Kindergarten Registration Medical Forms

Kindergarten Registration Medical Forms

CARROLL COUNTY IIEALT'II DEPARTMENT
290 SouthCenter Street
Westminster,Ma ryland 21151
Toll-free: 800-966-3877
FAX:410-87G4988
Ithdeoartnrelrt.dhmh.md.gov
ulvrv.carr.qlllllea
Henry G. Taylor, M.D., M.P.H,
Deputy Health Officer
Larry L. Leitch, M.4.,l\{.P.A.
Health Officer, Carroll County
DearParents/Guardians:
andthe Carroll
TheCarrollCountySchoolHealthProgramis a jointendeavorof the Boardof Education
CountyHealthDepartment.lt is ourgoalto workwithall parentsin the countyto keepourchildren
thatenablesthemto achievetheirfullpotential.
healthyand to providean environment
beforeyourchildenters
is requiredand a dentalvisitstronglyrecommended
A physicalexamination
physician
your
anddentisthave
and/orMarylandpublicschoolsfor thefirsttime. After
kindergarten
please
returnthemto the school
records,
examination
and immunization
theaccompanying
completed
whereyourchildis enrolled.
or firstgradewho lives
kindergarten,
ln addition,the parentof anychildenteringpublicpre-kindergarten,
froma
in,or haseverlivedin a designated
"at-risk"area,is requiredto providecertifieddocumentation
healthcareproviderof a bloodtestfor leadpoisoning.
pertussis,
measles,mumps,rubella,chickenpox,hepatitisB, and
Diphtheria,
tetanus,poliomyelitis,
infections
are seriousdiseaseswhichcanbe prevented.Yourchildmustbe immunized
haemophilus
againstthesediseasesby yourfamilydoctoror the HealthDepartment.MarylandStatelaw requiresthat
or schoolauthority
immunityto the preschool
a parentor guardianprovideevidenceof age-appropriate
(FormDHMH896)or computergenerated
formpriorto schoolentry,lf
Certificate
on a MD lmmunization
book
you maypresentyourblackimmunization
youdo not havethe previously
mentionedpaperwork
provider.
provider's
by
the
and
then
signed
information
(babybook).Thisbookmustbe stampedwiththe
are met.lf you havequestionsabout
Yourchildwill notbe admittedto schooluntilthese requirements
at
pleasecontactyourprivatephysician
or theCarrollCountyHealthDepartment
theserequirements,
to helpyou.
healthnursewillbe available
A community
876-4942,876-4900.
to childrenin previsionand hearingscreening
willbe..performing
CarrollCountyHealthDepaftment
you
problems
will be notifiedso that
grades.
are
found,
lf
any
and
Stn
kindergarten,
1"t,4tn
kindergarten,
can
be
taken.
measures
appropriate
the nursesin theschooland
theteachers,
schooleducation,
Duringthe courseof yourchild'selementary
yourchildmightdevelopwhichcould
to detectanyproblems
publichealthnurseswillbeworkingtogether
affecthisabilityto learn.
adversely
Sincerelv.
r'ffi.-.;*-7
'Henry
---FS< 7*-7- -en-r
G. Taylor,
M.D,,tvl-P.H.
MedicalDirector
DeputyHealthOtficer
pb/school/m
anuaUschoolltr.kg
1/08;1/09
1/13rev.1/0G,
Rev.7/04,Revis€d1/05;
114
t h0,2h1;1t 12;7
|5l12,7113,7
*f tr
PUBLICSCHOOLS
COUNTY
CARROLL
SCHOOL DENTAL HEALTH RECORD
Nameof Student
Age
Nameof School
Grade
All studentscan achieveand benefitfrom a healthymouth. Regulardental
goodoralhygienehabits,healthydiets,and modernadvancesin dental
examinations,
prevention
and control,can benefiteveryone.lf yourchildhasnotvisitedyour
disease
famil! dentistwithinthe last six months,we adviseyou to make an appointment
the signedformshouldbe returnedto the
Afterthe dentalappointment,
immediately.
school.
REPORTOF DENTALEXAMINATION
A.
AT THISTIME
IS NECESSARY
TREATMENT
NO DENTAL
B.
HASBEENCOMPLETED
DENTALTREATMENT
ALL NECESSARY
C.
IS IN PROCESS
TREATMENT
D.
IS RECOMMENDED
CAREPROGRAM
PREVENTATIVE
A REGULAR
RECOM
MENDATIONS:
FURTHER
DATE
OF DENT IST
SIGNATURE
APPROVEDBY THE MARYLANDSTATEDENTALASSOCIATION
Maryland
Schools
Recordof
PhysicalExamination
To Parentsor Guardians:
ln orderfor your childto entera MarylandPublicschoolfor the firsttime,the followingare
required:
,
A physical examinationby a physician or certified nursepractitioner must be
completed within nine months prior to entering the public school system or within
six months after entering the system. A PhysicalExaminationform designatedby the
Maryland StateDepartmentof Educationand the Departmentof Healthand Mental
Hygiene shallbe used to meet this requirement.
)
)
Evidenceof completeprimary immunizations againstcertain childhood
communicable diseases is required for all sfudenfs in preschool through the
twelfth grade. A MarylandlmmunizationCertificationfofm for 4ewly gnrollip.gsfudenfs
may be obtainedfrom the local health departmentorfrom schoolpersonnel. The
immunizationcertificationform (DHMH 896)or a printed or a computergenerated
immunizationrecord form and the requiredimmunizationsmusf be completedbefore a
child may attend school.This form can be found at:
http://wvwv.edcp.
orq/pdf/DHMH896new.pdf.
.
Evidence of blood testing is required for all sfudenfs who reside in a designated at
risk area when first entering Pre-kindergarten, Kindergarten, and I"t grade. The
blood-leadtestingceftificate(DHMH4620) (or another writtendocumentsigned by a
Health Care Practitioner)shallbe usedto meet this requirement.This form can be found
at:
http://www.fha.state.md.usioch/pdf/MarvlandDHMHBloodLeadTestinqCertificateDHMH4
620.pdf.
are permittedif theyare contraryto
and immunizations
from a physicalexamination
Exemptions
a students'or family'sreligiousbeliefs.Studentsmay alsobe exemptedfrom immunization
practitioner
officialcertifiesthatthereis
or healthdepartment
if a physician/nurse
requirements
testingis permittedif it
from Blood-Lead
a medicalreasonnotto receivea vaccine.Exemptions
mustbe
is contraryto a familiesreligiousbeliefsand practices.The Blood-leadcertificate
was done.
statinga questionnaire
signedby a HealthCarePractitioner
on thisformwill be availableonlyto thosehealthand education
The healthinformation
personnelwho havea legitimate
interestin your child.
educational
PleasecompletePart I of this PhysicalExaminationform. Part ll must be completedby a
physicianor nurse practitioner,or a copy of your child's physicalexaminationmust be
attachedto this form.
lf your child requiresmedicationto be administeredin school,you must havethe
physiciancompletea medicationadministrationform for each medication.This form can
be obtainedat http://www.marylandpublicschools.orq/NR/rdonlvres/8D9E900E-1349-4700lf you do not have accessto a
9AA8-5529C5F4C749/3341imedicationform404.pdf.
health
physicianor nurse practitioneror if your child requiresa specialindividualized
procedure,pleasecontactthe p.rincipaland/orschool nurse in your child's school.
MarylandStateDepartmentof Education
MarylandStateDepartmentof Healthand MentalHygiene
Records Retention - This form must be retained in the school record until the student is age 21.
MarylandSchools-Recordof PhysicalExaminationRevised 12104
PARTI . HEALTHASSESSMENT
To be com
rentor
Student'sName(Last,First,Middle)
Address(Number,Street,City,State,Zip)
Wheredo you usuallytakeyour childfor routinemedicalcare?
\ryhenwas the lasttimeyourchildhad a physicalexam? Month
\Nheredo you usuallytakeyour childfor dentalcare?
OF STUDENTHEALTH
ASSESSMENT
To the.bestof your knowledgehas yourchildany problemwiththe following?Pleasecheck
Doesyourchildtake any medication?
Yes
Name(s)of Medications:
No
ls your childon any specialtreatments?(nebulizer,epi-pen'etc.)
(catheterization'
etc.)
Doesyourchildrequireany specialprocedures?
Yes
No
MarylandSchools-Recordof PhysicalExaminationRevised 12104
PARTII . SCHOOLHEALTHASSESSMENT
n/Nurse
To be
eted ONLY
Practitioner
Student'sName(Last,First,Middle)
2. Doesthe childhavea healthconditionwhichmay reguireEMERGENCY
ACTIONwhilehe/sheis at school?
(e.9.,seizure,insectstingallergy,asthma,bleedingproblem,diabetes,heartproblem,or otherproblem)lf yes,
pleaseDESCRIBE.Additionally,
please'Workwithyour schoolnurseto developan emergencyplan".
for concern?
3. Are thereany abnormalfindingson evaluation
PhysicalExam
\ NL
ABNL
Area of
Concern
HealthArea of Concern
YES
NO
REMARKS:(Pleaseexplainany abnormalfindings.)
- DHMH896 is requiredto be completedby a healthcareprovidergI a computergenerated
4. RECORDOF IMMUNIZATIONS
record must be
5. ls the childon medication?lf yes, indicatemedicationand diagnosis.
(A medicationadministrationform must be completedfor medicationadministrationin school),
6. Shouldtherebe any restriction
of physicalactivityin school? lf yes,specifunatureand durationof restriction.
MarylandSchools-Recordof PhysicalExaminationRevised 12l(X
- continued
PARTll - SCHOOLHEALTHASSESSMENT
Practitioner
To be completedONLY by Phvsician/Nurse
has had a completephysical
(Child'sName)
examination
and has:
. . no evidentproblemthat may affectlearningor full schoolparticipation . . problemsnotedabove
Additional
Comments:
(Typeor Print)
Practitioner
Physician/Nurse
PhoneNo.
Signature
Physician/Nurse
Practitioner
-Record
Revised12104
Examination
of Physical
Schools
Maryland
Date
MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE IMMUNIZATION CERTIFICATE
CHILD'S NAME
FIRST
LAST
SEX:
MALE !
FEMALE N
MI
BIRTHDATE
COLINTY
GRADE
SCHOOL
PHONENO.
PARENT NAME
OR
GUARDIAN ADDRESS
Zrc
CITY
(SeeNotes On Other Side)
RECORD OF IMMUNIZATIONS
VaccinesTwe
Dose #
DTP-DTaP.DT
Mo/DayIYr
Polio
Mo/OayA/r
Hib
N.4olDay/Yr
Hep B
N,lo/Day/Yr
Mo/Day^fr
KOIaVtTUS
Mo/Daynr'r
Mo/DayfYr
Hrv
Mo/Day^/r
Dose
HepA
N4o/Day^/r
MI\4R
l\,lo/Day^/r
Varicella
N,lo/Day^/r
MofYr
1
1
Hrsroryor
Varicella
2
Td
Mo/Day^/r Mo/Day^/r
J
FLU
Other
Mo/Day^/r Mo/Day^/r
4
5
Clinic / Office Name
OfficeAddress/PhoneNumber
To the best of my knowledge, the vaccines listed above were administeredas indicated.
l.
Title
Signature
(Medical provider, local health department official, scbool official, or child care provider only)
2.
Signature
J.
Signature
Lines 2 and 3 are for certification of vaccinesgiven after the initial signature.
LOST OR DESTROYED RECORDS: (Must be reviewedand approvedby a medicalprovider or the local health department. Seenotes)
I hereby certifu that the immunization records of this child have been lost, destroyedor are unobtainable.
Date:
Signed:
Parent or Guardian
COMPLETE THE APPROPRIATE SECTION BELOW IF THE CHILD IS EXEMPT F'ROM IMMUNIZATION ON MEDICAL
OR RELIGIOUS GROUNDS. ANY IMMUNIZATIONS THAT HAVE BEEN RECEIVED SHOULD BE ENTERED ABOVE.
MEDICAL CONTRAINDICATION :
to being immunized at this time.
Theabovechild hasa valid medicalcontraindication
This is a fl
permanent
condition n
temporarycondition until
I
/
box, indicatevaccine(s)andreasons:
Checkappropriate
Date
Signed:
Medical Provider / LHD Official
RELIGIOUS OBJECTION:
I am the parent/guardianofthe child identified above. Becauseofmy bona fide religious beliefs and practices,I object to any
immunizations being given to my child. This exemption does not apply during an emergencyor epidernic of disease.
Signed:
DHMII Form E96
Rev, 2/11
Date:
Center for Imutriatiotr
w.EDCP,org
fl muniation)
How To Use This Form
The medical provider that gave the vaccinations may record the dates directly on this form (check marks are not
acceptable)and certiff them by signing the signaturesection.Combination vaccinesshouldbe listed individually, per
eachcomponentof the vaccine.A different medical provider, local health departmentofficial, school official, or child
care provider may transcribe onto this form and certiff vaccination dates from any other record which has the
authenticationof a medical provider, health department,school, or child care service.
Only a medical provider, local health department official, school official, or child care provider may sign
oRecordof Immunization' sectionof this form. This form may not be altered, changed,or modified in any way.
Notes:
1. When immunization recordshavebeenlost or destroyed,vaccinationdatesmaybe reconstructedfor all vaccines
exceptvaricella, measles,mumps, or rubella.
2. Reconstructeddatesfor all vaccinesmust be reviewed and approvedby a medical provider or local health
departmentno later than20 calendardays following the datethe studentwas temporarily admitted or retained.
3. Blood test results are NOT acceptableevidence of immunity against diphtheria, tetanus, or perfussis
(DTP/DTaP/Tdap/DT/Td).
4. Blood test verification of immunity is acceptablein lieu of polio, measles,mumps, rubella, hepatitisB, or
varicella vaccinationdates,but revaccination may be more expedient.
s. History of diseaseis NOT acceptablein lieu of any of the requiredimmunizations,exceptvaricella.
Immunization Requirements
(COMAR) 10.06.04.03
appliesto schools:
Thefollowingexcerptfrom theDHMH Codeof MarylandRegulations
"A preschool or school principal or other person in chargeofa preschool or school,public or private, may not
knowingly admit a studentto or retain a studentin a:
(1) Preschoolprogram unlessthe student'sparent or guardianhas furnished evidenceof age appropriateimmunity
againstHaemophilus influenzae,type b, and pneumococcaldisease;
(2) Preschoolprogram or kindergartenthrough the secondgrade of school unlessthe student'sparent or guardianhas
fumished evidenceof age-appropriateimmunity againstperfussis;and
(3) Preschoolprogram or kindergartenthrough the 12th gradeunlessthe student'sparent or guardian has fumished
evidenceof age-appropriateimmunity against:(a) Tetanus;(b) Diphtheria; (c) Poliomyelitis; (d) Measles(rubeola);
(e) Mumps; (f) Rubella; (g) Hepatitis B; and (h) Varicella."
Please refer to the "
Sg@!q" to determine age-appropriate immunity for preschool through grade 12 enrollees. The minimum vaccine
requirements and DHMH COMAR 10.06.04.03 are available at www.EDCP.org (Immunization).
Age-appropriate immunizationrequirements
for licensed childcare centers and family day care homes are based on
G & H andthe
andCOMAR 13A.16.03.04
COMAR 13A.15.03.02
of HumanResources
theDepartment
'r guideline
,,
chartareavailableat www.EDCP.org(Immunization).
DIIMH Fom
Rev.2/11
896
Center for Immuniation
(Imnuniation)
ww.EDCP.org
MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE BLOOD LEAD TESTING CERTIFICATE
CHILD'S NAME
FIRST
LAST
MIDDLE
CHILD'SADDRESS
ADDRESS
SEX:
E MALE
tr FEMALE
CITY
STATE
BIRTHDATE
COLINTY
GRADE
SCHOOL
PARENT
OR
GUARDIAN
ZIP
FIRST
LAST
MIDDLE
PHONE
II
ADDRESS
CITY
CERTIFICATION
STATE
ZIP
INFORMATION
The following applies to blood lead testing requirementsand the duties of health care providers, parentsiguardians,and the public
schools:
1. The health care provider for a child who residesin an at-risk area,or has ever resided in an at-risk areaas designatedby the
Maryland Targeting Plan for Childhood Lead Poisoning, shall administer a blood test for lead poisoning during the 12-month
visit and again during the 24-month visit. Alrisk areasby Zip Code are listed on the back of this form.
2. Beginning not later than September2003, the parent or guardian of a child who currently resides,or has ever resided, in an atrisk area,shall provide to the designatedadministrator of the child's school or program, evidencethat the child has had blood
lead testing, on entry into a Maryland public pre-kindergartenprogrilm or Maryland public school system at the level of prekindergarten,kindergarten or first grade.
3. Evidence ofblood testing for lead poisoning sent to or received by a program or school shall be documentedon a form approved
by the Departmentthat includes the following: name of the child, addressof the child, date of the blood test(s) for lead
poisoning, and the signatureofthe child's health care provider or designee,or school health professionalor designeethat
transcribedthe information onto the approved form.
4. A list of children (including home contact information) whose parent/guardiandoes not comply with the requirementto provide
evidenceof blood lead testing, must be forwarded to the Local Health Departmentin the jurisdiction where the child resides.
RECORDOF BLOOD LEAD TESTING
Test# 2.
Test#1.
Date
Comments:
Date
Signature
Health Care Provider or Desisnee OR School Health Professional or Desisnee
Date
RECORD OF'BLOOD LEAD TESTING EXEMPTION
certifu that mv child doesnot AND has never resided in an at-risk area.
Parent or Guardian (Print)
Signature
Date
Parent or Guardian
COMPLETE TIIE SECTION BELOW IF TITE CHILD IS EXEMPT FROM LEAD TESTING ON RELIGIOUS GROUNDS.ANY LEAD TESTS
THAT HAVE BEEN ADMINISTERED SHOI.ILDBE ENTERED ABOVE. A LEAD RISK ASSESSMENTQIIESTIONNAIRE MUST BE
ADMINISTERED BY A HEALTH CARE PRO\IDER IF THE CHILD IS EXEMPT FROM LEAD TESTING ON RELIGIOUS GROUNDS.
RELIGIOUS OBJECTION:
I.
2.
I am the parent/guardianof the child identifred above. Becauseof my bona fide religious beliefs and practices,I obj ect to any blood lead
t_
testing of my child. Signed
Parent or Guardian
Lead Risk Assessment Questionnaire Administered: YES tr
Date
NO tr
Signed
Health Care Provider
DHMH #4620 Revised May 2004
410.767.6713
Maryland Department of Health and Mental Hygiene, Center for Maternal and Child Health
Date
HOW TO USE THIS FORM
The documentedtests should be the tests at 12 months and24 months of age. Two test datesare required if the 1" test
was done prior to 24 months of age. If the 1't test is done after 24 months of age, one test date is required. The child's
primary health care provider may record the test datesdirectly on this form (check marks are not acceptable)and
certiff them by signing or stamping the signature section. A school health professional or designeemay transcribe
onto this form and certiff test datesfrom any other record that has the authenticationof a medical provider, health
department,or school. All forms are kept on file with the child's school health record. A list of children (including
home contact information) whose parent/guardiandoes not comply with the requirement to provide evidence of blood
lead testing, must be forwarded to the Local Health Department in the jurisdiction where the child resides.
Marvland Childhood Lead Poisoning Targetine Plan
At Risk Areas bv Zip Code
Allesanv
ALL
Anne Arundel
20'711
20714
20764
20779
21060
21061
21225
21226
21402
BaltimoreCo.
21027
2t052
21071
21082
21085
21093
21tl1
Z]
TJJ
21155
21161
21204
21206
2t207
2t208
21209
21210
2t2t2
21215
21219
21220
21221
21222
21224
2t227
2t228
2r229
21234
21236
2t237
Baltimore Co. (Cont.)
2t239
2t244
2t250
21251
21282
21286
BaltimoreCitv
ALL
Calvert
20615
20714
Caroline
ALL
Carroll
21155
21757
2r776
2r787
21791
Cecil
21913
Charles
20640
20658
20662
Dorchester
ALL
Frederick
20842
2t701
2t703
2t704
21716
21718
21719
21727
Frederick. (Cont)
21757
21758
2t'762
21769
2t776
2r778
2t780
2t783
2r787
2t791
21798
OueenAnne's
21607
21617
2t620
2 to2-3
21628
21640
21644
21649
2165r
21657
21668
21670
Garrett
ALL
Harford
21001
21010
2t034
2t040
21078
21082
21085
21130
2tltl
21t60
21161
lloward
20763
Kent
21610
21620
21645
21650
21651
21661
2t66',7
Montgomerv
20783
20787
Maryland Department of Health and Mental Hygiene Blood Lead Testing Certificate
DHMH #4620RevisedMay 2004
410.767.6713
Montsomerv(Cont)
208t2
20815
20816
20818
20838
20842
20868
20877
20901
209r0
20912
20913
PrinceGeorpe's
20703
20710
20712
20722
20731
20737
20738
20740
20741
20742
20743
20746
20748
20752
20770
20781
20782
20783
20784
20785
20787
20788
20790
20791
20792
20799
20912
20913
Somerset
ALL
St, Marvts
20606
20626
20628
20674
20687
Talbot
2t612
21654
21657
21665
21671
21673
21676
Washington
ALL
Wicomico
AIL
Worcester
ALL
htto:ir'rl'nrv.fha.state.md.usr'ochlhtrnlr'lead.himl
Maryland Department of Health and Mental Hygiene, Center for Maternal and Child Health