Packet for Incoming Students
Edgemont School District Greenrtille School Seely Place School Scarsdale, NY 10583
I ennifer
Allen, Principal
Cnrol
B
artlik,
P
rincip al
Dear Parent(s)/G uard ian(s),
Welcome to Edgemont! We are thrilled that you are joining our community and we look fonryard to getting to know your children and you over the years to come! Attached you will find a packet of required medical forms to fill out as well as information about our Health Office practices and requirements. Please read everything thoroughly and contact our school nurses if you have any questions. We would like to stress a particularly important piece of information which is that students must be completelv up-to-date with all required immunizations prior to the first dav of school or thev will not be permitted to attend class. This packet contains a chart with all required immunizations; please consult with your pediatrician to confirm that all have been administered. We are all eager to meet all of our new students on the first day of school so we strongly encourage you to ensure that all of your child's immunizations are current so that he/she can get off to a great start! ln addition, all students must have a current medical exam completed within the first two weeks of school. We encouraqe vou to have this done prior to the start of school in order to ensure that there is no disruption to your child's school attendance.
We hope that your transition to Edgemont is a smooth one and wish you the best. Sincerely,
Jennifer Allen Greenville School Principal
Carol Bartlik Seely Place School Principal
Edgemont School District Greenville and Seely Place Elementary Schools New Student Welcome Packet Health Office Hello families, Welcome to Edgemont School District. We are very excited for you to join our community! Please read the following information to ensure that your child's transition willbe a smooth one.
within New York State, we ask that you submit a copy of your child's current Health Appraisal (physical exam) and immunizationrecord. This must be from within the last year. All immunizations must be up to date before the start of school. New York State requires all students to be immunized before they attend school. The only exceptions are students with medical or religious exemptions. Please note, if you are unable to provide this information, then your child will be excluded from school.
If you
are transferring to Edgemont from
students will need to have a completed Health Appraisal (physical York State physician within 2 weeks from the start of school. New by a exam) administered If you are out of the country, you will be granted a 30 day grace period from the start of school to complete this process.
All out of state incoming
A dental examination is required during the school year. o'Seely" school website. Look under o'departments" Forms are located on the "Greenville" and and then under "health office". You will need to print out "incoming student packet". You will only need to fill out the "Emergency Health Forms" if your child has a food or insect allergy.
Our school physician is Dr. Berman who is located at244 Westchester Ave., White Plains 914948-7016. Please call ow office for a list of other physicians in the area.
If you have any medical concerns or issues, please
speak with the Health Office before your
child starts school. We have attached a copy of our Health Office policy for your review.
Greenville Health Office phone rs914-472-7764. Seely Place Health Office phone is914-4728043. Our offrce hours are from 8:15am -3:45pm Monday through Friday. We can also be reached by email if there are any questions andlot concerns. Thank you very much.
Greenville School Nurses Diane Rakoff, RN drakoff@mail. edqemont. org Gail Krone, RN skrone@,mail.edsemont.org
Seely Place School Nurse
Emily Duncan, RN eduncan@mail. edgemont.org
Edgemont Union Free School District at Greenburgh Scarsdale, New York 10583
Elementarv School Health Office Policv Seely Place School 914-472'8043 Greenville Health Office 914-472-7764 Diane Rakoff, RN [email protected] Emily Duncan, RN Gail Krone, RN [email protected] [email protected]
ln order to best care for your children, we ask that you follow the reminders we have listed below:
1.
Please call or email the Health Offrce by 8:45 am if your child is going to be absent or late. If you know of any absence in advance, please notify the teacher and the Health
Office.
2.
Please have your child stay at home
if he/she is not feeling well. If he/she
goes to
school, hislher condition may worsen and hisArer illness may spread to others. A child may retum to school after all symptoms are gone and he/she is diarrhea/vomit/fever free for 24 hours. Please report to our office any confirmed diagnosis of any contagious illness such as strep throat, conjunctivitis, fifths disease, flu, etc.. Also please report any case of head lice.
3. Please keep all medical information
up to date.
4.
Physical exams (health appraisals) are required every year. All students must have a current health appraisal on file from a New York State physician. All immunizations that are required by New York State must be given prior to entrance to school.
5.
New York State has regulations for the administration of medication in school. The following steps should be taken if your child is in need of any medication, including over the counter medication during the school day. a. We must have on file a written request signed by you and your physician. b. A11 medication must be delivered to the Health Office by the parent. c. The medication must be in the original container, as it is received from the pharmacist. Over the counter medication must be in the original container and be labeled with the name of the child and the description of the dosage. d. The medication must be kept in the Health Office.
.
6. If a student needs to be excused from PE and/or recess, they must submit a note from their doctor explaining why and for how long.
7.
Vision and hearing tests are done throughout the school year. If you should notice a problem, please call us. Teachers will also bring any concems they have to our attention.
8.
Please remember to notify us when there is a change in your emergency or work
telephone numbers.
9.
Keep in close contact with the school if there are any significant changes in your home.
Thank you for your cooperation. Diane Rakoft RN and Gail Krone, Greenville School Nurses
RN
Emily Duncan, RN Seely Place Nurse
EDGEMONT UNION FREE SCHOOL DISTRICT
Note:NYSEDrequiresanannualphysicalexamforn"*"nt.a,'ts'nu'tuo" interscholastic sports and working papers DOB:
Gender:
Grade:
EAsthma (Elntermittent
or flpersiitent inhaler: Eyes ENo Asthma Action plan: Eyes EINo
)
Quick relief
Diabetes [lHyperlipidemia [3Type 1
trM
trF
Exam Date:
PPD: flPositive Elevated Lead: [Yes Dental Referral: Eyes
ENegative ENot Done
Date:
ENo
Date:
nNot
Done
EIType 2 Diabetes
flHypertension
ElAllergies - See page 2 for details.
flOther: Medical/Surgical lnformation
:
PHYSICAT EXAMINATION
Pulse: Degree of deviation:
nespiratlons:
_
Angle of trunk rotation via scoliometer: ight Status Category (BMt percentile):
Distance acuity with lenses Vision - near vision
<sth E 85th- 94nh 5,h_ 4g,h n gs,h_ ggrh Ef 5oth-84th E ggth & dl!rl!T,",ilil"'e"
(o
SYSTEM REVIEW AND EXAM ErurIneIv I'Ionruar. Specify any abnormalities:
E
Zo aO sweep screen both ears
or
"
RECOMMENDATIONS OR RE5TRICTIONS FOR PARTICIPA
3I:::1oT^.o:.1*ion''ndhysed,athletics,playground,work,school) EI Expected Body contact (full or limited): football, wrestling,
fl
E
fl E
basketball, ice/field/floor hockey, baseball, softball, strenuous: cross-country, gymnastics, track & field, swim, diving, crew, ski, cheering, tennis, badminton, fencing, Non-contact/Non-strenuous: bowling, golfing, table tennis, archery, riflery, shuffleboard, walking Protective Equipment: flAthletic cup Esport/safety goggles flother: Medical/prosthetic device:
Recom mendations/restrictions:
Page L of 2
Name:
DOB:
MEDICATIONS To be completed by Health Care Provider
Diagnosis
>err urrecEeq: ! assess rnrs SIuoenI
Route
Dose
Time
Self
Self
15
Admin/
Directed*
Self Carry**
n
tr
tr tr
n
n u
cf taking or not taking the medication,
rnd
Medication Name
ICD Code
tr tr tr
setT-otrefieo regarotng tnetr meotcauon. tney tne purpose, name, amount, dose, timingEncfeffi can recognize the medication and refuse to take it inappropriately, and can ingest, inhale, apply or calculate
administer the correct dose of the medication independently
.-5elfAdmin/5elf-ca'ry:lhavedeterminedthisstUdentisconsistentandresponsibleintakingtheirownmedicatio@ give them permission to self-carry and self-administer this medication. They will be considered independent in medication delivery and need ntervention only during emergencies.
To be completed by Parent/Guardian if medication is prescribed
f]lgivepermissionfortheabovemedicationtobeadministeredtomychitda will furnish the medication in the original pharmacy container, properly labeled with directions
and dosage, or original over-the-counter medication container/package with my child's name on it. phone: ( Parent/Guardian Siglature: Date: ) tr Parent permission & provider consent is required for students to self-administer & self-carrv medication- Srrrrtontc with this designation are considered independent in taking their medication at school and require no supervision by the nurse. Parents assume responsibility for ensuring that their child is carrying and taking their medication as ordered. Schools may revoke the self-carry/self-administer privilege if the student proves to be irresponsible or incapable. To request this option please sign below. Pa rent/Guardian Signature: Date: Phone: ( ) AttERGIES
tl
tr
None
tr
Non Life-Threatening
life-Threatening
fype: flFood Elnsect ILatex EMedication [fSeasonal/Environmental EOther: Specify allergen(s): Specify previous symptoms: Emergency Care Plan for anaphylaxis: E Yes
rreatmen! prescribed:
flHistory of anaphylaxis; last occurrence:
tr
No
ENone EAntihistimine
EEpinephrine Autoinjector
IMMUNIZATIONS
E lmmunization record attached E lmmunizations reported on NYSIIS
fl
No immunizations received today
fl lmmunizations I
Will return
Provider
/
received today:
on:
to receive:
Parental Authorization
All information contained herein is valid through the last day of the month flor L2 months from the date Uelor,y. Medical Provider Signature: Date: phone #: Provider Name: (please print) Provider Address: Fax #: Parent/Guardian Signature: Date:
Return to: School Nurse: Phone #:
(
)
Fax:
(
)
School: Date: Page 2 of 2
'elre
F{EP\I-TF{ SFFffGE
t'! rdK m[ i
ffi
AT$G
$d
AUThd6)
Rfi
A,,4T[S [U Fe)
n*ivrdualieed tlrders fsr:
R 6!il
D.O,B
a.;1qr,gie$
t. Stegdgfd-ff-Yqgdhryqggffilgq/-F4,ry;futedlgEtlig$1s; rhs following nredication* are the onty *nes ar"'ailebl* in the Health Office. For any sthar modisctions, eee below. These medieations v,rill be adnrinistereri at the discretion of the RN, wnty if sf$r?sd approvel fs lndfesfsd ey SOfFd ffte sfuderaf 's prftysfefaru dffiS paremf, i nlrrsg ruamne
, i.uvvrGt
ri.-.-----
t
-_-*-i
lrr rvtr*r rv. r,,
Ro*rt€-Tmssegs
ii
| !vn,
I' I
i
tab$etsl__l ;lihuproten) il*o
ii
Ii ,ee .dvn$ vnfl db6ets**
,i:ilr r_ ---_* rllli
*-
------*_*"-l
lE"€E-ffiilte@ffilts
i t I
.
I
___ _, i", fnr"a e t.:t. I Q*--*
i
for:
i
* ___
*=**_-____.l
i
r
i
,
i -*-
ThnCIat fi-ouenges i po
2. FBF$SRIPBQI{ ryd apv c{fupr Qver--thg€oumter tutgdB"egtiqqg:
piease
+oniriete lvith
ocrirent's current regirnen for both scheduled snd FRN rnedicatisns.
lAd 4:edicatrgn$$?#s-{ bc ersy{S,fff dge68f{lle ffi:;}r€e*b,ueJtrefln$g&{e-wlup8' csnfarner wittt vour stsdenfk naffie on rt I
Pr,ig
ruafins
I
Route
i D,osagw
$ehedu*fe &
rp
j&Cegjgjtrg
Gomtm'r*nte
trlrysician $ignature:
trrsnse
#:
I I
Phcne #:
::{-cgtt?sry.{e r&e"sE&lglf;ff'-Ls*glssense-.rfisss-{d,rqel{+:i,prg$q"rySed- Fq-{Le .e$qv,e qftygr,p{enr Parent sicnature: Dmte
2A76-17 School Year
New York State lmmunization Requirements for School Entrance/Attendancer l,,l0TE5:
Chilcjren in a prekindergarten setting should be age-appropriateiy inrmunized. The number of doses depends orr the schedule recommended by the Acivisory Comlrittee on lmmllnizotion Practices (AClPi. For grades Pre-k through 8, intervdis bei'fieefi doses of vaccine should be in accordance wlth the AC|P-recornmended lmmunization schedule for persoes O thraugh 18 yeais of age. (Exception: interyals betvJeen doses of polio vaccjne need to be revaewed only for grades prekindergarten, kindergaden. 1,2, 6,7 and 8.) D,f ses rcce ived beforc the mininlLrm 6ge or intervals are not valid ancl do not coufit toward tho number of doses listed be low. lnt*rusis *et\,ve rn doses of i,a*ciire DO NOT need to be reviev,red for grades g through 12. See footnotes for srecific information for each vaccine, Cnilciren vrho are enroliiirg in grede-less classes should meet the immunization requiremenls of the gracjes fcr wirich they 6fe agi3 equivalenl.
Dcse requiremenis MUST be r€ad with the foot*at€s 6f this schedul€.
i j i
Vaccines
Prekindergarten
Kindergarten
(Day Care,
arrd Grades
Head Start, Nursery or Pre-k)
1and2
Piphtheria 6nd Tetanu* toxoid-cont6inins vaccine and Pertussis vaccine {$TaF/DTPlTdap}'
Grades
3.4 and
Tetanus xnd Fiphiheria toxsid-cofi tai ninb vacEine and Pertusgis vaccins: bo*rster fl1dap)3 Pqlio vaccine (lPV/OPV)4
4 doses or 3 doses if lhe 3rd dsse was reccived at
3 dcses
I dose
3 doses
4 doses or 3 dos€s if the 3rC dose wss received
4 years of ege
nt 4 y€ars
0r older
Measlss,
trv'igrnp$
and
1
11
3 doses
.f-&rt,afftlcabrl*
,
9, lC,
and"l2
5 doses or 4 doseg if the 4th dosr wns received at 4 years 0f age 0r older or 3 doses if eged 7 years or older and the series was started at 1 year of age 0r older
4 doses
Grad*s
Grades 6. 7 arrcl 8
5
3 dases
0f
ege or older ? di'8€s
dose
Eubefla tere'ine{MMX}'
hlepatitis
I
3 doses
vaccineE
3 doses or 2 dcses of adult hepatitis B vaccine {Recombivax) for chiidren v,/ho received the dos€s *t le*st 4 months epo|1 between the ages of 11 thraugh 15 years of age
Varicel la (Chiqh€rlpoxl
vaccine? :,'
2 dd5ei
"l:d$Sb
t dose
2 doxes
1
dose
:
Meningococcal cEnju$at€ vaccine {MenACWYls Not applicable
7: dose
8y Grade 1
Grsde':2: 2 doses or 1 dose
ifthe dose was receiveci
TJ:;::i:."j Haemophilus influ*nzae type b cor{ugata, vaccine
(Hibl3 1
::
:
Pneumococcal *nnjugnte vaccine (PCV)!0
{ to 4 do:es '
: . 1
l{ot applirahl€
,::
to 4 dsses
Hot applicable
rr Z-
firw YonK
STATE
jDepartment
lof Health
'1.
:.
Dfinloirstraled sefoiaEii:crvid€n[e ol mcaslcs, mumps, ful]eile. ite[atitis i], vaii;el1€ oi po:ro {fcr ail llrree seiolypes} antiltrciie5 is acceplafiie piocf ci immunri'y' io Lhese ciis€oses. Dingncsis by a physicisr. ohyiicidn assisiart or nuise cr.ra1:tinncr iirat a cltild has lt.rd vaticclla disciisu as sccepteblc Droof of irrimunity to \,/aricelli.
rlepdtiiis $ v;rclno
o. ilose l moy
be givei dt itiiih or anyirme ilterea1ter Dt:-. 2 firi5t o€ Ceys) aftei close 1. Dcae 3 musi lt.j ai lL-is" I .raeks afiei close 2 AND at iesst 16 weeks afler dose i AND nc eaiiiei than 24 weeks ot s$e.
givei nt ieast 4 vieeks i:8
b.
Dlphih€fio anrl tFit*rLjs to\oids a[C nceiiLjlrr.perluss]s {DToP) vaccine. (Miiliir!m oqlc; 6 weeks)
a.
Children slortlrg lire sefies 9* iicte should tece ve .r 5-dose series ef DlaF vaccin! 6t .rqtcs 2 rnoritir5. 4 ficnihs. S nlontts ancl di 15 ittfcLrciii 18 ilroniir: dn{i at 4 yeefr ci allE .ir olde{: iite lodilli {ios.t nt€y ite re'ceived et €oriy nt cge 12 nloilhs. pro\?icieci at ieasl 6 mrrths heve elopfied sjnae il-,e tirirc ciose. Hawevei tlrc fourllr alore cf DTop reed nei be repealed ii it vrds edfrtinlstereij a,r tea$l 4 ilonllis ai1.er the iirili cose o{ DTsp. Tlre iindt riose in iire:eries mlst ile re{eived ot or dflef the forflh i}iithclat.
b. li ille lb!*n
dose c,f DTaP was adfiinistered ai:trjr.. 4 yeitfs
rr
Z Virii.ellir {r:hi.l
I ennifer
Allen, Principal
Cnrol
B
artlik,
P
rincip al
Dear Parent(s)/G uard ian(s),
Welcome to Edgemont! We are thrilled that you are joining our community and we look fonryard to getting to know your children and you over the years to come! Attached you will find a packet of required medical forms to fill out as well as information about our Health Office practices and requirements. Please read everything thoroughly and contact our school nurses if you have any questions. We would like to stress a particularly important piece of information which is that students must be completelv up-to-date with all required immunizations prior to the first dav of school or thev will not be permitted to attend class. This packet contains a chart with all required immunizations; please consult with your pediatrician to confirm that all have been administered. We are all eager to meet all of our new students on the first day of school so we strongly encourage you to ensure that all of your child's immunizations are current so that he/she can get off to a great start! ln addition, all students must have a current medical exam completed within the first two weeks of school. We encouraqe vou to have this done prior to the start of school in order to ensure that there is no disruption to your child's school attendance.
We hope that your transition to Edgemont is a smooth one and wish you the best. Sincerely,
Jennifer Allen Greenville School Principal
Carol Bartlik Seely Place School Principal
Edgemont School District Greenville and Seely Place Elementary Schools New Student Welcome Packet Health Office Hello families, Welcome to Edgemont School District. We are very excited for you to join our community! Please read the following information to ensure that your child's transition willbe a smooth one.
within New York State, we ask that you submit a copy of your child's current Health Appraisal (physical exam) and immunizationrecord. This must be from within the last year. All immunizations must be up to date before the start of school. New York State requires all students to be immunized before they attend school. The only exceptions are students with medical or religious exemptions. Please note, if you are unable to provide this information, then your child will be excluded from school.
If you
are transferring to Edgemont from
students will need to have a completed Health Appraisal (physical York State physician within 2 weeks from the start of school. New by a exam) administered If you are out of the country, you will be granted a 30 day grace period from the start of school to complete this process.
All out of state incoming
A dental examination is required during the school year. o'Seely" school website. Look under o'departments" Forms are located on the "Greenville" and and then under "health office". You will need to print out "incoming student packet". You will only need to fill out the "Emergency Health Forms" if your child has a food or insect allergy.
Our school physician is Dr. Berman who is located at244 Westchester Ave., White Plains 914948-7016. Please call ow office for a list of other physicians in the area.
If you have any medical concerns or issues, please
speak with the Health Office before your
child starts school. We have attached a copy of our Health Office policy for your review.
Greenville Health Office phone rs914-472-7764. Seely Place Health Office phone is914-4728043. Our offrce hours are from 8:15am -3:45pm Monday through Friday. We can also be reached by email if there are any questions andlot concerns. Thank you very much.
Greenville School Nurses Diane Rakoff, RN drakoff@mail. edqemont. org Gail Krone, RN skrone@,mail.edsemont.org
Seely Place School Nurse
Emily Duncan, RN eduncan@mail. edgemont.org
Edgemont Union Free School District at Greenburgh Scarsdale, New York 10583
Elementarv School Health Office Policv Seely Place School 914-472'8043 Greenville Health Office 914-472-7764 Diane Rakoff, RN [email protected] Emily Duncan, RN Gail Krone, RN [email protected] [email protected]
ln order to best care for your children, we ask that you follow the reminders we have listed below:
1.
Please call or email the Health Offrce by 8:45 am if your child is going to be absent or late. If you know of any absence in advance, please notify the teacher and the Health
Office.
2.
Please have your child stay at home
if he/she is not feeling well. If he/she
goes to
school, hislher condition may worsen and hisArer illness may spread to others. A child may retum to school after all symptoms are gone and he/she is diarrhea/vomit/fever free for 24 hours. Please report to our office any confirmed diagnosis of any contagious illness such as strep throat, conjunctivitis, fifths disease, flu, etc.. Also please report any case of head lice.
3. Please keep all medical information
up to date.
4.
Physical exams (health appraisals) are required every year. All students must have a current health appraisal on file from a New York State physician. All immunizations that are required by New York State must be given prior to entrance to school.
5.
New York State has regulations for the administration of medication in school. The following steps should be taken if your child is in need of any medication, including over the counter medication during the school day. a. We must have on file a written request signed by you and your physician. b. A11 medication must be delivered to the Health Office by the parent. c. The medication must be in the original container, as it is received from the pharmacist. Over the counter medication must be in the original container and be labeled with the name of the child and the description of the dosage. d. The medication must be kept in the Health Office.
.
6. If a student needs to be excused from PE and/or recess, they must submit a note from their doctor explaining why and for how long.
7.
Vision and hearing tests are done throughout the school year. If you should notice a problem, please call us. Teachers will also bring any concems they have to our attention.
8.
Please remember to notify us when there is a change in your emergency or work
telephone numbers.
9.
Keep in close contact with the school if there are any significant changes in your home.
Thank you for your cooperation. Diane Rakoft RN and Gail Krone, Greenville School Nurses
RN
Emily Duncan, RN Seely Place Nurse
EDGEMONT UNION FREE SCHOOL DISTRICT
Note:NYSEDrequiresanannualphysicalexamforn"*"nt.a,'ts'nu'tuo" interscholastic sports and working papers DOB:
Gender:
Grade:
EAsthma (Elntermittent
or flpersiitent inhaler: Eyes ENo Asthma Action plan: Eyes EINo
)
Quick relief
Diabetes [lHyperlipidemia [3Type 1
trM
trF
Exam Date:
PPD: flPositive Elevated Lead: [Yes Dental Referral: Eyes
ENegative ENot Done
Date:
ENo
Date:
nNot
Done
EIType 2 Diabetes
flHypertension
ElAllergies - See page 2 for details.
flOther: Medical/Surgical lnformation
:
PHYSICAT EXAMINATION
Pulse: Degree of deviation:
nespiratlons:
_
Angle of trunk rotation via scoliometer: ight Status Category (BMt percentile):
Distance acuity with lenses Vision - near vision
<sth E 85th- 94nh 5,h_ 4g,h n gs,h_ ggrh Ef 5oth-84th E ggth & dl!rl!T,",ilil"'e"
(o
SYSTEM REVIEW AND EXAM ErurIneIv I'Ionruar. Specify any abnormalities:
E
Zo aO sweep screen both ears
or
"
RECOMMENDATIONS OR RE5TRICTIONS FOR PARTICIPA
3I:::1oT^.o:.1*ion''ndhysed,athletics,playground,work,school) EI Expected Body contact (full or limited): football, wrestling,
fl
E
fl E
basketball, ice/field/floor hockey, baseball, softball, strenuous: cross-country, gymnastics, track & field, swim, diving, crew, ski, cheering, tennis, badminton, fencing, Non-contact/Non-strenuous: bowling, golfing, table tennis, archery, riflery, shuffleboard, walking Protective Equipment: flAthletic cup Esport/safety goggles flother: Medical/prosthetic device:
Recom mendations/restrictions:
Page L of 2
Name:
DOB:
MEDICATIONS To be completed by Health Care Provider
Diagnosis
>err urrecEeq: ! assess rnrs SIuoenI
Route
Dose
Time
Self
Self
15
Admin/
Directed*
Self Carry**
n
tr
tr tr
n
n u
cf taking or not taking the medication,
rnd
Medication Name
ICD Code
tr tr tr
setT-otrefieo regarotng tnetr meotcauon. tney tne purpose, name, amount, dose, timingEncfeffi can recognize the medication and refuse to take it inappropriately, and can ingest, inhale, apply or calculate
administer the correct dose of the medication independently
.-5elfAdmin/5elf-ca'ry:lhavedeterminedthisstUdentisconsistentandresponsibleintakingtheirownmedicatio@ give them permission to self-carry and self-administer this medication. They will be considered independent in medication delivery and need ntervention only during emergencies.
To be completed by Parent/Guardian if medication is prescribed
f]lgivepermissionfortheabovemedicationtobeadministeredtomychitda will furnish the medication in the original pharmacy container, properly labeled with directions
and dosage, or original over-the-counter medication container/package with my child's name on it. phone: ( Parent/Guardian Siglature: Date: ) tr Parent permission & provider consent is required for students to self-administer & self-carrv medication- Srrrrtontc with this designation are considered independent in taking their medication at school and require no supervision by the nurse. Parents assume responsibility for ensuring that their child is carrying and taking their medication as ordered. Schools may revoke the self-carry/self-administer privilege if the student proves to be irresponsible or incapable. To request this option please sign below. Pa rent/Guardian Signature: Date: Phone: ( ) AttERGIES
tl
tr
None
tr
Non Life-Threatening
life-Threatening
fype: flFood Elnsect ILatex EMedication [fSeasonal/Environmental EOther: Specify allergen(s): Specify previous symptoms: Emergency Care Plan for anaphylaxis: E Yes
rreatmen! prescribed:
flHistory of anaphylaxis; last occurrence:
tr
No
ENone EAntihistimine
EEpinephrine Autoinjector
IMMUNIZATIONS
E lmmunization record attached E lmmunizations reported on NYSIIS
fl
No immunizations received today
fl lmmunizations I
Will return
Provider
/
received today:
on:
to receive:
Parental Authorization
All information contained herein is valid through the last day of the month flor L2 months from the date Uelor,y. Medical Provider Signature: Date: phone #: Provider Name: (please print) Provider Address: Fax #: Parent/Guardian Signature: Date:
Return to: School Nurse: Phone #:
(
)
Fax:
(
)
School: Date: Page 2 of 2
'elre
F{EP\I-TF{ SFFffGE
t'! rdK m[ i
ffi
AT$G
$d
AUThd6)
Rfi
A,,4T[S [U Fe)
n*ivrdualieed tlrders fsr:
R 6!il
D.O,B
a.;1qr,gie$
t. Stegdgfd-ff-Yqgdhryqggffilgq/-F4,ry;futedlgEtlig$1s; rhs following nredication* are the onty *nes ar"'ailebl* in the Health Office. For any sthar modisctions, eee below. These medieations v,rill be adnrinistereri at the discretion of the RN, wnty if sf$r?sd approvel fs lndfesfsd ey SOfFd ffte sfuderaf 's prftysfefaru dffiS paremf, i nlrrsg ruamne
, i.uvvrGt
ri.-.-----
t
-_-*-i
lrr rvtr*r rv. r,,
Ro*rt€-Tmssegs
ii
| !vn,
I' I
i
tab$etsl__l ;lihuproten) il*o
ii
Ii ,ee .dvn$ vnfl db6ets**
,i:ilr r_ ---_* rllli
*-
------*_*"-l
lE"€E-ffiilte@ffilts
i t I
.
I
___ _, i", fnr"a e t.:t. I Q*--*
i
for:
i
* ___
*=**_-____.l
i
r
i
,
i -*-
ThnCIat fi-ouenges i po
2. FBF$SRIPBQI{ ryd apv c{fupr Qver--thg€oumter tutgdB"egtiqqg:
piease
+oniriete lvith
ocrirent's current regirnen for both scheduled snd FRN rnedicatisns.
lAd 4:edicatrgn$$?#s-{ bc ersy{S,fff dge68f{lle ffi:;}r€e*b,ueJtrefln$g&{e-wlup8' csnfarner wittt vour stsdenfk naffie on rt I
Pr,ig
ruafins
I
Route
i D,osagw
$ehedu*fe &
rp
j&Cegjgjtrg
Gomtm'r*nte
trlrysician $ignature:
trrsnse
#:
I I
Phcne #:
::{-cgtt?sry.{e r&e"sE&lglf;ff'-Ls*glssense-.rfisss-{d,rqel{+:i,prg$q"rySed- Fq-{Le .e$qv,e qftygr,p{enr Parent sicnature: Dmte
2A76-17 School Year
New York State lmmunization Requirements for School Entrance/Attendancer l,,l0TE5:
Chilcjren in a prekindergarten setting should be age-appropriateiy inrmunized. The number of doses depends orr the schedule recommended by the Acivisory Comlrittee on lmmllnizotion Practices (AClPi. For grades Pre-k through 8, intervdis bei'fieefi doses of vaccine should be in accordance wlth the AC|P-recornmended lmmunization schedule for persoes O thraugh 18 yeais of age. (Exception: interyals betvJeen doses of polio vaccjne need to be revaewed only for grades prekindergarten, kindergaden. 1,2, 6,7 and 8.) D,f ses rcce ived beforc the mininlLrm 6ge or intervals are not valid ancl do not coufit toward tho number of doses listed be low. lnt*rusis *et\,ve rn doses of i,a*ciire DO NOT need to be reviev,red for grades g through 12. See footnotes for srecific information for each vaccine, Cnilciren vrho are enroliiirg in grede-less classes should meet the immunization requiremenls of the gracjes fcr wirich they 6fe agi3 equivalenl.
Dcse requiremenis MUST be r€ad with the foot*at€s 6f this schedul€.
i j i
Vaccines
Prekindergarten
Kindergarten
(Day Care,
arrd Grades
Head Start, Nursery or Pre-k)
1and2
Piphtheria 6nd Tetanu* toxoid-cont6inins vaccine and Pertussis vaccine {$TaF/DTPlTdap}'
Grades
3.4 and
Tetanus xnd Fiphiheria toxsid-cofi tai ninb vacEine and Pertusgis vaccins: bo*rster fl1dap)3 Pqlio vaccine (lPV/OPV)4
4 doses or 3 doses if lhe 3rd dsse was reccived at
3 dcses
I dose
3 doses
4 doses or 3 dos€s if the 3rC dose wss received
4 years of ege
nt 4 y€ars
0r older
Measlss,
trv'igrnp$
and
1
11
3 doses
.f-&rt,afftlcabrl*
,
9, lC,
and"l2
5 doses or 4 doseg if the 4th dosr wns received at 4 years 0f age 0r older or 3 doses if eged 7 years or older and the series was started at 1 year of age 0r older
4 doses
Grad*s
Grades 6. 7 arrcl 8
5
3 dases
0f
ege or older ? di'8€s
dose
Eubefla tere'ine{MMX}'
hlepatitis
I
3 doses
vaccineE
3 doses or 2 dcses of adult hepatitis B vaccine {Recombivax) for chiidren v,/ho received the dos€s *t le*st 4 months epo|1 between the ages of 11 thraugh 15 years of age
Varicel la (Chiqh€rlpoxl
vaccine? :,'
2 dd5ei
"l:d$Sb
t dose
2 doxes
1
dose
:
Meningococcal cEnju$at€ vaccine {MenACWYls Not applicable
7: dose
8y Grade 1
Grsde':2: 2 doses or 1 dose
ifthe dose was receiveci
TJ:;::i:."j Haemophilus influ*nzae type b cor{ugata, vaccine
(Hibl3 1
::
:
Pneumococcal *nnjugnte vaccine (PCV)!0
{ to 4 do:es '
: . 1
l{ot applirahl€
,::
to 4 dsses
Hot applicable
rr Z-
firw YonK
STATE
jDepartment
lof Health
'1.
:.
Dfinloirstraled sefoiaEii:crvid€n[e ol mcaslcs, mumps, ful]eile. ite[atitis i], vaii;el1€ oi po:ro {fcr ail llrree seiolypes} antiltrciie5 is acceplafiie piocf ci immunri'y' io Lhese ciis€oses. Dingncsis by a physicisr. ohyiicidn assisiart or nuise cr.ra1:tinncr iirat a cltild has lt.rd vaticclla disciisu as sccepteblc Droof of irrimunity to \,/aricelli.
rlepdtiiis $ v;rclno
o. ilose l moy
be givei dt itiiih or anyirme ilterea1ter Dt:-. 2 firi5t o€ Ceys) aftei close 1. Dcae 3 musi lt.j ai lL-is" I .raeks afiei close 2 AND at iesst 16 weeks afler dose i AND nc eaiiiei than 24 weeks ot s$e.
givei nt ieast 4 vieeks i:8
b.
Dlphih€fio anrl tFit*rLjs to\oids a[C nceiiLjlrr.perluss]s {DToP) vaccine. (Miiliir!m oqlc; 6 weeks)
a.
Children slortlrg lire sefies 9* iicte should tece ve .r 5-dose series ef DlaF vaccin! 6t .rqtcs 2 rnoritir5. 4 ficnihs. S nlontts ancl di 15 ittfcLrciii 18 ilroniir: dn{i at 4 yeefr ci allE .ir olde{: iite lodilli {ios.t nt€y ite re'ceived et €oriy nt cge 12 nloilhs. pro\?icieci at ieasl 6 mrrths heve elopfied sjnae il-,e tirirc ciose. Hawevei tlrc fourllr alore cf DTop reed nei be repealed ii it vrds edfrtinlstereij a,r tea$l 4 ilonllis ai1.er the iirili cose o{ DTsp. Tlre iindt riose in iire:eries mlst ile re{eived ot or dflef the forflh i}iithclat.
b. li ille lb!*n
dose c,f DTaP was adfiinistered ai:trjr.. 4 yeitfs
rr
Z Virii.ellir {r:hi.l
