CompletedbyParent orCaregiver:
SanFranciscoUnified School District School Health Form - 2016/2017
Child’sName:Birthdate:MaleFemale School/Grade:
Last,Firstmonth/day/year
Address:Phone:E-mail:
StreetZipHomeCellWork
ReleaseofHealthInformation:IgivepermissiontosharetheresultsofthisexaminationwiththeSchool
Signature ofParent/CaregiverDate
NOTE:Kindergartenentrance physicalexaminationtobe donenoearlier thanMarch oftheyear the child entersKindergarten
COMPLETED BY HEALTH PROVIDER IMMUNIZATIONRECORD(EACHchild should have acompleted or updated officialImmunizationRecord)
Dose Given:Month/Day/Year / ☐Child has no risk factors for TB and does not require TB test* Risk factors on reverse
Health Provider Signature:______Date:______
Health Provider Signature Date
Vaccine / 1st / 2nd / 3rd / 4th / 5th
Polio (IPV)
DTaP(Diphtheria, Tetanus, Pertussis) / TuberculinSkinTest: □ Mantoux □IGRA blood test
Date:______
Induration: ___mm Result: □Negative □Positive
Td/Tdap(Tetanus,Diphtheria,Pertussis)
MMR
Hib(HaemophilusinfluenzaTypeB)
H
Hepatitis B / ChestX-Ray/RX:RequiredwithPositive TBSkinor TB Blood Test
CXRDate: Impression:□Negative □Positive
RX treatment & duration: ______
Hepatitis A (not required)
Varicella / Had Varicella – Date:______
EXAM DATE______ / SUMMARY OF FINDINGS/CONDITIONS / REFERRALS - F/U
Screenings / Weight:______Height:______BMI%ile: B/P:______Lead: ______Hgb/Hct:______U/A: ______
Vision/Hearing / Near Vision: R: 20/____ L: 20/____ Both: 20/____ Color Vision (2nd grade boys): ☐ Pass☐ Fail
Distance Vision: R:20/____ L:20/_____ Both: 20/_____ ☐Has glasses Hearing: R: ☐Pass ☐ Fail L: ☐Pass ☐Fail
AudiometricScreening
PhysicalExamination / ☐ Medicalcondition(s)identified *Specify:______
☐Medication taken at school:**______☐At home:______
☐Restrictions from school activities Specify:______
*Emergency Care Plan(s) required for condition needing potential action at school. **Medication form required for each med.
Forms can be found in the SFUSDSchool Health Manual:
☐Examination revealedNOcondition relevanttothe school program,e.g.allergies,asthma,cardiac,diabetes,epilepsy,other
Dental Assessment / ☐ NO dental problems ☐ Dental problems Specify:______
Developmental
Assessment / ☐ Development is within age expectations
☐ Developmental concern(s) Specify:______
☐Developmental diagnosis Specify:______
NutritionalAssessment
Other
Signature/Title of Health Provider / Date / / / Address/Phone (Print/Stamp)
Name (Please print or stamp)
SCHOOL HEALTH FORMFOR SCHOOL ENTRY
GradesK-12
REFERENCE:Healthand SafetyCode, Division105, Part2, Chapter1, Sections120325-120380;California Code of
Regulations, Title17, Division1, Chapter 4, Subchapter 8, Sections6000-6075
IMMUNIZATIONREQUIREMENTS: Toenter or transferinto publicand private elementaryand secondaryschools
(gradestransitional kindergartenthrough12), childrenunder age 18yearsmust have immunizationsasoutlined below.
VACCINE / REQUIRED DOSESPolio / 4doses atanyage,but...3 doses meetrequirementforages 4–6years if
atleast one was given onorafter the 4thbirthday;3 doses meetrequirement forages 7–17years ifatleast one wasgiven on orafter the 2ndbirthday.
Diphtheria,Tetanus,andPertussis
DTaP(diphtheria,tetanus,pertussis)
Age6years and under
Age7years andolder
(Tdap,Td, DTaporanycombination) / 5doses atanyage,but... 4 doses meetrequirementsforages 4–6years ifatleast one was on orafter the 4th birthday.
4doses atanyage,but...3dosesmeetrequirementforages 7–17years ifatleast one was on orafter the 2ndbirthday.Ifthelastdosewasgiven before the 2ndbirthday, one more(Tdap) doseis required.
TdapBooster
(Tetanus,reduceddiphtheria,andpertussis)
7th grade / 1dose on orafter 7thbirthday
1dose 8th-12th grade students transferringfromoutofCalifornia must meetthe requirement.
Measles,Mumps,Rubella(MMR)
Kindergarten
7th grade
Grades1–6and8–12 / 2dosesbothonorafter 1st birthday
2dosesbothonorafter 1st birthday
1dose must be onorafter 1st birthday
HepatitisB
Kindergarten / 3doses atanyage
Varicella
Kindergarten – 12 years
13-17 years / 1dose
2 doses
EXEMPTIONS: Effective January 1,2016, SB 277 eliminates personal and religious exemptions from immunization requirements forchildren in child care and public and private schools. The law will allow personal belief exemptions (PBEs) submitted before January 1, 2016 to remain valid untila child coming from child care reaches TK/Kindergarten, oran existing K-6 student reaches 7thgrade. The following exempt categories will not have to meet existing immunization requirements for entry:
Home-based schools Students enrolled in an independent study program who do not receive classroom-based instruction.
For MEDICAL EXEMPTIONS ONLY, a written statement from a licensed physician (M.D. orD.O.) is required, which states:
- that the physical condition or medical circumstances of a child are such that the required immunization(s) is not considered safe
- which vaccines are being exempted
- the specific nature and probable duration of the condition or circumstances, including but not limited to family medical history,
for which the physician does not recommend immunization
- the expiration date, if the exemption is temporary.
Tuberculosis (TB)Screening Requirements: Doneinthe U.S.within1yearpriorto Pre-K and Kindergarten entrance (or at first admission to SFUSD) using universal risk assessment. If no risk factors, the signature of health provider attesting to NO RISK
FACTORS FOR TB is required. If a child has one or more risk factors for TB, the health provider should perform a TB symptom
review and administer a TB test(tuberculin skin test or interferon gamma release assay blood test/IGRA).
Risk Factors for Tuberculosis (TB) in Children
- Have a family member or contact with history of confirmed or suspected TB
- Are in foreign-born families and from high-prevalence countries (Asia, Africa, Central and South America, Eastern Europe)
- Adopted from any high-risk area
- Travel to countries with high rate of TB
- Live in out-of-home placements
- Have, or are suspected to have, HIV infection
- Live with an adult with HIV seropositivity
- Live with an adult who has been incarcerated in the last five years
- Live among, or are frequently exposed to, individuals who are homeless, migrant farm workers, users of street drugs, or residents
of nursing homes
- Have contact with individuals(s) with positive TB skin test(s)
- Have abnormalities on chest X-ray suggestive of TB
- Have clinical evidence of TB: Cough > 3 weeks, coughing up blood, fever, weight loss or growth/development concerns, night sweats
THE KINDERGARTEN/FIRSTGRADE HEALTHEXAMINATION
Acompleted physicalexamisrequiredfor childrenenteringschool: forkindergartenthe exam can be no earlier than 6 months prior to school entry. Forfirstgraders the exammustbe done notmore than 18 months prior toentry. Lackofevidence ofa physical examination mayresultindenialofentrance to school.(If you do not want your child to have an exam, sign the waiver form 171B obtained from your child’s school.) SFUSD - School HealthForm –page2, 2016-2017