COMMONWEALTH OF VIRGINIA SCHOOL ENTRANCE HEALTH FORM Health Information .
COMMONWEALTH OF VIRGINIASCHOOL ENTRANCE HEALTH FORMHealth Information Form/Comprehensive Physical Examination Report/Certification of ImmunizationPart I – HEALTH INFORMATION FORMState law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering publickindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of theform. This form must be completed no longer than one year before your child’s entry into school.Name of School: Current Grade:Student’s Name:LastFirstMiddleStudent’s Date of Birth: / / Sex: State or Country of Birth: Main Language Spoken:Student’s Address: City: State: Zip:Name of Parent or Legal Guardian 1: Phone: - - Work or Cell: - -Name of Parent or Legal Guardian 2: Phone: - - Work or Cell: - -Emergency Contact: Phone: - - Work or Cell: - -ConditionAllergies (food, insects, drugs, latex)Allergies (seasonal)Asthma or breathing problemsAttention-Deficit/Hyperactivity DisorderBehavioral problemsDevelopmental problemsBladder problemBleeding problemBowel problemCerebral PalsyCystic fibrosisDental problemsYesCommentsConditionDiabetesHead injury, concussionsHearing problems or deafnessHeart problemsLead poisoningMuscle problemsSeizuresSickle Cell Disease (not trait)Speech problemsSpinal injurySurgeryVision problemsYesCommentsDescribe any other important health-related information about your child (for example; feeding tube, hospitalizations, oxygen support, hearing aid, dental appliance,etc.):List all prescription, over-the-counter, and herbal medications your child takes regularly:Check here if you want to discuss confidential information with the school nurse or other school authority.YesNoPlease provide the following information:NamePhoneDate of Last AppointmentPediatrician/primary care providerSpecialistDentistCase Worker (if applicable)Child’s Health Insurance: NoneFAMIS Plus (Medicaid)FAMISPrivate/Commercial/Employer sponsoredI, (do ) (do not ) authorize my child’s health care provider and designated provider of health care in theschool setting to discuss my child’s health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless youwithdraw it. You may withdraw your authorization at any time by contacting your child’s school. When information is released from your child’s record,documentation of the disclosure is maintained in your child’s health or scholastic record.Signature of Parent or Legal Guardian: Date: / /Signature of person completing this form: Date: / /Signature of Interpreter: Date: / /MCH 213G reviewed 03/20141
COMMONWEALTH OF VIRGINIASCHOOL ENTRANCE HEALTH FORMPart II - Certification of ImmunizationSection ITo be completed by a physician or his designee, registered nurse, or health department official.See Section II for conditional enrollment and exemptions.A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health departmentofficial indicating the dates of administration including month, day, and year of the required vaccines shall be acceptablein lieu of recording these dates on this form as long as the record is attached to this form.Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by theMedical Provider or Health Department Official in the appropriate box.Student’s Name:LastFirstIMMUNIZATIONDate of Birth: Mo. Day Yr.MiddleRECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN*Diphtheria, Tetanus, Pertussis (DTP, DTaP)12345*Diphtheria, Tetanus (DT) or Td (given after 7years of age)12345*Tdap booster (6th grade entry)1*Poliomyelitis (IPV, OPV)1234*Haemophilus influenzae Type b(Hib conjugate)*only for children 60 months of age*Pneumococcal (PCV conjugate)*only for children 60 months of age12341234Measles, Mumps, Rubella (MMR vaccine)12*Measles (Rubeola)12*Rubella1*Mumps12*Hepatitis B Vaccine (HBV)Merck adult formulation used123*Varicella Vaccine12Date of Varicella Disease OR Serological Confirmation of VaricellaImmunity:Hepatitis A Vaccine12Meningococcal Vaccine1Human Papillomavirus l Confirmation of Measles Immunity:Serological Confirmation of Rubella Immunity:I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child*careRequiredvaccineor preschoolprescribed by the State Board of Health’s Regulations for the Immunization of School Children (Reference Section III).Signature of Medical Provider or Health Department Official:Date (Mo., Day, Yr.): / /Certification of Immunization 11/06MCH 213G reviewed 03/20142
Student’s Name:Date of Birth: Section IIConditional Enrollment and ExemptionsComplete the medical exemption or conditional enrollment section as appropriate to include signature and date.MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would bedetrimental to this student’s health. The vaccine(s) is (are) specifically contraindicated because (please specify):.DTP/DTaP/Tdap:[]; DT/Td:[This contraindication is permanent: []; OPV/IPV:[]; Hib:[], or temporary []; Pneum:[]; Measles:[]; Rubella:[]; Mumps:[]; HBV:[]; Varicella:[]] and expected to preclude immunizations until: Date (Mo., Day, Yr.): .Signature of Medical Provider or Health Department Official:Date (Mo., Day, Yr.): RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or thestudent’s parent/guardian submits an affidavit to the school’s admitting official stating that the administration of immunizing agents conflicts with the student’s religioustenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained atany local health department, school division superintendent’s office or local department of social services. Ref. Code of Virginia § 22.1-271.2, C (i).CONDITIONAL ENROLLMENT: As specified in the Code of Virginia § 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccinesrequired by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. Nextimmunization due on .Signature of Medical Provider or Health Department Official:Date (Mo., Day, Yr.): Section IIIRequirementsFor Minimum Immunization Requirements for Entry into School andDay Care, consult the Division of Immunization web site ationChildren shall be immunized in accordance with the Immunization Schedule developed and published bythe Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), theAmerican Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP),otherwise known as ACIP recommendations (Ref. Code of Virginia § 32.1-46(a)).(Requirements are subject to change.)Certification of Immunization 03/2014MCH 213G reviewed 03/20143
Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORTA qualified licensed physician, nurse practitioner, or physician assistant must complete Part III. The exam must be done no longer than one year before entryinto kindergarten or elementary school (Ref. Code of Virginia § 22.1-270). Instructions for completing this form can be found at ealth AssessmentStudent’s Name: Date of Birth: / /Sex: M FPhysical ExaminationDate of Assessment: / /1 Within normal2 Abnormal finding 3 Referred for evaluation or treatmentWeight: lbs. Height: ft. in.123123123Body Mass Index (BMI): BPHEENT Neurological Skin Age / gender appropriate history completedLungsAbdomenGenital Anticipatory guidance providedHeart Extremities Urinary TB Screening: No risk for TB infection identified No symptoms compatible with active TB disease Risk for TB infection or symptoms identifiedTest for TB Infection: TST IGRA Date:TST Reading mmTST/IGRA Result: Positive NegativeCXR required if positive test for TB infection or TB symptoms.CXR Date: Normal AbnormalEPSDT Screens Required for Head Start – include specific results and date:Blood Lead:Hct/HgbAssessed for:Emotional/SocialWithin normalAssessment Method:Concern identified:Referred for EvaluationProblem SolvingLanguage/CommunicationFine Motor SkillsGross Motor Skills10002000 Referred to Audiologist/ENT4000RVisionScreenScreened by OAE (Otoacoustic Emissions): PassWith Corrective Lenses (check if yes)StereopsisPassFailDistanceBothR20/20/Care, or Early Intervention PersonnelRecommendations to (Pre) School , ChildPass Unable to test – needs rescreen Permanent Hearing Loss Previously identified:LL20/Referred to eye doctorLeftRight Hearing aid or other assistive device ReferNot testedTest used:DentalScreenHearingScreenScreened at 20dB: Indicate Pass (P) or Refer (R) in each box.Unable to test – needs rescreenProblem Identified: Referred for treatmentNo Problem: Referred for preventionNo Referral: Already receiving dental careSummary of Findings (check one): Well child; no conditions identified of concern to school program activities Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here):Allergy food: insect: medicine: other:Type of allergic reaction: anaphylaxis local reaction Response required: none epinephrine auto-injector other:Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)Restricted Activity Specify:Developmental Evaluation Has IEP Further evaluation needed for:Medication. Child takes medicine for specific health condition(s). Medication must be given and/or available at school.Special Diet Specify:Special Needs Specify:Other Comments:Health Care Professional’s Certification (Write legibly or stamp) By checking this box, I certify with an electronic signature that all ofthe information entered above is accurate (enter name and date on signature and date lines below).Name:Signature: Date: / /Practice/Clinic Name:Address:Phone: - -MCH 213G reviewed 03/2014Fax: - - Email:4
Allergy and Anaphylaxis Emergency PlanChild’s name: Date of plan:Date of birth: / / Age Weight: kgChild has allergy toChild has asthma.Child has had anaphylaxis.Child may carry medicine.Child may give him/herself medicine.YesYesYesYesAttachchild’sphotoNo (If yes, higher chance severe reaction)NoNoNo (If child refuses/is unable to self-treat, an adult must give medicine)IMPORTANT REMINDERAnaphylaxis is a potentially life-threating, severe allergic reaction. If in doubt, give epinephrine.For Severe Allergy and AnaphylaxisWhat to look forGive epinephrine!What to doIf child has ANY of these severe symptoms after eating thefood or having a sting, give epinephrine. Shortness of breath, wheezing, or coughing Skin color is pale or has a bluish color Weak pulse Fainting or dizziness Tight or hoarse throat Trouble breathing or swallowing Swelling of lips or tongue that bother breathing Vomiting or diarrhea (if severe or combined with othersymptoms) Many hives or redness over body Feeling of “doom,” confusion, altered consciousness, oragitation1. Inject epinephrine right away! Note time whenepinephrine was given.2. Call 911. Ask for ambulance with epinephrine. Tell rescue squad when epinephrine was given.3. Stay with child and: Call parents and child’s doctor. Give a second dose of epinephrine, if symptomsget worse, continue, or do not get better in 5minutes. Keep child lying on back. If the child vomits or hastrouble breathing, keep child lying on his or herside.4. Give other medicine, if prescribed. Do not use othermedicine in place of epinephrine. AntihistamineSPECIAL SITUATION: If this box is checked, child hasan extremely severe allergy to an insect sting or thefollowing food(s): . Even if childhas MILD symptoms after a sting or eating these foods,give epinephrine. Inhaler/bronchodilatorFor Mild Allergic ReactionWhat to look forMonitor childWhat to doIf child has had any mild symptoms, monitor child.Symptoms may include: Itchy nose, sneezing, itchy mouth A few hives Mild stomach nausea or discomfortStay with child and: Watch child closely. Give antihistamine (if prescribed). Call parents and child’s doctor. If more than 1 symptom or symptoms of severeallergy/anaphylaxis develop, use epinephrine. (See“For Severe Allergy and Anaphylaxis.”)Medicines/DosesEpinephrine, intramuscular (list type): Dose:0.10 mg (7.5 kg to less than13 kg)*0.15 mg (13 kg to less than 25 kg)0.30 mg (25 kg or more)Antihistamine, by mouth (type and dose): (*Use 0.15 mg, if 0.10 mg is not available)Other (for example, inhaler/bronchodilator if child has asthma):Parent/Guardian Authorization SignatureDatePhysician/HCP Authorization SignatureDate 2017 American Academy of Pediatrics, Updated 03/2019. All rights reserved. Your child’s doctor will tell you to do what’s best for your child.This information should not take the place of talking with your child’s doctor. Page 1 of 2.
Allergy and Anaphylaxis Emergency PlanChild’s name: Date of plan:Additional Instructions:ContactsCall 911 / Rescue ardian:Phone:Other Emergency Phone: 2017 American Academy of Pediatrics, Updated 03/2019. All rights reserved. Your child’s doctor will tell you to do what’s best for your child.This information should not take the place of talking with your child’s doctor. Page 2 of 2.
Medication Authorization FormFor Prescription and Non-prescription MedicationsVDSS Division of Licensing Programs Model FormINSTRUCTIONS:Section A must be completed by the parent/guardian for ALL medication authorizations.Section A and Section B must be completed for any long-term medication authorizations (thoselasting longer than 10 working days).Section A: To be completed by parent/guardianMedication authorization for:(Child’s name)has my permission to administer the following medication:(Name of Child Care Provider)Medication name:Dosage and times to be administered:Special instructions (if any):This authorization is effective from: until:(Start date)(End date)Parent’s or Guardian’s Signature: Date:Section B: to be completed by child’s physicianI, certify that it is medically necessary for the medication(s) listed(Name of Physician)below to be administered to: for a duration that exceeds 10 work days.(Child’s name)Medication(s):Dosage and Times to be administered:Special instructions (if any):This authorization is effective from: until:(Start date)(End date)Physician’s Signature: Date:032-05-0570-05-eng (06/12)Physicians Phone:
YMCA OF GREATER ION FORM FOR NON-PRESCRIPTION OVER-THE-COUNTERSKIN PRODUCTSSCHOOL AGED CAMP (Not required for school aged childcare or preschool programs)INSTRUCTIONS:This form must be completed by the parent/guardian to authorize use of: Insect Repellent and SunscreenYMCA OF GREATER RICHMOND has my permission to apply the non-prescription over-the-counter (OTC) skinproducts(s) listed below to my child,(Child’s name).Please check below the product(s) which you permit YMCA of Greater Richmond to apply to your child: Members Mark SPF50 Continuous SprayKnown Adverse Reaction, as stated on WARNING label: When using this product, keep out of eyes. Rinsewith water to remove. Keep away from face to avoid breathing it. Product Name:Known Adverse Reactions (if any): Product Name:Known Adverse Reactions (if any): All OTC products must:– Be in the original container and, if provided by the parent, labeled with the child’s name,– Be used according to the manufacturer’s recommendation and instructions for application, and– Not be used beyond the expiration date of the product. Sunscreen:– Must have a minimum sunburn protection factor (SPF) of 15,– Shall be inaccessible to children under 5 yrs. & children in therapeutic or special needs programs, and– Children nine yrs. and older may self-administer sunscreen if supervised. Insect repellents:– Shall be inaccessible to all children.This authorization is effective from June 21, 2021 until September 3, 2021.Parent’s Signature:Date:Bring this completed form to your child’s first day of camp. Prior to each day of camp, applysunscreen and insect repellent to your child.
SCHOOL ENTRANCE HEALTH FORM Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization Part I - HEALTH INFORMATION FORM State law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering public kindergarten or elementary school.
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