ﻣﺮﺣﺒﺎً أﻧﺎ أﺗﺤﺪث اﻟﻌﺮﺑﻴﺔ - Institute for Health Professions at Cambria Heights

ً‫ﻣﺮﺣﺒﺎ‬
!‫إدارة اﻟﺘﻌﻠﻴﻢ مبﺪﻳﻨﺔ ﻧﻴﻮﻳﻮرك ﺗﺘﺤﺪث ﺑﺎﻟﻠﻐﺔ اﻟﻌﺮﺑﻴﺔ‬
‫ﻳﺘﻤﺘﻊ اﻵﺑﺎء ﺑﺤﻘﻬﻢ ﰲ اﻟﺤﺼﻮل ﻋﲆ ﻣﻌﻠﻮﻣﺎت ﻋﺎﻣﺔ ﻋﻦ‬
‫ﺑﺮاﻣﺞ إدارة اﻟﺘﻌﻠﻴﻢ وﺧﺪﻣﺎﺗﻬﺎ ﺑﺎﻟﻠﻐﺔ اﻟﻌﺮﺑﻴﺔ ﻋﲆ‬
‫ أو ﻋﻦ ﻃﺮﻳﻖ‬،schools.nyc.gov ‫اﳌﻮﻗﻊ اﻹﻟﻜﱰوين‬
.311 ‫اﻻﺗﺼﺎل ﺑﺮﻗﻢ ﻫﺎﺗﻒ اﻻﺳﺘﻌﻼﻣﺎت‬
‫ميﻜﻨﻜﻢ أﻳﻀﺎً ﻓﺼﻞ اﻟﺒﻄﺎﻗﺔ اﳌﺮﻓﻘﺔ أدﻧﺎه وإﺣﻀﺎرﻫﺎ‬
‫ﻣﻌﻜﻢ ﰲ ﻛﻞ ﻣﺮة ﺗﺰورون ﻓﻴﻬﺎ ﻣﺪرﺳﺔ ﻃﻔﻠﻜﻢ أو أي‬
‫ أﻃﻠﻌﻮا أﺣﺪ أﻓﺮاد ﻃﺎﻗﻢ‬.‫ﻣﻜﺘﺐ ﺗﺎﺑﻊ ﻹدارة اﻟﺘﻌﻠﻴﻢ‬
.‫اﳌﺪرﺳﺔ ﻋﲆ اﻟﺒﻄﺎﻗﺔ ﻟﻠﺤﺼﻮل ﻋﲆ ﻣﺴﺎﻋﺪة‬
‫ﻧﻮد أن ﻧﺴﻤﻊ ﻣﻨﻜﻢ ﺣﻮل ﺗﺠﺮﺑﺘﻜﻢ ﻣﻊ اﻟﺨﺪﻣﺎت‬
‫ اﺗﺼﻠﻮا ﺑﺈدارة اﻟﺘﻌﻠﻴﻢ‬.‫اﻟﻠﻐﻮﻳﺔ اﳌﻘﺪﻣﺔ ﰲ ﻣﺪرﺳﺘﻜﻢ‬
‫ أو اﻟﱪﻳﺪ‬،(718) 935-2013 ‫ﻋﲆ رﻗﻢ اﻟﻬﺎﺗﻒ‬
،[email protected] :‫اﻹﻟﻜﱰوين‬
.‫وأﻃﻠﻌﻮﻧﺎ ﻋﲆ آراءﻛﻢ ﺣﻮل ﺧﺪﻣﺎﺗﻨﺎ‬
‫أﻧﺎ أﺗﺤﺪث‬
‫اﻟﻌﺮﺑﻴﺔ‬
I SPEAK ARABIC
?
!
schools.nyc.gov
311
.
ДОРОГИЕ РОДИТЕЛИ!
ALO
Департамент образования г. Нью-Йорка
говорит на вашем языке!
Depatman Edikasyon Vil Nouyòk pale lang ou
pale a!
Родители имеют право на получение общей
информации на русском языке о программах
и услугах Департамента образования
на сайте schools.nyc.gov и по телефону 311.
Paran gen dwa pou yo jwenn enfòmasyon
sou pwogram ak sèvis Depatman Edikasyon an
KREYÒL nan schools.nyc.gov ak si yo rele 311.
Вырежьте и сохраните карточку с этой
страницы, чтобы предъявлять ее для
получения услуг переводчика в школе
и отделах Департамента образования.
.
.
(718) 935-2013
[email protected]
.
Чтобы поделиться с нами мнением
о языковой поддержке в вашей школе,
обращайтесь в Департамент образования
по телефону (718) 935-2013 или по адресу
[email protected].
Avwg evsjvq
K_v ewj
Ou ka dekoupe kat ki anba tablo sa a tou epi
pote l lè w ap vizite lekòl pitit ou a oswa yon biwo
Depatman Edikasyon. Montre yon manm estaf la
kat la pou yo ka ede w.
Nou ta renmen konnen eksperyans ou fè
avèk sèvis lang nan lekòl ou a. Rele Depatman
Edikasyon nan (718) 935-2013 oswa voye yon
imèl nan [email protected]
epi fè nou konnen kòman n ap travay.
‫میری زبان‬
‫اردو ہے‬
저는 한국말을
합니다
I SPEAK KOREAN
Я ГОВОРЮ
ПО-РУССКИ
I SPEAK RUSSIAN
MWEN PALE
KREYÒL
I SPEAK HAITIAN CREOLE
Parent’s Guide to
Language Access
HELLO
HOLA
n¨v‡jv
The New York City Department of Education
speaks your language!
¡El Departamento de Educación de la Ciudad
de Nueva York habla su idioma!
wbD BqK© wmwU wWcvU©‡g›U Ae GWy‡Kkb Avcbvi fvlvq
K_v e‡j!
Parents have the right to obtain general
information on the Department of Education’s
programs and services in English, as well as in
Arabic, Bengali, Chinese, French, Haitian Creole,
Korean, Russian, Spanish and Urdu at
schools.nyc.gov and by calling 311.
Los padres tienen el derecho a obtener
información en español acerca de los
programas y servicios que ofrece el
Departamento de Educación, ingresando
al sitio web schools.nyc.gov y llamando al 311.
You may also cut out the “I Speak Card” in your
language and bring it with you when you visit
your child’s school or Department of Education
office. Show the card to a staff member to receive
assistance.
También puede recortar la tarjeta que se
encuentra en la parte inferior de este cuadro
y llevarla con usted cuando visite la escuela
de su hijo o una oficina del Departamento de
Educación. Muéstrele la tarjeta a un empleado
para recibir ayuda.
We want to hear from you about your
experiences with language services
at your school. Call the Department
of Education at (718) 935-2013 or email
[email protected] and
let us know how we are doing.
Queremos que nos cuente sobre sus
experiencias con los servicios de idioma en su
escuela. Llame al Departamento de Educación
al (718) 935-2013 o envie un correo electronico
a [email protected]
y comparta sus experiencias.
HABLO
ESPAÑOL
I SPEAK SPANISH
evsjv fvlvq wWIB-Gi Kg©m~wP I cwi‡mev m¤ú‡K© mvaviY
Z_¨ schools.nyc.gov I‡qemvBU ‡_‡K I 311 b¤^‡i
‡dvb K‡i Rvbvi AwaKvi wcZvgvZv‡`i i‡q‡Q|
GQvovI Avcwb mšÍv‡bi ¯‹y‡j ev wWcvU©‡g›U Ae GWy‡Kk‡bi
‡Kvb Awd‡m ‡M‡j wb‡Pi KvW©wU ‡K‡U m‡½ wb‡q ‡h‡Z
cv‡ib| mnvqZvi Rb¨ KvW©wU ‡h ‡Kvb ÷vd‡K ‡`Lv‡eb|
Avcbvi mšÍv‡bi ¯‹y‡j Avcwb fvlv m¤úwK©Z †h cwi‡lev
jvf K‡ib, †m e¨vcv‡i Avgiv Rvb‡Z AvM«nx| wWcvU©‡g›U
Ae GWy‡Kk‡b (718) 935-2013 b¤^‡i ‡dvb Kiæb A_ev
[email protected] wVKvbvq B‡gBj
Kiæb Ges Avgiv †Kgb KvR KiwQ, †m e¨vcv‡i gšÍe¨ w`b|
‫ہیلو‬
‫نیویارک شہر محکمہء تعلیم آپکی زبان‬
!‫بولتا ہے‬
Le Département de l’Éducation de la Ville de New
York parle dans la même langue que vous !
311 ‫ پر جاکر یا‬schools.nyc.gov ‫والدین کو‬
‫کو فون کرکے محکمئہ تعلیم کے پروگراموں اور‬
‫خدمات پر اردو میں عام معلومات حاصل کرنے‬
‫کا حق ہے۔‬
Les parents d’élèves ont le droit d’avoir accès
en francais à des informations générales sur
les programmes et appuis du Departement
de l’Education sur schools.nyc.gov ou en
composant le 311.
‫آپ اس مراسلے کے نیچے دیے گئے کارڈ کو‬
‫بھی کاٹ کر اسے اپنی مالقات کے وقت اپنے‬
‫بچے کے اسکول یا محکمہء تعلیم کے دفتر میں‬
‫ساتھ السکتے ہیں۔ امداد حاصل کرنے کے لیے‬
‫عملے کے رکن کو کارڈ دکھائیں۔‬
Vous pouvez également découper la carte en
bas de ce volet et la prendre sur vous quand vous
vous rendez dans l’établissement scolaire de votre
enfant ou dans l’un des services administratifs
du Département de l’Éducation. Montrez-la à un
membre du personnel pour qu’on vous assiste.
‫ہم آپ سے آپکے اسکول میں لسانی خدمات‬
‫کے بارے میں آپکے تجربات کے متعلق جاننا‬
‫ پر‬718-935-2013 ‫چاہتے ہیں۔ محکمہء تعلیم کو‬
[email protected] ‫فون کریں یا‬
‫پر ای امیل کریں اور ہمیں آگاہ کریں کہ ہماری‬
‫کارکردگی کیسی ہے۔‬
‫میری زبان‬
‫اردو ہے‬
Avwg evsjvq
K_v ewj
I SPEAK BENGALI
BONJOUR
I SPEAK URDU
Nous voulons entendre ce que vous avez à dire sur
la manière dont on a pu vous fournir une assistance
linguistique dans l’établissement scolaire de
votre enfant. Contactez le Département de
l’Éducation au (718) 935-2013 ou envoyez un email
à [email protected] et dites-nous
ce que vous pensez de nos efforts.
JE PARLE
FRANÇAIS
I SPEAK FRENCH
您好
市教 局 您
！
家
有權在
schools.nyc.gov以及
311來 得以中文提供
於教 局 劃和
服務 一 性
。
您也可以把 一 底
卡 剪下來，並在
前往您 子女 學校或教 局 公室時帶上
它。向工作人員出
張卡 ，以便 得協
助。
我們想
您對子女 學校所提供
服務 感受。
教 局
，
即
(718) 935-2013或
子 件
[email protected]，
我們
我們 工作做得怎 樣。
我
中文
I SPEAK CHINESE
InstituteforHealthProfessionsatCambriaHeights
207-01116thAve
CambriaHeights,NY11411
(718)723-7301
[email protected]
www.ihpch.org
InstituteforHealthProfessionsat
CambriaHeights
July14,2016
DearIHPCHFamily,
Onbehalfoftheschoolandourpartners,wearepleasedtowritethisletterinvitingyoutoan
orientationforreturningstudents!Duringthisorientation,wewillintroduceyoutothenewest
membersofourstaffandexplainsomeofthechangesthatwehavemadeforthe2015-2016
schoolyear.
ThestaffhasbeenhardatworkreadyingtheschoolforSeptember.Weareexcitedforthe
experiencesthathavebeenplannedforyourchild.Amongtheseexperiencesarethefollowing
courses:
12thGrade
11thGrade
• ExploringHuman
• Playwritingthe
NatureinLiterature
AmericanDream
• Money,Power,
• ItWasAllaDream
Respect
• AlgebraIIor
• Precalculus,Calculus,
Precalculus
orStatistics
• Physics
• Neuroscience
• WorldHealth&
• EMT-B,CFR,orNurse
Fundamentalsof
Aide
Healthcare
• TransitiontoCollege
• SpanishII
• MovementThrough
• PathwaystoSuccess
Sports
• MovementThrough
Sports
10thGrade
• InLoveandWar
• GetUp,StandUp!
• GeometryorAlgebraII
• Chemistry
• AnatomyandPhysiologyor
HealthCareersExploration&
Biotechnology
• SpanishI
• Leadership
• MovementThroughSports
Weareexcitedtoserveastheleadersofthisschoolcommunity.Welookforwardtomeeting
youandyourchildatourNewStudentandFamilyOrientation,whichwilltakeplaceat1:00pm
onThursday,September1,2016intheCampusMagnetAuditorium.Parentsshouldexpectto
stayforatleastonehoursothatwecantalktoyouabouttheschool’sprogramsandhaveyou
completerequiredpaperwork.Studentsshouldexpecttostayforonehoursothattheycan
meettheiradvisors.
DevelopingLeadersandScholarsinServiceofHumanity,
GarethRobinson
FoundingPrincipal
CrystalDavis
Co-Director
InstituteforHealthProfessionsat
CambriaHeights
InstituteforHealthProfessionsatCambriaHeights
207-01116thAve
CambriaHeights,NY11411
(718)723-7301
[email protected]
www.ihpch.org
UNIFORMS
Uniformsareavailableathttp://www.ihpch-apparel.com/IHPCH_Apparel/products.Ordersplacedby
August12thwillbeavailableforpickupduringorientation.
Tops:
GrayUniformPoloShirtwithSchoolLogo(9thand10thGrades)
NavyUniformPolowithSchoolLogo(11thand12thGrades)
NavyUniformScrubswithSchoolLogo(11thand12thGrades)
SolidNavySweaters
Bottoms:
NavyPantsorSkirt
NavyCargoPants
Footwear:
Closedtoeflatshoesorsneakersthatarenon-noiseproducing.
SneakersonPhysicalEducationDays
GymUniform
T-shirtwithSchoolLogo
UniformSweatshirtwithSchoolLogoforgymdays
UniformSweatPantswithSchoolLogoforgymdays
UniformNotes:
1. StudentIDsmustbevisibleatalltimes.
2. Theschoolhasmanytemperaturezones,soitisimportanttodressappropriately.Wearlayers
andbringauniformcompliantsweater.
3. Layersmeansyoucanwear:white,long-sleevet-shirtorturtleneckunderyourpoloshirt.No
othercolorsareallowed.
4. Sweatersmustbefreeoflogosanddesignsotherthantheschoollogo.
5. Jacketsandallouterwear,includinghatsandscarves,mustbekeptinyouradvisoryclosetsor
lockersandarenottobeworninclassrooms.
6. Studentsmustcometoschoolandleaveschoolintheuniform.
7. StudentsmayNOTwearanyelectronicaccessories,exceptawatch.
8. StudentswhoarenotwearingtheofficialschooluniformwillbesenttotheFairnessCommittee.
9. Studentsareresponsibleforkeepingtrackoftheirownpossessionsandforrespectingthe
propertyofothers.Allclothingandotherpossessionsshouldbemarkedwiththestudent’sfull
name.
10. Teachersmaystopanystudentwhoisinviolationofthedresscodeandsendthatstudentto
themainofficewhereschoolstaffwilltakeappropriateactiontounderstandwhythestudentis
outofuniformandtakestepstopreventareoccurrence.
11. Dressdowndaysareearnedformeetingbenchmarks(attendance)andareonlyannouncevia
emailfromthePrincipalorCo-Director.
Institute(for(Health(Professions(at(
Cambria(Heights(
School Supply List
Institute(for(Health(Professions(at(Cambria(Heights(
207801(116th(Ave(((
Cambria(Heights,(NY(11411(
(718)(72387301(
[email protected](
www.ihpch.org(
(
! 1 Backpack/Messenger Bag
! #2 Pencils
! 1 Pencil Pouch
! 1 Pencil Sharpener
! Pens (Blue or Black ink only)
! Regular Markers
! 3 Highlighters
! 1 12" Ruler
! 1 Dictionary
! 1 Thesaurus
! 6 Pocket Folders
! 2 1" or 1½" 3-Ring Binders
! Tabbed Dividers for 3-Ring Binders
! Loose-Leaf Filler Paper (College or Wide Ruled)
! 1 Pack of Graph Paper
! 1 Pack 3X3 Sticky Notes
! 1 Mini Stapler
! 1 Pack of 3x5 Index Cards
! 3-Ring Binder Hole Punch
! 1 USB Flash Drive
! 1 Combination Lock
! 1 Hand Sanitizer
! TI-84 Graphing Calculator (Optional, but highly recommended)
NEW YORK CITY DEPARTMENT OF
HEALTH AND MENTAL HYGIENE
Mary T. Bassett, MD, MPH
Commissioner
Gotham Center
42-09 28th Street, 8th Floor
Queens, NY 11101-4132
Spring 2016
Dear Parent/Guardian:
+ 1 347 396 4100 tel
A healthy school environment gives all students the best chance to learn and
grow. Vaccinations are very important to this effort; they help children avoid
getting or spreading diseases that can make them very sick.
Your registration packet includes an immunization chart that shows the
vaccinations your child needs to attend child care or go to school in New York
City. The requirements are for all children 2 months to 18 years old who go to
child care, public school or private school. The number of vaccine doses your
child needs may vary by age and previous vaccine doses he or she received.
Additional vaccines or vaccine doses may be needed if your child has certain
health conditions; talk to your child’s doctor if you have questions.
If your child does not have all required vaccines, he or she may be able to start
school with at least one dose of the required vaccines and then receive the other
doses based on an official schedule (i.e. start “provisionally”).
Your packet also includes a Physical Examination Form (CH-205). All students
entering New York City public or private schools or child care (including universal
pre-K classes) for the first time must submit a report of a physical examination
performed within one year of school entry. Because children develop and grow
so quickly at these early ages, if this initial examination is performed before the
student is 5 years old, a second examination, performed between the child’s 5th
and 6th birthday, is also required.
For more details on child care and school vaccinations, visit schools.nyc.gov or
nyc.gov/health (search “School Vaccines”). You may also call the Office of
School Health at 347-396-4720 or the Bureau of Child Care at 646-632-6100.
Sincerely,
Cheryl Lawrence, MD, FAAP
Medical Director
Office of School Health
2016-2017 School Year
Is Your Child Ready for Child Care or School?
Learn about required vaccinations in New York City
All students 2 months to 18 years old in New York City must get the following vaccinations to go to
child care or school. Review your child’s vaccine needs based on his or her grade level this school year.
Pre-Kindergarten
VACCINATIONS
Diphtheria, Tetanus and
Pertussis (DTaP)
(Child Care, Head Start,
Nursery or Pre-k)
Kindergarten –
Grade 2
4 doses
Grades 3 – 5
Grades 6 – 8
5 doses
Grades 9 – 12
3 doses
or 4 doses ONLY if the 4th dose was
received at 4 years of age or older
or 3 doses ONLY if the series is started
or completed at 7 years of age or older
1 dose
Tetanus, Diphtheria
and Pertussis booster
(Tdap)
4 doses
3 doses
Measles, Mumps and
Rubella (MMR)
1 dose
2 doses
Hepatitis B
3 doses
3 doses
Varicella (Chickenpox)
1 dose
Haemophilus influenzae
type b conjugate (Hib)
Pneumococcal Conjugate
(PCV)
Meningococcal Conjugate
(MenACWY)
4 doses
3 doses
Polio (IPV/OPV)
or 3 doses ONLY if the 3rd
dose was received at 4 years
of age or older
2 doses
3 doses
or 3 doses ONLY if the 3rd
dose was received at 4 years
of age or older
1 dose
2 doses
1 dose
1 to 4 doses
Depends on child’s age and
doses previously received
1 to 4 doses
Depends on child’s age and
doses previously received
Grade 7: 1 dose
The number of vaccine doses your child needs may vary based on age and previous vaccine doses he or she received. Additional vaccines or
vaccine doses may be needed if your child has certain health conditions. Talk to your doctor if you have questions. For more information, call
311 or visit nyc.gov/health and search for “Student Vaccines.”
Grade 12: 2 doses
or 1 dose ONLY if the 1st dose
was received at 16 years of age
or older
CHILD & ADOLESCENT HEALTH EXAMINATION FORM
Please
Print Clearly
NYC DEPARTMENT OF HEALTH & MENTAL HYGIENE — DEPARTMENT OF EDUCATION
NYC ID (OSIS)
TO BE COMPLETED BY THE PARENT OR GUARDIAN
Child’s Last Name
First Name
Middle Name
Child’s Address
Sex ! Female Date of Birth (Month/Day/Year )
! Male
___ ___ / ___ ___ / ___ ___ ___ ___
Hispanic/Latino?
! Yes ! No
City/Borough
State
Zip Code
Race (Check ALL that apply)
School/Center/Camp Name
District __ __
Phone Numbers
Number __ __ __ Home ___________________
First Name
Health insurance
! Yes ! Parent/Guardian Last Name
(including Medicaid)? ! No ! Foster Parent
! American Indian ! Asian ! Black ! White
! Native Hawaiian/Pacific Islander ! Other _____________________________
Cell _________
Email
Work
TO BE COMPLETED BY THE HEALTH CARE PRACTITIONER
Birth history (age 0-6 yrs)
Does the child/adolescent have a past or present medical history of the following?
! Asthma (check severity and attach MAF): !
If persistent, check all current medication(s): !
! Complicated by _________________________________
!
Asthma Control Status
! Anaphylaxis
!
Allergies ! None ! Epi pen prescribed
! Behavioral/mental health disorder
!
! Congenital or acquired heart disorder !
! Drugs (list) __________________________________________ ! Developmental/learning problem
!
!
! Diabetes (attach MAF)
! Foods (list) __________________________________________ ! Orthopedic injury/disability
!
!
! Other (list) __________________________________________ Explain all checked items above.
! Uncomplicated
! Premature: ______ weeks gestation
Intermittent
Quick Relief Medication
Well-controlled
! Mild Persistent
! Moderate Persistent
! Severe Persistent
! Inhaled Corticosteroid
! Oral Steroid ! Other Controller ! None
! Poorly Controlled or Not Controlled
Seizure disorder
Medications (attach MAF if in-school medication needed)
Speech, hearing, or visual impairment
! None
! Yes (list below)
Tuberculosis (latent infection or disease)
Hospitalization
Surgery
Other (specify)
Addendum attached.
Attach MAF if in-school medications needed
PHYSICAL EXAM
Height
_____________ cm
Weight
_____________ kg
Date of Exam: ___ /___ /___ General Appearance:
( ___ ___ %ile)
! Physical Exam WNL
Nl Abnl
Nl Abnl
( ___ ___ %ile) ! ! Psychosocial Development ! ! HEENT
! ! Dental
( ___ ___ %ile) ! ! Language
BMI
_____________ kg/m2
! ! Behavioral
! ! Neck
Head Circumference (age ≤2 yrs) _______ cm ( ___ ___ %ile)
Describe abnormalities:
Nl Abnl
Nl Abnl
Nl Abnl
! ! Lymph nodes
! ! Lungs
! ! Cardiovascular
! ! Abdomen
! ! Genitourinary
! ! Extremities
! ! Skin
! ! Neurological
! ! Back/spine
Blood Pressure (age ≥3 yrs) _________ / _________
Nutrition
DEVELOPMENTAL (age 0-6 yrs)
Validated Screening Tool Used?
Date Screened < 1 year ! Breastfed ! Formula ! Both
≥ 1 year ! Well-balanced ! Needs guidance ! Counseled ! Referred
! Yes ! No
____/____/____
Dietary Restrictions ! None ! Yes (list below)
Screening Results: ! WNL
! Delay or Concern Suspected/Confirmed (specify area(s) below):
Date Done
Results
SCREENING TESTS
! Cognitive/Problem Solving
! Adaptive/Self-Help
! Communication/Language
! Gross Motor/Fine Motor
Blood Lead Level (BLL)
____ /____ /____ _________ µg/dL
(required at age 1 yr and 2
! Other Area of Concern:
! Social-Emotional or
____ /____ /____ _________ µg/dL
Personal-Social
__________________________ yrs and for those at risk)
! At risk (do BLL)
Describe Suspected Delay or Concern:
Lead Risk Assessment
(annually, age 6 mo-6 yrs) ____ /____ /____
! Not at risk
—— Child Care Only ——
__________ g/dL
Hemoglobin or
Child Receives EI/CPSE/CSE services
CIR Number
! Yes ! No Hematocrit
____ /____ /____
__________ %
Hearing
Date Done
< 4 years: gross hearing
____/____/____ !Nl !Abnl !Referred
OAE
____/____/____ !Nl !Abnl !Referred
≥ 4 yrs: pure tone audiometry
Vision
<3 years: Vision appears:
____/____/____ !Nl !Abnl !Referred
Results
Date Done
Results
____/____/____
! Nl ! Abnl
Right _____ /_____
Acuity (required for new entrants
____/____/____ Left _____ /_____
and children age 3-7 years)
! Unable to test
Screened with Glasses?
Strabismus?
Dental
Visible Tooth Decay
Urgent need for dental referral (pain, swelling, infection)
Dental Visit within the past 12 months
! Yes
! Yes
! No
! No
! Yes
! Yes
! Yes
! No
! No
! No
Report only positive immunity:
Physician Confirmed History of Varicella Infection
IMMUNIZATIONS – DATES
IgG Titers Date
DTP/DTaP/DT ____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____ ____ /____ /____
Tdap
____ /____ /____
____ /____ /____
Hepatitis B ____ /____ /____
Td ____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
MMR
____ /____ /____
____ /____ /____
____ /____ /____
Measles ____ /____ /____
Polio ____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
Varicella
____ /____ /____
____ /____ /____
____ /____ /____
Mumps ____ /____ /____
Hep B ____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
Mening ACWY
____ /____ /____
____ /____ /____
____ /____ /____
Rubella ____ /____ /____
Hib ____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
Hep A
____ /____ /____
____ /____ /____
____ /____ /____
Varicella ____ /____ /____
PCV ____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
Rotavirus
____ /____ /____
____ /____ /____
____ /____ /____
Polio 1 ____ /____ /____
Influenza ____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
Mening B
____ /____ /____
____ /____ /____
____ /____ /____
Polio 2 ____ /____ /____
HPV ____ /____ /____ ____ /____ /____
ASSESSMENT
Well Child (Z00.129)
____ /____ /____
____ /____ /____
____ /____ /____
____ /____ /____
Polio 3 ____ /____ /____
Diagnoses/Problems (list)
Other
__ ____ /____ /____
_
ICD-10 Code RECOMMENDATIONS
Full physical activity
! Restrictions (specify) ____________________________________________________________________________
Follow-up Needed ! No ! Yes, for ___________________________ Appt. date: __ __ / ___ ___ / ___ ___
Referral(s):
! None
! Early Intervention
! IEP
! Dental
! Vision
! Other ____________________________________________________________________________
Health Care Practitioner Signature
Date Form Completed
DOHMH PRACTITIONER
_____ /_____ /_____ ONLY I.D.
Health Care Practitioner Name and Degree (print)
Practitioner License No. and State
Facility Name
National Provider Identifier (NPI)
TYPE OF EXAM:
Comments:
NAE Current
Date Reviewed:
Address
City
State
Zip
______ / ______ / ______
REVIEWER:
Telephone
CH205_Health_Exam_2016_June_2016.indd
Fax
Email
FORM ID#
NAE Prior Year(s)
I.D. NUMBER
InstituteforHealthProfessionsat
CambriaHeights
!
InstituteforHealthProfessionsatCambriaHeights
207-01116thAve
CambriaHeights,NY11411
(718)723-7301
[email protected]
www.ihpch.org
CampusMagnetFallPSALSportsTeams*
Girls’Teams
Boys’Teams
VarsityBowling
VarsityFootball**
VarsityCrossCountry**
JuniorVarsityFootball**
VarsitySoccer**
VarsitySoccer**
VarsityTennis**
VarsityVolleyball**
Ifyourchildisinterestedinpar>cipa>nginoneoftheabovefallsports,pleasedownloadthe
followingdocumentsfromwww.ihpch.orgorcontacttheAthle>cDirector:
PSALParentalConsent
h#p://www.psal.org/PDF/Official/2012_PSAL%20InterscholasBc%20AthleBcs%20Parental
%20Consent%20Form%200812.pdf
PSALPhysicalForm-Tobecompletedinaddi>ontostandardphysicalform
h#p://www.psal.org/PDF/Miscellaneous/2015_InterscholasBc%20Sports%20ExaminaBon
%20form10-26-2015.pdf
Parentsshouldalsoreadthestudentandparentinforma>onsheetonconcussions:
h#p://www.psal.org/PDF/Official/2012_ConcussionManagementstudentparenBnfo%20sheet
%20.pdf
LascellesAboagye
Athle>cDirector
CampusMagnetComplex
(718)978-6432,Ext.5123
Fax:(718)723-7306
*Informa>ononwinterandspringsportswillbegivenduringtheschoolyear.
**FallPrac>cesbeginonAugust21,2016.