Mcps Form Sr 6 – Fill Out and Use This PDF

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

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.

MCPS Form SR-6 • Page 4 of 4

PART II SCHOOL HEALTH ASSESSMENT (CONTINUED)

To be completed ONLY by authorized health care provider

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: