Certificate of Child Health Examination - English

Certificate of Child Health Examination - Spanish

The State of Illinois passed a bill that now requires students with asthma to provide the school nurse with an “Asthma Action Plan.” The “Asthma Action Plan” should be a written plan developed with a student’s medical provider to help control their asthma. Parents or guardians must provide the school nurse with written authorization for self-administration and self-carry of asthma medication. Permission needs to be renewed each school year. The “Asthma Action Plan” must be kept on file in the school nurse’s office. 

Asthma Action Plan - English

Asthma Action Plan - Spanish

Physician Authorization of Treatment is to be completed by a physician and signed by a parent/guardian for students who require specialized nursing care during the school day.

Physician Authorization of Treatment Form - English

Physician Authorization of Treatment Form - Spanish

Care of Students with Diabetes Act Procedure - English

Care of Students with Diabetes Act Procedure - Spanish

Authorization to Provide Diabetes Care by a Delegated Care Aide, Acknowledgement of Responsibilities, and Release of Healthcare Information - English

Authorization to Provide Diabetes Care by a Delegated Care Aide, Acknowledgement of Responsibilities, and Release of Healthcare Information - Spanish

Proof of School Dental Examination Form - English

Proof of School Dental Examination Form - Spanish

Dental Examination Waiver Form - English

Dental Examination Waiver Form - Spanish

Students with diabetes are required to have a Diabetes Medical Management Plan (DMMP) on file. A new plan must be provided to the school ever school year and updated as needed.

Diabetes Medical Management Plan - English

Diabetes Medical Management Plan - Spanish

Authorization to Provide Diabetes Care by a Delegated Care Aide, Acknowledgement of Responsibilities, and Release of Healthcare Information - English

Authorization to Provide Diabetes Care by a Delegated Care Aide, Acknowledgement of Responsibilities, and Release of Healthcare Information - Spanish

The State of Illinois passed a Public Act in 2006 that permits students to carry and self-administer epinephrine auto-injectors with the written authorization of a physician and parent/guardian. Authorization needs to be renewed each school year. A completed Food Allergy & Anaphylaxis Emergency Care Plan should be on file in the nurse’s office for students with severe allergies or who are at risk for anaphylaxis.

Food Allergy & Anaphylaxis Emergency Care Plan - English

Food Allergy & Anaphylaxis Emergency Care Plan - Spanish

All freshmen are required by law to have a physical examination, completed on a Department of Human Services State of Illinois Certificate of Child Health Examination form. Freshmen must present this current physical examination on freshman distribution day. The physical examination needs to be dated within the 12 months prior to freshman distribution day. Your physician will need to sign this form in two places; 1. The immunization portion; and 2. The physical examination portion. A Parent/Guardian needs to complete, sign, and date the “Health History” section on the back of the physical form prior to the appointment with a health care provider. If your student is interested in participating in athletics, an additional copy of the Certificate of Child Health Examination must be submitted to the Athletic Department.

In addition to the Certificate of Child Health Examination form, the Illinois Department of Public Health also requires that students entering grade 9 have a dental exam on file. School dental examinations must have been completed within 18 months of freshman year. The form you will need to submit for this requirement is called the “Proof of School Dental Examination Form.

Certificate of Child Health Examination - English

Certificate of Child Health Examination - Spanish

Proof of School Dental Examination Form - English

Proof of School Dental Examination Form - Spanish

Dental Examination Waiver Form - English

Dental Examination Waiver Form - Spanish

If your student requires medication at school, the medication authorization form must be on file in the nurse’s office. You may download this form using the steps listed above. This form, signed by both a physician and a parent/guardian, is required for both prescription and over-the-counter medications including Tylenol, aspirin, Midol, antacids, etc. as well as asthma inhalers and Epi-pens. Students may carry inhalers and Epi-pens with them during the school day.

Medication Authorization Form - English

Medication Authorization Form Medical Cannabis - English

Medication Authorization Form - Spanish

Medication Authorization Form Medical Cannabis - Spanish

Release of Information - English

Release of Information - Spanish

Illinois Certificate of Religious Exemption Form - English

Illinois Certificate of Religious Exemption Form - Spanish

Seizure Parent Questionnaire - English

Seizure Parent Questionnaire - Spanish

Seizure Action Plan - English

Seizure Action Plan - Spanish

Seizure Smart School Act Procedure - English

Seizure Smart School Act Procedure - Spanish

Authorization to Provide Seizure Care by a Delegated Care Aide, Acknowledgement of Responsibilities, and Release of Healthcare Information - English

Authorization to Provide Seizure Care by a Delegated Care Aide, Acknowledgement of Responsibilities, and Release of Healthcare Information - Spanish

The Illinois Department of Public Health requires that students entering 12th grade must be immunized for meningococcal disease. This vaccination will prevent your student from a severe form of bacterial meningitis as well as other illnesses caused by this bacterium.

All 12th graders will need to show proof of receiving two doses unless the first dose was administered after 16 years of age. In this case, only one dose after 16 years of age is required.

Documentation must be provided to the school nurse before Distribution Day in August. You can submit documentation to the nurse anytime between now and distribution day. If you have questions about the meningococcal vaccination, please contact your school nurse.

Medication Authorization Form - English

Medication Authorization Form - Spanish

Health and Developmental History Form - English

Health and Developmental History Form - Spanish

Health History Update Form - English

Health History Update Form - Spanish

Emergency Consent  & Medical Information - English

Emergency Consent  & Medical Information - Spanish

Physician Authorization for Treatment/Procedures - English

Physician Authorization for Treatment/Procedures - Spanish