Health Forms & Requirements

For New and Returning Students

Immunization Requirements

New Students: State of Connecticut Department of Public Health: “New entrants are any students who are new to the school district, including all preschoolers and all students coming from Connecticut private, parochial and charter schools located in the same or another community. All preschoolers as well as all students entering kindergarten, including those repeating kindergarten, and those moving from any public or private pre-school program, even in the same school district, are considered new entrants. The one exception is students returning from private approved special education placements-they are not considered new entrants.”

Children entering Pre-K or Kindergarten are required to have documentation of immunizations requirements and a physical exam prior to school entry. Your child’s physical exam must be performed after January 1st. Therefore, students will not receive placement until the school nurse has received proof of your child’s required immunization record.

However, if your child is not due for their annual physical exam until after the start of the new school year, we will accept a copy of their current physical. Once their medical provider has completed the updated physical please be sure to complete Part I of the Health Assessment Record before submitting to the school nurse.

CT State Law requires all Pre-K students receive a Flu shot between August 1st and December 31st in order to return to school after January 1st of the New Year, unless exempt.

Transfer Students: Documentation of all required immunizations prior to entry and a complete physical exam within 30 days of entrance for out of country students, and 60 days entrance for US transfer students. In-state transfer students may attend with documentation of all required immunizations prior to entrance. Out of state transfer students from within the US may attend with documentation of all required immunizations and a copy of a complete physical exam dated within one year of the date of entrance, or they will have 60 days to obtain a complete physical exam.

A PPD with results is required for specific individuals entering the school district based upon current district, state, and CDC Guidelines. See your student’s school RN with questions related to this screening.

Pre-K

Early Childhood Assessment Record Medical Evaluation (For children ages birth – 5) – To Parent or Guardian: In order to provide the best experience, early childhood providers must understand your child’s health needs. This form requests information from you (Part I), which will be helpful to the health care provider when he or she completes the health evaluation (Part II). State law requires complete primary immunizations and a health assessment by a physician, an advanced practice registered nurse, a physician assistant, or a legally qualified practitioner of medicine, an advanced practice registered nurse or a physician assistant stationed at any military base prior to entering an early childhood program in Connecticut.

Early Childhood Health Assessment Form – please print on "yellow" paper

Kindergarten to Grade 12

Health Assessment Record Medical Evaluation – To Parent or Guardian: In order to provide the best educational experience, school personnel must understand your child’s health needs. This form requests information from you (Part I), which will also be helpful to the health care provider when he or she completes the medical evaluation (Part II).

State law requires complete primary immunizations and a health assessment by a legally qualified practitioner of medicine, an advanced practice registered nurse or registered nurse, licensed pursuant to chapter 378, a physician assistant, licensed pursuant to chapter 370, a school medical advisor, or a legally qualified practitioner of medicine, an advanced practice registered nurse or a physician assistant stationed at any military base prior to school entrance in Connecticut (C.G.S. Secs. 10-204a and 10-206). An immunization update and additional health assessments are required in the 6th or 7th grade and in the 9th or 10th grade. Specific grade level will be determined by the local board of education. This form may also be used for health assessments required every year for students participating on sports teams.

Health Assessment Form – please print on "blue" paper

6th Grade Mandatory Physical

The State of CT mandates that all 6th grade students receive, and have on file in their cumulative health record, a comprehensive physical examination prior to entry into Grade 7. Parents must complete and sign Part I of the CT blue form, and the physician documents and signs the physical on Part II. This physical must include any needed immunizations, hearing, vision, scoliosis screening and a chronic disease assessment. Please be sure that all *(Mandated Screening) sections are performed and documented during your child’s physical. This physical fulfills the sports physical requirement as long as both the parent and medical provider complete Part I & II respectively.

Health Assessment Form – please print on "blue" paper

7th Grade Requirements

All students prior to entering 7th grade must show proof of having received a Tdap booster vaccine, meningococcal vaccine, and two (2) doses of the varicella vaccine or previous history of disease. Confirmation of vaccines or history of varicella disease must be in writing by a MD, PA, or APRN that the child has a previous history of disease, based on family or medical history.

Health Assessment Form – please print on "blue" paper

Due to new regulatory changes to school immunizations effective July 1, 2015 all students entering 7th grade who claim an immunization exemption based on religious beliefs, a child’s parent or guardian must present a statement that such immunization would be contrary to the religious beliefs of the child or the parent/guardian of the child. The statement must be acknowledged by a judge or family support magistrate, a clerk or deputy clerk of a court having a seal, a town clerk, a notary public, a justice of the peace, an attorney licensed to practice in the state of Connecticut, or a school nurse.

Religious Exemption Immunization Form

Medical Exemption Immunization Form

10th Grade Mandatory Physical

The State of CT mandates that all 10th grade students receive, and have on file in their cumulative health record, a comprehensive physical examination prior to entry into Grade 11. Parents must complete and sign Part I of the CT blue form, and the physician documents and signs the physical on Part II. This physical must include any needed immunizations, hearing, vision, scoliosis screening and a chronic disease assessment. Please be sure that all *(Mandated Screening) sections are performed and documented during your child’s physical. This physical fulfills the sports physical requirement as long as both the parent and medical provider complete Part I & II respectively.

State of CT Mandated Screenings

Mandated screenings are done at all levels and for any student recommended by parent, teacher or physician. The school RN will examine students individually and privately. Screenings are required to be done by the school RN and are mandated by law.
 
Vision Screening: Annually in grades K, 1 & 3 – 5.
Hearing Screening: Annually in grades K, 1 & 3 - 5.
Scoliosis Screening: Annually girls in grades 5 & 7 and boys in grade 8. School RN examines students individually and privately.
 
 
The school nurse will inform parents if any of these screenings indicate need for further examination.

Sports Participation

According to OSPS policy, as approved by the Board of Education, in order for your child to participate in any school sponsored sport and/or tryout a complete Health Assessment form must be on file in the nursing office. This must be updated annually. For the form to be considered complete the parent/guardian must complete Part I and the medical provider must complete Part II.

OSPS Medication Protocol/Policy

Old Saybrook Public Schools Authorization for the Administration of Medicine by School Personnel

Authorization to Administer Medications at School

Connecticut State Law and Regulations 10-212(a) require a written medication order. Any medication, including over-the-counter medications (cough drops, ointments, Advil, prescriptions, inhalers, allergy medications, etc.), needed during school (including before and after school activities) or on school-sponsored field trips MUST have the physician medication authorization form completed in order to be administered as noted in the student handbook. Both the physician’s signature and the parent or guardian signature are required.

Medications are to be delivered directly to the school nurse by the parent or guardian or other responsible adult. Medication prescribed for three times a day is to be given at home unless it is for breathing. Students are not allowed to carry any medication with them. Self-medication by students will only be allowed in situations evaluated by the school nurse to be appropriate. Self-medication in grades Pre-K through 8 will only be considered for medications used to treat a life threatening condition.

Medication must be in a container properly labeled by the pharmacy with the student’s name, medication name and strength, physician’s name, date of the original prescription, and directions for administration. Blister packaging is requested for long-term therapy such as Ritalin.

Not more than 45 school day supply of a prescribed medication will be kept at school. When there is extra medication or the medication order is discontinued, the parent or guardian will be notified. If the medication is not picked up within one week, it will be destroyed as stated on the authorization form.

In those situations where a student receives a medication on a continuous basis, whether at regular intervals or as needed (PRN), and this extends from school year to school year, the Authorization form must be completed at the start of each school year. Both the physician’s signature and the parent or guardian’s signature are required. If you have any questions contact your school’s nurse.

Standard Procedures to follow when students should stay home from school

  1. Fever greater than 100. Student should be fever free for 24 hours without Tylenol or Motrin.
  2. Episode of vomiting or diarrhea. Student should have no vomiting or loose stools for 24 hours before returning to school.
  3. Any student on any medication for a contagious infection must be on the medication for 24 hours before returning to school.
  4. Student who does not eat before school and is complaining of stomach pain.
  5. Excessive nasal discharge, which is colored and continuous.
  6. Sore throat or swollen glands and fever.
  7. Earache with continuous pain.
  8. Rash of unknown origin or blisters and/or discharge.

For questions regarding policies not listed please refer to your student’s school RN and/or handbook.

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District Nursing Coordinator

Karen van der Horst, BSN, RN
860-395-3174




Goodwin School Health Office

Sue Cowan, BSN, RN
860-395-3194
860-388-3360 fax

 

Middle School Health Office

Karen van der Horst, BSN, RN
860-395-3174
860-388-8971 fax

 

High School Health Office

Sheri D'Amato, BSN, RN
860-395-3195
860-388-8989 fax




50 Sheffield Street, Old Saybrook CT 06475
P: 860.395.3157
F: 860.395.3162
Old Saybrook Public Schools

50 Sheffield Street
Old Saybrook CT 06475

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Phone: 860.395.3157
Fax: 860.395.3162

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