health, growth, development or learning Check of your child s development Your report of your child s growth and learning Information about your child s health care and insurance Information about community resources and programs based on your child s or family s needs Child and Parent Rights, Obligations, and Assurances 1. The standards for screening are the same for every child regardless of race, income, creed, sex, national origin, or political beliefs. 2. Screening is required for your child s entry into public school kindergarten or first grade. You can also meet this requirement if your child has participated in a screening in the past year through Head Start, Child and Teen Checkups, or an equivalent developmental screening through another health provider that includes all required early childhood screening components. You or your provider will need to give summary results of the equivalent to your child s school district. 3. Screening is not required for your child s entry into kindergarten or first grade if you are a conscientious objector to screening. You will need to provide a written statement to your child s school district that documents your conscientious objector status. 4. You have the right to refuse to answer questions or provide information and still receive the rest of the required screening components. 5. You have the right to refuse referral for assessment, diagnosis, and possible treatment for your child. 6. Your child s medical assistance eligibility or eligibility in any other health, education, or social service programs will not be affected if you refuse this screening or any parts of this screening. I give permission for the Child Health and Development Screening checked below for: Child s Name: Check One: Complete screening as described above in A and B Screening described above except: Parent/Guardian Signature Date Relationship to Child REV: 11/2016

CHILD HEALTH AND DEVELOPMENTAL HISTORY (3-6 YEARS) Child s Name: (For office use only) MARSS other ID: M F Languages spoken at home: Birthdate: Age Parent/Guardian Name(s) &Phone # : Person completing form: Date: How often does your child see a doctor or nurse? Date of last well child visit: How often does your child see a dentist? Date of last dental check-up: Date of your child s most recent comprehensive vision (eye) exam, if your child received one: The comprehensive vision exam is performed by an optometrist or ophthalmologist. Does your child have health insurance? Yes No Applied Please check the boxes if you or your child use, if any: Early Childhood Family Education Child & Teen Check-ups Child care center Early Childhood Special Education School-based pre-k Family/neighbor care Follow Along program Private preschool Library Parenting Education Head Start WIC Parks and Recreation programs Foster Care Food shelf HEALTH Please check any concerns that apply to your child and describe: Allergies: food medicine animals/insect Takes medicines, herbs and/or vitamins: dust/mold seasonal Visits to health specialist(s), hospital stays and/or surgeries: Serious injuries or illnesses, visit to Emergency Room. Reason and date: Head injuries (loss of consciousness?) Lead poisoning, level if known: Trouble breathing, coughing or asthma: Skin problems or rashes: Seizures, staring spells: Vision problem or wears glasses: Updated May 2016 1

Ear (PE) tubes or hearing problems: Teeth: one or more cavities: Eating, stomach concerns or constipation: Mental health concerns such as anxiety, depression or attention concerns? Adopted, if Yes, at what age: Problems during pregnancy or birth? Born more than three weeks early or late # weeks at birth. Child s birth weight: At birth, stayed in the hospital longer than mother, reason: Is it possible that before you knew you were pregnant you took medications, alcohol, cigarettes, or street drugs? Please list any other concerns: Please check any Family Health problems (child s parents or siblings): Attention problems Vision problems Diabetes Allergy Learning Problems Growth Problems Asthma Mental Health Disorders Epilepsy/Seizures Deafness/Hearing Sickle Cell Anemia/Trait Other health problems CHILD S DAILY ROUTINES Sleeps at pm. Wakes up at am. Has difficulty falling/staying asleep Takes a nap: from to Gets 60 minutes or more of exercise each day Is NOT able to/does NOT get 60 minutes of exercise TV/Video Game/Screen Time: hours per day Every day eats some foods from the food groups: 5-9 servings fruits/vegetables: oranges, apples, bananas, mangos, berries, spinach, corn, peas 3 servings calcium rich foods: milk, cheese, yogurt, soymilk, tofu 2-3 serving iron rich foods: fish, poultry, meat, beans, legumes, eggs 3 or more servings: whole grains: whole wheat bread, cereal, brown rice, tortillas, crackers, pasta More than one serving of sweets, fruit drinks or junk food each day Updated May 2016 2

HOME SAFETY Do you and /or your child use/have the following: car seats bike helmets smoke detector carbon monoxide detector LEARNING My child learned to do things at the same age as other children (sit, stand, walk, toilet trained, etc.) If not, please explain: My child needs help with: toileting activity/mobility dressing nutrition/eating Other: Please check any of the following: Says numbers 1 to 10 Has trouble speaking or hard to understand Has trouble being understood by others Seems clumsy when using hands understands other people Able to follow directions Plays in a variety of ways Walks or runs poorly (falls) Updated May 2016 3

Early Childhood Screening Release of Information Child s Name: Birthdate: (For office use only) MARSS other ID: Parent/Guardian Name(s): (This organization) uses information from the Child Health and Developmental Screening to identify any possible problems that might interfere with your child s health, growth, development or learning. Under Minnesota law, screening results are classified as private data. This means the results cannot be released or discussed with anyone without your consent. If you refuse to release this information, it will not affect your child s eligibility for medical assistance or any other health, education, or social service program. Summary data about groups of children that does not include information about individual children may be shared without consent. Information from Your Child s Screening May be Used for the Following Purposes: 1. To obtain follow-up services for your child after the screening, if you choose to participate. 2. To arrange for further evaluation or assessment of your child s health, growth, development, or learning, if you choose to participate. 3. To fulfill the requirements for your child s entrance into public school or Early Learning Scholarship, School Readiness or Voluntary Pre-Kindergarten programs. 4. To evaluate screening programs by the Minnesota Departments of Education, Health and Human Services. Your child s name will not be identified in any evaluation results. 5. To develop appropriate educational programs to meet student needs and to design appropriate health education programs for the district. 6. To plan for early childhood programs and school entry. 7. To provide access to and accountability for government funds paid to the local school district for providing required early childhood screening services. Your signature indicates that you have read, understand and agree that the information can be used as stated above. CONSENT TO RELEASE INFORMATION I hereby authorize release of my child s screening information to the following checked programs or services for the purpose of evaluation, assessment, diagnosis, follow-up and /or programming. (Please provide names and addresses where available). Check any persons/agencies that you wish to receive screening information about your child. Child Care provider Dentist (Name) Early Childhood Family Education (ECFE) Early Childhood Special Education Follow Along Program Head Start (Name) Health Care Provider (Medical Clinic) Interagency Early Intervention Committee (IEIC) Mental Health Agency Public Health Agency (WIC) School District (Name) School Readiness Other (regionally specific programs) Understand Information Authorize release of information Parent/Guardian Signature: Date: Relationship to Child: REV: 11/2016

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 651-201-5503 or 800-657-3970. 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 Mo/Day/Yr 2nd Dose Mo/Day/Yr 3rd Dose Mo/Day/Yr 4th Dose Mo/Day/Yr 5th Dose Mo/Day/Yr 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 7-12. If a child received Tdap at age 7-10 years another dose is not needed at age 11-12 years. However, if it was only a Td, a Tdap dose at age 11-12 years is required. Students 11-15 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 www.health.state.mn.us/immunize (12/13)

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 Date 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 Date 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 Date *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 Date 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 www.health.state.mn.us/immunize (12/13)

Immunization Requirements Are Your Kids Ready? Minnesota s Immunization Law Use this chart as a guide to determine which vaccines are required to enroll in child care, early childhood programs, and school (public or private). Find the child s age/grade level and look to see if your child had the number of shots shown by the checkmarks under each vaccine. The table on the back shows the ages when doses are due. Birth through 4 years Early childhood programs & Child care Age: 5 through 6 years For Kindergarten 3 Age: 7 through 11 years For 1 st through 6 th grade Age: 12 years and older For 7 th through 12 th grade Hepatitis A (Hep A) Hepatitis B (Hep B) Polio MMR Varicella 5 Polio MMR Varicella Varicella Not required after 24 months. If the child has already had chickenpox disease, varicella shots are not required. If the disease occurred after 2010, the child s doctor must sign a form confirming disease. First graders who are 6 years old and younger must follow the polio and DTaP/DT schedules for kindergarten. Fifth shot of DTaP not needed if fourth shot was after age 4. Final dose of DTaP on or after age 4. Fourth shot of polio not needed if third shot was after age 4. Final dose of polio on or after age 4. Need proof of at least three tetanus and diphtheria containing doses. If up to date on DTaP/DT series, no additional doses needed. An alternate two-shot schedule of hepatitis B may also be used for kids age 11 through 15 years. One dose of Tdap is required beginning at 7th grade. Also need proof of at least two tetanus and diphtheria containing doses (DTaP/DT/Td). If a child received Tdap prior to 7th grade, another dose of Tdap is not needed. One dose is required beginning at 7th grade. The booster dose is usually given at 16 years. Exemptions Polio MMR Hib Pneumococcal Varicella Immunizations recommended but not required: Influenza Annually for all children age 6 months and older Rotavirus For infants 1 2 3 4 5 6 7 8 9 Looking for Records? DTaP/DT 1 2 Hepatitis B DTaP/DT 4 2 Hepatitis B 6 tetanus and diphtheria containing doses Hepatitis B 7 Tdap 8 & at least 2 tetanus and diphtheria containing doses Polio MMR Meningococcal 9 & booster Human papillomavirus At age 11-12 years To enroll in child care, early childhood programs, and school in Minnesota, children must show they ve had these immunizations or file a legal exemption. Parents may file a medical exemption signed by a health care provider or a non-medical exemption signed by a parent/guardian and notarized. For copies of your child s vaccination records, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-3980. Minnesota Department of Health, Immunization Program ID# 52799 (4/2017) 2

Birth 2 4 6 When to Get Vaccines Birth to 16 Years 12 15 18 4-6 YEARS 11-12 YEARS 16 YEARS Hep B Hep B* (1-2 months after 1st hep B dose) Hep B* (6-18 months) HPV** RV RV RV* DTaP DTaP DTaP DTaP (15-18 months) DTaP Tdap Hib Hib* Hib Hib (12-15 months) MCV MCV PCV PCV PCV PCV (12-15 months) IPV IPV IPV (6-18 months) IPV MMR (12-15 months) MMR Varicella (12-15 months) Hep A (2 doses at least 6 months apart) Varicella Concerned about cost? Free or low cost vaccines are available. Talk to your doctor or clinic. Influenza (each fall) It s not too late! If your child has fallen behind on their vaccinations, talk to your doctor or clinic to catch them up. Minnesota law requires written proof of certain vaccinations for children in child care, early childhood programs, and school. However, if a child has a medical reason or if his/her parents are conscientiously opposed to any or all of the vaccinations, a legal exemption is available. Children with certain medical conditions may need additional vaccines (e.g., pneumococcal or meningococcal). Talk to your doctor or clinic. Immunization Program 651-201-5503 or 1-800-657-3970 www.health.state.mn.us/immunize Pregnant? Protect yourself and your baby from whooping cough, get a Tdap vaccination between 27 and 36 weeks gestation. Talk to your doctor. *The number of doses depends on the product your doctor uses. **Two doses for 9 to 14 year olds; three doses for 15 to 26 year olds. For copies of your child's immunization records, talk to your doctor or call the Minnesota Immunization Information Connection (MIIC) at 651-201-3980. Key to vaccine abbreviations DTaP/Td/Tdap = diphtheria, pertussis, tetanus Hib = Haemophilus influenzae type b Hep B = hepatitis B Hep A = hepatitis A IPV = polio MCV = meningococcal MMR = measles, mumps, rubella PCV = pneumococcal RV = rotavirus ID# 52799 (4/2017)

Notice of Vision Screening Early Childhood Developmental Screening helps a school district identify children who may benefit from district and community resources available to help in their development. Early childhood developmental screening includes a vision screening that helps detect potential eye problems but is not a substitution for a comprehensive eye exam. Child s Name Date of your child s most recent comprehensive vision exam, if the child has received one. Date Parent Name Date

Dear Farmington School District Resident, Farmington is a growing community and it is critical that the district s decision makers have accurate household information to best serve the needs of the district s residents and students. We value your opinion, so please feel free to comment or ask questions. Please help us in our effort to gather census data by providing us with the information requested. This information is for educational purposes only and the release of this information is governed by State and Federal laws as well as School Board policy. Your address and phone number are considered private data (Please Print) NAME Phone No. Address City Number of Household Members in Each Age Group 0 4 5 10 11 15 16 18 19 25 26 35 36 50 51 60 61 + Children in School: Name Birth Date School GR Name Birth Date School GR Name Birth Date School GR Name Birth Date School GR Children Age 0 through 5 Not Attending School Name BirthDate Name BirthDate Name BirthDate We appreciate your comments and questions Thank you for helping make District 192 an excellent and innovative school district. Rev Jan 2010