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Thursday, September 21, 2017

Health Forms

Please have your child's health care providers complete and return the forms below.

English Health Physical Form = 2 pages

Spanish Health Physical Form = 2 pages

English Dental Examination Form

Spanish Dental Examination Form

State of Illinois Vision Examination Form = 2 pages

Medication Order Forms = 3 pages

Exams & Immunizations

Minimum Immunization Requirements
for Preschool

  • Diphtheria, Tetanus, Pertussis: 4 doses of DTP/DtaP

  • Polio: minimum of 3 doses of IPV

  • MMR (Measles, Mumps, Rubella): 1 dose received on or after the 1st birthday

  • Hepatitis B: 3 doses received at proper intervals

  • Haemophilus Influenza B: HIB vaccine appropriate to age

  • Varicella (Chicken Pox): immunization is required prior to entrance to preschool: 1 dose on or after 1st birthday, or physician’s statement verifying disease history, or laboratory evidence of varicella immunity.

  • Pneumococcal Conjugate: Children 24-59 months of age who have not received the primary series of pneumococcal conjugate vaccine, according to the recommended vaccination schedule, shall show proof of receiving one dose of pneumococcal vaccine. Any child who has reached his or her 5th birthday shall not be required to provide proof of immunization with pneumococcal conjugate vaccine.

Minimum Immunization Requirements
for Kindergarten

  • Diphtheria, Tetanus, Pertussis: 4 or more doses of DTP/DtaP with the last dose qualifying as a booster and received on or after the 4th birthday.

  • Polio: 3 or more doses of the same type of polio vaccine with the last dose qualifying as a booster and received on or after the 4th birthday.

  • MMR (Measles, Mumps, Rubella): 2 doses: the first dose received on or after the 1st birthday; second dose no less than 28 days later

  • Hepatitis B: No requirements

  • Haemophilus Influenza B: HIB immunization not required after 5th birthday

  • Varicella (Chicken Pox): 2 doses: the first dose received on or after the 1st birthday; second dose no less than 28 days later, or physician’s statement verifying disease history, or laboratory evidence of varicella immunity

Minimum Immunization Requirements
for Grades 1-5

  • Diphtheria, Pertussis, Tetanus: 3 or more doses of DTP/DtaP or Td with the last dose qualifying as a booster and received on or after the 4th birthday

  • Polio: 3 or more doses of the same type of polio vaccine with the last dose qualifying as a booster and received on or after the 4th birthday.

  • MMR: 2 doses: the first dose received on or after the 1st birthday; second dose no less than 28 days later

  • Hepatitis B: No requirement. (Required for entrance into Early Childhood classes and grades 6-12)

  • Varicella (Chicken Pox): 1 dose received on or after the 1st birthday, or physician’s verifying disease history, or laboratory evidence of varicella immunity.

Minimum Immunization Requirements
for Grades 6-8

  • Diphtheria, Tetanus, Pertussis: 3 or more doses of DTP/DtaP, with the last dose qualifying as a booster and received on or after the 4th birthday. Any student entering 6th through 12th grade is required to show proof of receiving one dose of Tdap (defined as tetanus, diphtheria, acellular pertussis) vaccine regardless of the interval since the last DTaP, DT or Td dose.

  • Polio: 3 or more doses of the same type of polio vaccine with the last dose qualifying as a booster and received on or after the 4th birthday

  • MMR: 2 doses: the first dose received on or after the 1st birthday; second dose no less than 28 days later

  • Hepatitis B: 3 doses received at proper intervals

  • Varicella (Chicken Pox): For school year 2014-2015: 2 doses of varicella is required for students entering 6th and 9th grade, or physician’s statement verifying disease history, or laboratory evidence of varicella immunity.

Meningococcal: Any child entering the sixth grade shall show proof of having received one dose of meningococcal conjugate vaccine on or after the 11th birthday. Any child entering 12th grade shall show proof of having received two doses of meningococcal conjugate vaccine prior to entering the 12th grade. The first dose shall have been received on or after the 11th birthday, and the second dose shall have been received on or after the 16th birthday, at least eight weeks after the first dose.

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