Contacts Nurse Mrs. Carla Andersen, BSN, RN 224.488.3250 candersen@nddons.org Health Services Forms Asthma Action Plan Anaphylaxis Action Plan Dental Form Diabetes Action Plan IHSA Pre-Participation Physical Form Medication Administration Form Over-the-Counter Medication Administration Form Religious Exemption to Immunization Form Seizure Action Plan State of Illinois Eye Exam All Students Medication Authorization Form: Complete these forms if your student is to take medication during the school day. This includes self-medication for Asthma inhalers, Epi-Pens, Insulin and over the counter medications stocked in the clinic (Ibuprofen, Acetaminophen, and Benadryl). This form must be signed by both the parent / guardian and your Health Care Provider. All medication needs to be stored in the nurse's office and cannot be kept in the locker or backpacks, except for rescue medication. Freshmen IDPH Certificate of Child Health Examination: The Illinois Department of Public Health (IDPH) mandates a physical for entry into ninth grade. This 2-page form consists of the following sections: Immunizations, Physical Exam and Health History. This form must be signed by your Healthcare Provider. A Parent / Guardian must complete and sign the Health History section.
IDPH Dental Examination: The Illinois Department of Public Health (IDPH) mandates a dental examination for entry into ninth grade. Transfer Students IDPH Certificate of Child Health Examination: This is an IDPH Mandate. This 2-page form consists of the following sections: Immunizations, Physical Exam and Health History. This form must be signed by your Healthcare Provider. A Parent / Guardian must complete and sign the Health History section. International or Transfer Students New to the State of Illinois IDPH Certificate of Child Health Examination: This is an IDPH Mandate. This 2-page form consists of the following sections: Immunizations, Physical Exam and Health History. This form must be signed by your Healthcare Provider. A Parent / Guardian must complete and sign the Health History section.
Illinois Eye Examination Report: This is a two-page form. Athletes IHSA Pre-Participation Form: All athletes must complete the IHSA Sports Physical form annually.
NOTE: this is a different form than what is required for admission. This form must be signed by your Healthcare Provider. A Parent/Guardian and Athlete must complete and sign the Health History section on page 1 of this form. Please email the completed form to the school nurse candersen@nddons.org . If the form is missing or incomplete the athlete will not be eligible for participation; practice or games, until corrected. Seniors Must submit an Immunization Record with proof of Meningococcal vaccination (MCV4) on or after 16 years of age.
Other Forms (If Applicable):
Medical Exemption to Immunization: This is an IDPH mandate. Requires a signed statement by your Health Care Provider delineating the specific contraindication to immunization and the expected duration.
Religious Exemption to Immunization: This is an IDPH mandate. Requires the Parent / Guardian to complete the Illinois Certificate of Religious Exemption. This form must be signed by your Health Care Provider.