CRITICAL INFORMATION MASSACHUSETTS PROGRAMS

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1 CRITICAL INFORMATION MASSACHUSETTS PROGRAMS June 2017 You are receiving this notice because your child is currently registered for a youth program in Massachusetts. The state of Massachusetts requires that the enclosed forms be completed and returned to id Tech prior to your child s attendance at the program. Forms cannot be accepted on the first day of the program. A state-certified physician or equivalent MUST sign that they have reviewed and confirmed the child s health history, current medical condition, and immunization history. The following documents are attached: 1) Youth Camp Health Form & Immunization History (REQUIRED) This form includes information regarding your child s past and current health. Massachusetts requires that a physical exam must have been completed within 24 months of attending the program. a. Parent/guardian completes and signs the top portion and then provides it to the child s physician. b. Physician completes and signs the form. Physician attaches the following documents: i. Recent physical exam report and ii. Full immunization history. IMPORTANT: The exam report is a health assessment document produced by your child s doctor based on your child s last physical exam. It must be included along with the child s full immunization history. The exam report required for school purposes is satisfactory. PLEASE SCAN AND UPLOAD THE FORM AND SUPPORTING DOCUMENTS TO id TECH AT LEAST 3 WEEKS BEFORE CAMP. To upload the form: a. Log into your My Account. b. Click on the Complete Forms icon on the top of the page. c. Use the Additional Required Forms Upload Tool to upload. d. Alternatively, you can fax the form toll-free to id Tech at , Attn: MA Compliance. Please do not form(s) as that is not a secured method. Registered within 7 days of camp? Please submit this form and all required documents to your My Account via the instructions above by the Friday before camp begins and bring a copy with you to check-in. QUICK TIPS: Fax forms to physician. No appointment should be necessary unless the child needs a physical exam or if an immunization is needed as required by the state. Merge multiple files into one PDF file before uploading, this can speed processing time. The Document Upload Tool currently only accepts files up to 2MB. If your file size is larger than 2MB, try saving your PDF as a Reduced Size PDF. Scanned images are best to upload. If you do not have access to a scanner, here is an alternative: You can download the free Adobe Reader app available on most mobile devices. Through this app, you can capture images of your document(s) which convert to PDF. Please ensure the images are clear and legible. Multiple images can be saved in one PDF file. While using the app: o Turn off auto-crop as this feature may scan only part of your document. o Once you capture an image of your document, simply save and it to yourself. o Once you have your saved PDF, ensure that the file size is under 2MB. o If one file is too large, split the file up into separate files sized to upload. o Then, simply follow the instructions above to upload to your My Account.

2 2) Required Immunizations Chart This chart shows required immunizations for students attending licensed camps in Massachusetts. This is for your reference only and should not be returned to id Tech. a. Medical/Religious Waiver: If you have medical or religious objections to immunizations, you must submit a signed written statement explaining the reason and that the child is in good health. If immunization is medically unsafe, a physician must also confirm the assertion and state that the child is in good health. The state of Massachusetts does not accept philosophical objections to immunization requirements. 3) Authorization for the Administration of Medication Form (only complete if child will be taking medication while at the program) This form is required if medication will be present at the program. The form authorizes our staff to administer medication to your child while at the program. If your child is NOT bringing medication to the program, then the page described below is not needed. a. Required for Medication: Parent/guardian completes ONLY if child brings medications (includes blood glucose testing kits, inhalers, emergency-use items like Epi-Pens, etc.). b. Parent Must Sign: Parent must complete and sign the form for medication as described in 3a, above. c. id Tech staff are NOT permitted to accept any medication at check-in which has not been included on a completed Authorization for the Administration of Medication form. i. Trained staff will collect and review all medication during check-in on the first day of the program with you. ii. Medications will be in the control of staff, except for Epipens, emergency inhalers and blood glucose testing kits which can be held by the child. Please bring two (2) Epipens, one for the staff and one for your child. PLEASE SUBMIT THIS MEDICATION FORM(S) TO id TECH AT LEAST 3 WEEKS BEFORE CAMP. ALL MEDICATION(S) MUST BE BROUGHT IN ORIGINAL CONTAINER(S) ON THE FIRST DAY OF THE PROGRAM AND GIVEN TO STAFF. BIOHAZARD CONTAINERS: If bringing a medication that include a needle syringe, glucose pen, and/or blood glucose testing strips, parents must provide a biohazard Sharps container for proper disposal. The medication(s) and container will be returned to you at check out. 4) Additional Information: These enclosed documents are for your reference only and should not be returned to id Tech: a. Meningococcal Disease Commonly Asked Questions b. Massachusetts Recreational Camps FAQ for Parents INTERNATIONAL STUDENTS: Parent/guardian should bring this entire health and medications packet to the child s physician as soon as possible, to ensure the child receives all required immunizations, a physical exam within the required timeframe, and/or anything else as required per this packet. All information must be submitted in English and must meet Massachusetts (MA) state standards, even if these standards differ from those of your home country. ALL STUDENTS: Per Massachusetts state law, we are not permitted to admit children who do not provide us with the requested health information and forms as applicable. If you have questions, please contact us at or (international), Monday through Friday from 6:00am to 5:00pm PT. You may also reach us by at info@idtech.com. Thank you for your cooperation in the fulfillment of these requirements. We look forward to having your child attend camp this summer. Sincerely, Team id 105 CMR D, B2 The following documentation is available upon request: Staff background check process Discipline policy Care of mildly ill campers policy Procedures for providing emergency health care Grievances can be filed by ing appeals@idtech.com. All grievances are addressed by the Appeals Committee.

3 SUBMIT TO id TECH AT LEAST 3 WEEKS BEFORE CAMP Registered within 7 days of camp? Please submit this form and all required attachments to your My Account and bring a copy with you to check-in. Scan and upload to your My Account Or fax toll-free: , Attn: MA Compliance Or mail to: MA Compliance id Tech 910 East Hamilton Avenue, Suite 300 Campbell, CA Please Include: Physical Exam Report Immunization History YOUTH CAMP HEALTH FORM STUDENT (MA) Parent/Guardian My Account Username: id Tech Location Attending Week(s) Student Name Date of Birth Phone Guardian Address Emergency Contact Phone Date of Arrival at Camp: Departure Date: If sunscreen is needed while at camp, do you authorize staff to assist in the application of sunscreen? NO YES Signature of Authorizing Parent/Guardian Date Signed TO BE COMPLETED BY THE SPECIFIED MEDICAL PRACTITIONER: Weight: lbs Height: ft in. Blood Pressure / Date of Physical Exam / / Physical exams are valid for 24 months from date of last exam. May participate in all camp activities May participate except for: Medical information pertinent to routine care and emergencies: (for example: past anaphylactic reaction) Is this individual taking medication(s) while at camp? NO YES. Please complete the attached Authorization for the Administration of Medication form for each medication being brought to camp. Form must be submitted for Epipens, Inhalers, and Blood Glucose Testing Kits as well. Does the individual have diabetes? NO YES Does the individual have allergies? NO YES Explain: Is the individual on a special diet? NO YES Explain: Does the individual have special needs? NO YES Explain: This student must be up-to-date on all immunizations as required by the state of Massachusetts per 105 CMR Please attach student s full immunization history. *REQUIRED* Comments: Print name of medical care provider: Medical care provider s address: Medical care provider s: City/Town ST Zip Code Signature of Physician, PA, APRN or RN Date Form Signed Telephone Number

4 SUBMIT TO id TECH AT LEAST 3 WEEKS BEFORE CAMP Registered within 7 days of camp? Please submit this form and all required attachments to your My Account and bring a copy with you to check-in. Scan and upload to your My Account Or fax toll-free: , Attn: MA Compliance Or mail to: MA Compliance id Tech 910 East Hamilton Avenue, Suite 300 Campbell, CA Authorization for the Administration of Medication (MA) IMPORTANT NOTES: Medication will be collected, handled, stored, and administered by trained camp staff. Any injectable medication/device must be self-administered by student under the observation of trained staff. Epipens (bring 2 pens), inhalers and blood glucose testing kits brought to camp must have this form returned. id Tech Location Attending Week(s) MULTIPLE MEDICATIONS = MULTIPLE FORMS Authorized Prescriber s Order (Physician, Dentist, Physician Assistant, Advanced Practice Registered Nurse): Name of Child Date of Birth / / Medication Name Controlled Drug? YES NO Dosage Method Time of Administration What condition is the medication / treatment for? Specific Instructions for Medication Administration: Medication Administration: Start Date / / Stop Date / / Relevant Side Effects of Medication Plan of Management for Side Effects Known Food or Drug: Allergies? YES NO Reactions to? YES NO Interactions with? YES NO If yes to any of the above, please explain Parent/Guardian Authorization (REQUIRED): I hereby authorize id Tech staff at to administer to my child,, the (write in program location) (write in child s name) medication listed above in accordance with 105 CMR Name of Parent/Guardian Date / / Relationship to Child: Mother Father Guardian/Other explain: Address Phone Number ( ) City ST Zip Parent/Guardian Authorizing Administration Signature 105 CMR (A) Medication prescribed for campers shall be kept in original containers bearing the pharmacy label, which shows the date of filling, the pharmacy name and address, the filling pharmacist s initials, the serial number of the prescription, the name of the patient, the name of the prescribing practitioner, the name of the prescribed medication, directions for use and cautionary statements, if any, contained in such prescription or required by law, and if tablets or capsules, the number in the container. All over the counter medications for campers shall be kept in the original containers containing the original label, which shall include the directions for use. 105 CMR (C) Medication shall only be administered by the health supervisor* or by a licensed health care professional authorized to administer prescription medications. If the health supervisor is not a licensed health care professional authorized to administer prescription medications, the administration of medications shall be under the professional oversight of the health care consultant. The health care consultant shall acknowledge in writing a list of all medications administered at the camp. Medication prescribed for campers brought from home shall only be administered if it is from the original container, and there is written permission from the parent/guardian. 105 CMR (D) When no longer needed, medications shall be returned to a parent or guardian whenever possible. If the medication cannot be returned, it shall be destroyed. * Health Supervisor A person who is at least 18 years of age, specially trained and certified in at least current American Red Cross First Aid (or its equivalent) and CPR, has been trained in the administration of medications and is under the professional oversight of a licensed health care professional authorized to administer prescription medications. Name of Camp Personnel Receiving Written Authorization and Medication Title/Position Signature (in ink)

5 2017 Required Immunizations Students Attending Camp in Massachusetts Immunization Dose(s) Additional Information Diphtheria, Tetanus & Pertussis 4 (DTap/DTP/DT/Td) MMR (measles, mumps, rubella) MMRV 2 (measles, mumps rubella, varicella) Polio 3 (IPV/OPV) Hepatitis B 3 4 doses of DTaP. Minimum 3 doses if all one type; 4 doses if mixed (IPV and OPV). Tdap/Td 1 1 dose of Td (Tdap preffered) for campers entering grade 7. Everyone else is required to have a dose of Td (Tdap preferred) if it has been more than 10 years since the previous dose of Td. Varicella (the V in MMRV) 2 RECOMMENDED (OR HAD DISEASE IN CHILDHOOD). To see the Massachusetts School Immunization Requirements for the school year, you may click on or copy and paste the following url into your browser:

6 Meningococcal Disease and Camp Attendees: Commonly Asked Questions What is meningococcal disease? Meningococcal disease is caused by infection with bacteria called Neisseria meningitidis. These bacteria can infect the tissue (the meninges ) that surrounds the brain and spinal cord and cause meningitis, or they may infect the blood or other organs of the body. In the US, about 1,000-1,200 people get meningococcal disease each year and 10-15% die despite receiving antibiotic treatment. Of those who survive, about 11-19% may lose limbs, become hard of hearing or deaf, have problems with their nervous system, including long term neurologic problems, or have seizures or strokes. How is meningococcal disease spread? These bacteria are passed from person-to-person through saliva (spit). You must be in close contact with an infected person s saliva in order for the bacteria to spread. Close contact includes activities such as kissing, sharing water bottles, sharing eating/drinking utensils or sharing cigarettes with someone who is infected; or being within 3-6 feet of someone who is infected and is coughing and sneezing. Who is most at risk for getting meningococcal disease? People who travel to certain parts of the world where the disease is very common, microbiologists, people with HIV infection and those exposed to meningococcal disease during an outbreak are at risk for meningococcal disease. Children and adults with damaged or removed spleens or persistent complement component deficiency (an inherited immune disorder) are at risk. Adolescents, and people who live in certain settings such as college freshmen living in dormitories and military recruits are at greater risk of disease from some of the serotypes. Are camp attendees at increased risk for meningococcal disease? Children attending day or residential camps are not considered to be at an increased risk for meningococcal disease because of their participation. Is there a vaccine against meningococcal disease? Yes, there are 3 different meningococcal vaccines. Quadrivalent meningococcal conjugate vaccine (Menactra and Menveo) protects against 4 serotypes (A, C, W and Y) of meningococcal disease. Meningococcal serogroup B vaccine (Bexsero and Trumenba) protects against serogroup B meningococcal disease, for age 10 and older. Quadrivalent meningococcal polysaccharide vaccine (Menomune) is recommended for people age 56 and older with certain highrisk conditions. Should my child or adolescent receive meningococcal vaccine? Meningococcal vaccine is not recommended for attendance at camps. However, these vaccines may be recommended for children with certain high-risk health conditions, such as those described above. MDPH strongly recommends two doses of quadrivalent meningococcal conjugate vaccine: a first dose at age 11 through 12 years, with a second dose at 16 years. Meningococcal serogroup B vaccine (Bexsero and Trumenba) is recommended for people with certain relatively rare high-risk health conditions age 10 or older (examples: persons with a damaged spleen or whose spleen has been removed, those with persistent complement component deficiency, and people who may have been exposed during an outbreak). Adolescents and young adults (16 through 23 years of age) may be vaccinated with a serogroup B meningococcal vaccine, preferably at 16 through 18 years of age, to provide short term protection for most strains of serogroup B meningococcal disease. Parents of adolescents and children who are at higher risk of infection, because of certain medical conditions or other circumstances, should discuss vaccination with their child s healthcare provider. How can I protect my child or adolescent from getting meningococcal disease? The best protection against meningococcal disease and many other infectious diseases is thorough and frequent handwashing, respiratory hygiene and cough etiquette. Individuals should: 1. wash their hands often, especially after using the toilet and before eating or preparing food (hands should be washed with soap and water or an alcohol-based hand gel or rub may be used if hands are not visibly dirty); 2. cover their nose and mouth with a tissue when coughing or sneezing and discard the tissue in a trash can; or if they don t have a tissue, cough or sneeze into their upper sleeve. 3. not share food, drinks or eating utensils with other people, especially if they are ill. If your child is exposed to someone with meningococcal disease, antibiotics may be recommended to keep your child from getting sick. You can obtain more information about meningococcal disease or vaccination from your healthcare provider, your local Board of Health (listed in the phone book under government), or the Massachusetts Department of Public Health Division of Epidemiology and Immunization at (617) or on the MDPH website at Provided by the Massachusetts Department of Public Health in accordance with M.G.L. c.111, s.219. Massachusetts Department of Public Health, Division of Epidemiology and Immunization, 305 South Street, Jamaica Plain, MA October 2016

7 What is a recreational camp for children? A recreational camp for children is a day or residential (overnight) sports, travel or wilderness program that offers recreational activities and instruction to campers. Such camps have five or more children and typically operate anytime between June 1 and September 30 and/or during school vacations. Please note that there are certain factors, such as length of time the camp is in session and type of entity operating a program, that influence whether a program is considered a recreational camp under applicable Massachusetts law (G.L.c. 111, 127A) and mandated regulations (105 CMR et. seq.: Minimum Sanitation and Safety Standards for Recreational Camps for Children). For further information on licensed recreational camps for children, contact the local board of health in the community where the camp is located. Do recreational camps for children have to be licensed? Yes. In Massachusetts, recreational camps for children must be inspected and licensed by the local board of health in the city or town where the camp is located. In order to be licensed, the camp must meet all regulatory standards established by the Massachusetts Department of Public Health (MDPH) and any additional local requirements. Are all summer programs licensed as recreational camps for children? No. There are certain regulatory requirements that a camp program must meet to be licensed as a recreational camp for children. The definition of a recreational camp for children and specific provisions for its licensure are found in regulations at 105 CMR Programs that do not meet the legal definition of a recreational camp for children are not subject to MDPH s regulatory provisions and therefore may not follow the mandatory requirements that apply to licensed recreational camps for children including: performing criminal record background checks on each staff person and volunteer prior to employment requiring proof of camper and staff immunizations requiring proof of appropriate training, certification, or experience for staff conducting or supervising specialized or high risk activities In addition, neither MDPH nor a local board of health conducts on-site inspections of facilities that are not considered recreational camps for children. To see if a camp is licensed, contact the local health department (board) in the community where the program is located. What is the purpose of the regulations? The regulations establish minimum health, safety, sanitary, and housing standards to protect the wellbeing of children who are in the care of recreational camps for children in Massachusetts. Where can I get information on the status of a recreational camp s license? The local health department/board in the community where the camp is located can confirm if the camp is a licensed recreational camp for children, confirm the status of the camp s license, and provide a copy of the camp s most recent inspection report. What does the local health department/ board evaluate as part of a camp inspection? The primary purpose of the inspection is to ensure that the camp provides an appropriate environment to protect the health, safety, and well being of the campers. Inspectors look to see that the camp has, for example: safe structures and equipment; adequate sanitary facilities; sufficient supervision of the campers; appropriate plans in case of medical emergencies, natural, and other physical disasters; sufficient health care coverage; and injury and fire prevention plans. Contact the local health department/ board of the community in which the camp is located to find out mandatory requirements, policies and standards. Are recreational camps required to provide copies of operating plans and procedures? Yes. You may ask a camp representative to let you see copies of any of the required plans and procedures. Are there minimum qualifications for camp counselors in Massachusetts? Yes. All counselors are required to have at least four weeks experience in a supervisory role with children or four weeks experience with group camping. Counselors must also complete an orientation program before campers arrive at camp. Any counselor who supervises children in activities such as horseback riding, hiking, swimming, and other events must also have appropriate specialized training, certification, and experience in the activity. You may ask to see proof that a counselor is certified in a particular activity. Is the camp required to conduct background checks on camp staff? Yes. For all camp staff and volunteers, the recreational camp for children must conduct a background check that includes obtaining and reviewing the applicant s previous work history and confirming three positive references. The camp must also obtain a Criminal Offender Record Information (CORI) history/juvenile record history from the Massachusetts Department of Criminal Justice Information Services to determine whether the applicant has a juvenile record or has committed a crime that would prevent the applicant from being with campers. The local health department/board will verify that CORI checks have been conducted during their annual licensing inspection. Where an applicant resides in another state or in a foreign jurisdiction, where practicable, the camp must also obtain from the applicant s criminal information system board, the chief of police, or other relevant authority a criminal record check or its recognized equivalent. The camp is required to hire staff and volunteers whose backgrounds are free of conduct that bears adversely upon his or her ability to provide for the safety and well-being of the campers. Is the camp required to check staff and volunteer backgrounds for a history of sexual offenses? Yes. The operator of the camp must obtain a Sex Offender Registry Information (SORI) report from the Massachusetts Sex Offender Registry Board (SORB) for all prospective camp staff, including any volunteers. The Sex Offender Registry Board is a public safety agency responsible for protecting the public from sex offenders. The local health department/ board will verify that SORI checks have been conducted during their annual licensing inspection. For more information concerning the Sex Offender Registry Board, and SORI information and policies available to the public, visit the SORB website at How can I be sure that such background checks have been conducted? You can request a copy of the camp s written policy on staff background checks from the camp director. Please note, however, that you are not authorized to review the staff person s actual CORI and SORI report. How old do camp counselors have to be? There are different age requirements depending on the type of camp. A counselor working at a licensed residential (overnight), sports, travel, trip, or special needs camp must be 18 years of age or have graduated from high school. Counselors working at a day camp must be at least 16 years of age. All counselors at licensed camps in Massachusetts are required to be at least three years older than the campers they supervise. Is the camp required to have a person on-site who knows first aid and CPR? Yes. All licensed camps are required to have a health supervisor at the camp at all times who is at least 18 years of age and is currently certified in first aid and CPR. The camp must provide backup for the health care supervisor from a Massachusetts licensed physician, physician assistant, or nurse practitioner who serves as a health care consultant. Special needs camps and residential camps where there are a large number of campers and staff must have a licensed health care provider, such as a physician or nurse, on site. How can I coordinate my child s medication administration while at a recreational camp? Licensed camps are required to keep all medications in their original containers and to store all prescription medications in a locked cabinet. If your child will be participating in off-site activities while taking prescription medication, a second

8 original pharmacy container must be provided to the camp. The only individual authorized to give your child his/her medication is a licensed health care professional or the camp health supervisor with oversight by the camp health care consultant. (Note that other arrangements may be made for emergency medications such as epi-pens and inhalers.) When your child returns from camp, the medication must be returned to you, if possible, or destroyed. Can a camp discipline my child? Yes. Camps are required to have a written disciplinary policy that explains their methods of appropriate discipline, e.g. time-out from activities, sending a child to the camp director s office, etc. Under no circumstances, however, may a camper be subjected to corporal punishment, such as spanking, or be punished by withholding food, or subjecting a camper to verbal abuse or humiliation. Parents and camp administrators can discuss the need for repellent with campers. Use of insect repellents that contain 30% or lower of DEET (N,Ndiethyl-m-toluamide) are widely available and have proven to be safe and effective for children (greater than 2 months of age) when used as directed and certain precautions are observed. These products should be applied based on the amount of time the camper spends outdoors and the length of time protection is expected as specified on the product label. Should products that contain both insect repellent and sunscreen be used? No. Use of DEET products that combine repellent with sunscreen are not recommended, as over application of DEET can occur if sunscreens need to be applied more frequently. It is generally recommended to apply sunscreen first, then insect repellant. Do not rely on glossy pictures and slick brochures when considering a recreational camp for your child. Contact the camp director to schedule an appointment for an informational meeting and tour of the facility prior to registering your child. Ask the camp for a copy of its policies regarding staff background checks, as well as health care and disciplinary procedures. Ask to see a copy of the procedures for filing complaints with the camp. Call the local health department/board in the city or town where the camp is located for information regarding inspections of the camp and to inquire about the camp s license status. Information about Recreational Camps in Massachusetts What steps does a camp have to take to protect my child from abuse and neglect? Public Health Regulation 105 CMR requires all camps to have policies and procedures in place to protect campers from abuse and neglect while at camp. You may ask a camp representative for specific information on the camp s policies, as well as its procedures for reporting a suspected incident. In order to protect your child from possible abuse, you should talk openly and frequently with your child about how to stay safe around adults and other children. Where can I get more information on abuse/neglect? For guidance on abuse prevention and counseling regarding a possible abuse situation, contact the Massachusetts Department of Children and Families (DCF) Child-At-Risk Hotline at or the Massachusetts Child Sexual Abuse Prevention Partnership at or ext.1 What steps can a camp (and parents) take to help protect children from mosquito-and tickborne disease such as Eastern Equine Encephalitis (EEE), West Nile Virus (WNV) and Lyme disease? What is the best way to apply repellents? Repellents containing DEET should only be applied to exposed skin, and children should be encouraged to cover skin with clothing when possible, particularly for early morning and evening activities when more mosquitoes are present. DEET products should not be applied near the eyes and mouth, applied over open cuts, wounds, or irritated skin, or applied on the hands of young children (the CDC recommends that adults apply repellents to young children). Skin where the repellent was applied should be washed with soap and water after returning indoors and treated clothing should be washed before it is worn again. Spraying of repellents directly to the face or in enclosed areas should be avoided. Obtain names of other families who have sent their children to the camp, and contact them for an independent reference. If you would like a copy of the state regulations or additional information concerning recreational camps for children, please visit or call the Massachusetts Department of Public Health, Bureau of Environmental Health s Community Sanitation Program at To order copies of Information About Recreational Camps in Massachusetts: Questions and Answers for Parents contact the Community Sanitation Program at: Telephone: Fax: TTY: Revised 2016 Questions and Answers for Parents Published by the Massachusetts Department of Public Health Bureau of Environmental Health Community Sanitation Program