Mcps Form Sr 6 PDF Details

Entering Maryland public schools for the first time demands meticulous health and immunization documentation, as outlined by the Montgomery County Public Schools (MCPS) through the meticulous MCPS Form SR-6. Updated in January 2020, this four-page document represents a critical bridge between health care providers, parents or guardians, and school authorities, ensuring each child's well-being is prioritized and monitored. From the compulsory physical examination that must occur within a specified timeline to the detailed immunization records against communicable diseases, the form is comprehensive. It also encompasses mandates for blood lead testing in at-risk areas or for children enrolled in Medicaid as they enter their early educational years. On top of these, exemptions based on religious beliefs or medical advisories against certain vaccines are addressed, allowing for the necessary accommodations. The form is divided into parts that facilitate the collection of health information from parents and authorized health care providers, amalgamating a wide range of data that includes routine care, emergency medical information, medication needs, and even special treatments required during school hours. In addition to ensuring compliance with Maryland State Department of Education and the Maryland Department of Health regulations, the form is a testament to the collaborative effort required to foster a safe and conducive learning environment for every student.

QuestionAnswer
Form NameMcps Form Sr 6
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesform sr 6, mcps sr form, 2020 mcps form, maryland record card

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MCPS Form SR-6

January 2020

Page 1 of 4

Student Record Card 6

Maryland State Department of Education (MSDE)

Maryland Department of Health (MDH)

MONTGOMERY COUNTY PUBLIC SCHOOLS (MCPS)

Rockville, Maryland

MARYLAND SCHOOLS RECORD OF PHYSICAL EXAMINATION

To Parents or Guardians:

In order for your child to enter a Maryland public school for the first time, the following are required:

A physical examination by an authorized health care provider must be completed within nine months prior to entering the public school system or within six months after entering the system. A physical examination form designated by the Maryland State Department of Education and the Maryland Department of Health must be used to meet this requirement.

Evidence of complete primary immunizations against certain childhood communicable diseases is required for all students in preschool through the twelfth grade. A Maryland Immunization Certification form for newly enrolling students may be obtained from the local Department of Health and Human Services or from school personnel. The form and the required immunizations must be completed before a child may attend school. (Form MDH 896).

Evidence of blood lead testing is required for all students who reside in a designated at risk area or who are enrolled in Medicaid when first entering Prekindergarten, Kindergarten, and Grade 1, and for ALL children born on or after January 1, 2015. The Maryland Department of Health and Mental Hygiene Blood Lead Testing Certificate (DHMH 4620) (or another written document signed by an authorized health care provider) shall be used to meet this requirement.

Exemptions from immunizations are permitted if they are contrary to a student’s or family's religious beliefs, and require parent/guardian signature on MDH Form 896. Students also may be exempted from immunization requirements if an authorized health care provider certifies that there is a medical reason not to receive a vaccine. Exemptions from blood lead testing is permitted if it is contrary to a family’s religious beliefs and practices. The Blood Lead Testing Certificate must be signed by an authorized health care provider stating a questionnaire was done.

The health information on this form will be available only to those health and education personnel who have a legitimate educational interest in your child.

In order to assist your child in gaining the most from their educational experience, please complete Part I of this Physical Examination form. Part II must be completed by an authorized health care provider, or attach a copy of your child’s physical examination to this form. If your child requires medication and or a treatment to be administered in school, you must have the authorized health care provider complete a medication and or treatment administration form for each medication and or treatment to be administered. These forms can be obtained from your child’s school or online from the Montgomery County Public Schools (MCPS) website at www.montgomeryschoolsmd.org: MCPS Form 525-12, Authorization to Provide Medically Prescribed Treatment, Release and Indemnification Agreement, MCPS Form 525-13, Authorization to Administer Prescribed Medication, Release and Indemnification Agreement, MCPS Form 525-14, Emergency Care for the Management of a Student with a Diagnosis of Anaphylaxis, Release and Indemnification Agreement for Epinephrine Auto Injector. If you do not have access to an authorized health care provider or if your child requires a special individualized health procedure, please contact the principal and/or school nurse in your child’s school.

Please complete this Physical Examination form and return it to your child’s school as quickly as possible.

MCPS Form SR-6 • Page 2 of 4

PART 1 HEALTH ASSESSMENT

 

 

 

 

 

 

MCPS ID#

 

To be completed by parent/guardian

 

 

 

 

 

 

 

 

 

 

 

 

 

Student’s Name

 

 

 

Birthdate

 

Name of School

Grade

(Last, First, Middle)

 

 

 

 

 

 

 

(Mo., Day, Yr.)

 

 

 

 

(Preferred Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (Number, Street, City, State, Zip)

 

 

 

 

 

 

Phone No.

 

 

 

 

 

 

 

 

 

 

 

Parent/Guardian Names

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Where do you usually take your child for routine medical care?

 

 

 

Phone No.

 

Name:

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

When was the last time your child had a physical exam?

Month

Year

 

 

 

 

 

 

 

 

 

 

 

 

When was the last time your child had a dental exam?

Month

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

Where do you usually take your child for dental care?

 

 

 

 

 

 

Phone No.

 

Name:

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ASSESSMENT OF STUDENT HEALTH

 

 

 

To the best of your knowledge, does your child have any of the following? Please check yes or no below.

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

Comments

 

Anaphylaxis or severe allergic reactions

 

 

 

 

 

 

 

 

 

Allergies (Food, Insects, Medications, Latex)

 

 

 

 

 

 

 

 

 

Allergies (Seasonal)

 

 

 

 

 

 

 

 

 

Asthma or Breathing Problems

 

 

 

 

 

 

 

 

 

Behavioral or Emotional Problems

 

 

 

 

 

 

 

 

 

Birth Defects

 

 

 

 

 

 

 

 

 

Bleeding Problems

 

 

 

 

 

 

 

 

 

Cerebral Palsy

 

 

 

 

 

 

 

 

 

Dental Problems

 

 

 

 

 

 

 

 

 

Diabetes

 

 

 

 

 

 

 

 

 

Ear Problem or Deafness

 

 

 

 

 

 

 

 

 

Eating Problems

 

 

 

 

 

 

 

 

 

Eye or Vision Problems

 

 

 

 

 

 

 

 

 

Head Injury

 

 

 

 

 

 

 

 

 

Heart Problems

 

 

 

 

 

 

 

 

 

Hospitalization (When, Where, Why)

 

 

 

 

 

 

 

 

 

Lead Poisoning/Exposure

 

 

 

 

 

 

 

 

 

Learning problems/disabilities

 

 

 

 

 

 

 

 

 

Limits on Physical Activity

 

 

 

 

 

 

 

 

 

Meningitis

 

 

 

 

 

 

 

 

 

Prematurity

 

 

 

 

 

 

 

 

 

Problem with Bladder

 

 

 

 

 

 

 

 

 

Problem with Bowels

 

 

 

 

 

 

 

 

 

Problem with Coughing

 

 

 

 

 

 

 

 

 

Seizures

 

 

 

 

 

 

 

 

 

Sickle Cell Disease

 

 

 

 

 

 

 

 

 

Speech Problems

 

 

 

 

 

 

 

 

 

Surgery

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

Does your child take any medication? No Yes

If yes, name(s) of medications:_______________________________________________________________________________________________________

Will your child require any medication to be administered in school? No Yes

If yes, name(s) of medications:_______________________________________________________________________________________________________

Will your child require any emergency medications (epinephrine auto-injectors, inhalers, glucagon, Diastat, nebulized medication, etc.) to be adminis- tered in school? No Yes If yes, please list _______________________________________________________________________________________

Will your child require any special treatments (G-tube feedings, catheterizations, etc.) to be administered in school? No Yes

If yes, please list _____________________________________________________________________________________________________________________

I agree that by typing my name and today’s date below, and submitting this form by electronic mail, I am intending that the below constitutes and is the equivalent to my personal signature.

Parent/Guardian Signature

Date

MCPS Form SR-6 • Page 3 of 4

PART II SCHOOL HEALTH ASSESSMENT

 

 

 

MCPS ID#

 

To be completed ONLY by authorized health care provider

 

 

 

 

 

 

 

 

 

Student's Name

Birthdate

 

Name of School

Grade

(Last, First, Middle)

 

(Mo., Day, Yr.)

 

 

 

 

(Preferred Name)

 

 

 

 

 

 

 

 

 

 

 

1. Does the child have a diagnosed medical condition? No Yes

 

 

 

 

 

Specify ___________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

2. Does the child have a health condition which may require EMERGENCY ACTION while at school? (e.g., seizure, severe allergic reaction/anaphylaxis to food or insect sting, asthma, bleeding problem, diabetes, heart problem, or other problem) If yes, please DESCRIBE. Additionally, please work with the school nurse to develop an emergency plan. No Yes

Specify ___________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

3. Are there any abnormal findings on evaluation of concern? No Yes

Specify ___________________________________________________________________________________________________________________________

EVALUATION FINDINGS/CONCERNS

PHYSICAL EXAM

WNL

ABNL

Area of

 

HEALTH AREA OF CONCERN

Yes

No

Concern

 

 

 

 

 

 

Head

 

 

 

 

Attention Deficit/Hyperactivity

 

 

Eyes

 

 

 

 

Behavior/Adjustment

 

 

ENT

 

 

 

 

Development

 

 

Dental

 

 

 

 

Hearing

 

 

Respiratory

 

 

 

 

Immunodeficiency

 

 

Cardiac

 

 

 

 

Lead Exposure/Elevated Lead

 

 

GI

 

 

 

 

Learning Disabilities/Problems

 

 

GU

 

 

 

 

Mobility

 

 

Musculoskeletal/Orthopedic

 

 

 

 

Nutrition

 

 

Neurological

 

 

 

 

Physical Illness/Impairment

 

 

Skin

 

 

 

 

Psychosocial

 

 

Endocrine

 

 

 

 

Speech/Language

 

 

Psychosocial

 

 

 

 

Vision

 

 

 

 

 

 

 

Other

 

 

REMARKS: (Please explain any abnormal findings/health concerns.)

 

 

 

 

 

4. RECORD OF IMMUNIZATIONS: MDH 896 is required to be completed and attached by an authorized health care provider OR a computer

 

generated immunization record must be provided.

 

 

 

 

 

5. Is the child on medication? If yes, indicate medication and diagnosis.

No Yes

 

 

__________________________________________________________________________________________________________________________________

(MCPS Form 525-13, Authorization to Administer Prescribed Medication, Release and Indemnification Agreement and/or MCPS Form 525-14, Emer- gency Care for the Management of a Student with a Diagnosis of Anaphylaxis, Release and Indemnification Agreement for Epinephrine Auto Injector, must be completed for medication administration in school).

6. Will the child require medically provided treatments, such as urinary catheterization, tracheostomy, gastrostomy feedings, and oral suctioning? No Yes If yes, MCPS Form 525-12, Authorization to Provide Medically Prescribed Treatment, Release and Indemnification Agreement, must be completed.

7. Should there be any restriction of physical activity in school? If yes, specify nature and duration of restriction. No Yes MCPS Form 345-22 may be completed.

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

MCPS Form SR-6 • Page 4 of 4

PART II SCHOOL HEALTH ASSESSMENT (CONTINUED)

To be completed ONLY by authorized health care provider

8. Screenings

Results/Date Taken

Comments

Tuberculin Test (PPD, QFT, Questionnaire)

Blood Pressure/Heart Rate

Height

Weight

BMI %tile

Blood Lead Testing (DHMH 4620)

Hemoglobin/Hematocrit

(Student Name) ________________________________________________________________________ has had a complete physical examination and has:

No evident problem that may affect learning or full school participation

Problems noted above

 

 

Additional Comments:

 

Name of Authorized Health Care Provider (Type or Print)

Phone No.

Authorized Health Care Provider Signature

Date

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