School Year Health Forms

Aug. 5, 2021.   Families are reminded to provide immunization and physical exam documents dated and signed by your child’s PCP (Primary Care Provider) from within the past year to help assure continuity of care while your child is in school.   All students entering grades K, 4, 7, 10, and 11 are required by MA Dept. of Public Health to have these forms filed with the School Nurse:

* Up-to-date Immunization Record (from PCP).  Click link within for School Immunization Requirements for 2021-22.  Note that students and staff ages 12 and above are also encouraged to get the Pfizer BioN Tech Covid Vaccine and all are encouraged to get this year's Influenza Vaccine.  Discuss timing of these doses with your PCP.  Written exemptions, if needed, should be submitted to your building nurse each school year.

* Physical Exam Record (from PCP).  While helpful to have on file for all, students newly enrolling or entering grades K, 4, 7, 10 and 11 are required to have these on file.   Student athletes are also required to provide up-dated physical exam records within every 13 months to maintain eligibility to play.  These need to be kept current for the entire season.  Check out Family ID for Smith Academy for further details and to enroll your student athlete.

Emergency Contact / Authorization to Treat Forms.  Please complete both sides and submit to your building nurse for each child enrolled.

(This section updated:  8/20/21).  "Routine COVID Safety Checks" (formerly "pooled testing")..  We've recently been informed that MA DESE will continue to fund this state-wide initiative to provide optional broad scale surveillance screening for all HPS individuals on a weekly basis.  Because this statewide endeavor is currently being expanded, schools (and families) will need to reapply.  Please watch for updated consent forms to be posted soon.

Exchange of Info Form.  Parents/guardians are encouraged to complete this form each school year to help facilitate coordination of care between school nurses and your child's provider during school hours.

Medication Orders Form  This form (or PCP equivalent) allowing school nurse or designee to administer medications of any kind during regular school hours needs to be filed with your child's building nurse for all prescription, over-the-counter (not already checked on the Auth to Treat form above) and holistic medications.  Medication Exchanges can be arranged by appointment only between the parent/guardian or adult designee directly with the school nurse.  Other staff may not accept medications at any time per DPH regulations.  For the general safety of all students, students may not carry medications of any kind in school without the written permission of the PCP, the parents, and the school nurse to assure safety (with certain exceptions allowed per DPH regulations).

Your child’s providers may fax or email these forms directly to your child’s school nurse.  This summer, please contact Jean Hobbie with any questions.  We look forward to working with you to help your child be healthy, safe, and ready to learn.

Jean Hobbie RN BSN                                         Martha Elliott LPN

School Nurse Manager/HES Nurse                    SA  Nurse                               

(F) (413) 247-0482 / (P) 413 247-5010                (F) (413) 247-0201 / (P) 247-5641

PS:  We encourage you to use the When to Stay Home General List and Streamlined Daily Symptom Report Form (2021) as helpful guides in deciding when to keep your children home if they develop symptoms of any kind.  Please contact your building nurse to report and discuss symptom management.