AR Health Screening for School Entry

Transcripción

1 LIVINGSTON UNION SCHOOL DISTRICT ADMINISTRATIVE REGULATION 5000 STUDENTS AR AR Health Screening for School Entry Cautionary Notice: AB 97 (Ch. 47, Statutes of 2013) repealed Education Code 42605, which provided temporary flexibility for specified "Tier 3" categorical programs, and instead redirects the funding for those categorical programs into the Local Control Funding Formula (LCFF) (Education Code ). The supplemental and concentration grant portions of the LCFF may be used for any schoolwide or districtwide educational purpose in accordance with state regulations to be adopted by January 31, 2014, with a goal of increasing or improving services for English learners, foster youth, and students eligible for free and reducedprice meals. Certain requirements related to Tier 3 categorical program(s) in the following policy or regulation are no longer applicable. Comprehensive Health Screening for Grades K-1 The parent/guardian of a student in kindergarten or first grade shall submit to the Superintendent or designee a certification form developed by the California Department of Health Care Services (DHCS) and signed by the student's health examiner certifying that the student has completed a comprehensive health screening within 18 months prior to entry into first grade or within 90 days thereafter. (Health and Safety Code , ) The Superintendent or designee shall notify parents/guardians of all kindergarten students of the requirement to obtain a health screening and of the availability of the Child Health and Disability Prevention (CHDP) program established pursuant to Health and Safety Code to assist eligible lowincome families in obtaining the health screening. (Health and Safety Code ) The notice and certification form shall be included with the notification of immunization requirements provided to parents/guardians prior to their child's enrollment in kindergarten and shall encourage completion of the health screening simultaneously with immunizations. The notice shall also be provided to the parent/guardian of any student who is enrolling in first grade without having attended kindergarten in the district. In lieu of the certification, the parent/guardian may submit a waiver on a form developed by DHCS indicating that he/she does not want or is unable to obtain a health screening. If the waiver indicates that the parent/guardian was unable to obtain the services, the reasons should be included in the waiver. (Health and Safety Code ) The waiver form shall be provided to a parent/guardian upon request. The completed certification form or the waiver shall be maintained in the student's health file or cumulative record. (5 CCR 432) During the first 90 days of the school year, the Superintendent or designee may contact any parent/guardian of a first-grade student who has not provided either the certification form or the waiver to ensure that the parent/guardian understands the health screening requirement and, if appropriate, his/her possible eligibility for the CHDP program. The Superintendent or designee may exempt a student from exclusion when his/her parents/guardians have been contacted at least twice between the first day and the 90th day after the student's enrollment in first grade and the parents/guardians refuse to provide either a certification form or a waiver. (Health and Safety Code ) (formerly BP ) AR

2 LIVINGSTON UNION SCHOOL DISTRICT ADMINISTRATIVE REGULATION 5000 STUDENTS AR Oral Health Assessment for Grades K-1 No later than May 31 of the relevant school year, the parent/guardian of a kindergarten student, or firstgrade student who was not previously enrolled in kindergarten in a public school, shall certify that the student has received an oral health assessment. The oral health assessment shall have been performed by a licensed dentist or other authorized dental health professional no earlier than 12 months prior to the date of the student's initial enrollment. The parent/guardian shall submit to the Superintendent or designee a California Department of Education standardized form which has been completed and signed by the dental health professional. (Education Code ) The Superintendent or designee shall notify parents/guardians of the oral health assessment requirements. The notification shall, at a minimum, consist of a letter that includes all of the following: (Education Code ) 1. An explanation of the administrative requirements of the law 2. Information on the importance of primary teeth 3. Information on the importance of oral health to overall health and to learning 4. A toll-free telephone number to request an application for Healthy Families, Medi-Cal, or other government-subsidized health insurance programs 5. Contact information for county public health departments 6. A statement of privacy applicable under state and federal laws and regulations The student may be excused from complying with the oral health assessment if his/her parent/guardian indicates on the standardized form that it could not be completed for any of the following reasons: (Education Code ) 1. Completion of an assessment poses an undue financial burden on the parent/guardian. 2. The parent/guardian lacks access to a licensed dentist or other dental health professional. 3. The parent/guardian does not consent to an assessment. Legal Reference: EDUCATION CODE Notice to parents in language other than English Pupil records; Oral health assessment HEALTH AND SAFETY CODE Child Health and Disability Prevention Program expansion Child Health and Disability Prevention Program, especially: Certificate documenting health screening and evaluation services; waiver by parent/guardian Distribution of program information to parents/guardians of kindergarten children Exclusions and exemption; legislative intent of notification contents CODE OF REGULATIONS, TITLE Student records CODE OF REGULATIONS, TITLE Child Health and Disability Prevention Program WEB SITES CSBA: California Department of Education, Health Services: California Dental Association: California Department of Health Care Services, Child Health and Disability Prevention Program: California Healthy Kids Resource Center: Board Revised: (formerly BP ) AR

3 State of California Health and Human Services Agency REPORT OF HEALTH EXAMINATION FOR SCHOOL ENTRY Department of Health Care Services Child Health and Disability Prevention (CHDP) Program To protect the health of children, California law requires a health examination on school entry. Please have this report filled out by a health examiner and return it to the school. The school will keep and maintain it as confidential information. PART I TO BE FILLED OUT BY A PARENT OR GUARDIAN CHILD S NAME Last First Middle BIRTH DATE Month/Day/Year ADDRESS Number, Street City ZIP code SCHOOL PART II HEALTH EXAMINATION TO BE FILLED OUT BY HEALTH EXAMINER NOTE: All tests and evaluations except the blood lead test must be done after the child is 4 years and 3 months of age. IMMUNIZATION RECORD Note to Examiner: Please give the family a completed or updated yellow California Immunization Record. Note to School: Please record immunization dates on the blue California School Immunization Record (PM 286). REQUIRED TESTS/EVALUATIONS DATE (mm/dd/yy) DATE EACH DOSE WAS GIVEN Health History VACCINE First Second Third Fourth Fifth Physical Examination Dental Assessment Nutritional Assessment POLIO (OPV or IPV) DtaP/DTP/DT/Td (diphtheria, tetanus, and [acellular] pertussis) OR (tetanus and diphtheria only) Developmental Assessment Vision Screening Audiometric (hearing) Screening MMR (measles, mumps, and rubella) HIB MENINGITIS (Haemophilus Influenzae B) (Required for child care/preschool only) TB Risk Assessment and Test, if indicated Blood Test (for anemia) Urine Test Blood Lead Test HEPATITIS B VARICELLA (Chickenpox) OTHER (e.g., TB Test, if indicated) Other OTHER PART III ADDITIONAL INFORMATION FROM HEALTH EXAMINER (optional) and RELEASE OF HEALTH INFORMATION BY PARENT OR GUARDIAN RESULTS AND RECOMMENDATIONS Fill out if patient or guardian has signed the release of health information. I give permission for the health examiner to share the additional information about the health check-up with the school as explained in Part III. Please check this box if you do not want the health examiner to fill out Part III. Examination shows no condition of concern to school program activities. Conditions found in the examination or after further evaluation that are of importance to schooling or physical activity are: (please explain) Signature of parent or guardian Date Name, address, and telephone number of health examiner Signature of health examiner Date PM 171 A (09/07) (Bilingual) If your child is unable to get the school health check-up, call the Child Health and Disability Prevention (CHDP) Program in your local health department. If you do not want your child to have a health check-up, you may sign the waiver form (PM 171 B) found at your child s school. CHDP website:

4 State of California Health and Human Services Agency INFORME DEL EXAMEN DE SALUD PARA EL INGRESO A LA ESCUELA Department of Health Services Child Health and Disability Prevention (CHDP) Program Para proteger la salud de los niños, la ley de California exige que antes de ingresar a la escuela todos los niños tengan un examen médico de salud. Por favor, pidale al examinador de salud que llene este informe y entregelo a la escuela este informe sera archivado por la escuela en forma confidencial. PARTE I PARA SER LLENADO POR EL PADRE/LA MADRE O EL GUARDIÁN NOMBRE DEL NIÑO/NIÑA Apellido Primer Nombre Segundo Nombre FECHA DE NACIMIENTO Mes/Día/Año DOMICILIO Número y Calle Ciudad Zona Postal Escuela PARTE II PARA SER LLENADO POR EL EXAMINADOR DE SALUD EXAMEN DE SALUD AVISO: Todas las pruebas y evaluaciones excepto el análisis de sangre para el plomo deben ser hechas después de la edad de 4 años y 3 meses. PRUEBAS Y EVALUACIONES REQUERIDAS FECHA(mm/dd/aa) Historia de Salud Examen Físico Evaluación de Dientes Evaluación de Nutrición Evaluación del Desarrollo Pruebas Visuales Pruebas con Audiómetro (auditivas) Evaluacion de Riesgo y prueba Tuberculosis* Análisis de Sangre (para anemia) Análisis de Orina Análisis de Sangre para el plomo Otra REGISTRO DE INMUNIZACIONES Aviso al Examinador: Por favor dé a la familia, una vez completado, o a la fecha, el Registro de Inmunización de California en papel amarillo. Aviso a la Escuela: Por favor apunte las fechas de inmunización sobre el Registro de Inmunización de la escuela de California en papel azul. FECHA EN QUE CADA DOSIS FUE DADA VACUNA Primero Segundo Tercero Quarto Quinto POLIO (OPV o IPV) DTaP/DTP/DT/Td (difteria, tétano y [acellular] pertusis [tos ferina]) O (tétano y difteria solamente) MMR (sarampión, paperas, rubéola) HIB MENINGITIS (Hemófilo, Tipo B) (Requerida para centros de cuidado para niños y centros preescolares solamente) HEPATITIS B VARICELLA (Viruelas locas) OTRA (e.g. prueba TB, de ser indicado) OTRA PARTE III INFORMACIÓN ADICIONAL DEL EXAMINADOR DE SALUD (optional) y PERMISO PARA DIVULGAR (DISTRIBUIR) EL INFORME DE SALUD RESULTADOS Y RECOMENDACIONES Yo le doy permiso al examinador de salud para que comparta con la escuela la información adicional Llene esta parte si el padre/la madre o el guardián ha firmado el consentimiento para divulgar de este examen como es explicado en la Parte III. (distribuir) la información de salud de su niño/niña. Por favor marque esta caja si Ud. no desea que el examinador llene la Parte III. El examen reveló que no hay condiciones que conciernen las actividades de los programas escolares. Las condiciones encontradas en el examen o después de una evaluación posterior que son de importancia para la actividad escolar o física son: (por favor explique) Firma del padre/madre o guardián Fecha *de ser indicado Firma del examinador de salud Fecha PM 171 A (3/03) (Bilingual) Si su niño o niña no puede obtener el examen de salud llame al Programa de Salud para la Prevención de Incapacidades de Niños y Jovenes (Child Health and Disability Prevention Program) en su departamento de salud local. Si Ud. no desea que su niño(a) tenga un examen de salud, puede firmar la orden (PM 171 B), formulario que se consigue en la escuela de su niño(a). CHDP website:

5 Oral Health Assessment Form California law (Education Code Section ) states your child must have a dental check-up by May 31 of his/her first year in public school. A California licensed dental professional operating within his scope of practice must perform the check-up and fill out Section 2 of this form. If your child had a dental check-up in the 12 months before he/she started school, ask your dentist to fill out Section 2. If you are unable to get a dental check-up for your child, fill out Section 3. Section 1: Child s Information (Filled out by parent or guardian) Child s First Name: Last Name: Middle Initial: Child s birth date: Address: City: Apt.: ZIP code: School Name: Teacher: Grade: Child s Sex: Male Female Parent/Guardian Name: Child s race/ethnicity: White Black/African American Hispanic/Latino Asian Native American Multi-racial Other Native Hawaiian/Pacific Islander Unknown Section 2: Oral Health Data Collection (Filled out by a California licensed dental professional) IMPORTANT NOTE: Consider each box separately. Mark each box. Assessment Date: Caries Experience (Visible decay and/or fillings present) Yes No Visible Decay Present: Yes No Treatment Urgency: No obvious problem found Early dental care recommended (caries without pain or infection; or child would benefit from sealants or further evaluation) Urgent care needed (pain, infection, swelling or soft tissue lesions) Licensed Dental Professional Signature CA License Number Date Section 3: Waiver of Oral Health Assessment Requirement To be filled out by parent or guardian asking to be excused from this requirement Please excuse my child from the dental check-up because: (Check the box that best describes the reason) I am unable to find a dental office that will take my child s dental insurance plan. My child s dental insurance plan is: Medi-Cal/Denti-Cal Healthy Families Healthy Kids Other None I cannot afford a dental check-up for my child. I do not want my child to receive a dental check-up. Optional: other reasons my child could not get a dental check-up: If asking to be excused from this requirement: Signature of parent or guardian Date The law states schools must keep student health information private. Your child's name will not be part of any report as a result of this law. This information may only be used for purposes related to your child's health. If you have questions, please call your school. Return this form to the school no later than May 31 of your child s first school year. Original to be kept in child s school record. T Page 1 of 1 AR (E)

6 Formulario de evaluación de la salud bucal La ley de California (Sección del Código de Educación) exige que su hijo se haga un chequeo dental antes del 31 de mayo de su primer año en una escuela pública. Un profesional de la salud dental matriculado de California que trabaje dentro de su área de especialización debe realizar el chequeo y completar la Sección 2 de este formulario. Si su hijo tuvo un chequeo dental en los 12 meses anteriores al comienzo del año escolar, pídale a su dentista que complete la Sección 2. Si no puede conseguir un chequeo dental para su hijo, complete la Sección 3. Sección 1. Información del menor (debe ser completada por el padre, la madre o el tutor) Primer nombre del menor: Apellido: Inicial del segundo nombre: Domicilio: Ciudad: Fecha de nacimiento del menor: Dpto.: Código postal: Nombre de la escuela: Maestro: Grado: Sexo del menor: Masculino Femenino Nombre del padre/madre/tutor: Raza/origen étnico del menor: Blanco Negro/Afroamericano Hispano/Latino Asiático Indio nativo americano Multirracial Otro Nativo de Hawai/islas del Pacífico Desconocido Sección 2. Información de salud dental: debe ser completada por un profesional de la salud dental matriculado de California (To be completed by a California licensed dental professional) NOTA IMPORTANTE: Considere cada casilla por separado. Marque cada casilla. [IMPORTANT NOTE: Consider each box separately. Mark each box.] Fecha de la evaluación: [Assessment Date:] Incidencia de caries [Caries Experience] (Caries visibles y/o empastes presentes) (Visible decay and/or fillings present)] Sí [Yes] No [No] Caries visibles presentes: [Visible Decay Present:] Sí [Yes] No [No] Urgencia de tratamiento: [Treatment Urgency:] Ningún problema obvio [No obvious problem found] Se recomienda atención dental temprana (caries sin dolor o infección o el niño se beneficiará del sellador dental o de una evaluación adicional) [Early dental care recommended (Caries without pain or infection or child would benefit from sealants or further evaluation)] Se necesita atención urgente (dolor, infección, inflamación o lesiones del tejido blando) [Urgent care needed (pain, infection, swelling or soft tissue lesions)] Firma del profesional de salud dental matriculado Número de matrícula de CA Fecha [Licensed Dental Professional Signature] CA License Number Date] Sección 3. Exención del requisito de evaluación de salud dental Debe ser completado por el padre, la madre o el tutor que solicita que su hijo/a sea eximido de este requisito. Solicito que mi hijo sea eximido de este chequeo dental porque: (marque la casilla que describa el motivo) No puedo encontrar un consultorio dental que acepte el plan de seguro dental de mi hijo. El plan de seguro dental de mi hijo es: Medi-Cal/Denti-Cal Healthy Families Healthy Kids Otro Ninguno No puedo pagar el chequeo dental de mi hijo. No quiero que a mi hijo se le haga un chequeo dental. Opcional: otras razones por las cuales mi hijo no pudo obtener un chequeo dental: Si pide ser eximido de este requisito: Firma del padre, madre o tutor Fecha La ley establece que las escuelas mantengan la privacidad de la información médica de los estudiantes. El nombre de su hijo no formará parte de ningún informe que se realice como resultado de esta ley. Esta información sólo puede ser utilizada para fines relacionados con la salud de su hijo. Si tiene alguna pregunta, comuníquese con la escuela. Regrese este formulario a la escuela antes del 31 de mayo del primer año escolar de su hijo. El original de este formulario será guardado en el registro escolar del menor. Oral Health Assessment Form T (Dec. 2007)

7 State of California Health and Human Services Agency Department of Health Care Services Child Health and Disability Prevention (CHDP) Program WAIVER OF HEALTH EXAMINATION FOR SCHOOL ENTRY CHILD S NAME Last First Middle DATE OF BIRTH Month/Day/Year ADDRESS Number, Street City ZIP Code SCHOOL Teacher PARENT OR GUARDIAN: Please fill out this form if you want to excuse your child from the health examination required by California law for school entry. SIGN AND RETURN THIS FORM TO THE SCHOOL where it will be maintained as confidential information. NOTE: SIGNING THIS WAIVER DOES NOT EXCUSE YOUR CHILD FROM RECEIVING THE IMMUNIZATIONS REQUIRED BY CALIFORNIA LAW FOR CHILDREN IN SCHOOL. ALSO, SIGNING THIS WAIVER WILL NOT DENY YOUR CHILD THE VISION AND HEARING TESTS DONE BY THE SCHOOL. I have been informed about the health examination recommended by health professionals and required by state law. I have been informed about where my child can receive a health examination and about the income levels for receiving it at no cost to me. Please check one of the following: I choose not to have my child receive a health examination as part of the school entry requirement. I would like my child to receive a health examination, but I am unable to obtain it. Reason (see Health and Safety Code, Section ): Signature of parent or guardian Date INQUIRE AT THE SCHOOL OFFICE OR YOUR LOCAL HEALTH DEPARTMENT IF YOU WANT MORE INFORMATION. CHDP website: PM 171 B (Bilingual) (09/07) AR

8 State of California Health and Human Services Agency Department of Health Care Services Child Health and Disability Prevention (CHDP) Program RENUNCIA VOLUNTARIA PARA RECIBIR UN EXAMEN DE SALUD PARA INGRESAR A LA ESCUELA NOMBRE DEL NIÑO/DE LA NIÑA Apellido Primer Nombre Segundo Nombre FECHA DE NACIMIENTO Mes/Día/Año DIRECCIÓN Número/Calle Ciudad Zona Postal ESCUELA Maestro(a) PADRE/MADRE O GUARDIÁN: Si desea que su niño(a) no reciba el examen de salud requerido por la ley de California antes de ingresar a la escuela, por favor llene este formulario. FIRMELO Y DEVUELVALO A LA ESCUELA donde será guardado en forma confidencial. AVISO: EL FIRMAR ESTA RENUNCIA VOLUNTARIA NO DISPENSA PARA QUE EL NIÑO/LA NIÑA RECIBA LAS INMUNIZACIONES REQUERIDAS POR LA LEY DE CALIFORNIA PARA LOS NIÑOS EN LA ESCUELA. TAMBIÉN, EL FIRMAR ESTE FORMULARIO NO LE NEGARÁ A SU NIÑO(A) EL DERECHO A RECIBIR LOS EXÁMENES DE LA VISTA Y EL OÍDO HECHOS POR LA ESCUELA. Se me ha informado acerca del examen de salud recomendado por los respectivos profesionales y requerido por la ley del estado. Se me ha informado también acerca de los lugares donde mi niño(a) puede recibir un examen de salud y sobre los diferentes niveles de ingresos para recibirlo sin costo alguno. Por favor marque uno de los siguientes casilleros: Escojo que mi niño(a) no reciba el examen de salud que es uno de los requisitos para ingresar a la escuela. Me gustaría que mi niño(a) reciba un examen de salud, pero estoy incapacitado(a) para obtenerlo. Razón (vea Health and Safety Code, Sección ): Firma del padre/madre o guardián Fecha SI DESEA MÁS INFORMACIÓN CONSIGALA EN LA ESCUELA O EN SU DEPARTAMENTO LOCAL DE SALUD. CHDP website: PM 171 B (Bilingual) (09/07) AR