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;

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; Dina Manka;; James Strezewski; Meg Woodman; Cynthia Zarkowsky

2019–2020 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, for children enrolling in kindergarten (even if they previously were enrolled in a District 96 Early Childhood program), and for students entering Grade 6.

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 2, 2019, so that staff may review them for compliance. In addition, all students entering or transferring into Grade 6 or 7 or 8 will be required to show proof of receipt of one dose of Tdap vaccine (containing tetanus, diptheria, acellular pertussis) and one MCV4 (meningococcal vaccine). Please provide the school with verifying documentation that can be obtained from your child’s 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 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, 2018, and May 15, 2020.

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 School

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; Dina Manka; James Strezewski, Meg Woodman, Cynthia Zarkowsky

2019-2020 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 2 de agosto de 2019, 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 o 7 o 8, muestren evidencia de haber recibido una dosis de la vacuna Tdap (combinación de tétano, difteria y tos ferina). Por favor, provea a la escuela de la documentación que se puede obtener del proveedor de cuidado de la salud de su hijo.

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 2018 también son requeridos a tener un examen dental. Este examen debe de estar completado entre el 15 de noviembre de 2018, y el 15 de mayo de 2020.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

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.

Fecha de Nacimiento Sexo Escuela Grado/Núm. de Ident.

Apellido Nombre Inicial Mes / Día / Año

HISTORIAL MÉDICO- PARA SER COMPLETADO Y FIRMADO POR PADRES/TUTOR Y VERIFICADO POR EL PROVEEDOR DE CUIDADO DE SALUD

ALERGIAS (Alimentos,

drogas, insectos, otro)

Sí

No

Anótelas todas: MEDICINAS (Anote todas

las recetadas o tomadas con

regularidad)

Sí

No

¿Tiene diagnóstico de asthma?

¿Despierta el niño tosiendo en la noche? 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? ¿Para qué? Sí No

¿Tiene retrasos del desarrollo? Sí No

¿Tiene problemas de la sangre? Hemofilia,

Glóbulos Falciformes (Sickle Cell), Otro

Sí No ¿Ha tenido alguna cirugía?(anótelas todas)

¿Cuándo? ¿Para qué? Sí No

¿Tiene diabetes? Sí No ¿Ha tenido 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 el 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/visión? _____ Lentes Lentes de Contacto Último examen _____

¿Otras Preocupaciones? (bizco, párpados caídos, parpadear, dificultad cuando lee)

Dental Ganchos Puente Placas Otro

¿Tiene problemas de los 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) 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 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

2019 – 2020

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

DISTRITO96FORMULARIODEPERMISODELOSPADRESPARAQUESUESTUDIANTEPARTICIPEENACTIVIDADESATLETICASY DEPORTES 2019/2020

NOMBREDELESTUDIANTE:___________________________________________________________________

Apellido Nombre

FECHADENACIMIENTO:

______/_____/______ CMIHKPTGW______________mes dia año Escuela(hagauncirculo) grado

PERMISODELOSPADRESYRENUNCIAAACCIONLEGAL:Actividadextracurricularodeporte________________________________________________

_________________________________ tienemipermisoparaparticipar y/ocompetirenlaactividadatléticaodeporte extracurriculararribamencionado,duranteelpresenteañoescolar.Estoyconcientedelosriesgosyposibilidadesdeserherido.Lanaturalezadelaheridapuedesersevera,incluyendoriesgosdefractura,lesionesdelcerebro,parálisisyotrasheridascatastróficasyhastalamuerte.

Entiendoquedeberétransportaramihijo/adelaescuelaalacasadespuésdelasprácticasydeloseventosanoserque seaarregladodeotramanera.

______________________________ ____________________________________Firmadelpadre Fecha

_______________________________ ____________________________________Teléfonodecontactoprincipal Contactosecundario

***Porfavordevuelvaesteformularioalentrenadoroauspiciador.***Nota:todoparticipanteenactividadesextracurricularesoatléticasqueincluyencontactodirectoconotrosjugadores,debencompletaryfirmarelformularioconmocióncerebral.***Esposiblequehayaotroformulariorequeridoporelentrnadordesuestudiante,quedebacompletar.

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

             Información sobre la Conmoción Cerebral

¿Qué puede pasar si mi hijo/a sigue jugando o regresa muy prontoa jugar después de una conmoción cerebral?

Atletas con síntomas o señales de conmoción cerebral deben salir del juego inmediatamente. Seguir

jugando con señales o síntomas de conmoción cerebral pone al joven atleta en riesgo de una lesión

mayor. El riesgo de una lesión más grave continúa después de haber sufrido una conmoción cerebral,

especialmente si el atleta sufre una segunda conmoción cerebral antes de haberse recuperado

totalmente de la primera. Esto puede conducir a un largo período de recuperación o incluso hasta una

grave hinchazón del cerebro (síndrome del segundo impacto) con consecuencias devastadoras y

hasta fatales. Es muy conocido que los atletas adolescentes no reportan

los síntomas de sus lesiones. Es lo mismo con las conmociones cerebrales. Por lo tanto es muy

importante la educación de los administradores, entrenadores, padres y estudiantes, para la

protección del estudiante-atleta.

Si usted piensa que su hijo ha sufrido una conmoción cerebral

Cualquier atleta que se sospecha ha sufrido una conmoción cerebral debe de dejar el juego o el

entrenamiento inmediatamente. Ningún atleta puede regresar al juego o actividad después de haber

recibido una lesión cerebral o conmoción, aunque la lesión parezca leve o los síntomas desaparezcan

rápido, sin la autorización de un médico. La observación médica del atleta debe continuar por algunas

horas. La regla para poder Regresar-Al-Juego que tienen las asociaciones IESA y IHSA requiere que los

atletas presenten a la escuela una autorización médica, sea de un doctor con licencia para practicar

todas las ramas de la medicina o de un entrenador de atletas con certificación para trabajar junto con

un doctor con licencia para ejercer todas las ramas de la medicina, antes de regresar a jugar o a

entrenar después de una conmoción cerebral o después de haber sido sacado de alguna competencia

intercolegial debido a una lesión cerebral o conmoción cerebral y no ha sido autorizado para

regresar a la misma competencia. De acuerdo a las leyes estatales todas las escuelas deben seguir

estas reglas.

Usted también debe informar al entrenador de su hijo/a si usted piensa que su hijo/a ha sufrido una

conmoción cerebral. Recuerde que es mejor que no asista a un juego a que no asista toda la

temporada. Cuando hay alguna duda el atleta no participa en el juego.

Para información al dia sobre conmociones cerebrales puede ir a la página web:

http://www.cdc.gov/ConcussionInYouthSports/

_______________________________ ______________________ ______

Nombre del estudiante-atleta Firma del estudiante-atleta Fecha

en letra de molde

_______________________________ ______________________ ______

Nombre del padre/tutor en Firma del padre/tutor Fecha

letra de molde

Adaptado del CDC y de la 3ra Conferencia Internacional sobre Conmociones Cerebrales en Deportes.

Documento creado el 7/1/2012

Name: _________________________________________________________________________ D.O.B.: ____________________

Allergy to: __________________________________________________________________________________________________

Weight: ________________ lbs. Asthma: [ ] Yes (higher risk for a severe reaction) [ ] No

PLACE PICTURE

HERE

1. Antihistamines may be given, if ordered by a healthcare provider.

2. Stay with the person; alert emergency contacts. 3. Watch closely for changes. If symptoms worsen,

give epinephrine.

PARENT/GUARDIAN AUTHORIZATION SIGNATURE DATE PHYSICIAN/HCP AUTHORIZATION SIGNATURE DATE

FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (WWW.FOODALLERGY.ORG) 5/2014

1. INJECT EPINEPHRINE IMMEDIATELY.2. Call 911. Tell them the child is having anaphylaxis and may

need epinephrine when they arrive.• Consider giving additional medications following epinephrine:

» Antihistamine » Inhaler (bronchodilator) if wheezing

• Lay the person flat, raise legs and keep warm. If breathing is difficult or they are vomiting, let them sit up or lie on their side.

• If symptoms do not improve, or symptoms return, more doses of epinephrine can be given about 5 minutes or more after the last dose.

• Alert emergency contacts.• Transport them to ER even if symptoms resolve. Person should

remain in ER for at least 4 hours because symptoms may return.

HEART Pale, blue, faint, weak pulse, dizzy

MOUTH Significant

swelling of the tongue and/or lips

OR A COMBINATION of symptoms from different body areas.

LUNG Short of breath,

wheezing, repetitive cough

SKIN Many hives over body, widespread

redness

GUT Repetitive

vomiting, severe diarrhea

NOSE Itchy/runny

nose, sneezing

MOUTH Itchy mouth

SKIN A few hives,

mild itch

GUT Mild nausea/discomfort

THROAT Tight, hoarse,

trouble breathing/swallowing

OTHER Feeling

something bad is about to happen, anxiety, confusion

Epinephrine Brand: __________________________________________

Epinephrine Dose: [ ] 0.15 mg IM [ ] 0.3 mg IM

Antihistamine Brand or Generic: _______________________________

Antihistamine Dose: __________________________________________

Other (e.g., inhaler-bronchodilator if wheezing): __________________

____________________________________________________________

MEDICATIONS/DOSES

SEVERE SYMPTOMS MILD SYMPTOMS

FOR MILD SYMPTOMS FROM MORE THAN ONE SYSTEM AREA, GIVE EPINEPHRINE.

FOR MILD SYMPTOMS FROM A SINGLE SYSTEM AREA, FOLLOW THE DIRECTIONS BELOW:

FOR ANY OF THE FOLLOWING:

NOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. USE EPINEPHRINE.

Extremely reactive to the following foods: ____________________________________________________________

THEREFORE:[ ] If checked, give epinephrine immediately for ANY symptoms if the allergen was likely eaten.

[ ] If checked, give epinephrine immediately if the allergen was definitely eaten, even if no symptoms are noted.

EPIPEN® (EPINEPHRINE) AUTO-INJECTOR DIRECTIONS1. Remove the EpiPen Auto-Injector from the plastic carrying case.2. Pull off the blue safety release cap.3. Swing and firmly push orange tip against mid-outer thigh. 4. Hold for approximately 10 seconds.5. Remove and massage the area for 10 seconds.

AUVI-QTM (EPINEPHRINE INJECTION, USP) DIRECTIONS1. Remove the outer case of Auvi-Q. This will automatically activate the voice

instructions.2. Pull off red safety guard.3. Place black end against mid-outer thigh.4. Press firmly and hold for 5 seconds.5. Remove from thigh.

ADRENACLICK®/ADRENACLICK® GENERIC DIRECTIONS1. Remove the outer case.2. Remove grey caps labeled “1” and “2”.3. Place red rounded tip against mid-outer thigh.4. Press down hard until needle penetrates.5. Hold for 10 seconds. Remove from thigh.

OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.):

2

2

2 3

3

4

1

2

PARENT/GUARDIAN AUTHORIZATION SIGNATURE DATE

FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (WWW.FOODALLERGY.ORG) 5/2014

EMERGENCY CONTACTS — CALL 911

RESCUE SQUAD: ______________________________________________________________________

DOCTOR: _________________________________________________ PHONE: ____________________

PARENT/GUARDIAN: ______________________________________ PHONE: ____________________

OTHER EMERGENCY CONTACTS

NAME/RELATIONSHIP: __________________________________________________________________

PHONE: ______________________________________________________________________________

NAME/RELATIONSHIP: __________________________________________________________________

PHONE: _______________________________________________________________________________

Treat the person before calling emergency contacts. The first signs of a reaction can be mild, but symptoms can get worse quickly.