Dear Parent/Guardian:

Dear Parent/Guardian: Welcome to Indian Prairie School District. The purpose of this letter is to inform you of the health examination and immunization requirements in Illinois and the policy of the school district. Indian Prairie School District will follow the mandates of the Illinois Department of Public Health with regards to required immunizations for our students. Students entering preschool, kindergarten, sixth, and ninth grades, and new students to the district, must present proof of the required state of Illinois physical examination and immunizations. The student history portion of the examination form must be completed and signed by the parent. If this is not completed, the student will be excluded from school on October 15, 2015. Out-of-state physical examinations written on approved forms, which meet current state of Illinois requirements, are acceptable if they are less than one year old. An out-of-state transfer student may, at the time of registration, provide an appointment card showing these requirements will be completed within thirty days. At the end of the thirty day period, if the completed forms have not been presented to health services, the student will be excluded from school. All students entering kindergarten, second, and sixth grades are required to present proof of an oral health examination completed by a licensed dentist. This will be due prior to May 15 th of that academic year. A vision examination is required of all students entering kindergarten or enrolling in an Illinois public school for the first time. Written proof of having been examined by a physician licensed to practice medicine in all of its branches or a licensed optometrist will be required. Beginning with the 2015-2016 school year, all students entering grades six and twelve must show proof of receiving meningococcal conjugate vaccine. Students, who were enrolled last school year in District 204, should not need a new physical exam unless he/she is entering kindergarten or grade six or nine. Returning students who need immunization(s) will receive individual letters notifying the parent of the immunization(s) needed. The DuPage (630-682-7400) and Will (815-727-8480) County Health Departments offer immunizations at their clinics for a nominal fee. Please contact them directly to schedule an appointment. Please note that a current physical is required to try out for any interscholastic sport (grades 7-12). A physical is not required for intramural sports (grades 6-12). If a physical, dental, or vision exam is needed, check with your health care provider to see if he/she has the mandated Illinois form. If he/she does not have the Illinois form, it will be available at www.ipsd.org. The District s Medication Policy is found in the Parent/Student Handbook and at www.ipsd.org. Please reference the section on School Board Policy. A student, who has asthma or allergies, is allowed to carry necessary medication while at school. Physician orders or a photocopy of the pharmaceutical label on the medication box for rescue inhalers must be on file with the nurse. Enclosed in the registration packet, you will find an emergency medical card, which must be filled out, signed, and returned to your child s school. This card is kept in the nurse s office and used in the event of an emergency. This card is needed in the nurse s office prior to your child starting school. If you have any questions, please do not hesitate to call your school health office. Sincerely, Linda Herwaldt RN, BSN, MS, PEL-CSN Coordinator of Health Services

State of Illinois Certificate of Child Health Examination FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 2/2013 Student s Name Last First Middle Birth Date Month/Day/Year Sex Race/Ethnicity School /Grade Level/ID# Address Street City Zip Code Parent/Guardian Telephone # Home Work IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be attached explaining the medical reason for the contraindication. Vaccine / Dose DTP or DTaP 1 2 3 4 5 6 Tdap; Td or Pediatric DT (Check specific type) Polio (Check specific type) TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV Hib Haemophilus influenza type b Hepatitis B (HB) Varicella (Chickenpox) COMMENTS: MMR Combined Measles Mumps. Rubella Single Antigen Vaccines Measles Rubella Mumps Pneumococcal Conjugate Other/Specify Meningococcal, Hepatitis A, HPV, Influenza Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates to the above immunization history section, put your initials by date(s) and sign here.) Signature Title Date Signature Title Date ALTERNATIVE PROOF OF IMMUNITY 1. Clinical diagnosis is acceptable if verified by physician. *(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.) *MEASLES (Rubeola) MUMPS VARICELLA Physician s Signature 2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below is verifying that the parent/guardian s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease. Date of Disease Signature Title Date 3. Laboratory confirmation (check one) Measles Mumps Rubella Hepatitis B Varicella Lab Results Date (Attach copy of lab result) VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN Date Age/ Grade Vision Hearing R L R L R L R L R L R L R L R L R L Code: P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/Contacts IL444-4737 (R-02-13) (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois

Birth Date Sex School Grade Level/ ID # Last First Middle Month/Day/ Year HEALTH HISTORY ALLERGIES (Food, drug, insect, other) Diagnosis of asthma? Child wakes during night coughing? TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER Yes Yes No No MEDICATION (List all prescribed or taken on a regular basis.) Loss of function of one of paired organs? (eye/ear/kidney/testicle) Birth defects? Yes No Hospitalizations? Developmental delay? Yes No When? What for? Blood disorders? Hemophilia, Yes No Surgery? (List all.) Yes No Sickle Cell, Other? Explain. When? What for? Diabetes? Yes No Serious injury or illness? Yes No Head injury/concussion/passed out? Yes No TB skin test positive (past/present)? Yes* No *If yes, refer to local health department. Seizures? What are they like? Yes No TB disease (past or present)? Yes* No Heart problem/shortness of breath? Yes No Tobacco use (type, frequency)? Yes No Heart murmur/high blood pressure? Yes No Alcohol/Drug use? Yes No Dizziness or chest pain with exercise? Yes No Family history of sudden death before age 50? (Cause?) Yes No Eye/Vision problems? Glasses Contacts Last exam by eye doctor Dental Braces Bridge Plate Other Other concerns? (crossed eye, drooping lids, squinting, difficulty reading) Ear/Hearing problems? Yes No Information may be shared with appropriate personnel for health and educational purposes. Parent/Guardian Bone/Joint problem/injury/scoliosis? Yes No Signature Date PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA HEAD CIRCUMFERENCE if < 2-3 years old HEIGHT WEIGHT BMI B/P DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI>85% age/sex Yes No And any two of the following: Family History Yes No Ethnic Minority Yes No Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No At Risk Yes No LEAD RISK QUESTIONNAIRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.) Questionnaire Administered? Yes No Blood Test Indicated? Yes No Blood Test Date Result TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. No test needed Test performed Skin Test: Date Read / / Result: Positive Negative mm Blood Test: Date Reported / / Result: Positive Negative Value LAB TESTS (Recommended) Date Results Date Results Hemoglobin or Hematocrit Urinalysis Sickle Cell (when indicated) Developmental Screening Tool SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs Skin Ears Endocrine Gastrointestinal Eyes Amblyopia Yes No Genito-Urinary LMP Nose Throat Mouth/Dental Cardiovascular/HTN Neurological Musculoskeletal Spinal Exam Nutritional status Respiratory Diagnosis of Asthma Mental Health Currently Prescribed Asthma Medication: Quick-relief medication (e.g. Short Acting Beta Agonist) Controller medication (e.g. inhaled corticosteroid) NEEDS/MODIFICATIONS required in the school setting Other DIETARY Needs/Restrictions SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup MENTAL HEALTH/OTHER Is there anything else the school should know about this student? If you would like to discuss this student s health with school or school health personnel, check title: Nurse Teacher Counselor Principal EMERGENCY ACTION needed while at school due to child s health condition (e.g.,seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)? Yes No If yes, please describe. On the basis of the examination on this day, I approve this child s participation in (If No or Modified please attach explanation.) PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS Yes No Limited Print Name (MD,DO, APN, PA) Signature Date Address Phone (Complete Both Sides) Yes Yes No No

State of Illinois Eye Examination Report Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides eye examinations be submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school for other children. The examination must be completed within one year prior to the first day of the school year the child enters the Illinois school system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school. Student Name (Last) (First) (Middle Initial) Birth Date Gender Grade (Month/Day/Year) Parent or Guardian (Last) (First) Phone (Area Code) Address (Number) (Street) (City) (ZIP Code) County To Be Completed By Examining Doctor Case History Date of exam Ocular history: Normal or Positive for Medical history: Normal or Positive for Drug allergies: NKDA or Allergic to Other information Examination Distance Near Right Left Both Both Uncorrected visual acuity 20/ 20/ 20/ 20/ Best corrected visual acuity 20/ 20/ 20/ 20/ Was refraction performed with dilation? Yes No Normal Abnormal Not Able to Assess Comments External exam (lids, lashes, cornea, etc.) Internal exam (vitreous, lens, fundus, etc.) Pupillary reflex (pupils) Binocular function (stereopsis) Accommodation and vergence Color vision Glaucoma evaluation Oculomotor assessment Other NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test. Diagnosis Normal Myopia Hyperopia Astigmatism Strabismus Amblyopia Other Page 1 Continued on back

State of Illinois Eye Examination Report Recommendations 1. Corrective lenses: No Yes, glasses or contacts should be worn for: Constant wear Near vision Far vision May be removed for physical education 2. Preferential seating recommended: No Yes Comments 3. Recommend re-examination: 3 months 6 months 12 months Other 4. 5. Print name Optometrist or physician (such as an ophthalmologist) who provided the eye examination MD OD DO Address License Number Consent of Parent or Guardian I agree to release the above information on my child or ward to appropriate school or health authorities. (Parent or Guardian s Signature) Phone (Date) Signature Date (Source: Amended at 32 Ill. Reg., effective ) Page 2 Printed by Authority of the State of Illinois 6/09 IOCI1271-09

AUTHORIZATION FOR ADMINISTRATION OF MEDICATION IN SCHOOL BY SCHOOL PERSONNEL To be completed by the child s parent(s)/guardian(s). A new form must be completed every school year. Keep in the school nurse s office or, in the absence of a school nurse, the Principal s office. STUDENT S NAME DATE OF BIRTH PARENT/GUARDIAN HOME PHONE ADDRESS GRADE/SCHOOL EMERGENCY CONTACT NAME AND PHONE NUMBER: I. TO BE COMPLETED BY THE PHYSICIAN To be completed by the student s physician, physician assistant, or advanced practice nurse: Name of Medication Administration Route Dosage Time/Frequency/Circumstances when Medication Should be Administered Student s Diagnosis Possible Side Effect(s) Actions to be taken if the student has side effects and/or an adverse reaction to the medication: Intended Effects of this Medication Date of Prescription Discontinuation Date Other medications student is receiving: Is it absolutely necessary that this medication be administered in school? Yes No *The physician must authorize changes in dosage of any medications in writing. PHYSICIAN S NAME (PRINT) PHYSICIAN S SIGNATURE DATE PHONE II. TO BE COMPLETED BY THE STUDENT S PARENT OR GUARDIAN By signing below, I,, parent/guardian of, confirm that I have reviewed and understand IPSD 204 s Policy regarding the administration of medication in school. I understand that I am primarily responsible for administering medication to my child. However, in a medical emergency or if necessary for the critical health and well-being of my child, I hereby authorize IPSD 204 and its employees and agents, on my behalf and in my stead, to administer or attempt to administer lawfully prescribed medication in the manner described above pursuant to State law. I acknowledge that it may be necessary for the administration of medication to my child to be performed by an individual other than a nurse, and specifically consent to such practice. I will notify the school in writing if the medication is discontinued and will obtain a written order from the physician if the medication dosage or treatment is changed. I understand that this medication authorization is only effective for the current school year and will need to be renewed each subsequent school year. I further acknowledge and agree to waive any claims I might have against IPSD 204, its employees and agents arising out of the administration or attempted administration of said medication. In addition, I agree to hold harmless and indemnify IPSD 204, its employees and agents, either jointly or severally, from and against any and all claims, damages, causes of action or injuries, including reasonable attorney s fees and costs expended in defense thereof, except a claim based on willful and wanton conduct, arising out of, incurred or resulting from the administration or attempted administration of said medication regardless of whether the authorization was given by me, as the child s parent/guardian, or by my child s physician, physician s assistant, or advanced practice registered nurse. Finally, I understand and agree that it is my responsibility according to IPSD 204 policy to deliver the legally prescribed medication to the school, and pick up any remaining medication at the end of the school year from the school, myself or via another adult designee. Parent/Guardian Signature Date

AUTHORIZATION FOR SELF-ADMINISTRATION OF MEDICATION IN SCHOOL To be completed by the child s parent(s)/guardian(s). A new form must be completed every school year. Keep in the school nurse s office or, in the absence of a school nurse, the Principal s office. STUDENT S NAME DATE OF BIRTH PARENT/GUARDIAN HOME PHONE ADDRESS GRADE/SCHOOL I.TO BE COMPLETED BY THE STUDENT S PHYSICIAN To be completed by the student s physician, physician assistant, or advanced practice nurse: Name of Medication Administration Route Dosage Time/Circumstances when Medication Should be Administered in School Student s Diagnosis Possible Side Effect(s) Intended Effects of this Medication Date of Prescription Discontinuation Date PHYSICIAN S NAME (PRINT) PHYSICIAN S SIGNATURE DATE ADDRESS OFFICE PHONE PHONE EMERGENCY Self-Administration of Epinephrine: Yes No. The student listed above has a life threatening allergy that may necessitate the immediate administration of epinephrine followed by emergency medical attention. I certify that the student has been instructed in the self-administration of the medication listed above and is capable of administering the medication independently. I certify that the student understands the need for the medication and the necessity to notify a staff member and the health office immediately following the self-administration of the epinephrine auto-injector. Self-Administration of Diabetes Medication: Yes No. The student listed above has been diagnosed with diabetes. I have determined that it is medically necessary for this child to monitor and treat his/her diabetic condition during school and/or schoolrelated activities.. I certify that the student has been instructed in the self-administration of the medication listed above and use of his/her diabetes supplies and equipment. I certify that the student understands the need for the medication and the necessity of reporting to school personnel any unusual side effects. I certify that the student is capable of doing the following independently: Checking blood glucose Administering insulin Treating hypoglycemia and hyperglycemia and otherwise attending to the care and management of his or her diabetes Having on his or her person at all times the supplies and equipment necessary to monitor and treat diabetes (e.g., glucometers, lancets, test strips, insulin, syringes, insulin pens and needle tips, insulin pumps, infusion sets, alcohol swabs, a glucagon injection kit, glucose tablets). II. ASTHMA MEDICATION A written statement from the student s physician, physician assistant, dentist, optometrist, podiatrist, or advanced practice RN is not required for a student to carry and self-administer asthma medication. Parent(s)/Guardian(s) must attach the prescription label here, which must include the name of medication, the prescribed dosage, and the time at which/circumstances under which the medication is to be administered. [Attach prescription label here]

III. SELF-CARRY OF ASTHMA MEDICATION AND/OR EPINEPHRINE AUTO-INJECTOR For only parents/guardians authorizing students to carry asthma medication or an epinephrine auto-injector: By signing below, I,, parent/guardian of, authorize IPSD 204 and its employees and agents to allow my child to carry and self-administer his or her asthma medication and/or use his or her epinephrine auto-injector: (1) while in school, (2) while at a school-sponsored activity, (3) while under the supervision of school personnel, or (4) before or after normal school activities. I hereby acknowledge that IPSD 204, its officials, employees and agents will incur no liability, except for willful and wanton conduct, as a result of any injury arising from the self-administration of medication or use of an epinephrine auto-injector by my child regardless of whether authorization was given by me or by my child s physician, physician s assistant, dentist, optometrist, podiatrist, or advanced practice register nurse. I hereby agree to indemnify and hold harmless IPSD 204, its officials, employees, and agents against any claims, except a claim based on willful and wanton conduct, arising out of the self-administration of medication or use of an epinephrine auto-injector by my child regardless of whether authorization was given by me or by my child s physician, physician s assistant, dentist optometrist, podiatrist, or advanced practice register nurse. (105 ILCS 5/22-30). Parent/Guardian Printed Name Parent/Guardian Signature Date IV. TO BE COMPLETED BY THE STUDENT S PARENT OR GUARDIAN For all parents/guardians: By signing below, I,, parent/guardian of, confirm that I have reviewed and understand IPSD 204 s Policy regarding the self-administration of medication in school. I agree that I am primarily responsible for administering medication to my child. However, in a medical emergency or if necessary for the critical health and well-being of my child, I hereby authorize my child to self-administer lawfully prescribed medication in the manner described above pursuant to State law, while under the supervision of the IPSD 204 employees and agents. I will notify the school in writing if the medication is discontinued and will obtain a written order from the physician if the medication dosage or treatment is changed. I understand that this medication authorization is only effective for the current school year and will need to be renewed each subsequent school year. I acknowledge that it may be necessary for the administration of medication to my child to be performed by an individual other than a school nurse and specifically consent to such practices. I further acknowledge and agree that, when the medication is selfadministered, I waive any claims I might have against IPSD 204, its employees and agents arising out of the self-administration of said medication. In addition, I agree to hold harmless and indemnify IPSD 204, its employees and agents, either jointly or severally, from and against any and all claims, damages, causes of action or injuries, including reasonable attorney s fees and costs expended in defense thereof, except a claim based on willful and wanton conduct, arising out of, incurred or resulting from the administration or self-administration of said medication regardless of whether the authorization was given by me, as the child s parent/guardian, or by my child s physician, physician s assistant, or advanced practice registered nurse. Parent/Guardian Signature Date

INFORMATION REGARDING ADMINISTRATION AND SELF-ADMINISTRATION OF MEDICATION IN SCHOOL A.INDIAN PRAIRIE SCHOOL DISTRICT 204 POLICY Administering Medication to Students Students should not take medication during school hours or during school-related activities unless it is necessary for a student s health and well-being. When a student s licensed health care provider and parent/guardian believe that it is necessary for the student to take a medication during school hours or school-related activities, the parent/guardian must request that the school dispense the medication to the child and otherwise follow the District s procedures on dispensing medication. No School District employee shall administer to any student any prescription or nonprescription medication until a properly completed and signed Authorization for Administration of Medication in School form is submitted by the student s parent/guardian. No student shall possess or consume any prescription or non-prescription medication on school grounds or at a school-related function other than as provided for in this policy and its implementing procedures. Nothing in this Policy shall prohibit any school employee from providing emergency assistance to students, including administering medication. B. PARENT RESPONSIBILITIES FOR REQUESTING ADMINISTRATION OF MEDICATION 1. The parent/guardian must provide a completed Authorization for Administration of Medication in School form each school year for the administration of prescription and non-prescription medications (e.g., Tylenol, Advil, cough medicine, cough drops, cold remedies, etc.). This requires written statement from a licensed health care provider and parent/guardian permission. 2. The student s parent/ guardian must obtain written orders for the administration of medication at the beginning of the school year, and whenever a change in the child s medication or health occurs, or upon request of a IPSD 204 nurse. The school must receive an updated physician s order in writing before administering a new dosage. 3. Medication must be provided in its original container labeled by the pharmacist with the student s name, medication, dosage and time to be given at school. 4. Medications must be brought to school by a parent or a designated adult and are never to be sent to school with the student. The exception to this guideline is when the student has been approved to self-administer such medication. 5. The initial dose of any medication should be given at home. 6. Medications and special items necessary to administer medications or treatments (such as syringes, feeding bags, and testing supplies) must be supplied by a parent or guardian and will be stored in an appropriate area designated by the IPSD 204 nurse or building principal. 7. Unless the child has been approved to self-administer the medication, the parent/guardian must submit a written request for the student to receive medication during a field trip or extracurricular activity to the nurse at the school or the building principal at least five (5) school days prior to the scheduled event. Administration of medication on field trips or extracurricular activities is at the discretion of IPSD 204, except as provided in a student s IEP or Section 504 plan.

INFORMATION REGARDING SELF- CARRY AND SELF-ADMINISTRATION OF MEDICATION IN SCHOOL Self-Carry and Self-Administration of Medication A student may self-carry and/or self-administer an epinephrine auto-injector, medication prescribed for asthma, and/or medication prescribed for diabetes for immediate use at the student s discretion, provided the student s parent/guardian submits a properly completed and signed Authorization for Self-Administration of Medication in School form. The School District shall incur no liability, except for willful and wanton conduct, as a result of any injury arising from a student s selfadministration of an epinephrine auto-injector, medication prescribed for asthma, and/or medication prescribed for diabetes or the storage of such medication by school personnel. A student s parent/guardian must indemnify and hold harmless the School District and its employees and agents, against any claims, except a claim based on willful and wanton conduct, arising out of a student s selfadministration of an epinephrine auto-injector, medication prescribed for asthma, and/or medication prescribed for diabetes, or the storage of such medication by school personnel. C. GUIDELINES FOR SELF-CARRY AND SELF-ADMINISTRATION OF MEDICATION 1. Proper documentation (Authorization for Self-Administration of Medication in School form) must be completed before a student is allowed to self-carry and/or self-administer medications. Students are not permitted to keep medication on their person or in their lockers unless authorized to possess such medication. 2. The student who self-carries and/or self-administers medication must demonstrate consistent responsibility in: A. Understanding when it is medically appropriate to take medication. B. Knowing how to administer the medication and prescribed frequency. C. Being familiar with expected effects and possible side effects of the medication. D. Understanding that medication is not to be shared with anyone. E. Seeking additional help from the teacher, nurse or other school personnel if symptoms persist or if student is experiencing side effects after administering a medication. F. The student will only carry a one day supply of medication on his/her person. 3. The student s name must be marked on the medication. 4. The school will not keep a record of the student s self-administration of medication unless determined necessary by the student s IEP or Section 504 team. 5. Students will be allowed to self-administer approved medication during the school day, at school sponsored activities, and at before or after school activities. 6. The self-administration of asthma inhalers does not require a physician s order if the parent/guardian provides the student s prescription label from the pharmaceutical box, which must contain the name of the medication, the prescribed dosage, and the time at which or circumstances under which the medication is to be administered, and completes the Authorization for Self-Administration of Medication in School form. 7. If a student self-administers epinephrine, the student must notify a teacher/nurse/school staff member immediately. EMS (911) will be called when epinephrine is administered. 8. The privilege to self-carry and self-administer medication will be revoked for safety reasons if the student does not demonstrate appropriate responsibility. 9. IPSD 204 is committed to supporting capable students, assuming appropriate parental and medical authorization is provided, in becoming independent in their ability to self-administer medication to treat their medical condition.