DESIGNATION OF MEDICAL EXAMINER

Transcription

1 DESIGNATION OF MEDICAL EXAMINER I understand that New Jersey Statute, N.J.S.A. 18A: 40A-12, requires the Board of Education to immediately conduct a medical evaluation of my child for possible drug use if my child is in possession of and/or shows symptoms associated with the use of drugs, alcohol and/or steroids. I understand that the school principal or his/her designee will contact me upon discovering the possession of and/or any drug, alcohol or steroid related symptoms in my child and inform me that an immediate drug screen has been arranged for my child with the physician I have designated below. My daytime telephone is: My evening telephone is: If my child requires drug screening during the school year, I hereby designate the following physician to conduct a medical examination and drug screening of my child: AT NO COST TO ME: CONCENTRA WEST NEW YORK 6701 Bergenline Avenue West New York, NJ AT MY OWN EXPENSE: Physician s Name: Physician s Address: Physician s Telephone: Student s Name (print): Parent/Guardian s Name (print): Parent/Guardian s Signature: Date: School:

2 Special Education Medicaid Initiative (SEMI) Parental Consent form West New York school district is participating in the Special Education Medicaid Initiative (SEMI) program that allows school districts to bill Medicaid for services that are provided to students. In accordance with the Family Educational Rights and Privacy Act,34 CFR and Section 617 of the IDEA Part B, consent requirements in 34 CFR require a one-time consent before accessing public benefits. This consent establishes that your child's personally identifiable information, such as student records or information about services provided to your child including evaluations, and services as specified in my child's Individualized Education Program (IEP) (occupational therapy, physical therapy, speech therapy, psychological counseling, audiology, nursing and specialized transportation) may be disclosed to Medicaid and the Department of the Treasury for the purpose of receiving Medicaid reimbursement at the school district. As parent/guardian of the child named below, I give permission to disclose information as described above and I understand and agree that Medicaid may access my child's or my public benefits or insurance to pay for special education or related services under Part 300 (services under the IDEA). Child's Name: Child's Date of Birth: / / *I give consent to bill for SEMI: Yes No Parent Signature: Date: / / This consent can be revoked at any time by contacting your child s Case Manager or West New York Board of Education, Department of Special Services. SEMI Parental Consent 2013

3 SCHOOL HEALTH SERVICES Authorization For Exchange of Confidential Information Name of Student: Date of Birth: (Print) Date: Room: As a Parent/Guardian of the above named student, I hereby authorize the release of pertinent information (medical conditions, allergies, and/or medication regimes) to be exchanged among appropriate professional staff involved in the care of the above named student. This consent is valid for the school year and is intended to allow the staff to better serve my child. Parent/Guardian s Name (print): Parent/Guardian s Signature: (For Office Use Only) Information given to Parent/Guardian/Información administrada al Padre/Guardian Asthma Action Plan/Plan para el tratamiento del asma Allergy Action Plan/Plan para el tratamiento de alergias Seizure Action Plan/Plan para el tratamiento de convulsiones Medication Permission Form/Permiso para la administración de medicamentos Other/Otro: Parent/Guardian Initial: Date:

4 Dear Parent/Guardian: STUDENT HEALTH HISTORY Please complete this brief health history about your child. Answer every question. This information will only be shared with the staff as needed. Thank you. Student s Name: Date of Birth: 1. Allergies to any food: Yes No If yes, what kind(s): 2. Allergies to medicine: Yes No If yes, what kind(s): 3. Allergies to animals/insects: Yes No If yes, what kind(s): 4. Other Allergies: Yes No If yes, what kind(s): 5. Asthma: Yes No If yes, does your child use a machine for medicine: Yes No If yes, how often does your child use it: 6. Heart Problems: Yes No If yes, what kind: 7. Seizures/Febrile Seizures: Yes No How high and when was the last one: If yes, does your child take medication (name, dose and how often): 8. Operations: Yes No If yes, what kind and when: 9. Hospitalized: Yes No If yes, what for and when: 10. Injuries: Yes No If yes, what kind and when: 11. Stitches: Yes No If yes, where and how many: 12. Any broken bones: Yes No If yes, where and when: 13. Frequent Ear infections: Yes No 14. Frequent Sore Throat: Yes No 15. Skin Condition: Yes No If yes what kind: 16. Has your child ever had Chicken pox, Measles or Mumps: Yes No If Yes, which one and when: 17. Does your child take any medication other than vitamins: Yes No If yes, what are the names of the medications: 18. Does your child have any restrictions on physical activity: Yes No If Yes, what are the limitations: 19. Does your child have or has he/she ever had health, emotional or behavioral problems that we should be aware of: Yes No If Yes, what are they: 20. When your child was born, was he/she premature or full term: 21. Did your child have normal developmental milestones: Yes No 22. Does your child wear glasses or contact lenses: Yes No If yes, which one: 23. Does your child wear hearing aids: Yes No If Yes, what kind: 24. Does your child use a cane, crutches or wheelchair: Yes No If Yes, which one and what for: 25. Does your child have any special needs: Yes No If Yes, what kind: 26. Is there a family history of Diabetes: Yes No 27. Is there a family history of Cancer: Yes No 28. Is there a family history of Convulsions: Yes No 29. Is there a family history of Heart problems: Yes No If yes, what kind: 30. Is there a family history of high blood pressure: Yes No Parent/Guardian s Signature: Date:

5 WEST NEW YORK PUBLIC SCHOOLS Physical Examination for Student Health Appraisal [PART 1 of 2] TO BE COMPLETED BY THE PHYSICIAN AND RETURNED TO THE SCHOOL NURSE WITHIN 15 DAYS THE EXAMINING PHYSICIAN IS RESPONSIBLE FOR INFORMING THE SCHOOL OF ANY HEALTH PROBLEMS, WHICH MAY HINDER THIS CHILD FROM FULL PARTICIPATION IN THE SCHOOL HEALTH AND PHYSICAL EDUCATION PROGRAM. Note: check mark indicates normal findings Name: Birth Date: Address: School: History of Immunizations: DTaP/DTP/ 1. Pneumococcal 1. I.P.V: 1. Td: 2. Conjugate: (PCV ) HEP A: 1. M.M.R: Varicella: MANTOUX: Date given: Date Read: H.I.B: 1. Reaction: 2. X-ray: 3. Quantitative Test Given: Results: 4. TREATMENT: INH STARTED: HEP B: 1. DOSE: 2. DURATION: 3. COMPLETED: 4. Pre-K must have FLU Vaccine administered between Sept. 1 st & Dec. 31 st Date given: 11 YR. Olds must have: Tdap: MENINGOCOCCAL: CONJUGATE (MCV 4) Recommended for ages 9 & older: H.P.V: Rotavirus: OTHER: Laboratory Findings: Hgb/Hct.: Urinalysis: Lead: Other: Does this child take any medication? Yes No Please indicate name of the medication and if it is to be given in school: Is there a history of any serious injuries, accidents or operations? Yes No Is there any impairment, disease or illness, past or present, of which the school should be informed, and to which special consideration should be given? Yes No Please indicate feedings, procedures, etc. Is the child under the care of a specialist? Yes No If yes, who and why? General condition: Print Doctor s Name Signature Date Health Care Provider s Stamp

6 WEST NEW YORK PUBLIC SCHOOLS Physical Examination for Student Health Appraisal [PART 2 of 2] STUDENT S NAME: Height: Ears: Dermatitis: Weight: Blood Pressure: Hearing loss: Rt. Head / Neck: Tonsils: Lt. Nutrition: Lungs: Pulse: Glands: Allergies: Eye/Schlera/Pupils: Teeth: Anaphylaxis: Vision without glasses: Rt. Lt. Vision correction with Glasses/Contacts: Rt. Lt. Gums: Nose: Speech: Genitalia: Glands: (specify) Seizures: Abdomen: Stomach: Hernia: Orthopedic: Scoliosis: Structural: Feet: Asthma/RAD (circle which one): Yes No Medication: Inhaler: Nebulizer: Dosage: Frequency: No Medication: Physical Education: : Heart Rhythm: Murmur: Yes No Is this child under the care of a Pediatric Cardiologist? Yes No Diagnosis: Developmental Assessment: Fine/Gross Motor: Language Development: Autism Spectrum: Yes No Down s Syndrome: Yes No 1. Full activity recommended: 2. No competitive or contact sports: 3. Limited activity prescribed as follows: 4. Exclusion because: 5. Restricted (dates) from: to: HISTORY OF COMMUNICABLE DISEASES DIPHTHERIA: MEASLES: GERMAN MEASLES: MUMPS: CHICKEN POX: SCARLET FEVER: WHOOPING COUGH: INF. PARALYSIS: FIFTH DISEASE: DATE OF EXAMINATION: Doctor s Name: (Please Print) Doctor s Signature: Doctor s Office Stamp: School Nurse: Signature Date

7 PROOF OF ELIGIBILITY PRELIMINARY INFORMATION: PLEASE READ BEFORE PROCEEDING 1. The District shall accept a combination of any of the following or similar forms of documentation from persons attempting to demonstrate a pupil s eligibility for enrollment in the District: a. Property tax bills, deeds, contracts of sale, leases, mortgages, signed letters from landlords and other evidence of property ownership, tenancy or residency; b. Voter registrations, licenses, permits, financial account information, utility bills, delivery receipts, and other evidence of personal attachment to a particular location; c. Court orders, State agency agreements and other evidence of court or agency placements or directives; d. Receipts, bills, cancelled checks, insurance claims or payments, and other evidence of expenditures demonstrating personal attachment to a particular location, or, where applicable, to support of the pupil; e. Counselor or social worker assessments, employment documents, unemployment claims, benefit statements, and other evidence of circumstances demonstrating, where applicable, family or economic hardship, or temporary residency; f. Affidavits, certifications and sworn attestations pertaining to statutory criteria for school attendance, from the parent, guardian, person keeping an "affidavit pupil," adult pupil, person(s) with whom a family is living, or others as appropriate; g. Documents pertaining to military status and assignment; and h. Any other business record or document issued by a governmental entity. While any of the documents above shall be considered, supplying the documents may still necessitate a home visit. If you supply the Commonly Acceptable Proofs of Residency listed below from Categories A, B and C (1 document each) a home visit may not be required. The inability to provide any document from Category A will initiate an investigation. Providing documents from Category A and either Category B or C may require a home visit. 2. The District may accept forms of documentation not listed above, and shall not exclude from consideration any documentation or information presented by a person seeking to enroll a pupil. 3. The District shall consider the totality of information and documentation offered by an applicant, and shall not deny enrollment based on failure to provide a particular form of documentation, or a particular subset of documents, without regard to other evidence presented. 4. The District shall not require or request, as a condition of enrollment in school, any information or document protected from disclosure by law, or pertaining to criteria which are not legitimate bases for determining eligibility to attend school. These include but are not limited to: a. Income tax returns; b. Documentation or information relating to citizenship or immigration/visa status, except as set forth in N.J.A.C. 6A:22-3.3(b); c. Documentation or information relating to compliance with local housing ordinances or conditions of tenancy; and d. Social security numbers. 5. Documents or information of the type referenced in paragraph 4. above, or pertinent parts thereof, may be considered by the district if voluntarily disclosed by the applicant seeking enrollment. However, the district may not, directly or indirectly, require or request such disclosure as an actual or implied condition of enrollment. COMMONLY ACCEPTABLE PROOFS OF RESIDENCY Category A Category B Category C Lease Medicaid Correspondence PSE&G Bill Landlord Certificate Employment Pay-Stub Telephone Bill Deed Unemployment Documentation Cell Phone Bill Property Tax Bill / Statement Voter Registration Cable Bill Mortgage Statement Driver s License (Recent Issue) Credit Card Bill Landlord Certification (see attached) Bank Statement (ALL PROOFS MUST BE RECENT)

8 LANDLORD CERTIFICATION COUNTY OF HUDSON STATE OF NEW JERSEY I,, being of full age certify and say: 1) I am the owner or agent of the owner of residential property located in the Town of West New York known by the street address of 2) If I am the agent of the owner, the owner is, telephone number. 3) One of the residents of this property is, who lives in apartment # along with who I understand, is applying to be a student in the West New York School District. 4) Resident has occupied this apartment from to present. 5) The child has occupied this apartment from to present. 6) Number of rooms in residence/apartment. 7) Number of individuals occupying residence/apartment. I CERTIFY THAT THE FORGOING STATEMENTS MADE BY ME ARE TRUE. I AM AWARE THAT IF ANY OF THE FORGOING STATEMENTS MADE BY ME ARE WILLFULLY FALSE, I AM SUBJECT TO PUNISHMENT BY LAW. Landlord or Agent Signature *AGENT MUST PROVIDE A SIGNED LETTER OF AUTHORIZATION FORM FROM OWNER OF BUILDING Rvsd 9/2017 LC

9 APPENDIX H UNIVERSAL CHILD HEALTH RECORD Endorsed by: SECTION I - TO BE COMPLETED BY PARENT(S) Child s Name (Last) (First) Gender Does Child Have Health Insurance? Yes No Parent/Guardian Name Parent/Guardian Name Male If Yes, Name of Child's Health Insurance Carrier Home Telephone Number ( ) - Home Telephone Number ( ) - American Academy of Pediatrics, New Jersey Chapter New Jersey Academy of Family Physicians New Jersey Department of Health Female Date of Birth / / Work Telephone/Cell Phone Number ( ) - Work Telephone/Cell Phone Number ( ) - I give my consent for my child s Health Care Provider and Child Care Provider/School Nurse to discuss the information on this form. Signature/Date This form may be released to WIC. SECTION II - TO BE COMPLETED BY HEALTH CARE PROVIDER Date of Physical Examination: Results of physical examination normal? Yes No Abnormalities Noted: Weight (must be taken within 30 days for WIC) IMMUNIZATIONS Chronic Medical Conditions/Related Surgeries List medical conditions/ongoing surgical concerns: Medications/Treatments List medications/treatments: Limitations to Physical Activity List limitations/special considerations: Special Equipment Needs List items necessary for daily activities Allergies/Sensitivities List allergies: Special Diet/Vitamin & Mineral Supplements List dietary specifications: Behavioral Issues/Mental Health Diagnosis List behavioral/mental health issues/concerns: Emergency Plans List emergency plan that might be needed and the sign/symptoms to watch for: Hgb/Hct Immunization Record Date Next Immunization Due: MEDICAL CONDITIONS Yes Height (must be taken within 30 days for WIC) Head Circumference (if <2 Years) Blood Pressure (if >3 Years) PREVENTIVE HEALTH SCREENINGS Type Screening Date Performed Record Value Type Screening Date Performed Note if Abnormal Hearing Lead: Capillary Venous Vision TB (mm of Induration) Other: Other: Dental Developmental Scoliosis I have examined the above student and reviewed his/her health history. It is my opinion that he/she is medically cleared to participate fully in all child care/school activities, including physical education and competitive contact sports, unless noted above. Name of Health Care Provider (Print) Health Care Provider Stamp: No PRE K ONLY Signature/Date CH-14 OCT 17 Distribution: Original-Child Care Provider Copy-Parent/Guardian Copy-Health Care Provider

10 Section 1 - Parent Instructions for Completing the Universal Child Health Record (CH-14) Please have the parent/guardian complete the top section and sign the consent for the child care provider/school nurse to discuss any information on this form with the health care provider. The WIC box needs to be checked only if this form is being sent to the WIC office. WIC is a supplemental nutrition program for Women, Infants and Children that provides nutritious foods, nutrition counseling, health care referrals and breast feeding support to income eligible families. For more information about WIC in your area call Section 2 - Health Care Provider 1. Please enter the date of the physical exam that is being used to complete the form. Note significant abnormalities especially if the child needs treatment for that abnormality (e.g. creams for eczema; asthma medications for wheezing etc.) Weight - Please note pounds vs. kilograms. If the form is being used for WIC, the weight must have been taken within the last 30 days. Height - Please note inches vs. centimeters. If the form is being used for WIC, the height must have been taken within the last 30 days. Head Circumference - Only enter if the child is less than 2 years. Blood Pressure - Only enter if the child is 3 years or older. 2. Immunization - A copy of an immunization record may be copied and attached. If you need a blank form on which to enter the immunization dates, you can request a supply of Personal Immunization Record (IMM-9) cards from the New Jersey Department of Health, Vaccine Preventable Diseases Program at The Immunization record must be attached for the form to be valid. Date next immunization is due is optional but helps child care providers to assure that children in their care are up-to-date with immunizations. 3. Medical Conditions - Please list any ongoing medical conditions that might impact the child's health and well being in the child care or school setting. a. Note any significant medical conditions or major surgical history. If the child has a complex medical condition, a special care plan should be completed and attached for any of the medical issue blocks that follow. A generic care plan (CH-15) can be downloaded at or pdf. Hard copies of the CH-15 can be requested from the Division of Family Health Services at b. Medications - List any ongoing medications. Include any medications given at home if they might impact the child's health while in child care (seizure, cardiac or asthma medications, etc.). Short-term medications such as antibiotics do not need to be listed on this form. Long-term antibiotics such as antibiotics for urinary tract infections or sickle cell prophylaxis should be included. PRN Medications are medications given only as needed and should have guidelines as to specific factors that should trigger medication administration. CH-14 (Instructions) OCT 17 Please be specific about what over-the-counter (OTC) medications you recommend, and include information for the parent and child care provider as to dosage, route, frequency, and possible side effects. Many child care providers may require separate permissions slips for prescription and OTC medications. c. Limitations to physical activity - Please be as specific as possible and include dates of limitation as appropriate. Any limitation to field trips should be noted. Note any special considerations such as avoiding sun exposure or exposure to allergens. Potential severe reaction to insect stings should be noted. Special considerations such as back-only sleeping for infants should be noted. d. Special Equipment Enter if the child wears glasses, orthodontic devices, orthotics, or other special equipment. Children with complex equipment needs should have a care plan. e. Allergies/Sensitivities - Children with lifethreatening allergies should have a special care plan. Severe allergic reactions to animals or foods (wheezing etc.) should be noted. Pediatric asthma action plans can be obtained from The Pediatric Asthma Coalition of New Jersey at or by phone at f. Special Diets - Any special diet and/or supplements that are medically indicated should be included. Exclusive breastfeeding should be noted. g. Behavioral/Mental Health issues Please note any significant behavioral problems or mental health diagnoses such as autism, breath holding, or ADHD. h. Emergency Plans - May require a special care plan if interventions are complex. Be specific about signs and symptoms to watch for. Use simple language and avoid the use of complex medical terms. 4. Screening - This section is required for school, WIC, Head Start, child care settings, and some other programs. This section can provide valuable data for public heath personnel to track children's health. Please enter the date that the test was performed. Note if the test was abnormal or place an "N" if it was normal. For lead screening state if the blood sample was capillary or venous and the value of the test performed. For PPD enter millimeters of induration, and the date listed should be the date read. If a chest x-ray was done, record results. Scoliosis screenings are done biennially in the public schools beginning at age 10. This form may be used for clearance for sports or physical education. As such, please check the box above the signature line and make any appropriate notations in the Limitation to Physical Activities block. 5. Please sign and date the form with the date the form was completed (note the date of the exam, if different) Print the health care provider's name. Stamp with health care site's name, address and phone number.