If yes regarding

medication,

special treatments

or procedures,

physician must

complete over-

the-counter

and/or

medication

authorization

forms.

Bishop McNamara High School Student Medical Forms PART 1 - HEALTH ASSESSMENT (Questionnaire)

This form is to be completed by the Parent or Guardian

List all Prescription, Emergency and OTC medications on forms: Admin of OTC Meds and/or MD State Medication Admin Auth. Forms

TO BE COMPLETED BY PHYSICIAN

NAME: __________________________________________________ D.O.B.: ____/____/_____ Grade: _______ PE-Sport(s)-Dance:___________________________

1. MEDICAL CONDITION: Does the child have a diagnosed medical condition? YES NO (e.g., seizure, insect sting allergy, asthma, bleeding problem, diabetes, heart problem, other). Specify:____________________________________________________________ _________________________________________________________________________________________________________________________________________________________

2. If YES does the condition require EMERGENCY ACTION while he/she is at school or athletic activities? Please describe necessary actions or indicators for condition.

__________________________________________________________________________________________________________________________________________________________

3. SICKLE CELL: Has this individual been tested for SICKLE CELL? YES NO Date: ________________

IF YES please indicate the results: NEGATIVE POSITIVE POSITIVE TRAIT

4. Is the child on regular medication? YES NO IF YES – Name of Medication(s) - ______________________________________________________________________________________________________________

5. Date of most recent TETANUS immunization: ____________________________

Height: ___________ Weight: __________ BP: ___________ Pulse: ___________ Vision ______/__20__

CLEARED FOR ALL PHYSICAL ACTIVITY

NOT CLEARED - REASON: __________________________________________________________________________________________________________________________

Note, should the above named individual have any restrictions, a letter from the individual’s physician must accompany this form explaining any and all medical conditions as well as indicate restrictions and level of participation. Bishop McNamara High School reserves the right to make final decisions as to the above named individual’s status regarding participation in PE, Dance or interscholastic athletics for Bishop McNamara High School.

Bishop McNamara High School

PART II - PHYSICAL EXAMINATION FORM (must be dated June 1, 2017 or later)

GENERAL MEDICAL WNL Abnormal MUSCULOSKELETAL WNL Abnormal HEALTH AREA CONCERN WNL Abnormal

General Appearance Spine (Neck/Back) ADD / ADHD

Skin Shoulders Behavior/Adjustment

E N T Arms / Elbow Psychosocial

Dental Elbows Development

Lymph Nodes Hands/Wrists Hearing

Chest Hips Immunodeficiency

Heart/Cardiac Legs Lead Exposure/Elevated Lead

Lungs Knees Learning Disabilities/Problems

Abdomen Ankles Nutrition

Hernias Feet GI / GU

Endocrine Neurological/Sensory Speech/Language

Other Other Other

REMARKS: (Please explain any abnormal findings/health concerns or other medical issues that the health staff need to be aware of)

I certify that I have on this date examined this student and that, on the basis of the examination requested by the school authorities and the student’s medical history as furnished to me, I have found no reason which would make it inadvisable for this student to compete in supervised PE, Dance or athletic activities. _____________________________________________________ ________________________________________________________________ _______________________ Examiner Name (Print or Type) Examiner Signature DATE _________________________________________________________________________________________________ _____________________________________ City State Zip Telephone Number If the Physician’s Assistant or Nurse Practitioner performed exam, please give the Name & Address of collaborating physician/group

Bishop McNamara High School ▪ 6800 Marlboro Pike ▪ Forestville, Maryland 20747 ▪ 301-735-8401

Bishop McNamara High School ADMINISTRATION OF OVER-THE-COUNTER MEDICATION

School Year 2017-2018

Dear Parent or Guardian: To request that Bishop McNamara High School administer any Over-the-Counter medication to your child at school, the following is required:

The physician’s signed dated authorization for selected medication at school. Parent signed dated authorization to administer selected medication at school. Parent provided over-the-counter medication is in the original manufacturer’s labeled container Parent/Guardian only must bring medications to the school Nurse’s office Child’s name must be written on the container Physician’s directions, if differing from manufacturer’s instructions Annual renewal of authorization and immediate notification, in writing, of changes.

Please take this form to your physician for his/her signature and instructions for administration if differing from manufacturer’s instructions.

Student’s Name: _________________________________________________DOB_______/_______/_______ Over-the-counter medication Who provides Sign if you want

this given Physician’s instructions, if differing from product label

Advil / ibuprofen School provides

Allegra / fexofenadine School provides

Bio freeze/Icy Hot School provides

Calamine lotion School provides

Children’s acetaminophen School provides

Children’s ibuprofen School provides

Claritin / loratadine Parent provides

Cold medicine/cough syrup Parent provides

Cough drops School provides

Eye drops School provides

Hydrocortisone 1% / anti-itch cream

School provides

Neosporin antibiotic ointment School provides

Tums / calcium carbonate School provides

Tylenol / acetaminophen School provides

Zyrtec / cetirizine Parent provides

I request the above student be given the over-the-counter medications I have signed for above on an as needed basis at school and school activities by qualified staff, according to the manufacturer’s instructions or the physician’s instructions if they should differ.

I understand the law provides that there shall be no liability for civil damages as a result of the administration of medication where the person administering the medication acts as an ordinarily reasonably prudent person would under the same or similar circumstances. I agree to provide safe delivery of medications to and from school and to pick up remaining medication and equipment.

Parent or Guardian: _________________________________________ Date: ________________________ Physician’s Signature: ______________________________________ Date: ________________________ Physician’s Printed Name ___________________________________________________________________ Physician’s Address _______________________________________________________________________ Physician’s Phone_______________________________________Fax________________________________

MARYLAND STATE SCHOOL MEDICATION ADMINISTRATION AUTHORIZATION FORM

This order is valid only for school year (current) ___________________ including the summer session. School: _________________________________________________________________________________________________ This form must be completed fully in order for schools to administer the required medication. A new medication administration form must be completed at the beginning of each school year, for each medication, and each time there is a change in dosage or time of administration of a medication.

* Prescription medication must be in a container labeled by the pharmacist or prescriber. * An adult must bring the medication to the school. * The school nurse (RN) will call the prescriber, as allowed by HIPAA, if a question arises about the child and/or the child’s medication.

Prescriber’s Authorization

Name of Student: ___________________________________ Date of Birth: ___________________________ Grade: __________ Condition for which medication is being administered: ______________________________________________________________ Medication Name: ______________________________________Dose: ______________________Route: ___________________ Time/frequency of administration: ____________________________________________ If PRN, frequency: __________________ If PRN, for what symptoms: __________________________________________________________________________________ Relevant side effects: □ None expected □ Specify: ______________________________________________________________ Medication shall be administered from: ________________________________to________________________________

Month I Day / Year Month I Day I Year Prescriber’s Name/Title:_______________________________________ (Type or print) Telephone: _______________________FAX: _____________________ Address:___________________________________________________

___________________________________________________

Prescriber’s Signature: _________________________Date:__________ (Original signature or signature stamp ONLY) (Use for Prescriber’s Address Stamp) A verbal order was taken by the school RN (Name): _______________________ for the above medication on (Date): ___________

PARENT/GUARDIAN AUTHORIZATION I/We request designated school personnel to administer the medication as prescribed by the above prescriber. I/We certify that I/we have legal authority to consent to medical treatment for the student named above, including the administration of medication at school. I/We understand that at the end of the school year, an adult must pick up the medication, otherwise it will be discarded. I/We authorize the school nurse to communicate with the health care provider as allowed by HIPAA. Parent/Guardian Signature: _______________________________________________________ Date: ______________________ Home Phone #: _____________________ Cell Phone #: _______________________ Work Phone #: _______________________

SELF CARRY/SELF ADMINISTRATION OF EMERGENCY MEDICATION AUTHORIZATION/APPROVAL

Self carry/self administration of emergency medication may be authorized by the prescriber and must be approved by the school nurse according to the State medication policy. Prescriber’s authorization for self carry/self administration of emergency medication: _____________________________________ Signature Date School RN approval for self carry/self administration of emergency medication: __________________________________________ Signature Date Order reviewed by the school RN: _____________________________________________________________________________ Signature Date

DHMH Form 896 Center for Immunization

Rev. 2/14 www.dhmh.maryland.gov

MARYLAND DEPARTMENT OF HEALTH AND MENTAL HYGIENE IMMUNIZATION CERTIFICATE

CHILD'S NAME__________________________________________________________________________________________ LAST FIRST MI

SEX: MALE □ FEMALE □ BIRTHDATE___________/_________/________ COUNTY _________________________________ SCHOOL: BISHOP MCNAMARA HIGH SCHOOL GRADE_______ PARENT NAME ______________________________________________ PHONE NO. _____________________________ OR GUARDIAN ADDRESS ____________________________________________ CITY ______________________ ZIP________

To the best of my knowledge, the vaccines listed above were administered as indicated. Clinic / Office Name Office Address/ Phone Number 1. _____________________________________________________________________________ Signature Title Date (Medical provider, local health department official, school official, or child care provider only) 2. _____________________________________________________________________________ Signature Title Date 3. _____________________________________________________________________________ Signature Title Date

Lines 2 and 3 are for certification of vaccines given after the initial signature.

RECORD OF IMMUNIZATIONS (See Notes On Other Side) Vaccines Type

Dose # DTP-DTaP-DT

Mo/Day/Yr

Polio

Mo/Day/Yr

Hib

Mo/Day/Yr

Hep B

Mo/Day/Yr

PCV

Mo/Day/Yr

Rotavirus

Mo/Day/Yr

MCV

Mo/Day/Yr

HPV

Mo/Day/Yr

Dose

#

Hep A

Mo/Day/Yr

MMR

Mo/Day/Yr

Varicella

Mo/Day/Yr

History of

Varicella

Disease

1 1 Mo/Yr

2 2

3 Td Mo/Day/Yr

____

____

____

Tdap Mo/Day/Yr

____

____

FLU Mo/Day/Yr

____

____

Other Mo/Day/Yr

_____

_____ 4

5

COMPLETE THE APPROPRIATE SECTION BELOW IF THE CHILD IS EXEMPT FROM VACCINATION ON MEDICAL

OR RELIGIOUS GROUNDS. ANY VACCINATION(S) THAT HAVE BEEN RECEIVED SHOULD BE ENTERED ABOVE.

MEDICAL CONTRAINDICATION:

Please check the appropriate box to describe the medical contraindication.

This is a: □ Permanent condition □ Temporary condition until _______/________/________ The above child has a valid medical contraindication to being vaccinated at this time. Please indicate which vaccine(s) and the reason for the

contraindication,

Signed: _____________________________________________________________________ Date _______________________ Medical Provider / LHD Official

RELIGIOUS OBJECTION: I am the parent/guardian of the child identified above. Because of my bona fide religious beliefs and practices, I object to any vaccine(s) being given to my child. This exemption does not apply during an emergency or epidemic of disease. Signed: _____________________________________________________________________ Date: _______________________

Date OR

DHMH Form 896 Center for Immunization

Rev. 2/14 www.dhmh.maryland.gov

How To Use This Form

The medical provider that gave the vaccinations may record the dates (using month/day/year) directly on this form (check marks are not acceptable) and certify them by signing the signature section. Combination vaccines should be listed individually, by each component of the vaccine. A different medical provider, local health department official, school official, or child care provider may transcribe onto this form and certify vaccination dates from any other record which has the authentication of a medical provider, health department, school, or child care service.

Only a medical provider, local health department official, school official, or child care provider may sign

‘Record of Immunization’ section of this form. This form may not be altered, changed, or modified in any way.

Notes:

1. When immunization records have been lost or destroyed, vaccination dates may be reconstructed for all vaccines

except varicella, measles, mumps, or rubella. 2. Reconstructed dates for all vaccines must be reviewed and approved by a medical provider or local health

department no later than 20 calendar days following the date the student was temporarily admitted or retained.

3. Blood test results are NOT acceptable evidence of immunity against diphtheria, tetanus, or pertussis (DTP/DTaP/Tdap/DT/Td).

4. Blood test verification of immunity is acceptable in lieu of polio, measles, mumps, rubella, hepatitis B, or varicella vaccination dates, but revaccination may be more expedient.

5. History of disease is NOT acceptable in lieu of any of the required immunizations, except varicella.

Immunization Requirements

The following excerpt from the DHMH Code of Maryland Regulations (COMAR) 10.06.04.03 applies to schools: “A preschool or school principal or other person in charge of a preschool or school, public or private, may not knowingly admit a student to or retain a student in a: (1) Preschool program unless the student's parent or guardian has furnished evidence of age appropriate immunity

against Haemophilus influenzae, type b, and pneumococcal disease; (2) Preschool program or kindergarten through the second grade of school unless the student's parent or guardian has

furnished evidence of age-appropriate immunity against pertussis; and (3) Preschool program or kindergarten through the 12th grade unless the student's parent or guardian has furnished

evidence of age-appropriate immunity against: (a) Tetanus; (b) Diphtheria; (c) Poliomyelitis; (d) Measles (rubeola); (e) Mumps; (f) Rubella; (g) Hepatitis B; (h) Varicella; (i) Meningitis; and (j) Tetanus-diphtheria-acellular pertussis acquired through a Tetanus-diphtheria-acellular pertussis (Tdap) vaccine.”

Please refer to the “Minimum Vaccine Requirements for Children Enrolled in Pre-school Programs and in

Schools” to determine age-appropriate immunity for preschool through grade 12 enrollees. The minimum vaccine requirements and DHMH COMAR 10.06.04.03 are available at www.dhmh.maryland.gov. (Choose Immunization in the A-Z Index) Age-appropriate immunization requirements for licensed childcare centers and family day care homes are based on the Department of Human Resources COMAR 13A.15.03.02 and COMAR 13A.16.03.04 G & H and the “Age-

Appropriate Immunizations Requirements for Children Enrolled in Child Care Programs” guideline chart are available at www.dhmh.maryland.gov. (Choose Immunization in the A-Z Index)