Form Mch-213 E - School Entrance Health Form - Health Information Form/comprehensive Physical Examination Report/certification Of Immunization Page 4
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Anemia Screen (Required) *
Please print all pages
Screen for Anemia (hemoglobin or hematocrit) if any of the following are positive:
Family has low income (Child eligible for Medicaid)
Child eligible for WIC
Migrant or recently arrived refugee
Consumes a diet low in iron
Child has limited access to food
Child with special health care needs
Child with history of iron-deficiency anemia
Child takes medication that inhibits iron absorption
Urine Screen (Required) *
Dipstick test for glucose and protein
Vision Screen (Required) *
Test distance visual acuity in children over 3 years of age with Snellen letters, Snellen numbers, Tumbling E, HOTV, or
Picture tests (Allen figures or LH symbol test)
Distance testing at 10 feet is recommended
Refer if worse than 20/40 with either eye (if child 3-5 years old) or 20/30 (if child 6 years old or older)
Refer if two-line difference between eyes even if within passing range (i.e., 20/25 & 20/40 or 20/20 & 20/30)
Ocular Alignment *
Test ocular alignment in children 3 years of age and older using the unilateral cover test, the Random-dot-E test, or similar test.
Refer if there is any eye movement with the unilateral cover test or less than 4 of 6 correct with the Random-dot-E test.
Hearing Screen (Required) *
Must use pure tone audiometer (if at least 4 years old) - screen at 1000, 2000, & 4000 Hz tones at 20 dB HL in each
ear.
Reposition earphones and rescreen if the child does not pass at this dB level.
Refer to audiologist if child does not pass rescreen at 20dB level.
Lead Screen (Required)
Test children 6 and under who were not previously tested if any of the following are true:
Child receives services from Medicaid or WIC
Child resides in high-risk zip code area (consult
for list of high-risk zip codes)
Child lives in or regularly visits a house or child-care facility built before 1950
Child lives in or regularly visits a house or child-care facility built before 1978 that is being or was renovated within the
past 6 months
Child lives in or regularly visits a house or other structure in which one or more persons have elevated blood lead levels
Child lives with an adult whose job or hobby involves exposure to lead
Child lives near an active lead smelter, battery recycling plant, or other industry likely to release lead
Child’s parent or guardian requests the child’s blood be tested due to any suspected exposure
Health care provider recommends the child’s blood be tested due to any suspected exposure
Tuberculosis Infection Risk (Recommended)
Consider administering a Mantoux TB skin test if the child has one or more of the following risk factors:
Exposure to tuberculosis or to high risk adults
TB-like symptoms
Lived in high prevalence country or extensive travel in areas with high prevalence
Homelessness or resident in congregate living
Medically underserved
HIV infection or receiving immunosuppressive therapy
Other medical risk factors (i.e., malignancy, diabetes)
Local school systems may have specific testing requirements and policies. Please consult with your local health department.
Minimum Immunization Requirements for Entry into School and Day Care (requirements are subject to change)
th
th
3 DTP or DTaP – at least one dose of DTaP or DTP after 4
birthday unless received 6 doses before 4
birthday.
th
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3 Polio Vaccine – at least one dose after 4
birthday unless received 4 doses of all OPV or all IPV prior to 4
birthday.
Hib – 2-3 doses in infancy; 1 booster between 12-15 months; 1 dose between 15-60 months if unvaccinated.
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3 Hep B doses – required for children born on or after January 1, 1994 and for students enrolling in 6
grade on or after
July 1, 2001 if unvaccinated.
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2 Measles – 1
dose on/after 12 months (365 days) of age; 2
dose prior to entering kindergarten.
1 Mumps - on/after 12 months (365 days) of age.
1 Rubella - on/after 12 months (365 days) of age.
1 Varicella – to susceptible children born on/after January 1, 1997; dose on/after 12 months (365 days) of age.
* Source: Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, 2000
MCH-213 E, PART IV (Rev. 10/03)
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