Required Health Forms

03/11/10

Home
About the Nurse
Contact Us
Required Health Forms
FAQ's

 

bullet

School Physical Form (Required for Pre-K. K. 6th. All Transfer Students & 9th Grades-BEFORE
SCHOOL ENTRY.)

bullet

Dental Exam Form (Required for K, 2, 6th grades)

bullet

Eye Exam Form (Required for K, new students)

bullet

Eye Exam Waiver (must be approved by school nurse)

bullet

School Medication Form

bullet

Minimum Immunization Requirements

bullet

IHSA Sports Form

 
IMMUNIZATIONS AND PHYSICAL EXAMS
The requirements regarding immunization for students in the District will comply with the
standards adopted by the Illinois Department of Public Health.  Every student will present
proof of having received immunization for preventable communicable diseases.
   
The school staff will apprise parents of their obligation in these areas and will furnish the
necessary forms and keep records of compliance.  If the student’s physical condition is such
that any one or more of the immunizing agents should not be administered, the examining
physician will so state on the examination form.
      
All students must provide documentation of two doses of live measles virus vaccine.  The first
dose must have been given no earlier than 12 months and the second dose no less than one month
later; OR must provide proof of disease with a doctor’s note and blood titer results.
 
Students who will be entering Kindergarten or Sixth Grade are required to have the following
immunizations administered prior to starting school in August.  The health exam form must be
dated and signed by the physician.  The upper left-hand box should be completed and signed by
a parent.  Any student who does not comply with Immunization and Physical Examination
Requirements by the first day of school will be excluded from school until required health
forms are presented to the District.

   
Also, effective July 1, 2005, all children in kindergarten, 2nd, and 6th grades must have a
dental examination.  A copy of such exam must be on file with the school nurse prior to the
start of school.  
 
 
 
 
KINDERGARTEN:
 
Polio:  Has received three or more doses of TOPV with the las tdose being a booster and having
been received after the fourth birthday, but prior to school entrance.
 
Diphtheria, Tetanus, Pertussis (DTP):  Has received four or more doses with the last dose
being a booster and having been received after the fourth birthday but    prior to school
entrance.  If DT is given, a doctor’s note must accompany health form indicating
contraindication of Pertussis.
 
Measles (Rubeola):  Has received two measles vaccines as described above.  (ALL STUDENTS).
 
Rubella (3-Day):  Has received rubella vaccine at one year of age or later.
 
Mumps:  Has received vaccine at one year of age or later, or had the disease.  Proof of
disease must be provided by a doctor’s note and blood titer result.
 
Chicken Pox:  Must show proof of having received the Chickenpox (Varicella) vaccine or signed
verification from a licensed physician stating the child has already       had chickenpox
prior to entrance to kindergarten.
 
 
SIXTH GRADE:
 
Polio:  Has received three or more doses of TOPV with the last dose being a booster and having
been received on or after the fourth birthday.
 
Diphtheria, Tetanus, Pertussis (DTP):  Has received three or more doses of DTP or DT with the
last dose being a booster and having been received on or after the fourth birthday.  If ten
years have elapsed since the last booster, an additional booster is required.
 
Measles (Rubeola):  Has received two doses of live measles virus vaccine with the first dose
administered not earlier than 12 months of age and the second dose no less than one month
later; OR proof of disease provided by a doctor’s note and blood titer test.
 
Rubella (3-Day):  Has received rubella vaccine at one year of age or later.
 
Mumps:  Has received vaccine at one year of age or later, or had the disease.  Proof of
disease must be provided with a doctor’s note and blood titer test.
 
Hepatitis B:  The complete set of three Hepatitis B shots before entering 5th grade.
 
 
All students entering Kindergarten and Sixth Grade must have a physical examination according to state requirements.  Parent(s)/guardian(s) are encouraged to have their child/children undergo a dental examination, as it is now mandatory for kindergarten, 2nd, and 6th grade students by April 15th.


 
Doctors who see patients on Illinois Public Aide
 
Dr. Becker
Rockford Clinic
1-815-971-2000
 
Center for Sight and Hearing
8038 Macintosh Lane
Rockford, IL
815-332-6800

 

 



 


 

Home | About the Nurse | Contact Us | Required Health Forms | FAQ's

This site was last updated 03/09/10