ILLINOIS SCHOOL HEALTH REQUIREMENTS 2018-19 Forms are required by August 15, 2018 Students without proof of vaccination are subject to exclusion as described in the school code of Illinois http://www.ilga.gov/commission/jcar/admincode/077/07700665sections.html Minimum Immunization Requirements

QUESTIONS? Please contact your school nurse for health requirements or student medication and health concerns Ames: 708-447-7269 Blythe: 708-447-7444 Central: 708-447-7112 Hauser: 708-447-7494 Hollywood: 708-447-7721

New Early Learners (including Special Education Services) o Physical examination • completed within 1 year prior to date of entry by medical provider • recorded up to date State of Illinois age required immunizations o DPT/DTaP 4 doses (including 1 booster) o IPV/OPV 3 doses (including 1 booster) Varicella 1 dose after 12 months or proof of immunity o MMR 1 dose after 12 months o Hepatitis B 3 doses (at appropriate intervals) o HIB 1 dose after 15 months o Pneumococcal 1 dose (if did not receive primary series of vaccine) • medical history on back of form completed and signed by parent/guardian Kindergarten o Physical examination • completed within 1 year prior to date of entry by medical provider • recorded up to date State of Illinois age required immunizations o DPT/DTaP 4 doses (last one after 4th birthday) o IPV/OPV 4 doses (last one after 4th birthday) o Varicella 2 dose after 12 months OR proof of immunity o MMR 2 doses after 12 months • medical history on back of form completed and signed by parent/guardian o Vision Exam • exam performed by licensed optometrist within 1 year prior to date of entry • back of form signed and dated by parent/guardian o Dental Examination • Performed by a licensed dentist • exam date no older than 18 months before May 15th of current school year

2nd Grade o Dental Examination • Performed by a licensed dentist • Exam date no older than 18 months before May 15th of current school year 6th Grade o Physical examination • completed within 1 year prior to date of entry by medical provider • recorded up to date State of Illinois age required immunizations o IPV/OPV 4 doses (last one after 4th birthday) o MMR 2 doses after 12 months or proof of immunity o Hepatitis B vaccine 3 doses at the appropriate intervals. o Varicella 2 doses or proof of immunity o Proof of Tdap o Proof of one dose of Meningococcal Vaccine (meningitis). • medical history on back of form completed and signed by parent/guardian o Dental Examination • Performed by a licensed dentist • Exam date no older than 18 months before May 15th of current school year New Students from out of State o Physical examination o completed within 1 year prior to date of entry by medical provider o recorded up to date State of Illinois age required immunizations o medical history on back of form completed and signed by parent/guardian o Vision Exam • exam performed by licensed optometrist within 1 year prior to date of entry • back of form signed and dated by parent/guardian New Students from another Illinois School o Transfer of current Illinois school health records o Physical examination with up to date immunizations o Dental exam o Vision exam Returning Students: 1st Grade 3rd Grade 4th Grade 5th Grade o No new requirements o physical immunization on file in Health Office

STATE FORMS (REQUIRED) Child Health Examination Form Physical Examination/Immunization Forms

Child Health Examination Form in Spanish Illinois Certificate of Religious Exemption IHSA Pre-Participation Examination Form.pdf (sports Grades 6-8)

Sport Physical

Dental Examination Form

Dental Exam Forms

State of Illinois Eye Examination Form

Eye Exam Forms

SUBMIT FORMS TO MEDICATION FORMS

SCHOOL NURSE ALONG

(IF APPLICABLE)

WITH MEDICATION

Medication Authorization Form

District Medication Forms Required for all prescribed as well as over the counter medications

Student Asthma Action Plan Food Allergy Emergency Action Plan

63 Woodside Road Riverside, Illinois 60546 (708) 447-5007 Fax (708) 447-3252 www.district96.org

Feb 2018