2016-17 Middle School Registration Packet

Cambrian School District
Registration Schedule for New Cambrian Students
2016-17 School Year
Registration begins Tuesday, January 12, 2016.
*Open Enrollment (Intradistrict Transfers) will be accepted between
Tuesday, January 12 through Tuesday, March 1.
All completed registration packets are to be returned to the Cambrian School District Office.
Please see schedule below for specific details on registration times and dates.
Cambrian School District Residents
Kindergarten (K) and Transitional Kindergarten (TK): Kindergarten students must turn five (5) years of age before
or on September 1, 2016. Transitional Kindergarten students must turn five (5) years of age between September 2, 2016 and
December 1, 2016
 January 12th and January 14th
Tuesday (1/12)
Thursday (1/14)
 January 19th and ongoing
Tuesdays & Thursdays
7:30 – 11:00 a.m.
7:30 – 11:00 a.m.
Bagby/ Sartorette (TK & K only)
Fammatre/ Farnham (TK & K only)
8:30 – 11:00 a.m.
All Schools (TK & K only)
1st - 8th grade and ongoing registration for TK & K
 February 2nd and ongoing
Tuesdays & Thursdays
8:30 – 11:00 a.m.
All Schools (TK-8th grade)
Out Of District (Charters & Interdistrict Transfers)
 March 3rd and ongoing
Tuesdays & Thursdays
8:30 – 11:00 a.m.
All Schools & All Grades
Cambrian School District Residents: Requesting a school that is not your home school is called an Intradistrict
Transfers. Intradistrict Transfers are to be submitted January 12 through March 1, 2016. As a Cambrian Resident you have
the opportunity to request movement to Steindorf STEAM (K-8) or any other schools within the Cambrian District. If you
are requesting to attend a school that is not your home school please fill out the Intradistrict Transfer Request Form.
Intradistrict Transfer Request Forms may be picked up at any Cambrian School Site, District Office or downloaded from
the Cambrian School District website at www.cambriansd.org. If there are more students requesting Intradistrict Transfers
than space available, a priority list and lottery system will determine the order in which students will be admitted
(Cambrian School District Board Policy & Procedure 5116.1).
Out Of District (Charters & Interdistrict Transfers): Students who live outside the Cambrian School District
boundaries have the opportunity to request to attend a school within Cambrian School District. In order to request a
Charter Permit or Interdistrict Transfer please complete one of the following two forms:
 Charter Permits are required for Farnham, Fammatre, Sartorette and Ida Price Middle School.
 Interdistrict Attendance Permit Forms are required for Bagby and Steindorf STEAM (K-8).
If there are more students requesting Cambrian School District than space available, a priority list and lottery system will
determine the order in which students will be admitted. (Cambrian School District Board Policy & Procedure 5117).
All completed registration packets are to be returned to:
Cambrian School District Office
4115 Jacksol Drive ▪ San Jose, CA 95124
www.cambriansd.org
12/7/15
The ABC’s of Cambrian Registration
2016-17 Transitional Kindergarten - 8th Grade Registration
Please fill out the attached forms in accordance with the instructions below. Registration is not complete until a
completed registration packet is submitted. Return your registration packet as soon as possible. Students will
not be placed until the registration packet is complete and all immunizations requirements are met.
Registration packets must be returned to the Cambrian School District Office located at 4115 Jacksol Drive,
San Jose. Please refer to the Registration Schedule for specific dates and times.
Kindergarten and Transitional Kindergarten age requirements:
 Kindergarten students must turn five (5) years of age before or on September 1, 2016
 Transitional Kindergarten students must turn five (5) years of age between September 2, 2016 and
December 1, 2016
The following items are required by the District and/or California State Law and must be filled out completely.









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Registration Checklist: fill out top portion. Cambrian staff will fill out the rest.
Birth Certificate or passport: provide a certified original copy and one photocopy (Cambrian will keep
the photocopy).
Registration Form (Form A): must be signed at the bottom.
Home Language Survey (Form B)
Student Emergency Form (Form C): This form will serve as an emergency card when your student
starts school. It is important that you notify the school office if there are any changes once this form is
submitted.
Proof of Residence (Form D): must provide three different forms of documentation.
Immunizations (Form E): Original document and one photocopy (Cambrian will keep the photocopy).
Transitional Kindergarten students have the same required immunizations as Kindergarteners. All
immunizations must be up to date and proof provided to the school office before the 1st day of
school.
TB Clearance or Risk Assessment (Form F): This form must be filled out and signed by a health
provider.
Health Survey (Form G): must be signed at the bottom.
Oral Health Assessment (Form H): Kindergarten-1st Grade Only This form is due no later than May
2017.
Report of Health Examination for School Entry (Form I): Kindergarten-1st grade Only
 Kindergarten: This form is required to be completed within 18 months of 1st grade entry and
should be dated March 1, 2016 or later.
 1st grade: This form is required to be completed before the start of 1st grade
Request For Records (Form J): must be signed.
Other forms that might be needed and relevant to your child:
 Allergy Action Plan
 Medication Request Form
We look forward to having your child in the Cambrian School District!
The District determines the enrollment capacity for each district school. If a school is at its grade level capacity, it may be necessary for your child to
attend another school in the Cambrian School District. You will be notified if this goes into effect.
CAMBRIAN SCHOOL DISTRICT
Registration Checklist
4115 Jacksol Drive ● San Jose, CA 95124 ● (408) 377-2103 ● (408) 377-5944 (fax)
Student Data
Student’s Legal Name: _______________________________________________
LAST ,
(as it appears on birth certificate)
FIRST
School Year: ___________________
MIDDLE INTIAL
TK K 1 2 3 4 5
6 7 8 (Circle Grade Entering)
Daytime Phone Number
Date of Birth: _____/______/_________
(_______)
________ - __________________
School of Residence: (Home School)
Bagby Elementary
Fammatre Elementary
Farnham Elementary
Sartorette Elementary
Price Middle
Steindorf STEAM School (Used only with Approved Inter District Transfers)
Documents Required to Complete Registration
All of the following items must be received prior to your child attending school.
Cambrian Office use below
Registration Packet: Staff-initial boxes upon receipt of documents.
Certified Birth Certificate or Passport (Original certified document and one photocopy. Cambrian will keep photocopy)
A-Registration Form
B-Home Language Survey
C-Student Emergency Form
D-Proof of Residence (3 documents)
Evidence of Ownership or Rental
Address Verification 1
Address Verification 2
E-Immunizations (Original document and one photocopy. Cambrian will keep photocopy)
F-TB Clearance or Risk Assessment
G-Health Survey
H-Oral Health Assessment (TK-1)
I-Report of Health Exam (K-1)
J-Request for Records (1-8th grade)
Other Supporting Documents as needed ( * ) required for transfer students
TK-K:
Other Items:
Kindergarten Survey (Bagby)
Allergy Action Plan
Legal Guardianship Paperwork
TK Survey (Fammatre)
Caregiver Affidavit
Medication Authorization
CELDT Results
*Report Card-Recent (1st - 8th )
Charter Permit
Special Education
Middle School (6, 7 & 8):
*Grade Level Information Sheet
Inter District Request Form
Intra District Request Form
IEP
504
Sponsorship
Other: _______________________________________________________
_____________________________________________________________
11/10/15
Form A
CAMBRIAN SCHOOL DISTRICT
Registration Form
4115 Jacksol Drive ● San Jose, CA 95124 ● (408) 377-2103 ● (408) 377-5944 (fax)
Student Data
Student’s Legal Name: __________________________________________________
LAST,
(as it appears on birth certificate)
FIRST
District of Residence: ___________________________
Male
School of Residence: (Home School) ____________________
Birthplace: _____________________________________________________
Female
City
Residence Address:
School Year: _______________
TK K 1 2 3 4 5
6 7 8 (Circle Grade Level Entering)
Primary Phone:
_______________________
Date of Birth: ____/_____/________
Gender:
MIDDLE INTIAL
State
Country
_______________________________________________________________
Street
Apt #
City
State
Zip Code
Demographic Information
Parents are:
Together
Separated
Divorced
Deceased
Father/Guardian
Student resides with:
Mother/Guardian
Name
(Last, First)
Mother & Father
Father Only
Mother Only
Mother & Step-Father
Father & Step-Mother
Step-Mother
Step-Father
Grandparent
Mother & Partner
Father & Partner
Legal Guardians
Other Relative
Relationship
Check here if same as Student’s Residence
Check here if same as Student’s Residence
Address
Home Phone
Cell Phone
Work Phone
Employer
__________________________
Other children in home:
Name:
Date of Birth:
Email
Education
Level
________________ _________
________________ _________
Not a high school grad
High school graduate
Some college
College graduate
Graduate school/post graduate training
Not a high school grad
High school graduate
Some college
College graduate
Graduate school/post graduate training
Step-Parent
________________ _________
(Name, Phone)
Required Additional Information – for further explanation please see the reverse side of this page
1. Is the student Hispanic or Latino? Question 1 - 3 are required for all enrollments)
No, not Hispanic or Latino
Previous District/State/Country
Yes, Hispanic or Latino
2. What is the student’s race?
(Select one or more)
American Indian or Alaskan Native
Asian Indian
Black or African American
Cambodian
Chinese
Filipino
Guamanian
3. What is the student’s ethnicity? (Select one or
more)
American Indian
or Alaskan Native
Asian Indian
Black or African American
Cambodian
Previous School
Chinese
Filipino
Guamanian
Hawaiian
Hispanic/Latino
Hawaiian
Hmong
Japanese
Korean
Japanese
Korean
Laotian
Other Asian
Other Pacific Islander
Samoan
Tahitian
Vietnamese
White
Declined to
State
Laotian
Tahitian
Other Asian
Vietnamese
Other Pacific Islander
White
Samoan
Race Missing
Does your child receive:
Special Services Other Programs
SDC
RSP
Speech
504
EL
GATE
Title I
Other: __________________________________
I swear that the information provided on this form is true and complete to the best of my knowledge.
Signature of Parent or Legal Guardian:
Date: _________________
11/5/15
CAMBRIAN SCHOOL DISTRICT
4115 Jacksol Drive ● San Jose, CA 95124 ● (408) 377-2103 ● (408) 377-5944 (fax)
Statistical Standards – Glossary
#1 Hispanic or Latino person is of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture
or origin, regardless of race.
Ethnicity:

African American or Black - person has origins in any of the black racial groups of Africa. Terms such as "Haitian" or
"Negro" can be used in addition to "Black or African American."

American Indian or Alaska Native - person has origins in any of the original peoples of North and South America
(including Central America), and who maintains tribal affiliation or community attachment.

Asian person has origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent,
including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand,
and Vietnam.

Native Hawaiian or Other Pacific Islander person has origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.

White person has origins in any of the original peoples of Europe, the Middle East, or North Africa.
Glosario de Estándares Estadísticos
#1 Hispano o Latino la persona es Cubana, Mexicana, Puerto Rican, Américano del sur o central, o de otra cultura u
origen español, sin importar la raza.
Pertenencia Etnica:

Américano Africano o Negro - la persona tiene origenes en cualquiera de los grupos raciales negros de Africa.
Nombres así como "Haitian" o "Negro" pueden ser usados en adición a "Negro o Américano Africano."

Indio Américano o Nativo de Alaska - la persona tiene origenes en cualquier gente original del Norte y Sur América
(incluyendo América Central), y quien mantiene afiliaciones tribales o accesorio de la comunidad.

Asiático la persona tiene origines en cualquier gente original del Lejano oriente, Sudeste Asiático, o del
subcontinente Indio, incluyendo, por ejemplo, Camboya, China, India, Japón, Corea, Malasia, Paquistán, Las Islas
Filipinas, Tailandia, y Vietnam.

Nativo Hawaiano u otro Pacífico Isleño la persona tiene origenes en cualquiera de la gente original de Hawai, Guam,
Samoa,u otras Islas del Pacífico
Blanco la persona tiene origenes en cualquiera de la gente original de Europa, del Medio Este, o Africa del Norte.

Spec.Ed. fax to DO
OFFICE USE
ONLY
____/____/____
EL fax to DO
Transfer In: First
Records Req ___/___/___
Transfer Out: Last
Records Sent____/____/____
____/____/____
Day ___/___/___
Records Recd ___/___/___
Day ___/___/____
School _______________
11/5/15
Form B
CAMBRIAN SCHOOL DISTRICT
Home Language Survey
4115 Jacksol Drive ● San Jose, CA 95124 ● (408) 377-2103 ● (408) 377-5944 (fax)
Student Data
Student’s Legal Name: _____________________________________________________________________________
(as it appears on birth certificate)
LAST ,
FIRST
Daytime Phone Number:______________________________
MIDDLE INTIAL
School of Attendance: _________________________________
Part I: California Education Code, Section 52164.1 (a) requires schools to determine the language(s) spoken at home by
each student. This form is essential in order for schools to provide meaningful instruction for all students.
1. Which language did your daughter/son learn when she/he began to talk?
2. What language does your daughter/son most frequently speak at home?
3. What language do you most frequently use when speaking to your daughter/son?
4. Which language is most often spoken by the adults in the home?
Part II: If any response to questions 1-3 in Part I was a language other than English AND/OR your child was
born outside the United States, please complete Part II.
If a language other than English is listed in questions 1-4 above, California law requires testing for English proficiency with the
California English Language Development Test (CELDT), unless you provide CELDT test scores or proof of re-designation to Fully
English Proficient (FEP) Status.
Section A:
1. In what country was your child born?
2. If born out of the United States, on what date did your child first enter the United
States?
month/day/year
month/day/year
3. When did your child first attend a school in the United States?
month/day/year
4. When did/will your child first attend school in California?
Section B:
To your knowledge, has your child been tested for proficiency in English using the
state mandated CELDT?
No
Yes
If you answered “yes,” please
complete Section C.
Section C:
1. At which school was your child CELDT tested?
2. Date of most recent CELDT test. (Please provide a copy)
3. Was your child receiving supplemental services to promote her/his English
Language Development?
If yes, type of service: ________________________________________
month/day/year
No
Yes
OFFICE USE ONLY:
Sent copy to DO if a language other than English listed in Part I
Date sent: _____/_____/_____
Entered into Power School
Initials: __________________
Date entered: _____/_____/_____
11/2/15
Form C
CAMBRIAN SCHOOL DISTRICT
Student Emergency Form
4115 Jacksol Drive ● San Jose, CA 95124 ● (408) 377-2103 ● (408) 377-5944 (fax)
Student Data
Student’s Legal Name: _______________________________________________
(as it appears on birth certificate)
LAST ,
FIRST
Date of Birth: ______/______/________
MIDDLE INTIAL
Gender:
Male
Female
School Year: ___________________
TK K 1 2 3 4 5
6 7 8 (Circle Grade Level)
CA
Residence Address:
Street
Apt #
City
State
Zip Code
Demographic Information
Parents are:
Together
Separated
Custody: (Provide current legal documentation to school)
Divorced
N/A
Deceased
Mother only
Father only
Shared*
Other*
*Describe and include percentage of time per household: ___________________________________________________________________
Is there a restraining order in effect? (Provide current legal documentation to school)
No
Father/Guardian
Student resides with:
Mother & Father
Father Only
Mother Only
Mother & Step-Father
Father & Step-Mother
Step-Mother
Step-Father
Grandparent
Mother & Partner
Father & Partner
Legal Guardians
Other Relative
_____________________
Yes, against _____________________
Mother/Guardian
Name
(Last, First)
Relationship
Check here if same as Student’s Residence
Check here if same as Student’s Residence
Address
Home Phone
Cell Phone
Work Phone
Employer
Email
Step-Parent
(Name, Phone)
Emergency Contact Information
In case of illness, injury, or disaster, please list local emergency contacts that may be allowed to pick up your child in the event that a
parent/guardian cannot be reached. Students will not be released to persons not listed below without parent/guardian contact.
Name
Relationship
Day Care Provider: ______________________
Home
Phone: ___________________
Work
Emergency Contact?
Cell
Yes
No
Special health problems, medications, or considerations: _____________________________________________________
_________________________________________________________________________________________________________
Hospital Preference: ______________________________________________________________________________________
Medical Insurance: _________________________________
ID#: ______________________________________________
In the event that the school is unable to contact the parent/guardian, I authorize that my child be released to the person(s) listed above. If deemed necessary by
school authorities, my child may be taken to the nearest Emergency Station for treatment. I realize that the school district cannot assume responsibility for the
payment of medical fees or expenses incurred. I swear that the information provided on this form is true and complete to the best of my knowledge.
Signature of Parent or Legal Guardian: _________________________________________________ Date: _______________
10/28/15
Form D
CAMBRIAN SCHOOL DISTRICT
Proof of Residence
4115 Jacksol Drive ● San Jose, CA 95124 ● (408) 377-2103 ● (408) 377-5944 (fax)
Student Data
Student’s Legal Name: ___________________________________________________________________________
(as it appears on birth certificate)
LAST ,
FIRST
MIDDLE INTIAL
Current Residence Address
I am the parent or legal guardian of the child named above and I wish to enroll my child in the Cambrian
School District. I understand that California law provides, with few exceptions, that each child attend a
public school in the district where the parent or legal guardian resides. I reside at the following street
address that I believe to be in the Cambrian School District:
Street:
Street:
State:
City:
Zip Code:
CA
Verification of Residence
You must provide THREE (3) documents to verify that you reside at the address above. ONE (1) document
from List A and TWO (2) documents from List B are required. All address verification documents must
include: Name of Parent/Guardian AND Current Address of Residence.
List A: Evidence of Ownership or Rental
Provide ONE (1) of the following:
List B: Address Verification
Provide TWO (2) of the following:
Current Year County Property Tax Bill
Current PG&E bill
Closing Escrow Agreement (within the last calendar year)
Current water or trash bill
Current Rental Agreement
AND a copy of most recent rental payment
Current cable or internet bill
(Cancelled check, receipt or Bank statement)
Current payroll stub
Letter from Landlord stating current residence
AND a copy of most recent rental payment
(Cancelled check, receipt or Bank statement)
California Vehicle Registration
Verification of utility service connection
(Utility bill must be provided within 30 days to complete registration)
I declare under penalty of perjury under the laws of the State of California that the information provided by
me or others is true and correct.
Signature of Parent or Legal Guardian: _________________________________
Date: _____________
11/10/15
Form E
CAMBRIAN SCHOOL DISTRICT
Immunizations Required
4115 Jacksol Drive ● San Jose, CA 95124 ● (408) 377-2103 ● (408) 377-5944 (fax)
According to state law, we cannot allow your child to attend school unless we
receive evidence that the below requirements are met.
Immunizations Required for School Entry
Students need documentation of the immunizations listed below to meet the new
requirements of Senate Bill 277 effective 2016.
Update: As of July 1, 2016 all previously unvaccinated students entering 7th grade must provide
documentation of ALL vaccines needed for school entry based on age. These include the polio series,
diphtheria/tetanus/pertussis series, varicella vaccine and the two doses of MMR.
Vaccine:
Required Doses (if you submitted incomplete record, missing doses are circled):
Polio
#1
#2
#3
#4
DTP/DtaP/DT/Td
#1
#2
#3
#4
MMR
#1
#2
Hepatitis B
#1
#2
Varicella (Chickenpox)
#1
#5
#3
Tdap vaccine
Required for 7th and 8th grade
TB Test or TB Risk Assessment
 Kindergarten & TK: Dated March 1, 2015 or later
 Grades 1-8: must have proof of at least one TB test
 Coming from outside Santa Clara County within the last six months
Health Exam
Report of Health Examination for School Entry: Dated March 1, 2016 or
later; required to be completed within 18 months of 1st grade entry
PLEASE DO ONE OF THE FOLLOWING TO MEET THE IMMUNIZATION REQUIREMENTS
1. Take this form along with your child’s yellow California Immunization Record to your doctor or the local health
department to get needed immunization(s). Bring your updated child’s immunization record when registering.
2. If your child’s immunization record shows he or she already received these immunization(s), bring us the record so
we can update our files. Your child’s record must include a date for the immunizations circled above and the
doctor’s signature or stamp.
3. If any immunizations were not given to your child due to medical reasons, you must have a written/typed letter
signed by your licensed physician medical doctor with the following information: physical or medical circumstance
of the child (which include family history) listed vaccines that are being exempted, notation of the medical
exemption being permanent or temporary, and an expiration date, if the exemption is temporary.
As of July 2016, there are no longer exemptions for personal or religious beliefs. California Law SB 277
If you have any questions concerning immunizations, please contact your school office.
Bagby: 408-377-3882
Fammatre: 408-377-5480
Farnham: 408-377-3321
Price: 408-377-2532
Sartorette: 408-264-4380
Steindorf: 408-377-2103
11/5/15
Form F
Child’s Name: ________________________ Birthdate: _______________
Last,
First
Male/Female
School: ____________________
month/day/year
Address________________________________________________________ Phone: ______________
Street
City
Zip
Grade: __________
Santa Clara County Public Health Department TB Risk Assessment for School Entry This form must be completed by a licensed health professional and returned to the child’s school.
1. Was your child born in Africa, Asia, Latin America, or Eastern Europe?
 Yes
 No
2. Has your child traveled to a country with a high TB rate* (for more than a week)?
 Yes
 No
3. Has your child been exposed to anyone with tuberculosis (TB) disease?
 Yes
 No
4. Has a family member or someone your child has been in contact
with had a positive TB test or received medications for TB?
 Yes
 No
5. Was a parent, household member or someone your child has been in close
contact with, born in or traveled to a country with a high TB rate?*
 Yes
 No
6. Has another risk factor for TB (i.e. one of those listed on the back of this page)?
 Yes
 No
* This includes countries in Africa, Asia, Latin America or Eastern Europe. For travel, the risk of TB exposure is
higher if a child stayed with friends or family members for a cumulative total of 1 week or more.
If YES, to any of the above, the child has an increased risk of TB infection and should have a TST/ IGRA.
All children with a positive TST/IGRA result must have a medical evaluation, including a chest X-ray.
Treatment for latent TB infection should be initiated if the chest X-ray is normal and there are no signs of
active TB. If testing was done, please attach or enter results below.
Tuberculin Skin Test (TST/Mantoux/PPD)
Induration _____ mm
Date given:
Impression:  Negative
 Positive
Impression:  Negative
 Positive  Indeterminate
Date:
Impression:  Normal
 Abnormal finding
 LTBI treatment (Rx & start date):
 Prior TB/LTBI treatment (Rx & duration):
 Contraindications to INH or rifampin for LTBI
 Offered but refused LTBI treatment
Date read:
Interferon Gamma Release Assay (IGRA)
Date:
Chest X-Ray (required with positive TST or IGRA)
Providers, please check one of the boxes below and sign:
 Child has no TB symptoms, none of the above or other risk factors for TB and does not require a TB test.
 Child has a risk factor, has been evaluated for TB and is free of active TB disease.
_______________________________________
Health Provider Signature, Title
_____________
Date
Name/Title of Health Provider:
Facility/Address:
Phone number:
Fax number:
Rev 4/15/2014 Santa Clara County TB Assessment Form
County of Santa Clara
Public Health Department
Tuberculosis Prevention & Control Program
976 Lenzen Avenue, Suite 1700
San José, CA 95126
408.885.2440
Risk Factors for Tuberculosis (TB) in Children

Have clinical evidence or symptoms of TB


Have a family member or contacts with history of
confirmed or suspected TB
Live with an adult who has been incarcerated in
the last five years

Live among or frequently exposed to individuals
who are homeless, migrant farm workers,
residents of nursing homes, or users of street
drugs

Drink raw milk or eat unpasteurized cheese (i.e.
queso fresco or unpasteurized cheese)

Have, or are suspected to have, HIV infection or
live with an adult with HIV seropositivity. See
below for testing methods in children with HIV or
other immunocompromised conditions.

Are in foreign-born families from TB endemic
countries (including countries in Africa, Asia, Latin
America or Eastern Europe)

Travel to countries with high rate of TB

Contact with individual(s) with a positive TB test

Abnormalities on chest X-ray suggestive of TB

Adopted from any high-risk area or live in out-ofhome placements
Testing Methods
A Mantoux tuberculin skin test (TST) or an Interferon Gamma Release Assay (IGRA) (for children aged 4 and older)
should be used to test those at increased risk. A TST of ≥10mm is considered positive. If a child has had contact with
someone with active TB (yes to question 3 on reverse) then TST ≥5mm is considered positive.
Screening should be performed by CXR in addition to a TST/IGRA (consider doing both) and symptom review in HIV
infected or suspected HIV, other immunocompromised conditions or if a child is taking immunosuppressive
medications such as prednisone or TNF-alpha antagonists.
Referral, Treatment, and Follow-up of Children with Positive TB Tests

All children with a positive TST or IGRA result should have a medical evaluation, including a chest X-ray.

Report any confirmed or suspected case of TB disease to the TB Control Program within 1 day, including
any child with an abnormal chest X-ray.

If TB disease is not found, treat children and adolescents with a positive TST or IGRA for latent TB infection
(LTBI).

Isoniazid (INH) is the drug of choice for the treatment of LTBI in children and adolescents. The length of
treatment is 9 months with daily dosing: 10-15mg/kg (maximum 300 mg).

For management and treatment guidelines for TB or LTBI, go to: www.cdc.gov/tb or contact the TB Control
Program at (408) 885-4214.
References
American Academy of Pediatrics, Committee on Infectious Diseases. Tuberculosis. In L.K. Pickering (Ed.), 2009 Red Book: Report of the
th
Committee on Infectious Diseases. 27 ed. El Grove Vilage, IL: American Academy of Pediatrics, 2009:680-701.
California Health and Safety Code Section 121515.
Pediatric Tuberculosis Collaborative Group. Targeted Tuberculin Skin Testing and Treatment of Latent Tuberculosis Infection in Children and
Adolescents. Pediatrics 2004; 114 (14):1175-1201.
Pang J, Teeter LD, Katz DJ, et al. Epidemiology of Tuberculosis in Young Children in the United States. Pediatrics, 2014:494-504.
Board of Supervisors: Mike Wasserman, Cindy Chavez, Dave Cortese, Ken Yeager, S. Joseph Simitian,
County Executive: Jeffrey V. Smith
Form G
Health Survey Form
CAMBRIAN SCHOOL DISTRICT
4115 Jacksol Drive ● San Jose, CA 95124 ● (408) 377-2103 ● (408) 377-5944 (fax)
Student’s Legal Name: ________________________________________ DOB: __________ Grade: _____
(as it appears on birth certificate)
Last,
First
Does your child have any health problems the school should be aware of?  No  Yes-If yes, please
indicate and explain: __________________________________________________________________
___________________________________________________________________________________
Does your child wear glasses?  No  Yes-If yes,  all of the time?  Just for classroom?
Does your child use prescribed hearing devices?  No  Yes
Should your child’s activities be limited in any way?  No  Yes-If yes, please indicate and explain:
___________________________________________________________________________________
___________________________________________________________________________________
Has your child had any of the following conditions?
 Chicken Pox
 Measles
 German Measles
 Meningitis
 Hepatitis
 Mumps
 Polio
 Rheumatic Fever
Does your child have any of the following conditions?
 Anxiety
 Eczema
 Asthma
 Epilepsy
 Convulsions
 Fainting Spells
 Diabetes
 Frequent Colds
 Ear Infections
 Headaches
 Hearing Problems
 Heart Disease
 Joint Pains
 Nightmares
 Nosebleeds
 Scarlet Fever
 Whooping Cough
 Tires Easily
 Sore Throats
 Sleepwalking
 Vision Problems
Does your child have any allergies?  No  Yes-If yes, please indicate below:
___________________________________________________________________________________
Does your child have any severe allergies?  No  Yes-If yes, fill out Allergy Action Plan
Is your child severely allergic to insect stings?  No  Yes-If yes, fill out Allergy Action Plan
Is your child on a continuing medication regimen?  No  Yes-If yes, fill out Medication Authorization
Medication is: _______________________________________________________________
Condition: _______________________________________________________________________________
Dosage: ____________________________________________________________________
Physician’s Name: ______________________________________Phone:________________
Address: __________________________________________________________
City: ___________________________________ State: _______ Zip: _________
The above physician may be advised of my child’s progress at school.  No  Yes Initials: ________
Health Insurance Carrier: _______________________________________________________________
__________________________________________________________ Date: ____________________
Signature of Parent/Legal Guardian
11/5/15
Form J
Request for Student Records
(Solicitud del Registro Estudiantil)
CAMBRIAN SCHOOL DISTRICT
4115 Jacksol Drive ● San Jose, CA 95124 ● (408) 377-2103 ● (408) 377-5944 (fax)
Please send all records and files for the following student. Include transcript, health records, test scores
portfolios and confidential files. (Por favor, envíe todos los registros y archivos del estudiante nombrado. Por favor,
inlcuya el historial de salud, resultados de pruebas, portafolios, y archives confidenciaies.)
Student Data (Datos del estudiante)
Student’s Legal Name (Legal Nombre): ______________________________________
Last (apellido),
Date of Birth: ____/______/_______
First (nombre de pila)
Phone Number:________________________
(Fecha de nacimiento)
School Year:
(año escolar): __________________
TK K 1 2 3 4 5
6 7 8
(Circle Grade Level Entering)
(Nivel de grado circulo)
(número de teléfono)
Previous School Information (Información de la escuela anterior)
Name of the School (Nombre de la escuela)
School District (Distrito escolar)
Street (Dirección de la escuela)
City (Ciudad)
State (Estado)
School Phone Number (Número de teléfono)
School Fax (Número del fax)
Zip (Código postal)
I give my permission to forward the cumulative records and confidential educational, medical and psychological
information on file in your district regarding the above student to the school marked below in the Cambrian School
District. I understand that I have the right to review the records upon arrival and at any time in the future by making an
appointment with the principal. (Doy mi permiso para reenviar los registros acumulativos e información educativa, médica y
psicológica confidencial en el expediente de su distrito en cuanto al estudiante por encima de la marca de la escuela a continuación en
el Distrito Escolar del Cámbrico. Yo entiendo que tengo el derecho de revisar los registros de su llegada y en cualquier momento en el
futuro al hacer una cita con el director.)
_________________________________________________________________
_________________________________________________________________
Parent/Guardian Signature
School Secretary Signature
Date (Fecha)
Date
(Firma del Padre de familia/tutor)
Please send records to the school marked below to the attention of: Student Records
The above student registered on: __________________________
Bagby Elementary School
1840 Harris Ave.
San Jose, CA 95124
408-377-2883
Fax: 408-377-8648
Farnham Elementary School
15711 Woodard Rd.
San Jose, CA 95124
408-377-3321
Fax: 408-377-7237
Price Middle School
2650 New Jersey Ave.
San Jose, CA 95124
408-377-2532
Fax: 408-377-7406
Fammatre Elementary School
2800 New Jersey Ave.
San Jose, CA 95124
408-377-5480
Fax: 408-377-8751
Sartorette Elementary School
3850 Woodford Drive
San Jose, CA 95124
408-264-4380
Fax: 408-264-1758
Steindorf STEAM School
3001 Ross Ave.
San Jose, CA 95124
408-377-2103
Fax: 408-377-5944
11/5/15