2020-2021

PRESCHOOL REGISTRATION PACKET

There are three steps to the Chicago Early Learning process. This packet is for the Registration Stage.

The Registration Stage introduces families to the preschool program. This stage provides teachers an opportunity to build relationships and familiarize families with school environment and culture.

The following pages comprise the Preschool Registration Packet, which includes all the forms that are required by the preschool program to officially register each child. Registration forms should be updated on an annual basis.

Please ensure all appropriate documents are either completed and filed in the student’s cumulative folder or shared with the family as described below.

Please note, all other forms previously in the Registration Packet, i.e., School Enrollment Form, Home Language Survey, Student Medical Information, etc., should be given to families as part of your school's enrollment packet. These forms are still required to be completed.

REGISTRATION CHECKLIST At the registration meeting with each family:

Complete with the family: Share with the family:

Child Health History (Revised for SY20-21) CPS Health Requirements for Preschool Students

CPS Healthy Is Regular Check-Ups Flyer

Family Program Agreement and Interest Survey (New for SY20-21)

Families to complete and return before the first day of enrollment:

P roo f o f S c hoo l Dental Examination Form

Certificate of Child Health Examination Form (Included in packet)

Family Program Agreement and Interest Survey (Included in packet)

Rev. 5/8/20

Office of Early Childhood Education (773) 553-2010

Child Health History 2020-2021

The purpose of this form is to learn about the child’s health history and their health status at the time of enrollment. School staff will use this information to ensure that the student has access to basic health care and that all of their health needs are met in the classroom. This document will guide registration staff in conducting an informal interview with the family regarding their child’s health.

Child Name:

Yes No Is the student a “Returning Student”?

Child ID: DOB: / / Age: Gender:

*If you are completing the Health History for a returning student, please review each section and confirm with the family that allinformation is the same. If there are any updates or changes, please add new information. If all information is the same, only theconsent section and signature needs to be completed for returning students.

I. Preliminary Questions

How much did this child weigh at birth? lbs oz

Weight status at Birth (select 1): Premature (1-4 lbs) Underweight (5lbs) Within Normal Range (6-8 lbs) Overweight (Over 9 lbs)

Yes No Has anyone in the family ever had any serious illnesses or abnormalities (e.g, COVID-19, heart disease, diabetes,

cancer, tuberculosis, asthmas, etc.) that your child may also be at risk for? If yes, please explain.

II. Communicable/Chronic Diseases

Yes No Has your child had any communicable diseases (e.g. measles, mumps, chickenpox, etc.)?

Yes No Has your child had any chronic diseases (e.g. asthma, diabetes, heart disease, seizures, etc.)?

Yes No Have these or any other illness/injury required your child to be hospitalized or have surgery?

If yes, please provide the date it occurred, and explain:

Child Health History 2020-2021

III. Asthma / Allergy ScreeningThe purpose of this section is to learn more about the child’s allergies and experience with asthma (if they have been diagnosed). Please see section IV. Food Substitution for next steps if the child has any allergies. (See Best Practices document.) If the child has an asthma diagnosis, then the Asthma Action Plan and Physician’s Report on Child with Asthma forms need to be completed. If the child also has a nebulizer or inhaler, then the Parent Request for Administration of Medication and Physician Request for Administration of Medication needs to be completed as well.

Yes No Is your child taking any medications every day? If yes, please explain.

Yes No Has your child ever been diagnosed by a medical professional as having asthma?

Date of diagnosis: / /

How many episodes per year?

Is it seasonal? At what time of year do the episodes most often occur?

Is it well controlled? Yes No How?

Yes No Has your child experienced any of the following due to asthma? If yes, please check the ones that apply:

Treatment in ER If yes, # of times: Hospitalizations If yes, # of times:

Yes No Have you ever given your child any medications for asthma? If yes, please check all that your child has used in the last year:

Albuterol Proventil Pedia Pred Quiboron

Ventolin Marax Prelone Other:

Tedral Intal Primitine Mist

Child Health History 2020-2021

Yes No Does your child use a Nebulizer or Inhaler?

Yes No Does your child frequently have cold-like symptoms (stuffy nose, cough)?

Yes No Does your child suffer from hay fever or eczema?

Yes No Is your child allergic to any of the following? If yes, please check all that apply:

Animals Dust Pollen / Flowers Weather Changes

Birds Smoke Trees Other:

Grass Perfume Medication

Yes No Does anyone in the household smoke? (i.e. home/car) Comments:

IV. Food SubstitutionIf the child has food restrictions for medical reasons other than an allergy, the Healthcare Provider Statement for Food Substitution should be completed.

*Accommodations for breakfast, lunch, snack, after school snack/supper are only made when it is medically necessary.

Yes No Is your child restricted from foods due to religious, vegetarian/vegan, medical or personal beliefs? If yes, please check all that apply.

Child Health History 2020-2021

Pork Poultry Eggs Other (please specify below: )

Beef Fish Milk

Yes No Does your child have any food allergies or intolerances? If yes, please check all that apply:

Milk All foods containing eggs

Fish Legumes (Dry Beans/ Peas)

Soy Fruits/Juice, specify:

Milk Products

Whole Wheat Shellfish Tree Nuts/Seeds

Vegetable- specify:

Other, specify:

Eggs Wheat Gluten Beef Peanuts

What kind of reaction does your child have when your child eats the specified food, if applicable?

Life Threatening Rash Diarrhea Swelling Difficulty Breathing Other, Specify:

Yes No Is your child on any special diet prescribed by a doctor? If yes, please specify:

V. Consent

Date: / /

Date: / / Parent/Guardian:

Signed by School Staff:

Historia de Salud 2020-2021

El propósito de ésta forma es aprender acerca de la historia de salud del niño(a) y su estado de salud en el momento de inscripción. El personal de la escuela usará esta información para asegurar que el estudiante tenga acceso al cuidado básico de salud y que todas sus necesidades de salud se tomen en cuenta en el aula. Este documento guiará al personal de registración en conducir una entrevista informal con la familia con respecto a la salud de su niño(a).

Nombre del niño(a): Número de identificación del niño(a):

Fecha de nacimiento: / / Edad: Género:

Si No ¿El niño(a) es un estudiante que regresa a preescolar por el segundo año?

*Si usted está completando el historial de salud para un estudiante que regresa, por favor revise cada sección y confirme con lafamilia si toda la información es la misma. Si hay cambios, por favor agregue la nueva información. Si toda la información es la mismapara los niños que regresan, solamente las firmas se necesitan al final de la forma.

I. Preguntas Preliminares

¿Cuánto pesó el niño(a) al nacer? lbs oz

Estado de peso al nacer(escoger una respuesta): prematuro (1-4 lbs), Bajo peso (5lbs), Dentro del rango normal (6-8 lbs). Sobrepeso (más de 9 lbs)

Si No ¿Alguien en la familia ha tenido alguna enfermedad o anormalidad grave (como: COVID-19, enfermedad del corazón,

diabetes, cáncer, tuberculosis, asma, etc.) que su niño pudiese estar en riesgo? En caso afirmativo, explíquelo por favor.

II. Enfermedades Comunicable/Crónicas

Si No ¿Su niño(a) tiene alguna enfermedad comunicable (como: sarampión, paperas, varicela, etc)?

Si No ¿Su niño(a) tiene alguna enfermedad crónica (como: asma, diabetes, enfermedad del corazón, convulsiones, etc)?

Si No ¿Éstas o cualquier otra enfermedad/lesión han requerido que su niño(a) sea hospitalizado o tenga cirugía? En caso afirmativo, por favor proporcione la fecha que ocurrió y explique:

Historia de Salud 2020-2021

III. Detección de Asma/AlergiasEl propósito de esta sección es para aprender más acerca de las alergias de su niño(a) y experiencias con asma (si han sido diagnosticadas) Por favor vea sección IV. Sustitución de Alimentos si el niño(a) tiene una alergia como próximo paso. (consulte el documento de Mejores Prácticas). Si el niño(a) tiene un diagnóstico de asma, las formas del Plan de Acción para el Asma y el Reporte Médico de un Niño(a) con Asma deben ser completados. Si el niño(a) también tiene un nebulizador o inhalador, las formas de Solicitud de Padres para la Administración de Medicamentos y la Solicitud del Médico para la Administración de Medicamentos necesitan ser completadas también.

Si No ¿Está su niño(a) tomando algún medicamento todos los días? En caso afirmativo, por favor explique.

Si No ¿Alguna vez un profesional médico le ha diagnosticado asma a su niño(a)?

Fecha del diagnóstico: / /

¿Cuantos episodios por año?

¿Es estacional? ¿En qué época del año ocurren los episodios con mayor frecuencia?

¿Esta bien controlado(a)? Si No ¿Como?

Si No ¿Le ha pasado alguno de los siguientes síntomas debido al asma a su niño(a)? En caso afirmativo, indique las que correspondan:

Tratamiento de Emergencia Si es afirmativo, # de veces: Hospitalizaciones Si es afirmativo, # de veces:

Si No ¿Alguna vez le ha dado a su niño(a) algún medicamento para el asma? En caso afirmativo, por favor marque todas las que su niño(a) ha usado en el último año:

Albuterol Proventil Pedia Pred Quiboron

Ventolin Marax Prelone Otras:

Tedral Intal Primitine Mist

Historia de Salud 2020-2021

Si No ¿Su niño(a) usa un nebulizador o inhalador?

Si No ¿Su niño(a) tiene frecuentemente síntomas de resfriado (nariz tapada, tos)?

Si No ¿Su niño(a) sufre de fiebre del heno o eczema?

Si No ¿Su niño(a) es alérgico a alguno de los siguientes? En caso afirmativo, marque todo lo que corresponda:

Animales Polvo Pollen / Flores Cambio del tiempo

Pajaros Fumar árboles Otras:

Sacate Perfume Medicamentos

Si No ¿Alguien en la familia fuma ? (como: casa/carro) Comentarios:

IV. Sustitución de AlimentosSi el niño tiene restricciones alimenticias por razones médicas que no sean una alergia, se debe completar la Declaración del Proveedor de Atención Médica para la Sustitución de Alimentos.

* Las adaptaciones para desayuno, almuerzo, merienda o cena se hacen solamente cuando es médicamente necesario .

Si No ¿Su niño(a) está restringido de alimentos debido a creencias religiosas, vegetarianas / veganas, médicas o personales?

En caso afirmativo, por favor marque todo lo que corresponda.

Puerco Ave Huevos Otro (especifique a continuación)

Carne Pescado Leche

Historia de Salud 2020-2021

Si No ¿Su niño(a) tiene alguna alergia o intolerancia alimentaria? En caso afirmativo, marque todo lo que corresponda:

Leche Alimentos que contengan huevos

Pescado Legumbres (frijoles / chícharos)

Soya Frutas / jugos, especificar:

Productos de leche

Integral Mariscos Nueces de árbol / Semillas

Vegetables- especifique:

Otros, especifique:

Huevos Gluten de Trigo

Carne Cacahuate/ maní

¿Si le corresponde, qué tipo de reacción tiene su niño(a) cuando come el alimento especificado?

Amenazante para su vida

Ronchas Diarrea Hinchazón Dificultad al Respirar

Otros, especifique:

Si No ¿Su niño(a) tiene alguna dieta especial recetada por un médico? En caso afirmativo, por favor especifique:

V. Autorización

Fecha: / /

Firma de Familia/Guardián: Fecha: / /

Firma del Personal de la Escuela:

Plea ____

(Please print) Family Program Agreement & Interest Survey

School:

Parent/Guardian Name: Child’s Name:

❑ I will commit to being involved in the preschool program.❑ I understand the importance of daily attendance and agree to bring my child to school everyday

he/she is well enough to fully participate in the program, including daily outdoor play.❑ I will adhere to the school schedule so that my child is dropped off and picked up on time.❑ I will take full responsibility for his/her safe transportation to and from school.❑ I will stay in contact with the school and classroom via phone, email and/or Parent Portal. If my

contact information changes, I will provide updates to school staff.❑ I understand that I am expected to serve as a volunteer either in the classroom, school or from home.❑ I will attend family meetings, workshops or conferences at the school as offered and/or requested.❑ I give permission for my child to participate on field trips, including walking trips within the community.

Family Interest Survey

se choose at least four (4) interest topics below to help identify community resources to support your family: How violence affects children Financial planning

Effective parenting Substance/Alcohol abuse Healthy eating Child development Advocating for your children’s rights Dealing with grief Building reading and math skills Immigration with preschoolers Stress management

Transition to kindergarten Communication within your family Parenting a child with a disability Trauma in families Co-parenting Health & Wellness (ie - CPR/First Aid, Exercising, etc) How to strengthen your relationship Housing with your significant other Legal assistance

Employment/Job Training Domestic violence Child care (before, after and summer) Technology support

We would like to plan activities that are of interest to you. Feel free to add topics that are not listed.

The best time of day to schedule meetings/workshops (mark all that apply): Morning Afternoon Evenings Weekends

I’m available to volunteer: Classroom Field trips Send projects home to complete

The best way to send me information is (mark all that apply): Email Text Phone/Robocalls School Website Newsletter Social Media Apps (Aspen, Class Dojo, Remind, etc) Other:

Signature of Parent/Guardian Date Reviewed by - Staff Initials/Title Date

Acuerdo del Programa y Encuesta de Intereses de Familias (En letra de imprenta) Escuela:

Nombre del padre/tutor: Nombre del niño(a):

❑ Me comprometo a participar en el programa preescolar.❑ Entiendo la importancia de la asistencia diaria y estoy de acuerdo en llevar a mi hijo(a) a la escuela para

que participe enteramente en el programa, incluyendo en los juegos al aire libre diariamente.❑ Cumpliré con el horario escolar para que mi hijo(a) llegue a la escuela y sea recogido puntualmente.❑ Asumiré la responsabilidad total del transporte hacia y de regreso de la escuela de mi hijo(a).❑ Me mantendré en contacto con el personal de la escuela y la maestra por teléfono, correo electrónico

y/o el portal de padres. Si mi información de contacto cambia, notificare al personal de la escuela.❑ Entiendo que se espera que sirva como voluntario en el aula, la escuela o desde casa.❑ Asistiré a reuniones familiares, talleres o conferencias en la escuela según las ofrezcan y/o soliciten.❑ Doy permiso para que mi hijo(a) participe en excursiones, incluidas caminatas dentro de la comunidad.

Encuesta de Intereses de Familias

Favor de seleccionar cuatro (4) temas de interés para ayudar a identificar los recursos de la comunidad que puedan apoyar a su familia:

Cómo afecta la violencia a los niños Planificación financiera Crianza eficaz de niños Abuso de alcohol y/o drogas Nutrición saludable Desarrollo de niños Abogando por los derechos de sus niños Manejando el duelo Edificando destrezas de lectura y Inmigración matemática con niños preescolares Manejo del estrés

Transición al kínder Comunicación dentro de su familia Criando un niño(a) con discapacidades Trauma en las familias

Co-paternidad Salud y Bienestar (es decir, RCP/primeros auxilios, Cómo fortalecer su relación con su pareja ejercicio, etc.) Empleo/Entrenamiento laboral Alojamiento Cuidado de niños (antes/después de la Asistencia legal escuela y verano) Violencia doméstica

Apoyo tecnológico

Queremos planear actividades que sean de su interés. Favor de asistirnos en añadir temas de interés no mencionados en la lista de arriba.

El mejor momento del día para programar reuniones/talleres (marque todo lo que corresponda): Mañana Tarde Noche Fines de semana

La mejor manera de enviarme información es (marque todo lo que corresponda): Correo electrónico Texto Teléfono/Llamada automática Sitio web de la escuela Boletín Redes sociales Aplicaciones (Class Dojo, Remind, etc.) Otro:

Firma del Padre/Tutor Fecha Revisado por - Iniciales del personal/Título Fecha

State of Illinois Certificate of Child Health Examination

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: * indicates invalid dose

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.

Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and Maintained by the School Authority.

11/2015 (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois

/ / / /

Last First Middle

Birth Date Sex School Grade Level/ ID

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 BMI PERCENTILE B/P

DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI>85% 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 Certificate of Child Health Examination

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.

Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and Maintained by the School Authority.

11/2015 (COMPLETE BOTH SIDES) Printed by Authority of the State of Illinois

Apellido Nombre Inicial

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

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) BMI>85% 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 Illinois Department of Public Health

PROOF OF SCHOOL DENTAL EXAMINATION FORM

To be completed by the parent (please print):

Student’s Name: Last First Middle Birth Date: (Month/Day/Year)

/ /

Address: Street City ZIP Code Telephone:

Name of School: Grade Level: Gender: D Male

D Female

Parent or Guardian: Address (of parent/guardian):

To be completed by dentist:

Oral Health Status (check all that apply)

D Yes D No Dental Sealants Present

D Yes D No Caries Experience / Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1st molars.

D Yes D No Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the

walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, 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.

D Yes D No Soft Tissue Pathology

D Yes D No Malocclusion

Treatment Needs (check all that apply) D Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling

D Restorative Care — amalgams, composites, crowns, etc.

D Preventive Care — sealants, fluoride treatment, prophylaxis

D Other — periodontal, orthodontic

Please note

Signature of Dentist Date of Exam

Address Street City ZIP Code

Telephone

IOCI 0600-10

Illinois Department of Public Health, Division of Oral Health 217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • www.idph.state.il.us

Printed by Authority of the State of Illinois

Estado de Illinois Departamento de Salud Pública

FORMULARIO COMPROBANTE DEL EXAMEN DENTAL ESCOLAR

Para ser completado por el padre/madre (por favor impresión):

Nombre del Estudiante: Apellido Nombre Inicial Fecha de Nacimiento: / /

(Mes/Día/Año)

Dirección: Calle Ciudad Código Postal Número de Teléfono:

Nombre de la Escuela: Grado: Sexo: D Masculino D Femenino

Nombre del padre/madre o encargado: Dirección del padre/madre o encargado:

To be completed by dentist: (Para ser completado por el dentista:)

Oral Health Status (check all that apply)

D Yes D No Dental Sealants Present

D Yes D No Caries Experience / Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1st molars.

D Yes D No Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the

walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, 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.

D Yes D No Soft Tissue Pathology

D Yes D No Malocclusion

Treatment Needs (check all that apply) D Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling

D Restorative Care — amalgams, composites, crowns, etc.

D Preventive Care — sealants, fluoride treatment, prophylaxis

D Other — periodontal, orthodontic

Please note

Signature of Dentist Date of Exam

Address Street City ZIP Code

Telephone

Departamento de Salud Pública de Illinois, División de la Salud Oral 217-785-4899 • TTY (sólo para personas con impedimento auditivo) 800-547-0466 • www.idph.state.il.us

IOCI 0600-10 Impreso con Autoridad del Estado de Illinois

CPS HEALTH REQUIREMENTS FOR PRESCHOOL STUDENTS

Dear Parent/Guardian, The Chicago Public Schools (CPS)

Office of Student Health and Wellness (OSHW) aims to remove health-related barriers

to learning such that all CPS students may succeed in college, career and life.

As you and your family are about to embark on this new journey, we want to help your child get Ready To Learn by providing you

with health requirements and resources for Preschool Readiness. CPS preschool students, as with all CPS students, are

required to fulfill certainhealth requirements at various ages and grade levels.

Please review the snapshot of all health

requirements for preschool students to the right.

For more information, please contact oshw@cps.edu or (773) 553-3560.

HEALTHY CPS HEALTHY SCHOOLS HEALTHY STUDENTS HEALTHY CHICAGO

Physical Exams

All preschool students are required to have a physical exam including lead, diabetes, and tuberculosis screening conducted by a health care provider. Head Start requires an anemia risk assessment. The provider should give you a signed health form for you to bring to your child’s school when you enroll.

Immunizations

All preschool students are required to have up to date, required immunizations when enrolling in school. Upon entering preschool, all students must have had at least the following immunizations: 3 doses of Hepatitis B Vaccine; 4 doses of DTaP/Td Diptheria, Tetanus Vaccines; 3 doses of Polio Vaccine; age appropriate number of doses of Measles, Mumps, Rubella (MMR) Vaccine; 1 dose of Varicella (Chicken Pox) Vaccine; medically appropriate doses of Pneumoccocal conjugate vaccine (Prevnar13) and Haemophilus influenza Type B (HIB) based on age.

Vision Exam

All kindergarten students are required, by Illinois state law, to have a comprehensive vision exam from an optometrist or physician (such as an ophthalmologist). Parents must submit a proof of Vision Exam form to the school when enrolling in kindergarten. * Exams are valid for 12 months.*

Dental Exam

Students entering Head Start programs and all kindergarten students are required to have an annual dental exam completed by a licensed dentist. Parents must submit a proof of Dental Exam form to the school.

Hearing & Vision Screenings

Vision and hearing screenings will be conducted annually by CPS employees certified by the Illinois Department of Public Health before end of the school year.

HEALTHY IS... regular check-ups! Regular check-ups are important and so is connecting your family to a medical home where you can establish relationships with trusted doctors and nurses that know your child’s story and can help with their health care needs.

HAVING A MEDICAL HOME

ALLOWS A DOCTOR TO »

Make sure that your child is meeting their height and weight targets.

GOOD HEALTH

Check their vision and hearing to make sure that they will be successful in the classroom.

Screen for diseases such as diabetes, asthma, heart disease and developmental issues.

CAN’T WAIT! MAKE AN APPOINTMENT TODAY! »

1 Call 773-553-KIDS (5437)

2 Visit CPS.EDU/CFBU Visit a Benefits Coordinator at your local school

NOTE: In Illinois, children may qualify for low-cost/free health insurance regardless of Immigration Status.

The Children and Families Benefits Unit (CFBU) of the Chicago Public Schools (CPS) is funded by the

Supplemental Nutrition Assistance Program (SNAP) of the United States Department of Agriculture. This institution is

an equal opportunity provider.

The Office of Student Health and Wellness (OSHW) can help you apply for low-cost or free health insurance (Medicaid) and SNAP. We will:

» Walk you step-by-step through the Health Insurance (Medicaid) and SNAP application.

» Help you understand your eligibility and the documents needed to apply.

» Assist you with renewing your Health Insurance or SNAP benefits.

» Help you connect to a health plan, primary health physician, and a medical home.

3

SER SALUDABLE ES... ¡hacerse exámenes de rutina! Hacerse exámenes de rutina es importante, tanto como conectar a su familia con un hogar médico donde pueda conocer médicos y enfermeras confiables que conozcan el historial de su hijo y lo ayuden con sus necesidades de atención de salud.

TENER UN HOGAR MÉDICO PERMITE QUE UN MÉDICO »

Se asegure de que su hijo está dentro de los parámetros adecuados de estatura y peso.

Examine la visión y audición de su hijo para garantizar su éxito académico.

Detecte enfermedades como diabetes, asma, enfermedades del corazón y trastornos en el desarrollo.

¡LA BUENA SALUD NO DA ESPERA! ¡SOLICITE SU CITA HOY! »

1 Llame a la línea 773-553-KIDS (5437) 2 Visite CPS.EDU/CFBU

Visite al Coordinador de Beneficios en su escuela local

NOTA: en Illinois, los niños pueden ser considerados para el seguro médico de bajo costo/gratuito. Independientemente de su estado migratorio.

La Unidad de Beneficios para Niños y Familias (CFBU, por

sus siglas en inglés) de las Escuelas Públicas de Chicago (CPS, por sus siglas en inglés) es financiado por el

Programa Suplementario de Asistencia Nutricional (SNAP) del Departamento de Agricultura de los Estados Unidos.

Esta institución ofrece igualdad de oportunidades.

3

La Oficina de Salud y Bienestar Estudiantil (OSHW, por sus siglas en inglés) puede ayudarle a solicitar un seguro médico gratuito o de bajo costo (Medicaid), así como los servicios del Programa Suplementario de Asistencia Nutricional (SNAP, por sus siglas en inglés). Nosotros nos encargamos de:

» Guiarlo paso a paso para que solicite el seguro médico (Medicaid) y los servicios del SNAP.

» Ayudarlo a comprender su elegibilidad y los documentos necesarios para hacer la solicitud.

» Brindarle asistencia respecto a la renovación de su seguro médico o sus beneficios del SNAP.

» Ayudarlo a conectarse con un plan de salud, un médico de atención primaria y un hogar médico.