Section 665.150  Report Forms

Health examinations shall be reported on the forms that the Department of Public Health and the Illinois State Board of Education prescribe for statewide use.  The required form is the Certificate of Child Health Examination provided by the Department.  For eye examinations, the required form is the Illinois Department of Public Health Eye Examination Report. For dental examinations, the required form is the Illinois Department of Public Health Dental Examination Report.

a)         For transfer students from out of the State or out of the country, or from a federal Head Start program, a health form that is comparable to the Illinois requirements may be accepted only at the time of first entry into an Illinois school.  (A statement by a physician  or other health care provider indicating only that an examination was  conducted is not acceptable.)

b)         The physical examination shall include gender and date of birth; an evaluation of height, weight, BMI, blood pressure, skin, eyes, ears, nose, throat, mouth/dental; cardiovascular (including blood pressure), respiratory, gastrointestinal, genito-urinary, neurological, and musculoskeletal evaluations; spinal examination; evaluation of nutritional status; lead screening; and other evaluations deemed necessary by the health care provider.

c)          The strongly recommended evaluations include hemoglobin or hematocrit, urinalysis, and testing for sickle cell disease.  It is also recommended that the examiner list any medications that the child takes routinely, diet restrictions/needs, special equipment needed,  other needs, or known allergies.

d)         The health care provider shall summarize on the report form any condition that he/she suspects indicates a need for special services.

e)         The medical history section of the form shall be completed and signed by the parent or legal guardian of the student.  The medical history shall be inclusive, as indicated on the Certificate of Child Health Examination form.

f)         The individual verifying the administration of required immunizations shall record as indicated on the Certificate of Child Health Examination form that the immunizations were administered as required by this Part and any other Department rules requiring immunizations.

g)         Vision and hearing screening are required under the Child Vision and Hearing Test Act [410 ILCS 205] and the Department's rules governing hearing screening (77 Ill. Adm. Code 675) and vision screening (77 Ill. Adm. Code 685).  Completion of the vision and hearing screening data section of the Certificate of Child Health Examination is optional.

h)         If the vision and hearing screening data section is completed, it shall be completed with information provided by the vision and hearing screening personnel certified by the Department.

i)          If the student is required to have a sports physical in the year that coincides with the child health examination requirement, the Certificate of Child Health Examination may be accepted as proof of examination for interscholastic sports if the statement regarding participation in interscholastic sports is completed by the health care provider.

j)          The health care provider shall indicate on the form the results of a tuberculosis skin test screening, if conducted.

(Source:  Amended at 33 Ill. Reg. 8459, effective June 8, 2009)