H E L E N   K E L L E R  M I D D L E  S C H O O L

One can never consent to creep when one feels an impulse to soar...Helen A. Keller

Information on Health Assessments (Physicals) and Immunizations:

Health Assessment Record Form (click here for  two-sided form, print, complete and return to school nurse.)

When Physicals are required

Physicals (also called “Heath Assessments”) are required for:

· all new students

· all students entering preschool

· all students entering kindergarten

· all students entering 7th grade, please complete during grade 6 year

· all students entering 11th grade, please complete during grade 10 year

· students participating in athletics in grades 9 through 12

In accordance with the Connecticut General Statues, Section 10-206, the Health Assessment must be performed by a legally qualified physician, advanced practice registered nurse (APRN) or physician's assistance (PA) who works with an MD, in the twelve (12) months prior to the student's enrollment (15 months for grades 7 and 11). In Connecticut, a "legally qualified physician " includes MDs and ODs. It does not include chiropractors, naturopaths, or homeopaths.

Students may not enter school without a completed health assessment.

The Physical/Health Assessment Form (also called the “blue form” or the “HAR-3”)

The health assessment must be documented on the State Department of Education's required HAR-3 or "blue form, " and must include, but is not limited to, the following:

· state mandated immunizations

· hemoglobin or hematocrit

· blood pressure, height, and weight

· vision, hearing, dental, and postural screenings

· risk assessment for tuberculosis (If student is in a high-risk group, a Mantoux test for tuberculosis sensitivity must be been administered within the 12 months prior to school entry. It must also be administered at least 48 hours before school entry, since it takes that long before the results can be determined.)

The completed and signed health assessment form must be submitted to the school nurse prior to school entry, preferably before June 15th, but no later than August 15th.

A scanned version of the health assessment form will be accepted only if it is printed on blue paper (for legal and record maintenance purposes).

Attachments cannot be accepted, so be sure that the immunization dates are written directly on the blue form.

Families who may require financial assistance in order to obtain a health assessment for their child should contact the school nurse.

If a parent or legal guardian objects on religious grounds to either the health assessment or to immunizations, the school nurse must receive a signed statement to that effect prior to the start of school. The Immunization Exemptions and Exclusions-From-School form must also be completed and submitted.

If an immunization is contraindicated for medical reasons, a written statement from the physician, including the reason for deferment, must be submitted to the school nurse prior to school entry.

Required Immunizations

In accordance with Connecticut General Statutes, Sec. 10-204a, all students must be protected by adequate immunization. Students must show compliance with the immunization requirements by documentation from a physician or local health agency before they may attend school. This rule applies to: initial entry into school (all grades, including preschool & kindergarten); and to all sixth and seventh graders, who must comply with specific requirements before entering the 7th or 8th grade (see # 7, 8, 9).

Month, Day and Year must be recorded for each dose:

1. DIPTHERIA, TETANUS, PERTUSSIS (DTaP, DTP) – Five (5) doses, unless the last dose was given after the fourth birthday, in which case four is adequate.

2. POLIO (IPV) – Four (4) doses unless the third dose was given after the fourth birthday, in which case three may be accepted.

3. MEASLES – Two (2) doses, the first one given on or after the first birthday and a second dose prior to entering kindergarten.

4. MUMPS – One (1) dose given on or after the first birthday.

5. RUBELLA – One (1) dose given on or after the first birthday.

6. HEMOPHILUS INFLUENZAE TYPE B (HIB) – One (1) dose given on or after the first birthday if entering school prior to age five years; not required for students age five years and older.

7. VARICELLA (Chicken Pox) – One (1) dose given on or after the student’s first birthday and before the thirteenth birthday, OR two (2) doses given at least 4 weeks apart if the first dose was given on or after the thirteenth birthday OR a signed statement from the student’s physician indicating that the student has already had Chicken Pox. All students born January 1, 1997 or later entering preschool or kindergarten and all students entering the 7th grade must show proof of immunization OR immunity to varicella. Proof of immunity is a signed statement from the student’s physician indicating that the student has had a confirmed case of Chicken Pox or confirmation by specific blood test conducted by a certified laboratory.

8. HEPATITIS B (HBV) – Three (3) doses*, the second dose given at least 4 weeks after the first (6 weeks if Hib-containing combination vaccine is used), and the third dose given at least 8 weeks after the second dose and 16 weeks after the first. All new students born 1/1/94 or later must have the full series. Students born after 1/1/94 who are entering the 7th grade, must show proof of at least one dose of Hepatitis B vaccine, and all students entering the 8th grade must show proof of three doses*.

*Students immunized between the ages of 11-15 years with Merck’s 2-dose adolescent hepatitis B vaccine (brand name Recombivax HB, 10 mcg), with two doses spaced at least four months apart will meet the hepatitis B vaccine requirements if the brand name and dosage is documented.

9. TUBERCULOSIS TEST – A Mantoux test for sensitivity to tuberculosis is required as part of the health assessment for entry into school and for any 6th or 10th grade student who is identified as “high risk” for possible exposure to tuberculosis. Determination of high risk must be made by the physician, advanced practice registered nurse, or physician assistant who performs the required health assessment (school entry, 6th grade or 10th grade) according to guidelines of the Connecticut State Department of Public Health. If the school medical advisor questions a low-risk determination, the medical advisor may require the student to have a Mantoux test prior to school entry.


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