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1050 Ivy Hall Lane • Buffalo Grove, IL 60089 • 847.459.4260 • www.kcsd96.org
Administration: Julie A. Schmidt, Superintendent; Beth Dalton, Ed.D., Assistant Superintendent for Human Resources; Jonathan G. Hitcho, Assistant Superintendent for Business Services; Jeanne Spiller, Assistant Superintendent for Teaching & Learning;
Kevin Ryan, Director of 21st-Century Learning; Amy Gluck, Director of Educational Services; Kathryn Sheridan, Director of Language & Early Literacy Sam Miranda, Director of Facilities & Transportation; Board of Education: Marc Tepper, President; Renee Klass, Vice President;
Mike Burns, Secretary; Elizabeth Dietz; James Strezewski; Meg Woodman; Cynthia Zarkowsky
2017–2018 Student Health Requirements
Dear Parents:
To comply with Illinois State law, a physical examination, including current immunization records, is required for all children entering school for the first time and also for students entering 6th grade.
This exam must have been conducted within one year prior to school entry and be recorded on the State of Illinois form. (An out-of-State/country record must be on a comparable form.) This exam and age-appropriate immunizations and request for immunization waivers are required before the first day of attendance in order to avoid exclusion. Therefore, we request that the records and waiver requests be presented to the school by August 4, 2017, so that staff may review them for compliance. In addition, all students entering, transferring, or advancing into grades 6, 7, 8, 9, 10, 11, or 12 will be required to show proof of receipt of one dose of Tdap vaccine (containing tetanus, diptheria, acellular pertussis). Most students already have received this vaccine and simply need to provide the school with verifying documentation from the family health care provider. Note that District parents/guardians whose children have not fulfilled the physical examination/immunization requirements and request for immunization waivers before school begins in August will not receive their child’s information packet, which includes teacher assignment and other pertinent information.
A dental examination is required for students in Kindergarten, 2nd, and 6th grades. This examination must have been completed between Nov. 15, 2016, and May 15, 2018.
In addition, state law mandates an eye examination, by an ophthalmologist or optometrist, for Kindergarten students and for ALL children enrolling in an Illinois school for the first time.
Required forms are available from your doctor’s office and also at the District website (www.kcsd96.org).
For low-cost medical help, please contact the Lake County Health Department at 847-377-8470. We urge all families to schedule your appointments with your physicians and dentists promptly so there will be no delays for your children in complying with the law.
Sincerely,
Julie A. Schmidt Superintendent of Schools
1050 Ivy Hall Lane • Buffalo Grove, IL 60089 • 847.459.4260 • www.kcsd96.org
Administration: Julie A. Schmidt, Superintendent; Beth Dalton, Ed.D., Assistant Superintendent for Human Resources; Jonathan G. Hitcho, Assistant Superintendent for Business Services; Jeanne Spiller, Assistant Superintendent for Teaching & Learning
Kevin Ryan, Director of 21st-Century Learning; Amy Gluck, Director of Educational Services; Kathryn Sheridan, Director of Language & Early Literacy Sam Miranda, Director of Facilities & Transportation; Board of Education: Marc Tepper, President; Renee Klass, Vice President;
Mike Burns, Secretary; Elizabeth Dietz; James Strezewski, Meg Woodman, Cynthia Zarkowsky
2017-2018 Requisitos de Salud
Estimados Padres/Guardianes:
Para estar de acuerdo con la ley del Estado de Illinois, un examen de salud que incluye registros actuales de inmunizaciónes–es requerido para todos los niños que entran a la escuela por primera vez y también para estudiantes que cursan el sexto grado. Este reconocimento de examen físico debe de ser realizado un año antes de entrar a la escuela y debe estar registrado en la forma del Estado de Illinois. El examen físico y edad apropiada las inmunizaciones y la solicitud para la inmunizaciones son requeridas antes del primer día de escuela; por lo tanto, nosotros requerimos que los records sean presentado a la escuela no mas tarde del 4 de agosto de 2017, para que el personal los pueda revisar y confirmar. Al principio del próximo año escolar, se requerirá que todos los estudiantes que entran, avanzan o transfieren a los grados 6, 7, 8, 9, 10, 11 y 12 muestren evidencia de haber recibido una dosis de la vacuna Tdap (combinación de tétano, difteria y tos ferina), sin importar el tiempo que ha pasado desde la última vez que recibieron una dosis de DTap, DT o Tdi. La mayoría de los estudiantes pueden ya han recibido la vacuna y simplemente necesitan proveer a la escuela una documentación del proveedor de atención médica de la familia que lo verifique.
Padres/guardianes del distrito quienes no cumplen con el examen físico de su hijo(a) inmunización requeridos y la solicitud para la inmunizaciones antes de que la escuela empieze en agosto no recibirán el paquete de información de su hijo(a), que incluye el nombre del maestro(a) y otra información pertinente.
Estudiantes entrando al kinder, segundo grado, y sexto grado en agosto del 2017 también son requeridos a tener un examen dental. Este examen debe de estar completado entre el 15 de noviembre de 2016, y el 15 de mayo de 2018.Además, una nueva ley del estado requiere un examen de los ojos hecha por un optomólogo o un optometrista para entrar al kinder y para TODOS los niños que se matriculan en una escuela de Illinois por primera vez.Cada médico y dentista en el estado deben de tener las formas apropiadas para este requerimiento de exámenes de salud, dental, y visión. Las formas también están disponibles en el website del Distrito (www.kcsd96.org).
Para la asistencia médica de bajo costo, contacta por favor el Departamento de la Salud de Lake County en 847-377-8470.
Instamos que todas las familias cumplen estos exámenes obligatorios. Por favor planifique sus citas con sus médicos y con dentistas inmediatamente para que no haya demoras para que sus niños cumplan con la ley.
Sinceramente,
Julie A. SchmidtEl Supervisor de Escuelas
11/2015 (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois
State of Illinois
Certificate of Child Health Examination
Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and
Maintained by the School Authority.
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. The mo/da/yr for every dose administered is required. If a specific vaccine is
medically contraindicated, a separate written statement must be attached by the health care provider responsible for completing the health
examination explaining the medical reason for the contraindication.
REQUIRED
Vaccine / Dose
DOSE 1
MO DA YR
DOSE 2
MO DA YR
DOSE 3
MO DA YR
DOSE 4
MO DA YR
DOSE 5
MO DA YR
DOSE 6
MO DA YR
DTP or DTaP
Tdap; Td or Pediatric DT (Check
specific type)
TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT TdapTdDT
Polio (Check specific
type)
IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV IPV OPV
Hib Haemophilus
influenza type b
Pneumococcal
Conjugate
Hepatitis B
MMR Measles
Mumps. Rubella
Comments:
Varicella
(Chickenpox)
Meningococcal
conjugate (MCV4)
RECOMMENDED, BUT NOT REQUIRED Vaccine / Dose
Hepatitis A
HPV
Influenza
Other: Specify
Immunization
Administered/Dates
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 (measles, mumps, hepatitis B) is allowed when verified by physician and supported with lab confirmation. Attach
copy of lab result. *MEASLES (Rubeola) MO DA YR **MUMPS MO DA YR HEPATITIS B MO DA YR VARICELLA MO DA YR
2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official. Person signing below verifies 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
3. Laboratory Evidence of Immunity (check one) Measles* Mumps** Rubella Varicella Attach copy of lab result.
*All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.
**All mumps cases diagnosed on or after July 1, 2013, must be confirmed by laboratory evidence.
Completion of Alternatives 1 or 3 MUST be accompanied by Labs & Physician Signature: __________________________________________
Physician Statements of Immunity MUST be submitted to IDPH for review.
Student’s Name
Birth Date Sex School Grade Level/ ID
# Last First Middle Month/Day/ Year HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER
ALLERGIES (Food, drug, insect, other)
Yes
No
List: MEDICATION (Prescribed or
taken on a regular basis.)
Yes
No
List:
Diagnosis of asthma?
Child wakes during night coughing?
Yes No
Yes No
Loss of function of one of paired
organs? (eye/ear/kidney/testicle)
Yes No
Birth defects? Yes No Hospitalizations?
When? What for?
Yes No
Developmental delay? Yes No
Blood disorders? Hemophilia, Sickle Cell, Other? Explain.
Yes No Surgery? (List all.)
When? What for?
Yes No
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 ______
Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)
Dental Braces Bridge Plate Other
Ear/Hearing problems?
Yes No Information may be shared with appropriate personnel for health and educational purposes.
Parent/Guardian
Signature Date Bone/Joint problem/injury/scoliosis? Yes No
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) BMI85% 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. http://www.cdc.gov/tb/publications/factsheets/testing/TB_testing.htm.
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 Sickle Cell (when indicated)
Urinalysis Developmental Screening Tool
SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs
Skin Endocrine
Ears
Screening Result: Gastrointestinal
Eyes Screening Result: Genito-Urinary LMP
Nose Neurological
Throat
Musculoskeletal
Mouth/Dental
Spinal Exam
Cardiovascular/HTN
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) Other
NEEDS/MODIFICATIONS required in the school setting
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 Modified
Print Name (MD,DO, APN, PA) Signature Date
Address Phone
State of Illinois Certificate of Child Health Examination
FOR USE IN DCFS LICENSED CHILD CARE FACILITIES CFS 600 Rev 12/2011
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 1 MO DA YR
2 MO DA YR
3 MO DA YR
4 MO DA YR
5 MO DA YR
6 MO DA YR
DTP or DTaP
Tdap; Td or Pediatric DT (Check specific type)
Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT Tdap Td DT
Polio (Check specific type)
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) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR 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 MO DA YR (Attach copy of lab result)
VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN
Date Code:
P = Pass F = Fail U = Unable to test R = Referred G/C = Glasses/Contacts
Age/ Grade
R L R L R L R L R L R L R L R L R L
Vision Hearing
IL444-4737 (R-01-12) (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois
Apellido Nombre Inicial
Fecha de Nacimiento Mes / Día / Año
Sexo Escuela Grado/Núm. de Ident.
HISTORIAL MÉDICO - PARA SER COMPLETADO Y FIRMADO POR PADRES / TUTOR Y VERIFICADO POR EL PROVEEDOR DE CUIDADO DE SALUD
ALERGIAS (Alimentos, drogas, insectos, otro) MEDICINAS (Anote todas las recetadas o tomadas con regularidad.)
¿Tiene diagnóstico de asma? ¿Despierta el niño tosiendo en la noche?
Sí No Sí No
¿Tiene pérdida de Funciones en uno de los órganos? (Ojos/Oídos/Riñones/Testículos)
Sí No
¿Tiene defectos de nacimiento? Sí No ¿Ha sido hospitalizado? ¿Cuándo? ¿Por Qué?
Sí No ¿Tiene retrasos del desarrollo? Sí No ¿Tiene problemas de la sangre? Hemofilia, Glóbulos Falciformes (Sickle Cell), Otro Explique Explain.
Sí No ¿Ha atendido cirugía? (anótelas todas) ¿Cuándo? ¿Para Qué?
Sí No ¿Tiene diabetes? Sí No ¿Ha tendido heridas graves o enfermedades? Sí No
¿Tiene heridas en la cabeza / golpe / desmayo? Sí No ¿Prueba positiva de TB (Pasado o Presente)? Sí* No *Si contestó sí, refiera al
departamento de salud local ¿Tiene convulsiones? ¿Cómo se manifiestan? Sí No ¿Enfermedad de TB (Pasado o Presente)? Sí* No
¿Tiene problemas cardiacos / No respira bien? Sí No ¿Usa tabaco (tipo, Frecuencia)? Sí No ¿Tiene soplo en corazón / presión arterial alta? Sí No ¿Toma alcohol / drogas? Sí No ¿Tiene mareos o dolor de pecho al hacer ejercicios?
Sí No ¿Historial de familiares de muerte repentina antes de los 50 años ? (¿Causa?)
Sí No ¿Problemas con los Ojos? Lentes … Lentes de Contacto … Último Examen ¿Otras Preocupaciones? (bizco, párpados caídos, parpadear, dificultad cuando lee)
Dental … Ganchos … Puente … Placas Otro
¿Tiene problemas de oídos / No oye bien? Sí No La información en este formulario se puede compartir con el personal apropiado para propósitos de salud y educación. Firma del Padre/Tutor Fecha
¿Tiene problemas de los huesos / articulaciones / heridas / escoliosis?
Sí No
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. Questionnaire Administered ? Yes … No … Blood Test Indicated? Yes … No … Blood Test Date (Blood test required if resides in Chicago.) 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 Sickle Cell (when indicated) Urinalysis Developmental Screening Tool SYSTEM REVIEW Normal Comments/Follow-up/Needs Normal Comments/Follow-up/Needs Skin Endocrine Ears Gastrointestinal Eyes Amblyopia Yes… No… Genito-Urinary LMP
Nose Neurological Throat Musculoskeletal Mouth/Dental Spinal Exam Cardiovascular/HTN Nutritional status Respiratory … Diagnosis of Asthma Mental Health
Currently Prescribed Asthma Medication: … Quick-relief medication (e.g. Short Acting Beta Antagonist) … Controller medication (e.g. inhaled corticosteroid)
Other
NEEDS/MODIFICATIONS required in the school setting 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 (for one year) Yes … No … Limited … Print Name (MD,DO, APN, PA) Signature Date Address Phone
(Complete Both Sides)
State of Illinois Eye Examination Report
Illinois law requires that proof of an eye examination by an optometrist or physician who provides complete eye examinations be submitted to the school no later than October 15th 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 child beginning school.
Student Name: ___________________________________________ Birth Date: _____________ Sex: _____Grade: _____ (Last) (First) (Middle Initial) (Mo.) (Day) (Yr.)
Parent or Guardian: ____________________________________________________ Phone: ________________________ (Last) (First) (Area Code)
Address: ______________________________________________________________ County: _______________________ (Number) (Street) (City) (Zip Code)
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
Refraction: Distance Near Right Left Both Both
Unaided Visual Acuity: 20 / 20 / 20 / 20 / Best Corrected Visual Acuity: 20 / 20 / 20 / 20 /
Was refraction performed with cycloplegic agents? Yes No Normal Abnormal Not Able to Assess Comments External Exam (eye and adnexa) _________________________ Internal Exam (media, lens, fundus, etc.) _________________________ Neurological Integrity (pupils) _________________________ Binocular Function (stereopsis) _________________________ Accommodation and Vergence _________________________ Color Vision _________________________ IOP (glaucoma) _________________________ Oculomotor Assessment _________________________ Other: _______________________________ _________________________
Diagnosis
Normal Myopia Hyperopia Astigmatism Strabismus Amblyopia
Other: ______________________________________________________________________________________________
Recommendations
1. Corrective Lenses: No Yes, glasses 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 . __________________________________________________________________________________________________
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)
Print Name: ___________________________________________ Optometrist or Physician Who Provides Eye Examinations Address: ____________________________________________
____________________________________________
Signature: ____________________________________________ Phone: ________________________________ Optometrist or Physician Who Provides Eye Examinations
PROOF OF SCHOOL DENTAL EXAMINATION FORM
To be completed by the parent (please print):
State of IllinoisIllinois Department of Public Health
To be completed by dentist:
Oral Health Status (check all that apply)
! Yes ! No Dental Sealants Present
! Yes ! No Caries Experience / Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it wasextracted as a result of caries OR missing permanent 1st molars.
! Yes ! No Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of thewalls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retainedroot, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are consid-ered sound unless a cavitated lesion is also present.
! Yes ! No Soft Tissue Pathology
! Yes ! No Malocclusion
Treatment Needs (check all that apply)
! Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling
! Restorative Care — amalgams, composites, crowns, etc.
! Preventive Care — sealants, fluoride treatment, prophylaxis
! Other — periodontal, orthodontic
Please note____________________________________________________________________________________
Signature of Dentist _________________________________________ Date of Exam ____________________
Address ___________________________________________________ Telephone _______________________Street City ZIP Code
Illinois Department of Public Health, Division of Oral Health217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • www.idph.state.il.us
Printed by Authority of the State of Illinois
Student’s Name: Last First Middle Birth Date:/ /
Address: Street City ZIP Code Telephone:
Name of School: Grade Level: Gender:! Male ! Female
Parent or Guardian: Address (of parent/guardian):
(Month/Day/Year)
IOCI 0600-10
FORMULARIO COMPROBANTE DEL EXAMEN DENTAL ESCOLAR
Para ser completado por el padre/madre (por favor impresión):
Estado de IllinoisDepartamento de Salud Pública
To be completed by dentist: (Para ser completado por el dentista:)
Oral Health Status (check all that apply)
! Yes ! No Dental Sealants Present
! Yes ! No Caries Experience / Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it wasextracted as a result of caries OR missing permanent 1st molars.
! Yes ! No Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of thewalls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retainedroot, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are consid-ered sound unless a cavitated lesion is also present.
! Yes ! No Soft Tissue Pathology
! Yes ! No Malocclusion
Treatment Needs (check all that apply)
! Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling
! Restorative Care — amalgams, composites, crowns, etc.
! Preventive Care — sealants, fluoride treatment, prophylaxis
! Other — periodontal, orthodontic
Please note____________________________________________________________________________________
Signature of Dentist _________________________________________ Date of Exam ____________________
Address ___________________________________________________ Telephone _______________________Street City ZIP Code
Departamento de Salud Pública de Illinois, División de la Salud Oral217-785-4899 • TTY (sólo para personas con impedimento auditivo) 800-547-0466 • www.idph.state.il.us
Impreso con Autoridad del Estado de Illinois
Nombre del Estudiante: Apellido Nombre Inicial Fecha de Nacimiento:/ /
Dirección: Calle Ciudad Código Postal Número de Teléfono:
Nombre de la Escuela: Grado: Sexo: ! Masculino! Femenino
Nombre del padre/madre o encargado: Dirección del padre/madre o encargado:
(Mes/Día/Año)
IOCI 0600-10
PARENT CONSENT FORM for
STUDENT ACTIVITY/ATHLETIC PARTICIPATION 2017 – 2018
STUDENT NAME: _____________________________ ________________________________ Last First DATE OF BIRTH: ________/________/_________ CM IH K P TG W ____________ Month Day Year School (circle one) Grade PARENT PERMISSION AND RELEASE: Extracurricular athletic sport or activity: ___________________________ ______________________ has my permission to participate and/or compete in the above listed extracurricular sport or activity during the current school year. I realize that there may be an inherent risk of injury. The nature of the injury could be severe, including the risk of fractures, brain injuries, paralysis, and other catastrophic injuries, including death. I understand that I will provide transportation home from school after practice sessions and events unless otherwise arranged. _________________________________________________ _________________ Parent/Guardian signature Date ____________________________________________ ____________________________________ Contact number Secondary contact number ***Please return this form to the building coach or sponsor. ***Note: any extracurricular contact activity or athletic participant will need to complete a concussion signature form. ***Note: there may be an additional building activity/athletic form required your student’s building coach/sponsor.
KILDEER COUNTRYSIDE COMMUNITY CONSOLIDATED SCHOOL DISTRICT 96
DISTRITO96FORMULARIODEPERMISODELOSPADRESPARAQUESUESTUDIANTEPARTICIPEENACTIVIDADESATLETICASYDEPORTES 2017/2018
NOMBREDELESTUDIANTE:
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Concussion Information Sheet
Adapted from the CDC and the 3rd International Conference on Concussion in Sport Document created 7/1/2012
A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away. Symptoms may include one or more of the following:
Headaches “Pressure in head” Nausea or vomiting Neck pain Balance problems or dizziness Blurred, double, or fuzzy vision Sensitivity to light or noise Feeling sluggish or slowed down Feeling foggy or groggy Drowsiness Change in sleep patterns
Amnesia “Don’t feel right” Fatigue or low energy Sadness Nervousness or anxiety Irritability More emotional Confusion Concentration or memory problems
(forgetting game plays) Repeating the same
question/comment
Signs observed by teammates, parents and coaches include:
Appears dazed Vacant facial expression Confused about assignment Forgets plays Is unsure of game, score, or opponent Moves clumsily or displays in coordination Answers questions slowly Slurred speech Shows behavior or personality changes Can’t recall events prior to hit Can’t recall events after hit Seizures or convulsions Any change in typical behavior or personality Loses consciousness
Concussion Information Sheet
Adapted from the CDC and the 3rd International Conference on Concussion in Sport Document created 7/1/2012
What can happen if my child keeps on playing with a concussion or returns too soon?
Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athletes will often fail to report symptoms of injuries. Concussions are no different. As a result, education of administrators, coaches, parents and students is the key to student-athlete’s safety.
If you think your child has suffered a concussion
Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. The Return-to- Play Policy of the IESA and IHSA requires athletes to provide their school with written clearance from either a physician licensed to practice medicine in all its branches or a certified athletic trainer working in conjunction with a physician licensed to practice medicine in all its branches prior to returning to play or practice following a concussion or after being removed from an interscholastic contest due to a possible head injury or concussion and not cleared to return to that same contest. In accordance with state law, all schools are required to follow this policy. You should also inform your child’s coach if you think that your child may have a concussion. Remember it’s better to miss one game than miss the whole season. And when in doubt, the athlete sits out.
For current and up-to-date information on concussions you can go to:
http://www.cdc.gov/ConcussionInYouthSports/
_____________________________ _____________________________ _____________ Student-athlete Name Printed Student-athlete Signature Date __________________________ ___________________________ ___________ Parent or Legal Guardian Printed Parent or Legal Guardian Signature Date
