Mch 213 G Form PDF Details

Navigating the entrance into public kindergarten or elementary school in Virginia necessitates a thorough preparation in terms of health requirements, a primary aspect of which is encapsulated in the MCH 213 G form. This comprehensive document serves as a tri-partite tool, incorporating Health Information Form, Comprehensive Physical Examination Report, and Certification of Immunization, each section designed to fulfill the state's health prerequisites for school attendees. The form, updated in October 2010, demands that a child's immunization records be current and includes a detailed physical examination before their school entry, aligning with Virginia Code § 22.1-270. Parents or guardians are tasked with completing the initial segment, which captures vital health information and consent for medical discussions with school authorities. The subsequent sections, aimed at documenting immunizations and the physical examination, are strictly for healthcare providers to fill out, ensuring the student meets the minimum health standards for school attendance. Critical in this process is the presentation of a child's allergy status, existing conditions, and overall health readiness, pivotal for crafting a supportive educational environment. Additionally, the form delves into exemptions and conditional enrollments, guidelines that cater to specific health-related stipulations, ultimately safeguarding both the child's wellbeing and public health interests within the school setting.

QuestionAnswer
Form NameMch 213 G Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameshealth forms, virginia school physical form, virginia school entrance health form 2021, virginia school entrance health form

Form Preview Example

COMMONWEALTH OF VIRGINIA

SCHOOL ENTRANCE HEALTH FORM

Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization

Part I – HEALTH INFORMATION FORM

State law (Ref. Code of Virginia § 22.1 -270) requires that your child is immunized and receives a comprehensive physical examination before entering public

kindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of the form. This form must be completed no longer than one year before your child’s entry into school.

Name of School: ____________________________________________________________________________________ Current Grade: _________ ______________

Student’s Name: _________________________________________________________________________________________________________________________

Last

First

Middle

Student’s Date of Birth: _____/_____/_______ Sex: _______

State or Country of Birth: ________________________

Main Language Spoken: ______________

Student’s Address: ______________________________________________________ City: ____________________ State: _______________ Z ip: _______________

 

Name of Mother or Legal Guardian: ______________________________________________

Phone: ______ -______-________

Work or Cell: _____-_____-______

 

Name of Father or Legal Guardian: ______________________________________________

Phone: ______ -______-________

Work or Cell: _____-_____-______

 

Emergency Contact: __________________________________________________________

Phone: ______ -______-________

Work or Cell: _____-_____-______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Condition

Yes

Comments

 

Condition

Yes

Comments

 

Allergies (food, insects, drugs, latex)

 

 

Diabetes

 

 

 

Allergies (seasonal)

 

 

Head injury, concussions

 

 

 

Asthma or breathing problems

 

 

Hearing problems or deafness

 

 

 

Attention-Deficit/Hyperactivity Disorder

 

 

Heart problems

 

 

 

Behavioral problems

 

 

Lead poisoning

 

 

 

Developmental problems

 

 

Muscle problems

 

 

 

Bladder problem

 

 

Seizures

 

 

 

Bleeding problem

 

 

Sickle Cell Disease (not trait

 

 

 

Bowel problem

 

 

Speech problems

 

 

 

Cerebral Palsy

 

 

Spinal injury

 

 

 

Cystic fibrosis

 

 

Surgery

 

 

 

Dental problems

 

 

Vision problems

 

 

Describe any other important health-related information about your child (for example, feeding tube, hospitalizations, oxygen support, hearing aid, etc.):

_____________________________________________________________________________________________________________________________ __________

_______________________________________________________________________________________________________________________________ ________

List all prescription, over-the-counter, and herbal medications your child takes regularly:

_______________________________________________________________________________________________________________________________________

Check here if you want to discuss confidential information with the school nurse or other school authority.

Yes

No

Please provide the following information:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

Phone

 

 

Date of Last Appointment

Pediatrician/primary care provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specialist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dentist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case Worker (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

Child’s Health Insurance: ____ None

____ FAMIS Plus (Medicaid) _____ FAMIS

_____ Private/Commercial/Employer sponsored

I, ______________________________________ (do___) (do not___) authorize my child’s health care provider and designated provider of health care in the

school setting to discuss my child’s health concerns and/or exchange information pertaining to this form. This authorization will be in place until or unless you

withdraw it. You may withdraw your authorization at any time by contacting your child’s school. When information is released from your child’s record, documentation of the disclosure is maintained in your child’s health or scholastic record.

Signature of Parent or Legal Guardian: ______________________________________________________________________Date: _______/________/ _ _________

Signature of person completing this form: ____________________________________________________________________Date:_______/________/___________

Signature of Interpreter: __________________________________________________________________________________Date: ______/_____/_______

MCH 213 G revised 10/2010

1

 
*Poliomyelitis (IPV, OPV)
*Haemophilus influenzae Type b (Hib conjugate)
*only for children <60 months of age
*Pneumococcal (PCV conjugate) *only for children <2 years of age
Measles, Mumps, Rubella (MMR vaccine)
*Measles (Rubeola)
*Rubella
*Mumps
*Hepatitis B Vaccine (HBV)
Merck adult formulation used *Varicella Vaccine
Hepatitis A Vaccine

COMMONWEALTH OF VIRGINIA

SCHOOL ENTRANCE HEALTH FORM

Part II - Certification of Immunization

Section I

To be completed by a physician or his designee, registered nurse, or health department official.

See Section II for conditional enrollment and exemptions.

A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health department official indicating the dates of administration including month, day, and year of the required vaccines shall be acceptable in lieu of recording these dates on this form as long as the record is attached to this form.

Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by the Medical Provider or Health Department Official in the appropriate box.

Student’s Name:

 

 

 

 

 

 

Date of Birth: |____|____|____|

 

 

Last

 

First

 

Middle

Mo. Day Yr.

 

IMMUNIZATION

 

RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Diphtheria, Tetanus, Pertussis (DTP, DTaP)

1

 

2

3

 

4

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Diphtheria, Tetanus (DT) or Td (given after 7

1

 

2

3

 

4

 

5

 

 

years of age)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Tdap booster (6th grade entry)

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

3

 

 

 

 

 

 

 

 

 

1

2

3

 

 

 

 

4

4

 

 

1

2

3

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

Serological Confirmation of Measles Immunity:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

Serological Confirmation of Rubella Immunity:

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

Date of Varicella Disease OR Serological Confirmation of Varicella

 

 

 

 

 

 

Immunity:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

2

Meningococcal Vaccine

1

 

 

 

 

 

 

 

 

 

 

Human Papillomavirus Vaccine

1

2

3

 

 

 

 

 

 

 

 

Other

1

2

3

4

5

 

 

 

 

 

 

Other

1

2

3

4

5

 

 

 

 

 

 

Other

1

2

3

4

5

I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, child

care or preschool prescribed by the State Board of Health’s Regulations for the Immunization of School Children (Minimum requirements are listed in Section III).

* R quired vaccine

 

 

Signature of Medical Provider or Health Department Official:

 

Date (Mo., Day, Yr.):___/___/____

CERTIFICATION OF IMMUNIZATION 11/06

 

 

MCH 213 G revised 10/2010

2

 

Student’s Name:

 

Date of Birth: |____ |_ ___|___ _|

Section II

Conditional Enrollment and Exemptions

Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.

MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would be detrimental to this student’s health. The vaccine(s) is (are) specifically contraindicated because (please specify):

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________.

DTP/DTaP/Tdap:[ ]; DT/Td:[

]; OPV/IPV:[ ]; Hib:[ ]; Pneum:[ ]; Measles:[

]; Rubella:[ ]; Mumps:[

]; HBV:[ ]; Varicella:[ ]

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This contraindication is permanent: [

 

], or temporary [ ] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|.

 

 

 

 

 

 

 

 

 

 

Date (Mo., Day, Yr.):|___|___|___|

Signature of Medical Provider or Health Department Official:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the student’s parent/guardian submits an affidavit to the school’s admitting official stating that the administration of immunizing agents conflicts with the student’s religious

tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained at any local health department, school division superintendent’s office or local department of social services. Ref. Code of Virginia § 22.1-271.2, C (i).

CONDITIONAL ENROLLMENT: As specified in the Code of Virginia § 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccines required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. Next immunization due on __________________.

Signature of Medical Provider or Health Department Official:

 

Date (Mo., Day, Yr.):|___|___|___|

Section III

Requirements

For Minimum Immunization Requirements for Entry into School and

Day Care, consult the Division of Immunization web site at

http://www.vdh.virginia.gov/epidemiology/immunization

Children shall be immunized in accordance with the Immunization Schedule developed and published by

the Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP), otherwise known as ACIP recommendations (Ref. Code of Virginia § 32.1-46(a)).

(requirements are subject to change.)

CERTIFICATION OF IMMUNIZATION 10/2010

MCH 213 G revised 10/2010

3

 

Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT

A qualified licensed physician, nurse practitioner, or physician assistant must complete Part III . The exam must be done no longer than one year before entry into kindergarten or elementary school (Ref. Code of Virginia § 22.1 -270). Instructions for completing this form can be found at www.vahealth.org/schoolhealth

Student’s Name: _______________________________________________

Date of Birth: _____/_____/__________

 

 

Sex: □ M

□ F

 

 

 

 

 

 

 

 

 

Physical Examination

 

 

 

 

 

 

Date of Assessment: _____/_____/_______

1 = Within normal

2 = Abnormal finding

3 = Referred for evaluation or treatment

Assessment

 

Weight: ________lbs. Height: _______ ft. ______ in.

 

Lungs

□

□

□

Abdomen

□

□

□

Genital

□

□

□

 

 

 

 

1

2

3

 

1

2

3

 

1

2

3

 

Body Mass Index (BMI): ___________ BP____________

 

HEENT

□

□

□

Neurological

□

□

□

Skin

□

□

□

 

Age / gender appropriate history completed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health

Anticipatory guidance provided

 

 

□

□

□

 

□

□

□

 

□

□

□

TB Risk Assessment: □ No Risk □ Positive/Referred

 

Heart

Extremities

Urinary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mantoux results: __________________mm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EPSDT Screens Required for Head Start – include specific

results and date:

 

 

 

 

 

 

 

 

 

 

 

Blood Lead:___________________________________________

 

Hct/Hgb ____________________________________________

 

 

Developmental

Screen

Assessed for:

Assessment Method:

Within normal

Concern identified:

Referred for Evaluation

Emotional/Social

 

 

 

 

 

 

 

 

 

Problem Solving

 

 

 

 

 

 

 

 

 

Language/Communication

 

 

 

 

 

 

 

 

 

Fine Motor Skills

 

 

 

 

 

 

 

 

 

Gross Motor Skills

 

 

 

 

 

 

 

 

 

Hearing

Screen

Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.

 

 

1000

2000

 

4000

 

 

 

 

 

 

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

□ Refer

Screened by OAE (Otoacoustic Emissions):

□ Pass

□ Referred to Audiologist/ENT □ Unable to test – needs rescreen

□ Permanent Hearing Loss Previously identified: ___Left ___Right

□Hearing aid or other assistive device

 

With Corrective Lenses (check if yes)

 

 

 

 

Vision Screen

 

Stereopsis

Pass

Fail

 

 

Not tested

 

 

Distance

Both

R

L

 

Test used:

 

 

 

20/

20/

20/

 

 

 

 

Pass

Referred to eye doctor

Unable to test – needs rescreen

 

 

 

 

 

 

 

 

 

 

 

 

 

Dental

Screen

Problem Identified: Referred for treatment

No Problem: Referred for prevention

No Referral: Already receiving dental care

Recommendations to (Pre) School , Child Care, or Early

Intervention Personnel

Summary of Findings (check one):

□Well child; no conditions identified of concern to school program activities

□Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here): _______________________

_____________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________

___ Allergy □ food: _____________________ □ insect: _____________________ □ medicine: _____________________ □ other: _________________

Type of allergic reaction: □ anaphylaxis □ local reaction Response required: □ none □ epi pen □ other: _______________________________

___Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)

___ Restricted Activity Specify: ______________________________________________________________________________________________ ___

___ Developmental Evaluation □ Has IEP □ Further evaluation needed for: ___________________________________________________________

___ Medication.

Child takes medicine for specific health condition(s).

□ Medication must be given and/or available at school.

___ Special Diet

Specify: ______________________________________________________________________________________________________

___ Special Needs Specify: ____________________________________________________________________________________________________ __

Other Comments: _____________________________________________________________________________________________________________

Health Care Professional’s Certification (Write legibly or stamp):

Name : _____________________________________

Signature: ________________________________________ Date: ____/_____/______

Practice/Clinic Name: __________________________________________

Address: ____________________________________________________________

Phone: _______-_______-____________________ Fax: _______-_______-_____________________ Email: _________________________________________

MCH 213 G revised 10/2010

4

 

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