LJA Health Requirements for New Students K-12
Due July 1st or point of entry
Hawaii law requires each student to present a report of a physical exam, a certificate of TB exam, and a record of immunizations with the signature or stamp of a U.S. licensed Medical Doctor (MD), Doctor of Osteopathy (DL), Advanced Practice Registered Nurse (APRN), or Physician Assistant (PA) dated no later than one year from the start date of school.
Student transfer from a Hawaii school - May transfer health records from a Hawaii public or private school. You will need to submit a physical exam on Form 14/Student Health Record, TB certification and complete immunization record prior to entrance into LJA. Call the school nurse to ensure your child’s health records have been received. If the health record has not been received entrance into school will be delayed.
Student transfers from out-of-state or out-of-country - regardless of prior school attendance in Hawaii, if transferring from outside of Hawaii you must complete a physical examination on the Form 14/Student Health Record & TB certificate dated no later than one year from the start date of school, as well as, an up-to-date record of immunizations prior to entrance into LJA.
A student who has not completed the physical exam or all the required immunizations may be allowed a provisional attendance ONLY upon submitting a medical appointment card or letter from a practitioner showing that the student is in the process of obtaining the required immunizations(s) or physical exam.
A student may not attend school without a valid TB certificate -- The TB certificate may not be deferred.
▪ Tuberculosis (TB) Clearance --- NO TB, NO ADMITTANCE !!!
o A certificate of TB examination must be presented prior to first attendance at a Hawaii school.
o A valid certificate of TB examination must be issued within 12 months prior to first attendance at a Hawaii school. This requirement may not be deferred or postponed.
o If the diameter of induration is 10mm or greater, a chest x-ray must be provided prior to first attendance at school in Hawaii. See Department of Health requirements for TB certification if the results are 10mm or greater (website & phone number below).
▪ Physical Examination (Student Health Record/Form 14) – COMPLETED at point of entry
o Each student must have a physical examination and all required immunizations within 12 months before first attending school in Hawaii. Must be recorded on the Student Health Record/Form14.
o The exam must be performed and signed by a U.S. licensed Medical Doctor (MD), Doctor of Osteopathy (DO), Advanced Practice Registered Nurse (APRN), or Physician Assistant (PA).
▪ Health Room Form – COMPLETED YEARLY
o Each student must have a new form completed by July 1st each school year. Return to the school nurse.
▪ Medication Forms – COMPLETED YEARLY
○ Students needing medication at school must have a form completed and on file each school year.
○ Students with Asthma or Respiratory Airway Disease (RAD) need to complete the Asthma & RAD History,
Medication & Inhaler Form (see below).
▪ ILH Athletic Participation Form (Grades 7-12 only) – COMPLETED YEARLY
○ Must complete an ILH Athletic Participation Form each school year to participate in ILH athletics.
May not use the Student Health Record/Form 14 in place of this form.
○ Return to the Front Office of the main campus.
Where do I turn in the forms?
K-12, Main Campus: Mail to Le Jardin Academy, Attention: Health Room or bring to the Main Campus Front Office.
Junior School: Mail or bring to either campus, Attention: Junior School.
What if I still have questions medical or sports questions?
Main Campus:
School Nurse - Elaina Hall/RN @ , 261-0707 X1420
Receptionist - Denise Price-Nakagawa @ , 261-0707 X1410 or 0
Athletic Assistant- Jen Oiness @ , 261-0707 X1610
Junior School:
Administrative Assistant-Lauren Nakayama @ , 261-0707 X1150
* All forms are located on the LJA website @ www.lejardinacademy.org, click Parents, then Health Information.
to view and/or download health information and forms.
List of Forms:
1) Health Room Form, PK-JK
2) Health Room Form, K-12
3) Prescription Medication Form
4) Asthma & RAD History, Medication & Inhaler Form
5) Over-the-counter Medication Form (not provided by school)
6) Anaphylaxis Emergency Action Plan & EpiPen
7) ILH Athletic Participation Form, grades 7-12 only (2 pages)
8) Form 14/Student Health Record (Physical Exam, TB Clearance, Immunizations)
Dept. of Health Examination & Immunizations: http://gen.doh.hawaii.gov/sites/har/AdmRules1/11-157.pdf
Or call Hawaii Immunization Program (O’ahu) (808) 586-8332
Student Health Record (Form 14): http://doe.k12.hi.us/forms/form14_StudentHealthRecord.pdf