Fillable DOH Universal Health Certificatefillable

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DOH Universal Health Certificatefillable

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  • 119 other fields

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Department of Health | 899 North Capitol Street, N.E., Washington, DC 20002 | 202.442.5925 | dchealth.dc.gov version 03.13.19 pg1
Universal Health Certificate
Use this form to report your child’s physical health to their school/child care facility which is required by DC Official Code §38-602. Have a licensed
medical professional complete part 2 - 4.
Part 1: Child Personal Information | To be completed by parent/guardian.
Child Last Name: Child First Name: Date of Birth:
School or Child Care Facility Name: Gender:
Male
Female
Non-Binary
Home Address: Apt: City: State: ZIP:
Ethnicity:
(check all that apply)
Hispanic/Latino
Non-Hispanic/Non-Latino
Other
Race:
(check all that apply)
American Indian/
Alaska Native
Asian
Native Hawaiian/
Pacific Islander
Black/African
American
White
Prefer not
to answer
Parent First Name: Parent Last Name: Parent Phone:
Emergency Contact Name:
Emergency Contact Phone:
Insurance Type:
Medicaid
Private
None
Insurance Name/ID #:
Has the child seen a dentist/dental provider within the last year?
Yes
No
I give permission to the signing health examiner/facility to share the health information on this form with my child’s school, child care, camp, or
appropriate DC Government agency. In addition, I hereby acknowledge and agree that the District, the school, its employees and agents shall be immune
from civil liability for acts or omissions under DC Law 17-107, except for criminal acts, intentional wrongdoing, gross negligence, or willful misconduct. I
understand that this form should be completed and returned to my child’s school every year.
Parent/Guardian Signature: _______________________________________________ Date: ____________________
Part 2: Child’s Health History, Exam, and Recommendations | To be completed by licensed health care provider.
Date of Health Exam:
BP:
____ /_____
NML
Weight:
LB
Height:
IN
BMI:
BMI
Percentile:
ABNL
KG
CM
Vision
Screening:
Left eye: 20/________ Right eye: 20/________
Corrected
Uncorrected
Wears glasses Referred Not tested
Hearing Screening: (check all that apply)
Pass
Fail
Not tested
Uses Device
Referred
Does the child have any of the following health concerns? (check all that apply and provide details below)
Asthma
Autism
Behavioral
Cancer
Cerebral palsy
Development
Diabetes
Failure to thrive
Heart failure
Kidney Failure
Language/Speech
Obesity
Scoliosis
Seizures
Sickle Cell
Significant food/medication/environmental allergies that may require emergency medical care.
Details provided below.
Long-term medications, over-the-counter-drugs (OTC) or special care requirements.
Details provided below.
Significant health history, condition, communicable illness, or restrictions.
Details provided below.
Other:
_________________________________________________________________
Provide details. If the child has Rx/treatment, please attach a complete Medication/Medical Treatment Plan form; and if the child was referred, please
note. _______________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
TB Assessment | Positive TST should be referred to Primary Care Physician for evaluation. For questions call T.B. Control at 202-698-4040.
What is the child’s risk level for TB?
High complete skin test
and/or Quantiferon test
Low
Skin Test Date:
Quantiferon Test Date:
Skin Test Results:
Negative
Positive, CXR Negative
Positive, CXR Positive
Positive, Treated
Quantiferon Results:
Negative Positive Positive, Treated
Additional notes on TB test:
Lead Exposure Risk Screening | All lead levels must be reported to DC Childhood Lead Poisoning Prevention. Call 202-654-6002 or Fax: 202-535-2607
ONLY FOR CHILDREN
UNDER AGE 6 YEARS
Every child must have
2 lead tests by age 2
1
st
Test Date:
1
st
Result:
Normal
Abnormal,
Developmental Screening Date:
1
st
Serum/Finger
Stick Lead Level:
2
nd
Test Date:
2
nd
Result:
Normal
Abnormal,
Developmental Screening Date:
2
nd
Serum/Finger
Stick Lead Level:
HGB/HCT Test Date:
HGB/HCT Result:
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Department of Health | 899 North Capitol Street, N.E., Washington, DC 20002 | 202.442.5925 | dchealth.dc.gov version 03.13.19 pg2
Part 3: Immunization Information | To be completed by licensed health care provider.
Immunizations
Provide in the boxes below the dates of Immunization (MM/DD/YY)
Diphtheria, Tetanus, Pertussis (DTP, DTaP)
1
2
3
4
5
DT (<7 yrs.)/ Td (>7 yrs.)
1
2
3
4
5
Tdap Booster
1
Haemophilus influenza Type b (Hib)
1
2
3
4
Hepatitis B (HepB)
1
2
3 4
Polio (IPV, OPV)
1
2
3
4
Measles, Mumps, Rubella (MMR)
1
2
Measles
1
2
Mumps
1
2
Rubella
1
2
Varicella
1
2
Child had Chicken Pox (month & year):
Pneumococcal Conjugate
1
2
3
4
Hepatitis A (HepA) (Born on or after
01/01/2005)
1
2
Meningococcal Vaccine
1
2
Human Papillomavirus (HPV)
1
2
3
Influenza (Recommended)
1
2
3
4
5
6
7
Rotavirus (Recommended)
1
2
3
The child is behind on immunizations and there is a plan in place to get him/her back on schedule. Next appointment is: _________________
Medical Exemption (if applicable)
I certify that the above child has a valid medical contraindication(s) to being immunized at the time against:
Diphtheria
Tetanus
Pertussis
Hib
HepB
Polio
Measles
Mumps
Rubella
Varicella
Pneumococcal
HepA
Meningococcal
HPV
Alternative Proof of Immunity (if applicable)
I certify that the above child has laboratory evidence of immunity to the following and I’ve attached a copy of the titer results.
Diphtheria
Tetanus
Pertussis
Hib
HepB
Polio
Measles
Mumps
Rubella
Varicella
Pneumococcal
HepA
Meningococcal
HPV
Part 4: Licensed Health Practitioner’s Certifications| To be completed by licensed health care provider.
This child has been appropriately examined and health history reviewed and recorded in accordance with the
items specified on this form. At the time of the exam, this child is in satisfactory health to participate in all
school, camp, or child care activities except as noted on page one.
No
Yes
This child is cleared for competitive sports. Additional clearance(s) needed from:
___________________________________________________________________
N/A
No
Yes
Yes, pending additional
clearance
I hereby certify that I examined this child and the information recorded here was determined as a result of the examination.
Licensed Health Care Provider Office Stamp
Provider Name:
Provider Phone:
Provider Signature:
Date:
Access health insurance programs at https://dchealthlink.com. You may contact the Health Suite Personnel through the main office at your child’s school.
OFFICE USE ONLY | Universal Health Certificate received by School Official and Health Suite Personnel.
School Official Name:
Signature:
Date:
Health Suite Personnel Name:
Signature:
Date:
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Completed 19 July 2020

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