Ri School Form PDF Details

In Rhode Island, ensuring that students are ready to engage fully with their educational journey involves more than just enrolling in classes and purchasing school supplies. The STATE OF RHODE ISLAND SCHOOL PHYSICAL FORM plays a pivotal role in this process, serving as a standardized document that provides a comprehensive overview of a student's health status. This form, accepted across all school districts, requires detailed information including vaccinations, physical examination results, chronic health conditions, and any specific medical treatments or medication requirements that may affect the student's health or behavior at school. Additionally, it encompasses screenings for conditions like scoliosis, vision issues, and even lead exposure, ensuring that no aspect of the student's well-being is overlooked. The form also facilitates the creation of tailored action plans for conditions such as asthma, allergies, and diabetes, thereby promoting a safe and supportive learning environment for every student. Vaccination records are meticulously documented, with spaces provided for a wide range of inoculations from Hepatitis B to Influenza, reflecting the state’s commitment to public health within educational settings. Furthermore, the form accommodates for medical exemptions, acknowledging the diverse medical needs and conditions that students may have. Signed and dated by a health care provider, this document stands as a testament to the synergy between health care and education sectors in the pursuit of optimal health and learning outcomes for Rhode Island’s students.

QuestionAnswer
Form NameRi School Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesri school form, ri school physical form, rhode island school physical, ri school physical

Form Preview Example

School Name & Address:

Grade: ________________

STATE OF RHODE ISLAND SCHOOL PHYSICAL FORM

Health Care Provider Name and Address:

Phone:

This form may substitute for any district-issued form. All districts must accept this form. General health examinations shall be documented in a standardized format with one copy available from the Rhode Island Department of Health or in any such format that captures the same fields of information (R16-21SCHO Section 8.4)

Student Name: Last

First

Middle

Date of Birth

Sex

Address: Street

Apt #

City

State

Zip Code

Home Phone

PLEASE COMPLETE ALL INFORMATION BELOW (May attach immunization transcript).

IMMUNIZATIONS

Please enter dates in MM/DD/YYYY format

Hepatitis B

 

 

 

 

 

 

 

 

 

 

 

Diphtheria-Tetanus-Pertussis

 

 

 

 

 

DTaP < 7 years

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal Conjugate

 

 

 

 

 

PCV

 

 

 

 

 

Polio

 

 

 

 

 

 

 

 

 

 

 

Haemophilus Influenzae Type B

 

 

 

 

 

Hib

 

 

 

 

 

Measles-Mumps-Rubella

 

 

 

 

 

MMR

 

 

 

 

 

Varicella

 

 

Student has history of varicella disease

 

 

 

 

 

 

 

 

 

Tetanus-Diphtheria-Pertussis

 

 

 

 

 

Tdap/Td > 7 years

 

 

 

 

 

Rotavirus

 

 

 

 

 

 

 

 

 

 

 

Hepatitis A

 

 

 

 

 

 

 

 

 

 

 

Meningococcal

 

 

 

 

 

 

 

 

 

 

 

HPV

 

 

 

 

 

 

 

 

 

 

 

Influenza

 

 

 

 

 

 

 

 

 

 

 

Medical Exemption:

 

 

 

 

 

 

 

 

 

 

 

 

Hep B

DTaP

PCV

Polio

Hib

MMR

Varicella

Td/Tdap

Rotavirus

Hep A

Mening

HPV

Influenza

 

 

 

 

 

 

 

 

 

 

 

PHYSICAL EXAMINATION

 

 

 

 

 

 

 

 

 

 

Date of PE _____/_____/_____

 

 

Height ___________

Weight___________

 

BP____________

 

PLEASE NOTE ANY HEALTH PROBLEM, CHRONIC HEALTH CONDITION OR DISABILITY THAT MAY AFFECT BEHAVIOR OR HEALTH AT SCHOOL:

 

 

 

1. ASTHMA:

No

Yes If yes, complete an Asthma Action Plan ( www.health.ri.gov/publications/actionplans/2012Asthma.pdf )

 

 

2. ALLERGIES: No

Yes (Please explain) __________________________________EPINEPHRINE AUTO-INJECTOR REQUIRED: No Yes

 

If student has a severe allergy (food, insect, other) complete a

Food Allergy& Anaphylaxis Emergency Care Plan (www.foodallergy.org/document.doc?id=234 )

 

3.DIABETES: No Yes If yes, complete a Physicians Order Form For Students With Diabetes (www.health.ri.gov/forms/school/PhysicianOrdersForStudentsWithDiabetes.pdf)

4.OTHER: ________________________________________________________________________________________________________________________________

Treatment Plan: ____________________________________________________________________________________________________________________________

RESTRICTIONS: Can participate in physical education/sports:

Fully

With limitation _______________________________________________________

MEDICATION (REQUIRED AT SCHOOL): No

Yes

(Please list) _______________________________________________________________________

Other medication(s) that may affect behavior or health at school: _____________________________________________________________________________________

LEAD SCREENING (Required for children < 6 years old)

SCOLIOSIS SCREENING

VISION SCREENING (Children entering Kindergarten)

Student is in compliance with lead screening requirements:

Yes No

Passed Screening

Screened & referred for comprehensive exam

Yes No

 

 

 

Referred for comprehensive exam, but not screened

 

 

 

 

 

 

TUBERCULOSIS (If required by school district)

 

 

Screening / Referral

 

Comprehensive

 

Date of TB test:

 

 

Date:

 

Exam Date:

HEALTH CARE PROVIDER SIGNATURE:

________________________________________________________________

DATE: _________________________________

PRINT NAME:

________________________________________________________________

 

6-2016

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Filling out part 1 in form physical

2. After the previous array of fields is done, you have to include the essential particulars in MMR, Varicella, TetanusDiphtheriaPertussis, TdapTd years, Rotavirus, Hepatitis A, Meningococcal, HPV, Influenza, Medical Exemption, Student has history of varicella, Hep B, DTaP, PCV, and Polio so you're able to proceed further.

Stage # 2 in filling out form physical

Be extremely attentive when completing Meningococcal and Hep B, as this is where many people make mistakes.

3. In this particular stage, check out Treatment Plan, RESTRICTIONS Can participate in, Fully, With limitation, MEDICATION REQUIRED AT SCHOOL No, Yes Please list, Other medications that may affect, LEAD SCREENING Required for, SCOLIOSIS SCREENING, Yes No, Yes No, TUBERCULOSIS If required by school, Date of TB test, VISION SCREENING Children entering, and Comprehensive Exam Date. Each of these should be filled out with highest awareness of detail.

Completing segment 3 in form physical

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