Registration Health Packet – New Student Updated 3-1-2017

NEW STUDENT HEALTH PACKET

Spencer Community Schools Health Office Dear Parent/ Guardian, Welcome to Spencer Community Schools…your child’s health is our priority! Included are important messages from your school nurses as you begin your child’s educational journey at Spencer Community Schools: Screening Requirements The following pages explain what screenings and health documentation are required for students at Spencer Community Schools. A list of local agencies who offer school screenings is included on the last page of this packet. Health Status It is very important that your school nurse knows about any medical conditions, medication and any other information that might affect your child and their learning at school. Please complete the Health History form. Remember to update us during the school year if your child receives a new medical diagnosis, starts taking a new medication, or has any other significant change in health status. Emergency Contacts It is crucial that the school office has the most up-to-date contact phone numbers AT ALL TIMES in case we need to contact you for emergency or illness. If your work or cell phone number changes, or your child’s emergency contact information changes, immediately notify the school secretary. Sick Child Guidelines Spencer Schools collaborates with local public health and family care providers on the guidelines which determine when a student is well enough for school. Please review and become familiar with these guidelines to ensure good health and wellbeing of your child, and all students. Medications at School According to Iowa State law and Spencer Schools, medications can be administered at school only if certain guidelines are met. Refer to the Medication Guidelines in this packet for specific instructions. Please contact the health office at your school at any time to discuss specific needs for your child.

Cammy Cathryn Angie

Cammy Hinkeldey, RN BSN Cathryn Smith, RN Angie Huntoon, RN District Nurse Johnson School Nurse Middle and High School Nurse Lincoln & Fairview School Nurse

Registration Health Packet – New Student Updated 3-1-2017

HEALTH REQUIREMENTS CHECKLIST Spencer Community Schools

HEALTH REQUIREMENTS If your child is transferring from another school, Physical and Immunization forms should transferred from your child’s previous school. HEALTH HISTORY FORM

­ All students should have a Spencer Schools Health History form completed each year.

MEDICATION PERMISSION FORM – For Meds on Hand for Occasional Use ­ All students should have this form completed each year.

IMMUNIZATIONS ­ All students are required to have documentation of up to date immunizations according to state

law. Typically, after receiving “kindergarten shots”, students will only need their Tdap and Meningococcal boosters for 7th grade to be current with the law. It is highly recommended all students obtain a flu shot each year according to their healthcare provider’s recommendations.

WELL CHILD EXAM ­ All students are required to have a physical exam prior to Kindergarten. If your child is

transferring from another school, those records can be transferred. If Spencer Schools does not receive documentation of a kindergarten physical, your child will be required to have a physical.

IN ADDITION TO THE ABOVE REQUIREMENTS:

KINDERGARTEN / KINDERKIDS / PRESCHOOL ­ Immunizations ­ Physical (within the last year) ­ Lead Screening (State law requires at least one lead level before Kindergarten, your healthcare

provider should document this on the physical form) ­ TB Screening (completed at physical) ­ Vision (within the last year) ­ Dental (after age 3yrs)

NOTE: Preschool Students need screenings each year they attend preschool. Even if your child completed screenings for preschool, they need to complete screenings again for Kindergarten. If your child completed screenings for Kinder-Kids, they do not need to complete screenings again for Kindergarten.

3

rd GRADE ­ Vision Screening (within a year prior to entering 3

rd grade)

7

th GRADE ­ Tdap immunizations booster ­ Meningococcal booster (new state requirement in effect Jan, 2017)

9th

GRADE ­ Dental Screening (within a year prior to entering 9

th grade)

12th

GRADE ­ Meningococcal booster (new state requirement in effect Jan, 2017)

OTHER IMPORTANT FORMS:

MEDICATION GUIDELINES AND PERMISION FORM ­ Review & complete as needed only if medications are brought from home to be given at school.

DIET MODIFICATION FORM ­ Complete only if your child requires special modifications for meals due to a disability at school.

Physician signature is required.

SICK DAY GUIDELINES - Parent/Guardian to review

SCREENING RESOURCES - Parent/Guardian to review

Updated 5-5-2017

STUDENT HEALTH HISTORY FORM Spencer Community Schools

Student Name _____________________________________________________ Birth Date ________________ Grade _______ Last First

Primary Care Provider (Family Dr) _________________________________________ Phone Number_____________________

Specialist Name or NA ________________________________________________ Phone Number_____________________

EMERGENCIES Does the student have a known health problem that could result in an emergency? Yes No

If yes, describe___________________________________________________________________________________________

Does the child ride the bus or shuttle? Yes No

Info the driver should know: ________________________________________________________________________________

HEALTH CONCERNS

Mark the box and explain if your child has a history of, or now has, the following conditions or concerns.

ADD/ADHD ___________________________________ Life Threatening Allergy or other allergy

EpiPen at home EpiPen at school

Bees/Wasps Food __________________

Medication _______________________________

Other: ___________________________________

Seasonal Allergies

Mild Moderate Severe

Symptoms_________________________________

Medication taken?___________________________

Uses inhaler for seasonal allergies? ____________

Asthma

Triggers _____________________________________

Inhaler at school Inhaler at home

Nebulizer at school Nebulizer at home

How often inhaler/ neb typically used?

____________________________________________

Diabetes Type I Type II Uses Insulin

Developmental Concern ________________________

Emotional/ Behavior Concern ____________________

Eyes/ Sight ___________________________________

Wears Glasses? Yes No

Last seen at the eye doctor: ____________________

Eye doctor name _____________________________

Heart/ Murmur/Disease _________________________

Hx of Head Injury / Concussion

Date of diagnosed concussion __________________

Muscle/Bone/Joint ____________________________

Nose / Sinus __________________________________ Seizures

Type of seizures __________________________

Date of last seizure __________________________

Emergency Med at school ____________________

Physical Limitations _________________________

Other _______________________________________

____________________________________________________________

MEDICATIONS Does your child take medications on a routine basis? Yes No If yes, is it taken during school hours? Yes No

List ALL medications that the student takes every day or when needed:

Name of medication _____________________________________________ Purpose of medication: _______________________

Name of medication _____________________________________________ Purpose of medication: _______________________

Name of medication _____________________________________________ Purpose of medication: _______________________ Contact the School Nurse of school office regarding the policies if your child must take medication at school. I authorize the school to contact provider(s) named above in case of emergency, for necessary care related to a health concern for my child, or regarding their diagnosis. I will notify the school if my child’s health status changes, or there is an update or change in medications. The information will be shared only with appropriate school personnel who need to know.

__________________________________________________ ________________________________ Parent Signature Date

MEDICATION PERMISSION FORM For Medication the School Has on Hand for Occasional Use

Student Name _______________________________________________ Age: ______ Birth Date ______________ Last First

List any allergies to medicine here: ___________________________________________________________________ Primary Care Provider (Family Dr) _______________________________________ Phone Number________________

Spencer Schools has a limited supply of medications to be used occasionally as needed. All medications should be taken before or after school hours whenever possible. However, it is understood that under certain circumstances over-the-counter (OTC) medications may occasionally be necessary during the school day to keep the student from missing important education time (for example, hydrocortisone cream for an itchy bug bite).

If the student requires a medication on a regular basis, parent must provide the medication and appropriate forms must be signed.

State law requires written parent/ guardian permission for school health staff to administer medication. Review the medications below and initial the medications you give permission for; or, check the box indicating you do not want any stock OTC medications administered to your child at school.

I do NOT give permission for Spencer Schools to administer any medications the school has on hand.

GENERAL GUIDELINES

1. For Pk-5th grade, parent/ guardian will be notified before acetaminophen (Tylenol) or Ibuprofen is given.

2. For Pk-12th grade, parent will be called before Benadryl is given, unless needed for emergency allergy.

3. All medication will be administered only per label directions according to the age and weight of the student; what the medication is indicated for; and only by trained school staff.

Initial the medications you give permission for:

_____ Acetaminophen (ex:Tylenol): administered orally for minor aches and pains / headaches. Pk-5

th grade: parent will be notified before acetaminophen is given.

_____ Antibiotic Ointment (ex: triple antibiotic ointment): administered topically for minor cuts and scrapes.

_____ Benadryl (diphenhydramine, antihistamine): administered orally for signs of allergic reaction. Pk-12

th grade parent will be notified before Benadryl is given unless needed for emergency

_____ Burn gel/ spray: used to relieve pain from minor burns, cuts & insect bites. Contains Lidocaine HCL 2%

_____ Chewable Antacid (ex:Tums): administered orally for minor upset stomach.

_____ Cough drops: for cough or to sooth minor sore throat; given only to students in 2nd

grade and older who have no increased risk of choking. _____ Hydrocortisone Cream 1%: administered topically for minor itching, bug bites or rash.

_____ Ibuprofen (ex: Advil): administered orally for minor aches and pains / headaches. Pk-5

th grade: parent will be notified before ibuprofen is given.

_____ Lotion, Lip Balm and Vaseline; for dry skin or lips.

_____ Orajel: administered topically for tooth or gum pain. Contains Benzocaine 20%

_____ Sting Relief: to relieve pain for insect stings & bites. Contains Lidocaine HCL 2%

_____THE STUDENT NAMED ABOVE IS NOT ALLERGIC TO THE ABOVE LISTED MEDICATIONS.

Special Instructions: ___________________________________________________________________________

I authorize Spencer School Health Staff to administer the initialed medications as necessary to my child. I authorize Staff to contact my child’s Primary Care Provider as necessary. This information will be shared only with appropriate school personnel who need to know. This consent is valid for the grade/ school year indicated below, if there are changes in permission prior to expiration of this consent, I will notify the School Health Staff immediately. I understand the law provides that there shall be no liability for civil damages as a result of the administration of medication/health care where the person administering the medication/procedure acts as an ordinarily reasonably prudent person would under the same or similar circumstances.

Current Grade or grade my child will attend in the fall (if completing this in the summer): Grade: __________

______________________________________ _________________________________ _____________ Parent/ Guardian Signature Printed Parent Name Date

Init

ial

Last

Nam

e__

___

___

___

___

____

____

___

___

Iowa Department of Public Health CERTIFICATE OF VISION SCREENING

RETURN COMPLETED FORM TO CHILD’S SCHOOL.

Student Last Name: Student First Name: Birth Date (M/D/YYYY):

Parent/Guardian Telephone Number: Student Address:

Zip Code:

Date of Vision Screening: ________________________________

Results (visual acuity):

Right Eye__________ Left Eye__________

Overall Result (Please select one): Referral to eye health professional (Please select one):

Pass or Fail Yes or No

Screening Provider:

Provider Business Name/Source of Screening: (please print)

Provider Name: (please print) Phone:

Signature and Credentials of Provider: Date:

A parent or guardian of a child who is to be enrolled in a public or accredited nonpublic elementary school shall ensure the child is screened for vision impairment at least once before enrollment in Kindergarten and

again before enrollment in the 3rd grade.

To be valid, a minimum of one child vision screening shall be performed no earlier than one year prior to the date of enrollment in Kindergarten and no later than six months after the date of the child’s enrollment in

Kindergarten. To be valid, a minimum of one child vision screening shall be performed no earlier than one year prior to the

date of enrollment in 3rd grade and no later than six months after the date of the child’s enrollment in 3rd grade.

RETURN COMPLETED FORM TO CHILD’S SCHOOL.

Student Information (please print)

Screening Information (vision screening provider must complete this section or parents may attach a copy of vision screening results given to them by a provider.)

Iowa Department of Public Health • Bureau of Family Health FAX 515-725-1760 • 800-383-3826 •

www.idph.state.ia.us 3/01/2015

Iowa Department of Public Health CERTIFICATE OF DENTAL SCREENING

This certificate is not valid unless all fields are complete. RETURN COMPLETED FORM TO CHILD’S SCHOOL.

Iowa Department of Public Health Oral Health Center

515-242-6383 866-528-4020 http://idph.iowa.gov/ohds/oral-health-center A designee of the local board of health or Iowa Department of Public Health may review this certificate for survey purposes.

8/17/2016

Student Last Name:

Student First Name:

Birth Date (M/D/YYYY):

Parent or Guardian Name: Telephone (home or mobile):

Street Address: City: County:

Name of Elementary or High School: Grade Level: Gender: Male Female

Date of Dental Screening: ________________________________

Treatment Needs (check ONE only based on screening results, prior to treatment services provided):

No Obvious Problems – the child’s hard and soft tissues appear to be visually healthy and there is no apparent reason for the child to be seen before the next routine dental checkup.

Requires Dental Care – tooth decay¹ or a white spot lesion² is suspected in one or more teeth, or gum infection³ is suspected.

Requires Urgent Dental Care – obvious tooth decay¹ is present in one or more teeth, there is evidence of injury or severe infection, or the child is experiencing pain.

Screening Provider (check ONE only):

DDS/DMD RDH MD/DO PA RN/ARNP (High school screen must be provided by DDS/DMD or RDH)

Provider Name: (please print)

Phone:

Provider Business Address:

Signature and Credentials of Provider or Recorder*:

Date:

*Recorder: An authorized provider (DDS/DMD, RDH, MD/DO, PA, or RN/ARNP) may transfer information onto this form from another health document. The other health document should be attached to this form.

A screening does not replace an exam by a dentist. Children should have a complete examination by a dentist at least once a year.

RETURN COMPLETED FORM TO CHILD’S SCHOOL.

¹ Tooth decay: A visible cavity or hole in a tooth with brown or black coloration, or a retained root.

² White spot lesion: A demineralized area of a tooth, usually appearing as a chalky, white spot or white line near the gumline. A white spot lesion is considered an early indicator of tooth decay, especially in primary (baby) teeth.

³ Gum infection: Gum (gingival) tissue is red, bleeding, or swollen.

Student Information (please print)

Screening Information (health care provider must complete this section)

Updated 3-1-2017

MEDICATION ADMINISTRATION GUIDELINES Spencer Community Schools

All medications should be taken before or after school hours whenever possible. However, it is understood that certain medications may be required during the school day. Iowa State Law and Spencer Schools allow medications to be administered at school only when the following specific guidelines are met.

Medicine prescribed 3 times a day should be given at home; before, after school and at bedtime. Herbal remedies and supplements will not be administered by school staff.

Spencer Schools has a limited amount of medication on hand and can be used on occasion if parent permission is signed. See “Medication Administration Form – For Medication the School has on Hand for Occasional Use”

PRESCRIPTION MEDICATION: 1. Parent written permission is required each year. Parent instructions cannot conflict with prescriber’s orders.

2. Medication must be in the most current pharmacy-labeled container.

3. A prescription order is required. A current pharmacy-labeled container can serve as the written prescriber’s order.

4. Parents must ask the pharmacist to prepare 2 labeled containers, marking one for “SCHOOL USE” so you have proper containers both at home and school. Pharmacy will prepare a new bottle each time the medication is refilled with a current prescription.

5. Inhalers must have the prescription label directly on the inhaler as well as the box. Parents should request this from the pharmacy.

6. Empty bottles of prescription medication will not automatically be sent home with a student unless under specific circumstances arranged/ approved by nurse or school staff.

OVER THE COUNTER/NON-PRESCRIPTION MEDICATION: 1. Parent written permission is required each year. Parent instructions cannot conflict with label instructions.

2. Over-the-counter medication can only be administered if the label instructions correspond with the student’s age, weight and medication indications.

3. Must be in the unopened, ORIGINAL CONTAINER/ BOX, labeled with the student’s name.

4. School nurse may refuse to administer over-the-counter medication if it is felt that it may be detrimental to the student.

TRANSPORTING AND CARRYING MEDICATION: 1. To ensure the safety of all students, we request that a parent/ guardian deliver all medications to the school

office. In the event that a medication must be sent to school with a student, the parent should notify the school office that medication is being brought that day so the medication can be accounted for.

2. No medication is to be kept by students in their lockers, desks, or on them personally. Medications are to be kept in the school’s designated area.

3. Students who must carry inhalers, insulin or other emergency medications (epi-pen) throughout the school day are required to:

A. have written permission to carry the medication from a parent B. signature from physician certifying the student is capable of self-administration C. demonstrate to the school nurse correct use of medication and/or knowledge of indication of use

4. Parent/ Guardian must pick up remaining medication at the end of the school year or as necessary when a medication is discontinued/ changed.

5. Medications will be transported for field trips according to State of Iowa recommendations. Please contact your child’s school nurse if you have any questions.

SCHOOL USE

Updated 4-11-2017

MEDICATION PERMISSION FORM For Medication Brought From Home to be Given at School

Student’s Name__________________________________________________ Birthdate____________ Grade ______ Last First

Name and Dose of Medication_______________________________________________________________________

This medication is (select one): Over-the-Counter Expiration Date:__________ Prescribed by ____________________________

Amount to be Given___________________________________ __ Route(circle): Mouth Ear Eye other______ Time to be given at school: As needed per label instructions OR These specific times: _________________

Dates to be given at school: This school year OR These specific dates: ____________________________

Reason for Medication:_____________________________ Special instructions: ______________________________

Please review the Medication Administration Guidelines located on the Spencer School website under the “District”, “District Documents” tabs.

Quick Reminders:

Over-the-counter (OTC) medication can only be administered if the label instructions correspond with the student’s age, weight and medication indications unless a Dr Prescription is provided. (Directions must match child’s age – adult medication cannot be given to a child without Dr Script)

OTC medicine should be unopened, in the original container & labeled with the student’s name.

For prescription medication, request the pharmacist to prepare 2 bottles, one for home and one labeled “For School”.

For inhalers, request the pharmacist to label the actual inhaler device as well as the box.

Medicine prescribed 3 times a day should be given at home; before, after school and at bedtime.

PARENT AUTHORIZATION

I have read the Spencer School Medication Administration Guidelines and I request the above health care procedures and / or medications be administered to my child at school. My child has not experienced side effects from this medication. For prescription medications, my instructions do not conflict with the pharmacy label directions. For non-prescription medications, my instructions do not conflict with the product label directions on the original container.

I will notify the school immediately if my child’s health status changes, or there is a change or cancellation of the procedure / medication(s). I give my consent for the school health staff to contact or exchange information as needed with my child’s provider involved with the treatment of care. This information will be shared only with appropriate school personnel who need to know. Medication is only administered by trained school staff. This consent is valid for one year. I understand the law provides that there shall be no liability for civil damages as a result of the administration of medication/health care where the person administering the medication/procedure acts as an ordinarily reasonably prudent person would under the same or similar circumstances. I agree to provide a safe delivery of medication and equipment to and from school.

I agree to pick up remaining medication at the end of the school year, or it will be properly disposed of.

Primary Care Provider/ Prescriber___________________________________ Phone number: _______________

______________________________________ _________________________________ ________________ Parent / Guardian Signature Printed Parent/Guardian Name Date

OR

Child’s Name

For School

Nam

e: _

___

__

__

___

__

__

___

__

__

___

___

__

La

st

Fir

st

Developed by the Iowa Department of Education, Bureau of Nutrition and Health Services 8/2015

Diet Modification Request Form

Description: The United States Department of Agriculture (USDA) reimburses home day care providers, child and adult care centers, summer food service sponsors, schools, residential child care institutions, preschools, and Head Start for meals served to participants that meet USDA requirements. The Child Nutrition Program participating home provider or organization is listed below for meals served in their program. If a participant needs to avoid specific foods for a medical reason, a prescribing licensed medical professional must document the diet modifications and sign this form.

Please complete this form and return to your organization or provider: (Name of home provider or organization)

Participant’s Name: Birth Date: Grade:_________ Parent/Guardian’s Name: _________________________________________________________________

1) Does the participant have a disability? No Yes (identify) If yes, describe the major life activity or functions affected by the disability (see link for definitions of disability

http://www.eeoc.gov/laws/statutes/adaaa_info.cfm) If yes, explain why the disability restricts the participant’s diet: If no, identify the medical condition that does not rise to the level of a disability:

2) Food(s) or Formula to Omit: Food(s) or Formula to Substitute:

3) Texture modifications:

Infants must receive iron-fortified infant formula or breast milk unless an allergy/exception statement is on file.

The back of this form includes additional descriptions No Yes

Licensed prescribing medical professional*: Name (Print or Type) Title *In Iowa licensed prescribing medical professionals include Medical Doctor (MD), Doctor of Osteopathic Medicine (DO), Physician’s Assistant (PA), or Advanced Registered Nurse Practitioner (ARNP).

Signature of medical professional Date

If the participant has a disability, the provider must offer to supply the food substitutions unless doing so would be a documented financial hardship. If the participant does not have a disability, the provider is not required to supply the food substitutions. The parent/guardian may request a nutritionally equivalent substitute for fluid milk without medical professional direction. This site chooses to offer this nutritionally–equivalent product: __________________. Check here if you would like to request the soy milk listed in place of fluid milk and list the reason for the request. ____________________ USDA allows a parent/guardian to supply substitute foods. Check here if you wish to provide the substitute foods: Parent/Guardian signature: _________________________________________ Date: (To document choices and for permission to release information)

USDA is an equal opportunity employer and provider.

Updated 3-1-2017

SICK DAY GUIDELINES Spencer Community Schools

Spencer Schools collaborates with local public health and family care providers to provide guidelines which define when a student is well enough to attend school. Always consult your primary care provider to provide guidance regarding your child’s specific health. Plan ahead each year to arrange how your child will be cared for if they stay home from school due to illness. Always notify the school office immediately if your child’s emergency contact information changes.

Students with the following symptoms should remain home or may be sent home from school due to illness. Students should be symptom free for 24 hours without the use of fever reducing/ pain medication.

­ An oral temperature of 100.0 degrees or higher.

­ Vomiting or diarrhea

­ Symptoms that are paired together with other symptoms, such as:

Body aches, headache or earache

Cough that he or she cannot control, sneezing often

Reddened, or eyes that are draining

Sore Throat—a minor sore throat is ok for school, but a severe sore throat could be strep throat, even if there is no fever. Other symptoms of strep throat in children are headache, stomach upset, or rash. Call your doctor if your child has these symptoms. A special test is needed to know if it is strep throat. TIP: Remember to change your toothbrush if you have a diagnosis of strep throat!

Very tired or lack of appetite

­ Unexplained or undiagnosed rash

­ Communicable illness which poses a risk to disease transmission to others.

24-hour rule: Fever (100 degrees or higher): Keep your child home for 24 hours after fever is gone without the use of fever reducing medicine.

Vomiting or diarrhea: Keep your child home for 24 hours after the last time they vomited or had diarrhea and is eating a normal diet.

Antibiotics: Keep your child home at least 24 hours after the first dose of antibiotic. If your provider’s recommendations

are different, ask them to write a note for the school

Updated 5-18-2017

SPENCER COMMUNITY SCHOOL DISTRICT Health Office

RESOURCES FOR SCHOOL SCREENINGS IN THE SPENCER AREA

CARE COORDINATION Clinic Phone

Child Health Specialty Clinics 712-264-8517

Child Health Specialty Clinics (CHSC) helps families with children with special healthcare needs. They can help families to find local resources and coordinate care. CHSC staff can help you in obtaining resources for your child’s screenings.

VISION

Clinic Phone number Pertinent Info

Total Family Eye Care 712-262-3331 Free PK & kinder screenings

Exact Eye Care 712-262-3982 PK and Kinder screenings = $20

Eyecare Centre 712-262-1589 Free one time PK and Kinder screening

Walmart Vision Center 712-262-5451

Sibley Eye Care 712-754-4621 Satellite clinic in Hartley once a week. Vision Therapy offered in Hartley

DENTAL Clinic Phone Pertinent Info

Schmidt Pediatric Dentistry 712-262-3300

VanHofwegen & Munter Family Dentistry

712-262-7278

Fox, Boyd, Sailor & Shriver Dental 712-262-9650

Iowa Dentistry – Dr Phelps 712-262-9133

I-Smile 515-573-4017

I-Smile helps children connect with dental services. Coordinators can help families get their child screened & help find follow-up care.

WELL CHILD EXAM Clinic Phone Pertinent Info

Avera Medical Group- Spencer 712-264-3500

Crown Clinics 712-580-4570

Spencer Convenient Healthcare 712-580-6592

IMMUNIZATIONS Clinic Phone

Clay Co Public Health 712-264-6380

Open every Tuesday and Wednesday from 9am-5pm (closed 12 -1:00). Located on the 2nd floor of the Spencer Medical Arts Building, 116 E 11th St. South of Spencer Hospital. Call for an appointment. Most Insurances cover immunizations 100%. Resources are available to cover the cost of vaccine if you do not have insurance to cover.