Class of 2023 Health Forms


Physicals

**PHYSICALS ARE DUE BY JUNE 14, 2019 TO THE SCHOOL NURSE**

The School Code of Illinois requires a Physical Exam performed by a Physician, Advanced Practice Nurse (APN), or a Physician Assistant (PA) on all children entering a private school for 9th grade. Exams must be completed within one year prior to the first entrance to 9th grade. The exam must be completed on the required Certificate of Child Health Examination Form. A parent signature and completion of the Health History section are required on this form. Proof of immunizations from birth up until 9th grade must be provided as well. For any religious objections to vaccinations, the Religious Exemption Form must be completed for this school year by a parent/guardian and Physician.  

Health Examination Form

Religious Exemption Form

Please note: Mother McAuley has adopted a “first day exclusion” policy for the 2019-2020 school year. Any student who does not provide a completed physical (including all vaccines) turned into the health office will be sent home and not permitted to attend the first day of classes in August.

If you have changed doctors, obtain the immunization dates from the previous doctor or agency that administered the immunizations. If previous medical records are not available, elementary school records bearing a doctor’s signature may be used to verify immunization dates, but are not to be used in place of the examination required for entrance to high school.

You must provide proof of immunization for the following:

  • Diphtheria, Pertussis, Tetanus (DTP/DTaP/ or Tdap, Td): Three or more doses of DTP/DTaP or Td; with the last dose qualifying as a booster if received on or after the 4th birthday. Minimum interval between series doses: 4 weeks (28 days). Between series and booster: 6 months. No proof of immunity allowed. For students entering 6th thru 12th grades: in addition, One dose of TDAP.
  • Polio: Three or more doses of Polio with the last dose qualifying as a booster and received on or after the 4th birthday. If the series is given in any combination of polio vaccine types, four or more doses are required with the last being a booster on or after the 4th birthday. Minimum interval between series doses: 4 weeks (28 days). Booster doses: One after the 4th birthday For kindergarten entry: Booster dose 6 months from previous dose and 4th birthday. No proof of immunity allowed.
  • Measles: Two doses of Measles Vaccine, the first dose must have been received on or after the 1st birthday and the second dose no less than 4 weeks (28 days) later. Laboratory evidence of measles immunity or Certified physician verification of measles disease by date of illness. Cases diagnosed after 7/1/2002 must include lab evidence of infection.
  • Mumps: Two doses of Mumps Vaccine, the 1st dose must have been received on or after the first birthday and the second dose no less than 4 weeks (28 days) later. Laboratory evidence of mumps immunity or Certified physician verification of mumps disease by date of illness.
  • Rubella: Two doses of Rubella Vaccine, the first dose must have been received on or after the 1st birthday and the second dose no less than 4 weeks (28 days) later. Laboratory evidence of rubella immunity, History of disease is not acceptable proof of immunity to rubella.
  • Hepatitis B: For students entering grades 6 thru 12: Three doses of Hepatitis B vaccine administered at recommended intervals OR Two doses Adult Recombivax-HB vaccine for ages 11-15. Minimum intervals between doses: First and Second-at least 4 weeks (28 days), Second and Third-at least 2 months (56 days), First and Third-at least 4 months (112 days) OR Adult Recombivax-HB two doses separated by 4 months (112 days). Must start and finish series between 11 – 15 years of age.
  • Varicella: Two doses of varicella for students entering grades 2, 3, 4, 6, 7, 8, 9, 10, 11 & 12.  Minimum intervals for administration: The first dose must have been received on or after the 1st birthday and the second dose no less than 4 weeks (28 days) later. Statement from physician or healthcare provider verifying disease history OR laboratory evidence of varicella immunity.
  • Meningococcal Conjugate Vaccine: Applies to students entering 6th, 7th, 8th AND 9th grades: one dose of meningococcal conjugate vaccine. 12th grade entry: two doses of meningococcal conjugate vaccine. Minimum intervals for administration: For 6th grade entry: the first dose received on or after the 11th birthday. For 12th grade entry: second dose on or after the 16th birthday and an interval of at least eight weeks after the first dose. Only one dose is required if the first dose was received at 16 years of age or older. No proof of immunity allowed.

Medication Policy

If your daughter requires medication during school hours, prescribed or over-the-counter, it must be brought to school and kept in the Nurse’s Office and administered by the school nurse. This includes medication for headaches, menstrual cramps or any other medical condition.

If sending medication to school, the following procedures must be followed:

  • Medication Authorization Form must be completed by a licensed prescriber and parent/guardian whether for prescription as well as non-prescription medications and returned to the school nurse. This form is completed annually.

  • Prescription medication brought to the Nurse’s Office in original pharmacy container with pharmacy label. Your pharmacy should be able to supply an extra labeled container for school. Include student’s name, date of birth, and year of graduation affixed to the container.

  • Non-prescription medication brought to the Nurse’s Office in original package with student’s name, date of birth, and year of graduation affixed to the container.

  • If medication dose changes or is discontinued, parents must notify the school nurse in writing with confirmation from the licensed prescriber.

No medication will be given unless these guidelines are followed. The intent of these guidelines is to provide safe administration of medications.

School Medication Authorization Form
 


Use of Inhalers

Students diagnosed with Asthma should always carry their inhaler. A completed Medication Authorization Form should be sent to school annually for placement with her medical records. If desired, an extra inhaler may be kept locked up in the Nurse’s Office.

According to the Illinois Public Act 099-0843, schools are required to ask parents/guardians of students with Asthma to submit a current Asthma Action Plan. If your daughter has Asthma, please have your physician complete the Asthma Action Plan Form. It will be kept on file in the Nurse’s Office. This Asthma action plan needs to be updated yearly.

 School Medication Authorization Form

Asthma Action Plan
 


Diabetes

According to the Illinois Public Act 96-1485, The Care of Students with Diabetes Act, if your daughter has Diabetes and requires assistance with managing this condition while at school and school functions, a Diabetes Care Plan must be submitted to the school nurse. Please contact your daughter’s physician to develop the Diabetes care plan.            

Once the Diabetes care plan is on file with the school nurse, parents/guardians are responsible for and must:

  • Inform the school nurse of any change which needs to be made to the Diabetes Care Plan on file with the school for their daughter.

  • Inform the school in a timely manner of any changes to their emergency contact numbers or contact numbers of healthcare providers.

  • Sign the Diabetes Care Plan.

  • Grant consent for and authorize the school nurse to communicate directly with the healthcare provider whose instructions are included in the Diabetes Care Plan.

Keeping extra supplies/juices/snacks in the Nurse’s Office labeled with student's name, date of birth, and year of graduation is highly recommended.

School Medication Authorization Form


Please feel free to contact Mrs. Amanda Gaida, School Nurse, by email at agaida@mothermcauley.org or phone (773) 881-6524 with any questions or concerns.

For a complete list of print-friendly medical forms, click below:

Student Medical Forms