2015–2016 Student Health Requirements

2015–2016 Student Health Requirements
Dear Parents:
To comply with Illinois State law, a physical examination, including current immunization records, is
required for all children entering school for the first time and also for students entering 6th grade.
This exam must have been conducted within one year prior to school entry and be recorded on the
State of Illinois form. (An out-of-State/country record must be on a comparable form.) This exam and
age-appropriate immunizations are required before the first day of attendance in order to avoid
exclusion. Therefore, we request that the records be presented to the school by August 7, 2015,
so that staff may review them for compliance.
In addition, all students entering, transferring, or advancing into grades 6, 7, 8, 9, 10, 11, or 12 will be
required to show proof of receipt of one dose of Tdap vaccine (containing tetanus, diptheria, acellular
pertussis). Most students already have received this vaccine and simply need to provide the school with
verifying documentation from the family health care provider.
Note that District parents/guardians whose children have not fulfilled the physical examination/
immunization requirements before school begins in August will not receive their child’s information
packet, which includes teacher assignment and other pertinent information.
A dental examination is required for students in Kindergarten, 2nd, and 6th grades. This examination
must have been completed between Nov. 15, 2014, and May 15, 2016.
In addition, state law mandates an eye examination, by an ophthalmologist or optometrist, for
Kindergarten students and for ALL children enrolling in an Illinois school for the first time.
Required forms are available from your doctor’s office and also at the District website (www.kcsd96.org).
To find the forms on the District website, in the “About” drop-down menu, click on “Student Services.”
Then select “Student Health” link on the right.
For low-cost medical help, please contact the Lake County Health Department at 847-377-8470. If there
is an exception on religious grounds, please contact my office at 847-459-4260.
We urge all families to schedule your appointments with your physicians and dentists promptly so there
will be no delays for your children in complying with the law.
Sincerely,
Julie A. Schmidt
Superintendent of Schools
1050 Ivy Hall Lane • Buffalo Grove, IL 60089 • 847.459.4260 • www.kcsd96.org
Administration: Julie A. Schmidt, Superintendent; Beth Dalton, Ed.D., Assistant Superintendent for Human Resources;
Jonathan G. Hitcho, Assistant Superintendent for Business Services; Paul Louis, Director of Curriculum & Assessment;
Kevin Ryan, Director of Educational Technology & 21st-Century Learning; Heather Friziellie, Director, Educational Services;
Randall Warren, Director of Facilities & Transportation; Board of Education: Marc Tepper, President; Renee Klass, Vice President;
James Strezewski, Secretary; Mike Burns, Elizabeth Dietz; Lauren Gordon; Cynthia Zarkowsky
2015-2016 Requisitos de Salud
Estimados Padres/Guardianes:
Para estar de acuerdo con la ley del Estado de Illinois, un examen de salud que incluye registros actuales de
inmunizaciónes–es requerido para todos los niños que entran a la escuela por primera vez y también para
estudiantes que cursan el sexto grado.
Este reconocimento de examen físico debe de ser realizado un año antes de entrar a la escuela y debe estar
registrado en la forma del Estado de Illinois. El examen físico y edad apropiada las inmunizaciones son
requeridas antes del primer día de escuela; por lo tanto, nosotros requerimos que los records sean
presentado a la escuela no mas tarde del 7 de agosto de 2015, para que el personal los pueda revisar y
confirmar.
Al principio del próximo año escolar, se requerirá que todos los estudiantes que entran, avanzan o transfieren
a los grados 6, 7, 8, 9, 10, 11 y 12 muestren evidencia de haber recibido una dosis de la vacuna Tdap
(combinación de tétano, difteria y tos ferina), sin importar el tiempo que ha pasado desde la última vez que
recibieron una dosis de DTap, DT o Tdi. La mayoría de los estudiantes pueden ya han recibido la vacuna y
simplemente necesitan proveer a la escuela una documentación del proveedor de atención médica de la familia
que lo verifique.
Padres/guardianes del distrito quienes no cumplen con el examen físico de su hijo(a) inmunización requeridos
antes de que la escuela empieze en agosto no recibirán el paquete de información de su hijo(a), que incluye el
nombre del maestro(a) y otra información pertinente.
Estudiantes entrando al kinder, segundo grado, y sexto grado en agosto del 2015 también son requeridos a
tener un examen dental. Este examen debe de estar completado entre el 15 de noviembre de 2014, y el 15 de
mayo de 2016.
Además, una nueva ley del estado requiere un examen de los ojos hecha por un optomólogo o un optometrista
para entrar al kinder y para TODOS los niños que se matriculan en una escuela de Illinois por primera vez.
Cada médico y dentista en el estado deben de tener las formas apropiadas para este requerimiento de
exámenes de salud, dental, y visión. Las formas también están disponibles en el website del Distrito (www.
kcsd96.org). Para encontrar los formularios en el sitio web del Distrito, en el menú desplegable “About,” haga clic
en “Student Services” luego de Salud para Estudiantes.
Para la asistencia médica de bajo costo, contacta por favor el Departamento de la Salud de Lake County en 847377-8470. Si hay una excepción en el motivo religioso, contacta por favor a mi oficina en 847-459-4260.
Instamos que todas las familias cumplen estos exámenes obligatorios. Por favor planifique sus citas con sus
médicos y con dentistas inmediatamente para que no haya demoras para que sus niños cumplan con la ley.
Sinceramente,
Julie A. Schmidt
El Supervisor de Escuelas
1050 Ivy Hall Lane • Buffalo Grove, IL 60089 • 847.459.4260 • www.kcsd96.org
Administration: Julie A. Schmidt, Superintendent; Beth Dalton, Ed.D., Assistant Superintendent for Human Resources;
Jonathan G. Hitcho, Assistant Superintendent for Business Services; Paul Louis, Director of Curriculum & Assessment;
Kevin Ryan, Director of Educational Technology & 21st-Century Learning; Heather Friziellie, Director, Educational Services;
Randall Warren, Director of Facilities & Transportation; Board of Education: Marc Tepper, President; Renee Klass, Vice President;
James Strezewski, Secretary; Mike Burns, Elizabeth Dietz; Lauren Gordon; Cynthia Zarkowsky
FOR USE IN DCFS LICENSED CHILD CARE FACILITIES
CFS 600
Rev 12/2011
State of Illinois
Certificate of Child Health Examination
Student’s Name
Birth Date
Last
First
Address
Middle
Street
City
Sex
Race/Ethnicity
School /Grade Level/ID#
Month/Day/Year
Parent/Guardian
Zip Code
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.
1
MO DA YR
2
MO DA YR
3
MO DA YR
4
MO DA YR
5
MO DA YR
†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
Vaccine / Dose
6
MO DA YR
DTP or DTaP
Tdap; Td or Pediatric
DT (Check specific type)
Polio (Check specific
type)
Hib Haemophilus
influenza type b
Hepatitis B (HB)
COMMENTS:
Varicella
(Chickenpox)
MMR Combined
Measles Mumps. Rubella
Measles
Single Antigen
Vaccines
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
ALTERNATIVE PROOF OF IMMUNITY
Title
Date
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.)
Physician’s Signature
*MEASLES (Rubeola) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR
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
3. Laboratory confirmation (check one) ¨ †Measles
Lab Results
Date
Title
†Mumps
MO
DA
†Rubella
Date
†Hepatitis B
†Varicella
(Attach copy of lab result)
YR
VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN
Date
Code:
Age/
Grade
R
L
R
L
R
L
R
L
R
L
R
L
Vision
Hearing
IL444-4737 (R-01-12)
(COMPLETE BOTH SIDES)
R
L
R
L
R
L
P = Pass
F = Fail
U = Unable to test
R = Referred
G/C =
Glasses/Contacts
Printed by Authority of the State of Illinois
First
HEALTH HISTORY
ALLERGIES
Sex
Birth Date
Student’s Name
Last
Middle
School
Grade Level/ ID #
Month/Day/ Year
TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER
MEDICATION (List all prescribed or taken on a regular basis.)
(Food, drug, insect, other)
Diagnosis of asthma?
Child wakes during the night
?
Birthhidefects?
Yes
Yes
No
No
Loss of function of one of paired
organs? (eye/ear/kidney/testicle)
Yes
No
Yes
No
No
Developmental delay?
No
Hospitalizations?
When? What for?
Yes
Yes
Blood disorders? Hemophilia,
Sickle Cell, Other? Explain.
Diabetes?
Yes
No
Yes
No
Yes
No
Surgery? (List all.)
When? What for?
Serious injury or illness?
Yes
No
Head injury/Concussion/Passed out?
Yes
No
TB skin test positive (past/present)?
Yes*
Seizures? What are they like?
Yes
No
TB disease (past or present)?
Yes*
No *If yes, refer to local health
department.
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
Family history of sudden death
before age 50? (Cause?)
Yes
No
Yes
No
Dizziness or chest pain with
exercise?
Eye/Vision problems? _____ Glasses … Contacts … Last exam by eye doctor ______
Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)
Ear/Hearing problems?
Yes
No
Bone/Joint problem/injury/scoliosis?
Yes
… Braces
… Bridge
… Plate Other
Information may be shared with appropriate personnel for health and educational purposes.
Parent/Guardian
Signature
No
PHYSICAL EXAMINATION REQUIREMENTS
HEAD CIRCUMFERENCE
Dental
Date
Entire section below to be completed by MD/DO/APN/PA
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.
Questionnaire Administered ? Yes … No …
Blood Test Indicated? Yes … No …
Blood Test Date
(Blood test required if resides in Chicago.)
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 ______________
Date
LAB TESTS (Recommended)
Results
Date
Hemoglobin or Hematocrit
Urinalysis
SYSTEM REVIEW
Results
Sickle Cell (when indicated)
Developmental Screening Tool
Normal Comments/Follow-up/Needs
Normal Comments/Follow-up/Needs
Skin
Endocrine
Ears
Gastrointestinal
Eyes
Amblyopia Yes… No…
Neurological
Throat
Musculoskeletal
Mouth/Dental
Spinal Exam
Cardiovascular/HTN
Nutritional status
… Diagnosis of Asthma
Respiratory
Currently Prescribed Asthma Medication:
… Quick-relief medication (e.g.Short Acting Beta Antagonist )
… Controller medication (e.g. inhaled corticosteroid)
NEEDS/MODIFICATIONS required in the school setting
LMP
Genito-Urinary
Nose
Mental Health
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
PHYSICAL EDUCATION
Print Name
Address
Yes …
No …
(If No or Modified,please attach explanation.)
Modified …
INTERSCHOLASTIC SPORTS (for one year)
(MD,DO, APN, PA)
Signature
Phone
(Complete both sides)
Yes …
No …
Limited …
Date
FOR USE IN DCFS LICENSED CHILD CARE FACILITIES
CFS 600
Rev 12/2011
State of Illinois
Certificate of Child Health Examination
Student’s Name
Last
First
Address
Middle
Street
City
Zip Code
Birth Date
Sex
Race/Ethnicity
School /Grade Level/ID#
Month/Day/Year
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.
1
MO DA YR
Vaccine / Dose
DTP or DTaP
Tdap Td DT
Tdap Td DT
4
MO DA YR
Tdap Td DT
5
MO DA YR
Tdap Td DT
6
MO DA YR
Hib Haemophilus
influenza type b
Hepatitis B (HB)
Varicella
(Chickenpox)
MMR Combined
IPV
OPV
IPV
Measles
OPV
IPV
Rubella
OPV
IPV
OPV
IPV
Tdap Td DT
Polio (Check specific
type)
Tdap Td DT
Measles Mumps. Rubella
3
MO DA YR
Tdap; Td or Pediatric
DT (Check specific type)
2
MO DA YR
IPV
OPV
OPV
COMMENTS:
Mumps
Single Antigen
Vaccines
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) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR
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
Measles
3. Laboratory confirmation (check one)
Lab Results
Mumps
Date
MO
DA
Rubella
Date
Hepatitis B
Varicella
(Attach copy of lab result)
YR
VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN
Date
Age/
Grade
R
Vision
Hearing
L
IL444-4737 (R-01-12)
R
L
R
L
R
L
R
L
R
L
(COMPLETE BOTH SIDES)
R
L
R
L
R
L
Code:
P = Pass
F = Fail
U = Unable to test
R = Referred
G/C =
Glasses/Contacts
Printed by Authority of the State of Illinois
Sexo
Fecha de Nacimiento
Apellido
Nombre
Inicial
Escuela
Grado/Núm. de Ident.
Mes / Día / Año
HISTORIAL MÉDICO - PARA SER COMPLETADO Y FIRMADO POR PADRES / TUTOR Y VERIFICADO POR EL PROVEEDOR DE CUIDADO DE SALUD
ALERGIAS (Alimentos, drogas, insectos, otro)
MEDICINAS (Anote todas las recetadas o tomadas con regularidad.)
¿Tiene diagnóstico de asma?
¿Despierta el niño tosiendo en la noche?
Sí
Sí
No
No
¿Tiene pérdida de Funciones en uno de los
órganos? (Ojos/Oídos/Riñones/Testículos)
Sí
No
¿Tiene defectos de nacimiento?
Sí
No
Sí
No
¿Tiene retrasos del desarrollo?
Sí
No
¿Ha sido hospitalizado?
¿Cuándo? ¿Por Qué?
¿Tiene problemas de la sangre? Hemofilia,
Glóbulos Falciformes (Sickle Cell), Otro
Explique
Explain.
¿Tiene
diabetes?
Sí
No
Sí
No
Sí
No
¿Ha atendido cirugía? (anótelas todas)
¿Cuándo? ¿Para Qué?
¿Ha tendido heridas graves o enfermedades?
Sí
No
¿Tiene heridas en la cabeza / golpe / desmayo?
Sí
No
¿Prueba positiva de TB (Pasado o Presente)?
Sí*
No
¿Tiene convulsiones? ¿Cómo se manifiestan?
Sí
No
¿Enfermedad de TB (Pasado o Presente)?
Sí*
No
¿Tiene problemas cardiacos / No respira bien?
Sí
No
¿Usa tabaco (tipo, Frecuencia)?
Sí
No
¿Tiene soplo en corazón / presión arterial alta?
Sí
No
¿Toma alcohol / drogas?
Sí
No
Sí
No
¿Tiene mareos o dolor de pecho al hacer
ejercicios?
¿Problemas con los Ojos?
Lentes … Lentes de Contacto … Ú ltimo Examen
¿Otras Preocupaciones? (bizco, párpados caídos, parpadear, dificultad cuando lee)
¿Tiene problemas de oídos / No oye bien?
Sí
No
¿Historial de familiares de muerte repentina
antes de los 50 años ? (¿Causa?)
Sí
No
¿Tiene problemas de los huesos / articulaciones / heridas Sí
/ escoliosis?
Firma del Padre/Tutor
Dental
… Placas Otro
La información en este formulario se puede compartir con el personal apropiado para propósitos de
salud y educación.
No PHYSICAL EXAMINATION REQUIREMENTS
… Ganchos … Puente
*Si contestó sí, refiera al
departamento de salud
local
Fecha
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.
Questionnaire Administered ? Yes … No …
Blood Test Indicated? Yes … No …
Blood Test Date
(Blood test required if resides in Chicago.)
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
Date
LAB TESTS (Recommended)
Hemoglobin or Hematocrit
Urinalysis
SYSTEM REVIEW
Skin
Ears
Eyes
Nose
Throat
Mouth/Dental
Cardiovascular/HTN
Respiratory
Results
Normal Comments/Follow-up/Needs
Date
Sickle Cell (when indicated)
Developmental Screening Tool
Genito-Urinary
No…
Neurological
Musculoskeletal
Spinal Exam
Nutritional status
Mental Health
… Diagnosis of Asthma
Currently Prescribed Asthma Medication:
… Quick-relief medication (e.g. Short Acting Beta Antagonist)
… Controller medication (e.g. inhaled corticosteroid)
NEEDS/MODIFICATIONS required in the school setting
Normal Comments/Follow-up/Needs
Endocrine
Gastrointestinal
Amblyopia Yes…
Results
Other
LMP
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
PHYSICAL EDUCATION
Print Name
Address
Yes …
(If No or Modified please attach explanation.)
No … Modified …
INTERSCHOLASTIC SPORTS (for one year)
(MD,DO, APN, PA)
Signature
Phone
(Complete Both Sides)
Yes …
No …
Limited …
Date
State of Illinois
Eye Examination Report
Illinois law requires that proof of an eye examination by an optometrist or physician who provides complete eye examinations be submitted to the school no later than
October 15th 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 child
beginning school.
Student Name: ___________________________________________ Birth Date: _____________ Sex: _____Grade: _____
(Last)
(First)
(Middle Initial)
(Mo.) (Day)
(Yr.)
Parent or Guardian: ____________________________________________________ Phone: ________________________
(Last)
(First)
(Area Code)
Address: ______________________________________________________________ County: _______________________
(Number)
(Street)
(City)
(Zip Code)
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
Refraction:
Distance
Left
Right
Unaided Visual Acuity:
Best Corrected Visual Acuity:
20 /
20 /
20 /
20 /
Was refraction performed with cycloplegic agents?
Normal
External Exam (eye and adnexa)
‰
Internal Exam (media, lens, fundus, etc.)
‰
Neurological Integrity (pupils)
‰
Binocular Function (stereopsis)
‰
Accommodation and Vergence
‰
Color Vision
‰
IOP (glaucoma)
‰
Oculomotor Assessment
‰
Other: _______________________________ ‰
Near
Both
Both
20 /
20 /
‰ Yes
20 /
20 /
‰ No
Abnormal Not Able to Assess
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
Comments
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
Diagnosis
‰ Normal
‰ Myopia
‰ Hyperopia
‰ Astigmatism
‰ Strabismus
‰ Amblyopia
Other: ______________________________________________________________________________________________
Recommendations
1. Corrective Lenses:
‰ No ‰ Yes, glasses should be worn for:
‰ Constant Wear ‰ Near Vision ‰ Far Vision
‰ May Be Removed for Physical Education
‰ Yes Comments: _______________________________________
2. Preferential seating recommended:
‰ No
3. Recommend re-examination:
‰ 3 months
‰ 6 months
‰ 12 months
‰ Other _______________
4. __________________________________________________________________________________________________
5. __________________________________________________________________________________________________
Print Name: ___________________________________________
Consent of Parent or Guardian
I agree to release the above information on my child or ward
to appropriate school or health authorities.
Optometrist or Physician Who Provides Eye Examinations
Address: ____________________________________________
(Parent or Guardian’s Signature)
____________________________________________
Signature: ____________________________________________
Optometrist or Physician Who Provides Eye Examinations
Phone: ________________________________
State of Illinois
Illinois Department of Public Health
PROOF OF SCHOOL DENTAL EXAMINATION FORM
To be completed by the parent (please print):
Student’s Name:
Address:
Last
First
Street
Middle
City
Birth Date:
/
ZIP Code
Name of School:
Grade Level:
/
Telephone:
Gender:
! Male
Parent or Guardian:
(Month/Day/Year)
! Female
Address (of parent/guardian):
To be completed by dentist:
Oral Health Status (check all that apply)
! Yes ! No Dental Sealants Present
! Yes ! No 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 1st molars.
! Yes ! No 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.
! Yes ! No Soft Tissue Pathology
! Yes ! No 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 ___________________________________________________
Telephone _______________________
Street
City
ZIP Code
Illinois Department of Public Health, Division of Oral Health
217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • www.idph.state.il.us
IOCI 0600-10
Printed by Authority of the State of Illinois
Estado de Illinois
Departamento de Salud Pública
FORMULARIO COMPROBANTE DEL EXAMEN DENTAL ESCOLAR
Para ser completado por el padre/madre (por favor impresión):
Nombre del Estudiante:
Apellido
Nombre
Inicial
Fecha de Nacimiento:
/
/
(Mes/Día/Año)
Dirección:
Calle
Ciudad
Código Postal
Número de Teléfono:
Nombre de la Escuela:
Grado:
Sexo:
Nombre del padre/madre o encargado:
Dirección del padre/madre o encargado:
! Masculino
! Femenino
To be completed by dentist: (Para ser completado por el dentista:)
Oral Health Status (check all that apply)
! Yes ! No Dental Sealants Present
! Yes ! No 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 1st molars.
! Yes ! No 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.
! Yes ! No Soft Tissue Pathology
! Yes ! No 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 ___________________________________________________
Telephone _______________________
Street
City
ZIP Code
Departamento de Salud Pública de Illinois, División de la Salud Oral
217-785-4899 • TTY (sólo para personas con impedimento auditivo) 800-547-0466 • www.idph.state.il.us
IOCI 0600-10
Impreso con Autoridad del Estado de Illinois
PARENT CONSENT FORM for
STUDENT ACTIVITY/ATHLETIC PARTICIPATION
2015 – 2016
STUDENT NAME:
_____________________________
________________________________
Last
First
DATE OF BIRTH:
________/________/_________
CM IH K P TG W
____________
Month
School (circle one)
Grade
Day
Year
PARENT PERMISSION AND RELEASE:
Extracurricular athletic sport or activity: ___________________________
______________________ has my permission to participate and/or compete in the above listed
extracurricular sport or activity during the current school year.
I realize that there may be an inherent risk of injury. The nature of the injury could be severe,
including the risk of fractures, brain injuries, paralysis, and other catastrophic injuries,
including death.
I understand that I will provide transportation home from school after practice sessions and
events unless otherwise arranged.
_________________________________________________
_________________
Parent/Guardian signature
Date
____________________________________________
Contact number
____________________________________
Secondary contact number
***Please return this form to the building coach or sponsor.
***Note: any extracurricular contact activity or athletic participant will need to complete a concussion signature
form.
***Note: there may be an additional building activity/athletic form required your student’s building coach/sponsor.
KILDEER COUNTRYSIDE COMMUNITY
CONSOLIDATED SCHOOL DISTRICT 96
DISTRITO 96 FORMULARIO DE PERMISO DE LOS PADRES PARA QUE SU ESTUDIANTE PARTICIPE EN ACTIVIDADES ATLETICAS Y DEPORTES
201 5/2016 NOMBRE DEL ESTUDIANTE: _____________________________ ______________________________ Apellido Nombre FECHA DE NACIMIENTO: _________/________/________ CM IH K P TG W ______________ mes dia año Escuela (haga un circulo) grado PERMISO DE LOS PADRES Y RENUNCIA A ACCION LEGAL: Actividad extracurricular o deporte __________________________________________ __________________________________ tiene mi permiso para participar y/o competir en la actividad atlética o deporte extracurricular arriba mencionado, durante el presente año escolar. Estoy conciente de los riesgos y posibilidades de ser herido. La naturaleza de la herida puede ser severa, incluyendo riesgos de fractura, lesiones del cerebro, parálisis y otras heridas catastróficas y hasta la muerte. Entiendo que deberé transportar a mi hijo/a de la escuela a la casa después de las prácticas y de los eventos a no ser que sea arreglado de otra manera. ________________________________ _________________________ Firma del padre Fecha ________________________________ _________________________ Teléfono de contacto principal Contacto secundario *** Por favor devuelva este formulario al entrenador o auspiciador. *** Nota: todo participante en actividades extracurriculares o atléticas que incluyen contacto directo con otros jugadores, deben completar y firmar el formulario conmoción cerebral. *** Es posible que haya otro formulario requerido por el entrnador de su estudiante, que deba completar. 1050 Ivy Hall Lane – Buffalo Grove, IL 60089 – Phone: 847/459-4260 – www.kcsd96.org
Administration: Julie A. Schmidt, Superintendent of Schools; Beth Dalton, Ed.D., Assistant Superintendent of Human Resources; Jon Hitcho, Assistant Superintendent for Business;
Jeanne Spiller, Assistant Superintendent for Teaching and Learning
Board of Education: Marc Tepper, President; Renee Klass, Vice President; John Rouleau, Secretary; Elizabeth Dietz, Robert Gauthier, Lauren Gordon, James Strezewski
Concussion Information Sheet
A concussion is a brain injury and all brain injuries are serious. They are caused by a
bump, blow, or jolt to the head, or by a blow to another part of the body with the force
transmitted to the head. They can range from mild to severe and can disrupt the way
the brain normally works. Even though most concussions are mild, all concussions are
potentially serious and may result in complications including prolonged brain
damage and death if not recognized and managed properly. In other words, even a
“ding” or a bump on the head can be serious. You can’t see a concussion and most
sports concussions occur without loss of consciousness. Signs and symptoms of
concussion may show up right after the injury or can take hours or days to fully appear.
If your child reports any symptoms of concussion, or if you notice the symptoms or signs
of concussion yourself, seek medical attention right away.
Symptoms may include one or more of the following:
x
x
x
x
x
x
x
x
x
x
x
Headaches
“Pressure in head”
Nausea or vomiting
Neck pain
Balance problems or dizziness
Blurred, double, or fuzzy vision
Sensitivity to light or noise
Feeling sluggish or slowed down
Feeling foggy or groggy
Drowsiness
Change in sleep patterns
x
x
x
x
x
x
x
x
x
x
Amnesia
“Don’t feel right”
Fatigue or low energy
Sadness
Nervousness or anxiety
Irritability
More emotional
Confusion
Concentration or memory problems
(forgetting game plays)
Repeating the same
question/comment
Signs observed by teammates, parents and coaches include:
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Appears dazed
Vacant facial expression
Confused about assignment
Forgets plays
Is unsure of game, score, or opponent
Moves clumsily or displays in coordination
Answers questions slowly
Slurred speech
Shows behavior or personality changes
Can’t recall events prior to hit
Can’t recall events after hit
Seizures or convulsions
Any change in typical behavior or personality
Loses consciousness
Adapted from the CDC and the 3rd International Conference on Concussion in Sport
Document created 7/1/2012
Concussion Information Sheet
What can happen if my child keeps on playing with a concussion or returns too
soon?
Athletes with the signs and symptoms of concussion should be removed from play
immediately. Continuing to play with the signs and symptoms of a concussion leaves
the young athlete especially vulnerable to greater injury. There is an increased risk of
significant damage from a concussion for a period of time after that concussion occurs,
particularly if the athlete suffers another concussion before completely recovering from
the first one. This can lead to prolonged recovery, or even to severe brain swelling
(second impact syndrome) with devastating and even fatal consequences. It is well
known that adolescent or teenage athletes will often fail to report symptoms of injuries.
Concussions are no different. As a result, education of administrators, coaches, parents
and students is the key to student-athlete’s safety.
If you think your child has suffered a concussion
Any athlete even suspected of suffering a concussion should be removed from the
game or practice immediately. No athlete may return to activity after an apparent head
injury or concussion, regardless of how mild it seems or how quickly symptoms clear,
without medical clearance. Close observation of the athlete should continue for several
hours. The Return-to- Play Policy of the IESA and IHSA requires athletes to provide
their school with written clearance from either a physician licensed to practice medicine
in all its branches or a certified athletic trainer working in conjunction with a physician
licensed to practice medicine in all its branches prior to returning to play or practice
following a concussion or after being removed from an interscholastic contest due to a
possible head injury or concussion and not cleared to return to that same contest. In
accordance with state law, all schools are required to follow this policy.
You should also inform your child’s coach if you think that your child may have a
concussion. Remember it’s better to miss one game than miss the whole season. And
when in doubt, the athlete sits out.
For current and up-to-date information on concussions you can go to:
http://www.cdc.gov/ConcussionInYouthSports/
_____________________________
Student-athlete Name Printed
_____________________________
Student-athlete Signature
_____________
Date
__________________________
Parent or Legal Guardian Printed
___________________________
Parent or Legal Guardian Signature
___________
Date
Adapted from the CDC and the 3rd International Conference on Concussion in Sport
Document created 7/1/2012