Forms & Publications » Health Forms

Health Forms

Please download and return completed forms to the school nurse.

 

Allergy - Food

This form is to be used for students who have a severe allergic reaction to a food or foods. It requires physician orders for medication to be used in an emergency in the school setting and the physician's signature.

Allergy - Non-Food

This form is to be used for students who have a severe allergic reaction to bee stings, latex or other environmental triggers. It requires physician orders for medication to be used in an emergency in the school setting and the physician's signature.

Asthma

This form is to be used for students who require a nursing plan to help them deal with asthma symptoms during the school day. It requires a physician to write directions for this asthma care.

Dental Screening

This form should be completed for students for the following school years:

• Kindergarten
• Grade 1
• Grade 3
• Grade 7

Diabetes

These forms are for physicians and parents of students with diabetes. They provide the school nurse with appropriate information to care for the student and their diabetes during the school day. These forms are from the American Diabetes Association.

Emergency Care

This form is to be used for students who have a health problem, which is not allergy or asthma related, and need an emergency plan implemented for their safety in the school environment. If medications are an integral part of this plan please attach the Medication Consent Form as well.

Medication Administration

This form should be completed when requesting medication be dispensed to your child during the school day. School procedure regarding medications is included with the permission form.

Private Physical

This form should be completed by your child's Primary Health Care Provider for the following school years:


• Entry to school (Kindergarten or Grade 1)
• Grade 6
• Grade 11

 

This exam may be done within one year from the start of the school year the physical is required in. Example: If school starts in August 2018, the exam date can be as early as August 2017.

School Immunization Requirements

The Pennsylvania Department of Health requires every child to have the required vaccines or they will risk exclusion from school. Under the new regulation, the provisional waiver for school children to be fully immunized is reduced to five school days.
 
All Children in grades K-12 need the following immunizations:
  • 4 doses of tetanus, diphtheria, and acellular pertussis (1 dose on or after the 4th birthday) Usually given as DTP or DTaP or DT or Td
  •  4 doses of polio (4th dose on or after 4th birthday and at least 6 months after previous dose given) A 4th dose not necessary if the 3rd dose was administered at age 4 years or older and at least 6 months after the previous dose
  • 2 doses of measles, mumps, rubella (Usually given as MMR)
  • 3 doses of hepatitis B
  • 2 doses of varicella (chickenpox) or evidence of immunity
 Students going into 7th grade also need:
  • 1 dose of tetanus, diphtheria, acellular pertussis (Tdap) on the first day of 7th grade
  • 1 dose of meningococcal conjugate vaccine (MCV) on the first day of 7th grade
Students going into 12th grade also need:
  •  1 dose of meningococcal conjugate vaccine (MCV) on the first day of 12th grade
If one dose was given at 16 years of age or older, that shall count as the twelfth grade dose.
 
Exemptions:
A child has the ability to be exempted from the immunization requirements for these reasons:
  • Medical
  • Religious belief
  • Philosophical/strong moral or ethical conviction
Even if a child is exempt from immunizations, they may be excluded from school during an outbreak of a vaccine preventable disease.  
 
All immunizations are due within the first five days of school.
 
A child is required to have any single dose vaccine upon school entry, or risk exclusion.
  • Tdap (1) 7th grade
In the case of a multi-dose vaccine, regulations require that the child have at least one dose of the vaccine upon school entry or risk exclusion.
  • DTaP (4) kindergarten
  • Polio (4) kindergarten
  • HepB (3) kindergarten
  • MMR (2) kindergarten
  • Varicella (2) kindergarten
  • MCV (2) 7th -12th grades 

If additional doses are required and are medically appropriate within the first five days of school, the child shall have either the final dose during that five-day period or the child shall have the next scheduled dose and shall also provide a medical certificate setting out the schedule for the remaining doses.
 
If the child has at least one dose, but needs additional doses, and those doses are not medically appropriate during the first five days of school, the child may provide a medical certificate on or before the fifth school day showing the doses are scheduled to be administered. The medical certificate shall be signed by a physician, certified registered nurse practitioner (CRNP) or physician assistant (PA). If the child will be receiving the immunizations from the a public health department, a public health official may sign the medical certificate.
 
A child who meets these requirements may continue to attend school even if the child does not have all the required vaccinations, so long as the child complies with the vaccination schedule in the medical plan/certificate.