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Health Inventory

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 a physician or certified nurse practitioner 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 Department of Health and Mental Hygiene 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 DHMH 896)
  • Evidence of blood testing is required for all students who reside in a designated at risk area when first entering Pre-kindergarten, Kindergarten, and 1st grade. The blood-lead testing certificate (DHMH 4620) (or another written document signed by a Health Care Practitioner) shall be used to meet this requirement.

Exemptions from a physical examination and immunizations are permitted if they are contrary to a student’s or family's religious beliefs. Students may also be exempted from immunization requirements if a physician/nurse practitioner or health department official 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 families religious beliefs and practices. The Blood-Lead certificate must be signed by a Health Care Practitioner 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 his/her educational experience, please complete Part I of this Physical Examination form. Part II must be completed by a physician or nurse practitioner, or attach a copy of your child’s physical examination to this form. If your child requires medication to be administered in school, you must have the physician complete a medication administration form for each medication. This form can be obtained from your child’s school. If you do not have access to a physician or nurse practitioner or if your child requires a special individualized health procedure, please contact the principal and/or nurse in your child’s school.

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

  • This form is for: MCPS Students
  • Form number: SR-6
  • Last revised: January 2013
Name
PDF Size
Form Number
Health Inventory 125 K SR-6

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat

 

For questions regarding forms, call Harriet Potosky at (301) 279-3538.

Updated January 11, 2013 | Maintained by Missy Gumula
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