ADMINISTRATIVE CODE

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 665 CHILD AND STUDENT HEALTH EXAMINATION AND IMMUNIZATION CODE

SUBPART A: GENERAL PROVISIONS

Section 665.100 Statutory Authority (Repealed)

Section 665.105 Definitions

Section 665.110 General Considerations (Repealed)

Section 665.115 Referenced Materials

SUBPART B: HEALTH EXAMINATION

Section 665.120 Health Examination Requirements

Section 665.130 Performance of Health Examination and Verification of Certificate of Child Health Examination

Section 665.140 Timetable for Examinations

Section 665.150 Report Forms

Section 665.160 Proof of Examination

Section 665.210 Proof of Immunizations

Section 665.220 Local School Authority (Repealed)

Section 665.230 School Entrance

Section 665.240 Basic Immunization

Section 665.250 Proof of Immunity

Section 665.260 Booster Immunizations

Section 665.270 Compliance with the School Code

Section 665.280 Health Care Provider Statement of Immunity

Section 665.290 List of Non-immunized Child Care Facility Attendees or Students

SUBPART C: VISION AND HEARING SCREENING

Section 665.310 Vision and Hearing Screening

SUBPART D: DENTAL EXAMINATION

Section 665.410 Dental Examination Requirement

Section 665.420 Dental Examination Timetable

Section 665.430 Dental Examination

Section 665.440 Guidelines (Repealed)

Section 665.450 Waiver of Dental Examination Requirement

SUBPART E: EXCEPTIONS

Section 665.510 Religious Objection

Section 665.520 Medical Exemption

SUBPART F: EYE EXAMINATION

Section 665.610 Eye Examination Requirement

Section 665.620 Vision Examination (Repealed)

Section 665.630 Eye Examination Report

Section 665.640 Indigent Students (Repealed)

Section 665.650 Waiver of Eye Examination Requirement

SUBPART G: DIABETES SCREENING

Section 665.700 Diabetes Screening Requirement

Section 665.710 Diabetes Screening

Section 665.720 Testing Recommendations

Section 665.APPENDIX A Illinois Department of Public Health Eye Examination Report

Section 665.APPENDIX B Vaccination Schedule for Haemophilus influenzae type b Conjugate Vaccines (Hib) (Repealed)

Section 665.APPENDIX C Illinois Department of Public Health Eye Examination Waiver Form

Section 665.APPENDIX D Illinois Department of Public Health Dental Examination Form

Section 665.APPENDIX E Illinois Department of Public Health Dental Examination Waiver Form

Section 665.APPENDIX F Vaccination Schedule for Pneumococcal Conjugate Vaccines (PCV13) (Repealed)

SUBPART A: GENERAL PROVISIONS

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 665 CHILD AND STUDENT HEALTH EXAMINATION AND IMMUNIZATION CODE
SECTION 665.100 STATUTORY AUTHORITY (REPEALED)

Section 665.100 Statutory Authority (Repealed)

(Source: Repealed at 33 Ill. Reg. 8459, effective June 8, 2009)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 665 CHILD AND STUDENT HEALTH EXAMINATION AND IMMUNIZATION CODE
SECTION 665.105 DEFINITIONS

Section 665.105 Definitions

Act – Section 7 of the Child Care Act of 1969.

Advanced practice nurse – a person who is licensed as an advanced practice nurse under the Nurse Practice Act.

Advisory Committee on Immunization Practices or ACIP – a group of medical and public health experts selected by the Secretary of the U.S. Department of Health and Human Services (HHS) following an application and nomination process that develops recommendations on how to use vaccines to control diseases in the United States.

Attendance center – an individual building or site responsible for taking and maintaining attendance records of students.

Body mass index or BMI – the result of a calculation of weight and height measurement used to determine whether an individual's weight is appropriate for his or her height. Body mass index is calculated by multiplying weight in pounds by 703 and dividing by the square of the height in inches.

Weight (lbs) x 703/Height (inches)²

703 (Weight (lbs)/Height (inches)²

Certified vision screener − a person who has been trained by the Illinois Department of Public Health and who holds a current and valid certification from the Department as a vision screener in accordance with the Illinois Child Vision and Hearing Test Act.

Child care facility – any person, group of persons, center, organization or institution who or that is established and maintained for the care of children outside of their home.

Dental examination − an examination, performed by a dentist, that includes, at a minimum, oral health status and treatment needs.

Dentist – a person who is licensed to practice dentistry under the Illinois Dental Practice Act.

Department or IDPH – the Illinois Department of Public Health.

Eye examination – an examination, performed by an optometrist or a physician who provides eye examinations, that includes, at a minimum, history, visual acuity, subjective refraction to best visual acuity near and far, internal and external examination, and a glaucoma evaluation, as well as any other tests or observations that, in the professional judgment of the physician or optometrist, are necessary. (Section 27-8.1(2) of the School Code)

Glaucoma evaluation – an examination that includes the measurement by instrumentation of the intraocular pressure of the eye, and other tests focused on the optic nerve, as needed.

Health care official – a person with signature or administrative authority within a health care, child care or school setting.

Health care provider – a physician, advanced practice nurse, or physician assistant who is authorized to conduct health examinations under Section 27-8.1(2) of the School Code and a pharmacist who is authorized to administer vaccinations under the Illinois Pharmacy Practice Act of 1975.

Local school authority – that person, including, but not limited to, homeless liaison, principal, social worker or registered nurse employed by the school authority, who has ultimate control and responsibility for any public, private/independent or parochial elementary or secondary school, or any attendance center or nursery school operated by an elementary or secondary school or institution of higher learning.

Optometrist – a person who is licensed to practice optometry under the Illinois Optometric Practice Act of 1987.

Pharmacist – a person who is licensed to practice pharmacy under the Illinois Pharmacy Practice Act of 1975.

Physician – a person who is licensed to practice medicine in all of its branches as provided in the Medical Practice Act of 1987.

Physician assistant – a person who is licensed as a physician assistant under the Physician Assistant Practice Act of 1987.

Proof of immunity – documented evidence of the child's having received a vaccine verified by a health care provider, laboratory evidence or proof of disease as described in Section 665.250.

Registered nurse – a person who is licensed as a registered professional nurse under the Nurse Practice Act.

School program – nursery schools, pre-school programs, early childhood programs, Head Start, or other pre-kindergarten child care programs offered or operated by a school or school district.

Subjective refraction – determining the best visual status of the patient using ophthalmic lenses with directed patient response.

Vision screening − mandated vision screening by Department-certified vision screeners under the Child Vision and Hearing Test Act and the Department's rules titled Vision Screening. Vision screening services include testing, evaluation and follow-up, which may include a recommendation for an eye examination.

Visual acuity testing – a measurement of the resolving power of the human eye using standardized testing conditions, usually by distinguishing standardized targets such as letters or children's symbols. It is done far at 20 feet and near at 16 inches without correction, with the present refractive correction, and with best correction by examination, and includes monocular and binocular findings.

(Source: Amended at 41 Ill. Reg. 2973, effective February 27, 2017)

Section 665.110 General Considerations (Repealed)

(Source: Repealed at 18 Ill. Reg. 4296, effective March 5, 1994)

Section 665.115 Referenced Materials

a) The following materials are referenced in this Part:

1) Illinois Statutes:

A) Child Vision and Hearing Test Act [410 ILCS 205]

B) Medical Practice Act of 1987 [225 ILCS 60]

C) Illinois Optometric Practice Act of 1987 [225 ILCS 80]

D) School Breakfast and Lunch Program Act [105 ILCS 125]

E) Illinois Dental Practice Act [225 ILCS 25]

F) Nurse Practice Act [225 ILCS 65]

G) Physician Assistant Practice Act of 1987 [225 ILCS 95]

H) Lead Poisoning Prevention Act [410 ILCS 45]

I) Illinois Pharmacy Practice Act [225 ILCS 85]

J) School Code [105 ILCS 5]

K) Child Care Act of 1969 [225 ILCS 10]

2) Illinois Administrative Rules

A) Control of Tuberculosis Code (77 Ill. Adm. Code 696)

B) Vision Screening (77 Ill. Adm. Code 685)

C) Hearing Screening (77 Ill. Adm. Code 675)

D) Control of Communicable Diseases Code (77 Ill. Adm. Code 690)

b) The following materials are incorporated in this Part:

1) Prevention and Control of Haemophilus influenza Type b Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report (MMRW), February 28, 2014; Vol. 63 #RR-01 (available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6301a1.htm).

2) Prevention of Pneumococcal Disease Among Infants and Children – Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP); Morbidity and Mortality Weekly Report (MMRW), December 10, 2010; Vol. 59, #RR-11 (available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5911a1.htm).

(Source: Amended at 41 Ill. Reg. 2973, effective February 27, 2017)

SUBPART B: HEALTH EXAMINATION

Section 665.120 Health Examination Requirements

a) Health examinations for all public, private/independent and parochial school students in Illinois shall require a physical examination, in accordance with the timetable in Section 665.140, and protection from communicable disease. Lead screening is required as part of the health examination, as specified in Section 665.140(f).

b) Eye examinations are required, as specified in Section 665.610.

c) Dental examinations are required, as specified in Section 665.410.

d) Vision and hearing screenings are required as specified in 77 Ill. Adm. Code 675 (Hearing Screening) and 77 Ill. Adm. Code 685 (Vision Screening).

(Source: Amended at 33 Ill. Reg. 8459, effective June 8, 2009)

Section 665.130 Performance of Health Examination and Verification of Certificate of Child Health Examination

Health examinations, other than dental examinations, eye examinations, and hearing and vision screening, shall be performed by, and the Certificate of Child Health Examination shall be signed by, a physician licensed to practice medicine in all of its branches, an advanced practice nurse who has a written collaborative agreement with a collaborating physician that authorizes him/her to perform health examinations, or a physician assistant to whom has been delegated the performance of health examinations by his/her supervising physician. (Section 27-8.1(2) of the School Code) A physician is required to review and sign any portion of the Certificate of Child Health Examination completed by a registered nurse who is not an advanced practice nurse.

(Source: Amended at 33 Ill. Reg. 8459, effective June 8, 2009)

Section 665.140 Timetable for Examinations

a) The examination shall be conducted within one year:

1) Before the date of entering school (this includes nursery school, special education, Head Start or other pre-kindergarten programs operated by elementary school systems or secondary level school units or institutions of higher learning; and students transferring into Illinois from outside of the State or outside of the country);

2) Before the date of entering kindergarten or first grade;

3) Before the date of entering the sixth grade;

4) Before the date of entering the ninth grade.

b) For students attending school programs where grade levels are not assigned, examinations shall be completed before the date of entering and within one year prior to the school years in which the child reaches the ages of five, 11, and 15.

c) For students from other countries who attend classes, regardless of the duration of stay, examinations shall be completed within one year before the date of entering the school and at other intervals as provided in this Section.

d) Additional health examinations and further evaluations of students may be required when deemed necessary by local school authorities.

e) In programs operated by elementary school systems or secondary level school units or institutions of higher learning, health examinations are recommended for children under five years of age at intervals of not less than two years.

f) Lead screening is required as follows:

1) Lead screening is a required part of the health examination for children between one and seven years of age entering a day care center, day care home, preschool, nursery school, kindergarten or other child care facility, including programs run by a public school district. Each parent or legal guardian shall provide a statement from health care provider that the child has been assessed for risk of lead poisoning or tested or both, if the child resides in an area defined as high risk by the Department or if the child is potentially at high risk for lead poisoning. This statement shall be provided prior to admission and subsequently in conjunction with required physical examinations. (Section 7.1 of the Lead Poisoning Prevention Act)

2) Physicians and other health care providers shall also screen children age seven years and older for lead poisoning in conjunction with the school health examination when, in the medical judgment of the health care provider, the child is potentially at high risk of lead poisoning. (Section 6.2 of the Lead Poisoning Prevention Act)

(Source: Amended at 41 Ill. Reg. 2973, effective February 27, 2017)

TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER j: MATERNAL AND CHILD HEALTH
PART 665 CHILD AND STUDENT HEALTH EXAMINATION AND IMMUNIZATION CODE
SECTION 665.150 REPORT FORMS

Section 665.150 Report Forms

Health examinations shall be reported on the forms that the Department of Public Health and the Illinois State Board of Education prescribe for statewide use. The required form is the Certificate of Child Health Examination provided by the Department. For eye examinations, the required form is the Illinois Department of Public Health Eye Examination Report. For dental examinations, the required form is the Illinois Department of Public Health Dental Examination Report.

a) For transfer students from out of the State or out of the country, or from a federal Head Start program, a health form that is comparable to the Illinois requirements may be accepted only at the time of first entry into an Illinois school. (A statement by a physician or other health care provider indicating only that an examination was conducted is not acceptable.)

b) The physical examination shall include gender and date of birth; an evaluation of height, weight, BMI, blood pressure, skin, eyes, ears, nose, throat, mouth/dental; cardiovascular (including blood pressure), respiratory, gastrointestinal, genito-urinary, neurological, and musculoskeletal evaluations; spinal examination; evaluation of nutritional status; lead screening; and other evaluations deemed necessary by the health care provider.

c) The strongly recommended evaluations include hemoglobin or hematocrit, urinalysis, and testing for sickle cell disease. It is also recommended that the examiner list any medications that the child takes routinely, diet restrictions/needs, special equipment needed, other needs, or known allergies.

d) The health care provider shall summarize on the report form any condition that he/she suspects indicates a need for special services.

e) The medical history section of the form shall be completed and signed by the parent or legal guardian of the student. The medical history shall be inclusive, as indicated on the Certificate of Child Health Examination form.

f) The individual verifying the administration of required immunizations shall record as indicated on the Certificate of Child Health Examination form that the immunizations were administered as required by this Part and any other Department rules requiring immunizations.

g) Vision and hearing screening are required under the Child Vision and Hearing Test Act [410 ILCS 205] and the Department's rules governing hearing screening (77 Ill. Adm. Code 675) and vision screening (77 Ill. Adm. Code 685). Completion of the vision and hearing screening data section of the Certificate of Child Health Examination is optional.

h) If the vision and hearing screening data section is completed, it shall be completed with information provided by the vision and hearing screening personnel certified by the Department.

i) If the student is required to have a sports physical in the year that coincides with the child health examination requirement, the Certificate of Child Health Examination may be accepted as proof of examination for interscholastic sports if the statement regarding participation in interscholastic sports is completed by the health care provider.

j) The health care provider shall indicate on the form the results of a tuberculosis skin test screening, if conducted.

(Source: Amended at 33 Ill. Reg. 8459, effective June 8, 2009)

Section 665.160 Proof of Examination

a) Every student who is required by Section 27-2.8(1) of the School Code and Section 665.140 of this Part to have a health examination shall present proof to the local school authority of having had the health examination prior to the date of entrance to school.

b) For the purpose of this Part, "proof of health examination" refers to completion of the Certificate of Child Health Examination in accordance with Section 665.150.

c) For the purpose of this Part, "proof of eye examination" refers to completion of the Illinois Department of Public Health Eye Examination Report in accordance with Section 665.150.

d) For the purpose of this Part, "proof of dental examination" refers to completion of the Illinois Department of Public Health Dental Examination Report in accordance with Section 665.420.

(Source: Amended at 33 Ill. Reg. 8459, effective June 8, 2009)

Section 665.210 Proof of Immunizations

a) At or about the same time that a child receives a health examination, the child shall present proof to the local school authority of having received such immunizations against preventable communicable diseases as required by this Part. "Proof" means that the individual administering the required immunizations has verified by recording on the Certificate of Child Health Examination form that the immunizations were administered in accordance with this Part.

b) Immunizations shall be administered in accordance with Section 665.240.

(Source: Amended at 41 Ill. Reg. 2973, effective February 27, 2017)

Section 665.220 Local School Authority (Repealed)

(Source: Repealed at 29 Ill. Reg. 18127, effective October 24, 2005)

Section 665.230 School Entrance

a) Every child, prior to enrolling in any public, private, independent or parochial school (including nursery schools, preschool programs, early childhood programs, Head Start, or other pre-kindergarten child care programs offered or operated by a school or school district) in Illinois shall present to that school proof of immunity against:

1) Diphtheria

2) Pertussis

3) Tetanus

4) Poliomyelitis

5) Measles

6) Rubella

7) Mumps

8) Haemophilus influenzae type b (as noted in Section 665.240(h))

9) Hepatitis B (as noted in Section 665.240(i))

10) Varicella (as noted in Section 665.240(j))

11) Invasive pneumococcal disease (except as noted in Section 665.240(k))

12) Meningococcal disease (except as noted in Section 665.240(l))

b) The health care provider or registered nurse verifying the administration of the required immunizations shall record as indicated on the Certificate of Child Health Examination that the immunizations were administered.

c) Any child who does not submit proof of having protection by immunity as required shall receive the needed vaccine. If, for medical reasons, one or more of the required immunizations shall be given after the date of entrance of the current school year, a schedule for the administration of the immunizations and a statement of the medical reasons causing the delay shall be signed by the health care provider or registered nurse who will administer the needed immunizations and shall be kept on file at the local school.

d) Any decision by a school to exclude a student for school entrance for failing to comply with the health examination and immunization requirements set forth in this Part shall be done in accordance with Section 27-8.1 of the School Code and applicable Illinois State Board of Education policies or procedures.

(Source: Amended at 41 Ill. Reg. 2973, effective February 27, 2017)

Section 665.240 Basic Immunization

a) The optimum starting ages for the specified immunizing procedures are as follows:

1) Diphtheria − two to four months

2) Pertussis − two to four months, combined with tetanus toxoid

3) Tetanus − two to four months

4) Poliomyelitis − two to four months

5) Measles – 12 to 15 months

6) Rubella – 12 to 15 months

7) Mumps – 12 to 15 months

8) Haemophilus − two to four months influenzae type b

9) Hepatitis B – birth to two months

10) Varicella – 12 to 18 months

11) Invasive Pneumococcal Disease – two to four months

12) Meningococcal Disease – 11 to 12 years

b) Upon first entering a child care facility, all children two months of age and older shall show proof that the child has been immunized, or is in the process of being immunized, according to the recommended schedule, against diphtheria, pertussis, tetanus, polio, measles, mumps, rubella, Haemophilus influenzae type b, hepatitis B, varicella, and invasive pneumococcal disease, unless proved to be immune as determined by Sections 665.250 and 665.280, parents object based on religious grounds in accordance with Section 665.510, or a licensed physician, advanced practice nurse or physician assistant issues a medical exemption in accordance with Section 665.520.

c) Diphtheria, Pertussis, Tetanus

1) Any child entering a child care facility or school program below the kindergarten level shall show proof of having received three or more doses of Diphtheria, Tetanus, Pertussis (DTP or DTaP) vaccine by one year of age and one additional dose by the second birthday. The first three doses in the series shall have been received no less than four weeks (28 days) apart. The interval between the third and fourth doses shall be at least six months.

2) Any child entering school (kindergarten or first grade) for the first time shall show proof of having received four or more doses of Diphtheria, Tetanus, Pertussis (DTP or DTaP) vaccine, with the last dose being a booster and having been received on or after the fourth birthday. The first three doses in the series shall have been received no less than four weeks (28 days) apart. The interval between the third and fourth doses shall be at least six months. Children age six and under may receive DTaP or DTP. Children age seven and older may receive Tetanus, Diphtheria (Td) vaccine as recommended pursuant to the ACIP catch-up series in lieu of DTP or DTaP vaccine.

3) Any child entering school at a grade level not included in subsection (c)(1) or (2) shall show proof of having received three or more doses of DTP, DTaP, pediatric DT or adult Tetanus and Diphtheria (Td), with the last dose being a booster and having been received on or after the fourth birthday. The first two doses in the series shall have been received no less than four weeks (28 days) apart. The interval between the second and third doses shall be at least six months.

4) Receipt of pediatric Diphtheria Tetanus (DT) vaccine in lieu of DTP or DTaP is acceptable only if the pertussis component of the vaccine is medically contraindicated. Documentation of the medical contraindication shall be verified as specified in Section 665.520.

5) Any child entering sixth grade shall show proof of having received one dose of Tdap (defined as tetanus, diphtheria, acellular pertussis) vaccine regardless of the interval since the last DTaP, DT or Td dose.

6) Students entering grades seven through 12 who have not already received Tdap are required to receive one Tdap dose regardless of the interval since the last DTaP, DT or Td dose.

7) For students attending school programs in which grade levels (kindergarten through 12) are not assigned, including special education programs, proof of one dose of Tdap vaccine as described in subsection (c)(5) shall be submitted before the school years in which the child reaches the ages of 11 and 15. Students eligible to remain in public school beyond grade 12 (special education) shall meet the requirements for 12^th grade.

8) School-age children entering a child care facility shall comply with the immunization requirements of subsections (c)(2), (3), (4), (5), (6) and (7).

d) Polio

1) Any child entering a child care facility or school program below the kindergarten level shall show proof of having received two or more doses of polio vaccine (defined as oral poliovirus vaccine (OPV) or inactivated poliovirus vaccine (IPV)) by one year of age and a third dose by the second birthday. Doses in the series shall have been received no less than four weeks (28 days) apart. Any child 24 months of age or older shall show proof of at least three doses of polio vaccine appropriately spaced.

2) Any child entering school at any grade level (kindergarten through 12) shall show proof of having received three or more doses of polio vaccine (defined as oral poliovirus vaccine (OPV) or inactivated poliovirus vaccine (IPV)). A child who received any combination of IPV and OPV shall show proof of having received at least four doses, with the last dose having been received on or after the fourth birthday. Doses in the series shall have been received no less than four weeks (28 days) apart. A child who received IPV exclusively or OPV exclusively shall show proof of having received at least three doses, with the last dose having been received on or after the fourth birthday. Doses in the series shall have been received no less than four weeks (28 days) apart.

3) Beginning with the school year 2017-2018, any child entering kindergarten shall show proof of having received four or more doses of polio vaccine (defined as oral poliovirus vaccine (OPV) or inactivated poliovirus vaccine (IPV)). The first three doses in the series shall have been received no less than four weeks (28 days) apart. The fourth or last dose shall be administered on or after the fourth birthday and at least six months after the previous dose. A fourth dose is not needed if the third dose was administered at age four or older and at least six months after the previous dose, in accordance with the ACIP catch-up series.

4) For students attending school programs in which grade levels (kindergarten through 12) are not assigned, including special education programs, proof of polio vaccine shall be submitted before the school years in which the child reaches the ages of five, 11 and 15. Students eligible to remain in public schools beyond grade 12 (special education) shall meet the requirements for 12^th grade.

5) School-age children entering a child care facility shall comply with the immunization requirements in subsection (d)(2).

e) Measles

1) Any child entering a child care facility or school program below the kindergarten level shall show proof of having received one dose of live measles virus vaccine on or after the first birthday, or other proof of immunity described in Section 665.250(c).

2) Children entering school at any grade level (kindergarten through 12) shall show proof of having received two doses of live measles virus vaccine, the first dose on or after the first birthday and the second dose no less than four weeks (28 days) after the first or other proof of immunity described in Section 665.250(c).

3) For students attending school programs where grade levels (kindergarten through 12) are not assigned, including special education programs, proof of two doses of live measles virus vaccine as described in subsection (c)(2) shall be submitted before the school years in which the child reaches the ages of five, 11 and 15. Students eligible to remain in public schools beyond grade 12 (special education) shall meet the requirements for 12^th grade.

4) School-age children entering a child care facility shall comply with the immunization requirements in subsections (e)(2) and (3).

f) Rubella

1) Any child entering a child care facility or school program below the kindergarten level shall show proof of having received at least one dose of live rubella virus vaccine on or after the first birthday. Proof of disease is not acceptable unless laboratory evidence of rubella immunity is presented (see Section 665.250(d)).

2) Children entering school at any grade level (kindergarten through 12) shall show proof of having received two doses of live rubella virus vaccine, the first dose on or after the first birthday and the second dose no less than four weeks (28 days) after the first dose, or other proof of immunity described in Section 665.250(c).

3) For students attending school programs where grade levels (kindergarten through 12) are not assigned, including special education programs, proof of two doses of live rubella virus vaccine as described in subsection (f)(2) shall be submitted before the school years in which the child reaches the ages of five, 11 and 15. Students eligible to remain in public school beyond grade 12 (special education) shall meet the requirements for 12^th grade.

4) School-age children entering a child care facility shall comply with the immunization requirements in subsections (f)(2) and (3).

g) Mumps

1) Any child entering a child care facility or school program below the kindergarten level shall show proof of having received at least one dose of live mumps virus vaccine on or after the first birthday. Proof of disease, if verified by a physician, or laboratory evidence of mumps immunity may be substituted for proof of vaccination (see Section 665.250(e)).

2) Children entering school at any grade level (kindergarten through 12) shall show proof of having received two doses of live mumps virus vaccine, the first dose on or after the first birthday and the second dose no less than four weeks (28 days) after the first dose, or other proof of immunity described in Section 665.250(c).

3) For students attending school programs where grade levels (kindergarten through 12) are not assigned, including special education programs, proof of having received two doses of live mumps virus vaccine as described in subsection (e)(2) shall be submitted before the school years in which the child reaches the ages of five, 11 and 15. Students eligible to remain in public school beyond grade 12 (special education) shall meet the requirements for 12^th grade.

4) School-age children entering a child care facility shall comply with the immunization requirements in subsections (g)(2) and (3).

h) Haemophilus influenzae type b (Hib)

1) Any child entering a child care facility or school program below the kindergarten level shall show proof of immunization that complies with the ACIP recommendation for Hib vaccination.

2) Children 24 to 59 months of age who have not received the primary series of Hib vaccine, according to the Hib vaccination schedule, shall show proof of receiving one dose of Hib vaccine at 15 months of age or older.

3) Any child five years of age or older shall not be required to provide proof of immunization with Hib vaccine.

i) Hepatitis B

1) Any child entering a child care facility or school program below the kindergarten level shall show proof of having received three doses of hepatitis B vaccine. The first two doses shall have been received no less than four weeks (28 days) apart. The interval between the second and third doses shall be at least two months. The interval between the first dose and the third dose shall be at least four months. The third dose shall have been administered on or after six months of age. Proof of prior or current infection, if verified by laboratory evidence, may be substituted for proof of vaccination (see Section 665.250(f)).

2) Children entering the sixth grade shall show proof of having received three doses of hepatitis B vaccine, or other proof of immunity described in Section 665.250(f). The first two doses shall have been received no less than four weeks (28 days) apart. The interval between the second and third doses shall be at least two months. The interval between the first and third doses shall be at least four months. Proof of prior or current infection, if verified by laboratory evidence, may be substituted for proof of vaccination (see Section 665.250(f)).

3) The third dose of hepatitis B vaccine is not required if it can be documented that the child received two doses of adult formulation Recombivax-HB vaccine (10 mcg) and was 11 to 15 years of age at the time of vaccine administration, and that the interval between receipt of the two doses was at least four months.

4) Proof of prior or current hepatitis B infection shall be verified by laboratory evidence. Laboratory evidence of prior or current hepatitis B infection is acceptable only if one of the following serologic tests indicates positivity: HBsAg, anti-HBc or anti-HBs.

5) For students attending school programs for which grade levels (kindergarten through 12) are not assigned, proof of having received three doses of hepatitis B vaccine or other proof of immunity as described in subsections (i)(2), (3) and (4) shall be submitted before the school years in which the child reaches the ages of 11 and 15. Students eligible to remain in public school beyond grade 12 (special education) shall meet the requirements for 12th grade.

6) School-age children entering a child care facility shall comply with the immunization requirements in subsections (i)(2) and (3).

j) Varicella

1) Any child entering a child care facility or school program below the kindergarten level shall show proof of having received one dose of varicella vaccine on or after the first birthday, or other proof of immunity described in Section 665.250(g).

2) Children entering school at any grade level (kindergarten through 12) shall show proof of having received at least one dose of varicella vaccine on or after the first birthday, or other proof of immunity described in Section 665.250(g).

3) Any child entering kindergarten, sixth grade, or ninth grade for the first time on or after July 1, 2014 shall show proof of having received two doses of varicella vaccine, the first dose on or after the first birthday and the second dose no less than four weeks (28 days) after the first dose, or other proof of immunity described in Section 665.250(g).

4) For students attending school programs where grade levels (kindergarten through 12) are not assigned, proof of having received at least two doses of varicella vaccine in accordance with subsection (j)(2) or (3) or other proof of immunity as described in Section 665.250(g) shall be submitted prior to the school years in which the child reaches the ages of five, 11 and 15. Students eligible to remain in public school beyond grade 12 (special education) shall meet the requirements for 12^th grade.

5) School-age children entering a child care facility shall comply with the immunization requirements in subsections (j)(2) and (3).

k) Invasive Pneumococcal Disease

1) Any child entering a child care facility or school program below the kindergarten level shall show proof of immunization that complies with the ACIP recommendations for pneumococcal vaccination.

2) Children 24 to 59 months of age who have not received the primary series of pneumococcal conjugate vaccine, according to the recommended vaccination schedule, shall show proof of receiving one dose of pneumococcal vaccine after 24 months of age.

3) Any child who has reached his or her fifth birthday shall not be required to provide proof of immunization with pneumococcal conjugate vaccine.

l) Meningococcal Disease

1) Beginning with the school year 2015-2016, any child entering the sixth grade shall show proof of having received one dose of meningococcal conjugate vaccine on or after the 11^th birthday. Children who do not meet the age requirement will be monitored in accordance with Section 665.270.

2) Beginning with the school year 2015-2016, any child entering the 12^th grade shall show proof of having received two doses of meningococcal conjugate vaccine prior to entering the 12^th grade. The first dose shall have been received on or after the 11^th birthday, and the second dose shall have been received on or after the 16^th birthday, at least eight weeks after the first dose. If the first dose is administered when the child is 16 years of age or older, only one dose is required.

3) For students attending school programs where grade levels (kindergarten through 12) are not assigned, including special education programs, proof of having received one dose of meningococcal conjugate vaccine shall be submitted in the school year in which the child reaches age 11 and a second dose in the school year in which the child reaches age 16. If the first dose is administered when the child is 16 years of age or older, only one dose is required. Students eligible to remain in public school beyond grade 12 (special education) shall meet the requirements for 12^th grade.

m) The requirements of this Section also apply to children who transfer into Illinois child care facilities, school programs, and schools from other states, regardless of the age or grade level at which the child transfers.

n) It is not the intent of this Part that any child whose parents comply with the intent of this Part, the Act or the School Code should be excluded from a child care facility or school. A child or student shall be considered in compliance with the law if there is evidence of the intent to comply. Evidence may be:

1) a signed statement from a health care provider that he or she has begun, or will begin, the necessary immunization procedures; or

2) the parent's or legal guardian's written consent for the child's participation in a school or other community immunization program.

(Source: Amended at 41 Ill. Reg. 2973, effective February 27, 2017)

Section 665.250 Proof of Immunity

a) Proof of immunity shall consist of documented evidence of the child having received a vaccine (verified by a health care provider, defined as a physician, child care or school health professional, or health official) or proof of disease (as described in subsection (e), (f) or (g) or documentation of laboratory evidence of immunity to a specific disease (as described in subsection (c), (d), (e) or (g)). As used in this Section, "physician" (see Section 665.130) means a physician licensed to practice medicine in all of its branches (M.D., D.O.).

b) Day and month is required if it cannot otherwise be determined that the vaccine was given after the minimum interval or age.

c) Proof of prior measles disease shall be verified with date of illness signed by a physician or laboratory evidence of measles immunity. A diagnosis of measles disease made by a physician on or after July 1, 2002 must be confirmed by laboratory evidence.

d) The only acceptable proof of immunity for rubella is evidence of vaccine (dates, see subsection (b)) or laboratory evidence of rubella immunity.

e) Proof of prior mumps disease shall be verified with date of illness signed by a physician or laboratory evidence of mumps immunity.

f) Proof of prior or current hepatitis B infection shall be verified by laboratory evidence. Laboratory evidence of prior or current hepatitis B infection is acceptable only if one of the following serologic tests indicates positivity: HBsAg, anti-HBc or anti-HBs.

g) Proof of prior varicella disease shall be verified with:

1) date of illness signed by a physician; or

2) a health care provider's interpretation that a parent's or legal guardian's description of varicella disease history is indicative of past infection; or

3) laboratory evidence of varicella immunity.

(Source: Amended at 41 Ill. Reg. 2973, effective February 27, 2017)

Section 665.260 Booster Immunizations

Booster immunizations are required as prescribed in Section 665.240.

(Source: Amended at 29 Ill. Reg. 18127, effective October 24, 2005)

Section 665.270 Compliance with the School Code

A child shall be considered in compliance with the health examination and immunization requirement in Section 27-8.1 of the School Code if all applicable immunizations that a child can medically receive are given before entering school and a signed statement from a health care provider is presented indicating when the remaining medically indicated immunization will be administered within the current school year. Local school authorities shall monitor immunization schedules to assure their completion. If a child is delinquent for a scheduled appointment for immunization, he or she is no longer considered to be in compliance.

(Source: Amended at 41 Ill. Reg. 2973, effective February 27, 2017)

Section 665.280 Health Care Provider Statement of Immunity

A physician licensed to practice medicine in all of its branches, a physician assistant or an advanced practice nurse who believes a child to be protected against a disease for which immunization is required may so indicate in writing, stating the reasons, providing documentation of proof of immunity, when applicable and certifying that he or she believes the specific immunization in question is not necessary or indicated. These statements of lack of medical need, including documentation of proof of immunity, when applicable, shall be submitted to the Department by the attendance center accompanied by the necessary parental release. The Department will review the statements with appropriate medical consultation. The Department's response shall be placed in the child's permanent health record. After review, if the student is no longer considered to be in compliance, the student is subject to the exclusion provision of the School Code. If a school is not able to obtain parental release and the student is considered homeless, the local school authority may sign the form on behalf of a homeless student's parent or guardian. If a school is not able to obtain parental release, or if the documented intervals of vaccinations administered are not approved by the Department to be in accordance with Section 665.240, the student shall be noncompliant and subject to exclusion.

(Source: Amended at 41 Ill. Reg. 2973, effective February 27, 2017)

Section 665.290 List of Non-immunized Child Care Facility Attendees or Students

Every child care facility and attendance center shall maintain an accurate list of all children and students who have not presented proof of immunity (see Section 665.280) against any or all diseases for which immunization is required by Section 665.240 (see Section 665.280).

(Source: Amended at 41 Ill. Reg. 2973, effective February 27, 2017)

SUBPART C: VISION AND HEARING SCREENING

Section 665.310 Vision and Hearing Screening

Vision and hearing screening tests shall be conducted in accordance with the Department's rules titled Hearing Screening (77 Ill. Adm. Code 675) and Vision Screening (77 Ill. Adm. Code 685).

(Source: Amended at 29 Ill. Reg. 18127, effective October 24, 2005)

SUBPART D: DENTAL EXAMINATION

Section 665.410 Dental Examination Requirement

Except as otherwise provided in this Subpart, all children in kindergarten and the second, sixth, and ninth grades of any public, private, or parochial school shall have a dental examination in accordance with the timetable set forth in Section 665.420. The examination shall be performed by a licensed dentist. Each public, private, and parochial school must give notice of this dental examination requirement to the parents and guardians of students at least 60 days before May 15 of each school year. (Section 27-8.1(1.5) of the School Code)

(Source: Amended at 44 Ill. Reg. 18416, effective November 2, 2020)

Section 665.420 Dental Examination Timetable

a) Before May 15 of the school year, each child in kindergarten and the second, sixth, and ninth grades shall present to the school proof of having been examined by a dentist in accordance with Section 27-8.1(1.5) of the School Code and the requirements of this Part. (Section 27-8.1(1.5) of the School Code) The examination must have taken place within 18 months prior to May 15 of the school year.

b) For the purposes of subsection (a), "proof of having been examined by a dentist" means submission of a Department-prescribed dental examination form, signed and dated by a licensed dentist.

c) If a child in the second, sixth, or ninth grade fails to present proof of having been examined by a dentist by May 15, the school may hold the child's report card until one of the following occurs:

1) the child presents proof of a completed dental examination. (Section 27-8.1(1.5) of the School Code) Submission of a completed examination form, in accordance with subsection (b), constitutes proof of a completed dental examination;

2) the child presents proof that a dental examination will take place within 60 days after May 15. (Section 27-8.1(1.5) of the School Code) A written statement or appointment card, prepared by a dentist, dental hygienist, or his or her designee and signed by the child's parent or guardian, indicating the name of the child and the date and time of the scheduled dental examination, constitutes proof that a dental examination will take place. The child must present proof of a completed dental examination at the beginning of the following school year; or

3) the child presents a dental examination waiver form, in accordance with Section 665.450 of this Part.

(Source: Amended at 44 Ill. Reg. 18416, effective November 2, 2020)

Section 665.430 Dental Examination

The dental examination shall be recorded on the dental examination form prescribed by the Department for statewide use. The form is available on the Department's website. The completed form shall be presented to the local school authority.

(Source: Amended at 29 Ill. Reg. 18127, effective October 24, 2005)

Section 665.440 Guidelines (Repealed)

(Source: Repealed at 29 Ill. Reg. 18127, effective October 24, 2005)

Section 665.450 Waiver of Dental Examination Requirement

Children who show an undue burden or a lack of access to a dentist shall receive a waiver from the requirement for a dental examination. (Section 27-8.1(1.5) of the School Code) With the notice required in Section 665.410, the school or district shall provide notice of the availability of a waiver from the dental examination requirement, and shall include a Department-prescribed form that may be used to demonstrate the child's eligibility for a waiver.

a) For the purposes of this Section, an undue burden or lack of access to a dentist includes, but is not limited to, the following circumstances:

1) The child is enrolled in the free and reduced lunch program and is not covered by private or public (Medicaid/KidCare) dental insurance.

2) The child is enrolled in the free and reduced lunch program and is ineligible for public insurance (Medicaid/KidCare).

3) The child is enrolled in Medicaid/KidCare, but the parent or guardian is unable to find a dentist or dental clinic in the community that is able to see the child and accepts Medicaid/KidCare.

4) The child does not have any type of dental insurance, and there are no low-cost dental clinics in the community that will see the child.

b) The dental examination waiver form shall be submitted to the school by May 15 of the school year. If the dental examination waiver form is not submitted by May 15, the school may hold the child's report card until the dental examination waiver form is submitted.

(Source: Added at 29 Ill. Reg. 18127, effective October 24, 2005)

SUBPART E: EXCEPTIONS

Section 665.510 Religious Objection

a) Children entering any public, private or parochial school or a preschool program operated by an elementary or secondary school or institution of higher learning whose parents or legal guardians object to health, dental or eye examinations or any part thereof, to immunizations, or to vision and hearing screening tests on religious grounds shall not be required to undergo the examinations, tests or immunizations to which they so object if such parents or legal guardians present to the appropriate local school authority a signed Certificate of Religious Exemption detailing the grounds for the objection and the specific immunizations, tests or examinations to which they object in accordance with subsections (f) and (g).

b) The grounds for the religious objection must set forth the specific religious belief that conflicts with the examination, test, immunization or other medical intervention. The religious objection stated need not be directed by the tenets of an established religious organization. However, general philosophical or moral reluctance to allow physical examinations, eye examinations, immunizations, vision and hearing screenings, or dental examinations does not provide a sufficient basis for an exception.

c) The signed Certificate of Religious Exemption shall also reflect the parent's or legal guardian's understanding of the school's exclusion policies in the case of a vaccine-preventable disease outbreak or exposure.

d) The Certificate of Religious Exemption must also be signed by the authorized examining health care provider responsible for the performance of the child's health examination confirming that the provider provided education to the parent or legal guardian on the benefits of the immunization and the health risks to the student and to the community of the communicable diseases for which immunization is required in this State. However, the health care provider's signature on the certificate reflects only that education was provided and does not allow the health care provider grounds to determine a religious exemption.

e) The local school authority is responsible for determining if the content of the Certificate of Religious Exemption constitutes a valid religious objection. The local school authority shall inform the parent or legal guardian of exclusion procedures in accordance with the Control of Communicable Diseases Code at the time the objection is presented. The Certificate of Religious Exemption form shall be placed on file in the student's permanent record.

f) Parents or legal guardians must submit the Certificate of Religious Exemption to their local school authority prior to entering kindergarten, sixth, and ninth grade for each child for which they are requesting an exemption. (Section 27-8.1(8) of the School Code)

g) Use of the Certificate of Religious Exemption applies to students transferring into school districts at any grade or students entering preschool programs operated by elementary or secondary schools. If the permanent record transferred with the student includes a valid Certificate of Religious Exemption, the new school district or preschool program shall accept the Certificate presented as if the Certificate had been initially presented to the new school.

h) The Certificate of Religious Exemption and subsections (a), (b), (c) and (d) are also applicable to children entering child care facilities not operated by an elementary or secondary school or institution of higher learning whose parents or legal guardians object to health, dental or eye examinations, immunizations or vision or hearing screening tests on religious grounds. The child care facility shall inform the parents or legal guardians of outbreak control exclusion procedures, in accordance with the Control of Communicable Diseases Code, at the time the religious exemption is presented. The child care facility shall attach the form to the child's health record and place the record in the child's permanent record.

(Source: Amended at 41 Ill. Reg. 2973, effective February 27, 2017)

Section 665.520 Medical Exemption

a) Any medical exemption from an immunization shall be:

1) Made by the examining physician licensed to practice medicine in all its branches, an advanced practice nurse or a physician assistant responsible for the performance of the health examination indicating what the medical condition of the child is that makes administration of one or more of the required immunizing agents medically contraindicated; and

2) Endorsed and signed by the examining physician, advanced practice nurse or physician assistant responsible for the performance of the health examination on the health examination form.

b) An examining physician licensed to practice medicine in all its branches, an advanced practice nurse or physician assistant responsible for the performance of the health examination may consider including without limitation the nationally accepted recommendations from federal agencies such as the Advisory Committee on Immunization Practices, the information outlined in the relevant vaccine information statement, and vaccine package inserts, along with the examining physician's, advanced practice nurse's or physician assistant's clinical judgment, to determine whether any child may be more susceptible to experiencing an adverse vaccine reaction than the general population, and if so, the examining physician, advanced practice nurse or physician assistant may exempt the child from an immunization or adopt an individualized immunization schedule. (Section 27-8.1(8) of the School Code) Any exemption based upon an adverse vaccine reaction from an immunizing agent shall be endorsed and signed by the examining physician licensed to practice medicine in all its branches, advanced practice nurse or physician assistant responsible for the performance of the health examination.

c) The child care facility or local school authority shall attach the form to the child's health record and place the record in the child's permanent record. The child care facility or local school authority shall inform the parents or legal guardians of outbreak control exclusion procedures, in accordance with the Control of Communicable Diseases Code, at the time the medical exemption is presented.

d) Should the medical condition of the child later indicate that immunization is no longer contraindicated to the health of the child, the immunization requirements will then have to be met.

(Source: Amended at 41 Ill. Reg. 2973, effective February 27, 2017)

SUBPART F: EYE EXAMINATION

Section 665.610 Eye Examination Requirement

a) All children enrolling in kindergarten in a public, private, or parochial school and any student enrolling for the first time in a public, private, or parochial school shall have an eye examination. Each of these children shall present proof of having been examined by a physician who performs eye examinations or an optometrist within the previous year (within one year prior to the date of entering school), in accordance with Section 27-8.1(1.10) of the School Code and this Part before October 15 of the school year. (Section 27-8.1(1.10) of the School Code)

b) The eye examination requirement does not apply to children enrolling in preschool.

c) The required eye examination shall be completed within one year prior to the first day of the school year in which the child enters kindergarten or the child enters the Illinois school system for the first time, whether in a public, private, or parochial school. For students attending school programs where grade levels are not assigned, eye examinations shall be completed within one year prior to the first day of the school year of the child's first entry into the Illinois school system.

d) An eye examination shall at a minimum include history, visual acuity, subjective refraction to best visual acuity near and far, internal and external examination, and a glaucoma evaluation, as well as any other tests or observations that in the professional judgment of the doctor are necessary. (Section 27-8.1(2) of the School Code)

e) In addition to the requirements of subsection (d), optometrists shall include measurements of binocular acuity and ocular motility, and color vision screening in the required eye examination, as required by the Illinois Optometric Practice Act of 1987 [225 ILCS 80].

(Source: Amended at 33 Ill. Reg. 8459, effective June 8, 2009)

Section 665.620 Vision Examination (Repealed)

(Source: Repealed at 33 Ill. Reg. 8459, effective June 8, 2009)

Section 665.630 Eye Examination Report

The eye examination shall be recorded on the Department of Public Health Eye Examination Report prescribed by the Department for statewide use (see Appendix A). The report form is available on the Department's website. The completed form shall be presented to the local school authority.

(Source: Amended at 33 Ill. Reg. 8459, effective June 8, 2009)

Section 665.640 Indigent Students (Repealed)

(Source: Repealed at 33 Ill. Reg. 8459, effective June 8, 2009)

Section 665.650 Waiver of Eye Examination Requirement

Children who show an undue burden or a lack of access to an optometrist or to a physician who provides eye examinations shall receive a waiver from the requirement for an eye examination. (Section 27-8.1(1.10) of the School Code) The school or district shall make a waiver from the eye examination requirement available and, if requested by the parent or guardian, shall provide a Department-prescribed waiver form that shall be used to demonstrate the child's eligibility for a waiver (see Appendix C).

a) For the purpose of this Section, an undue burden or lack of access to an optometrist or to a physician who performs eye examinations includes, but is not limited to:

1) The child is enrolled in medical assistance/ALL KIDS, but the parent or guardian is unable to find an optometrist or physician in the community who performs eye examinations, who is able to see the child and who accepts medical assistance/ALL KIDS.

2) The child does not have any type of medical or vision/eye insurance coverage and does not qualify for medical assistance/ALL KIDS, there are no low-cost clinics in the community that provide eye examinations as required in Section 665.610 and that will see the child, and the parent or guardian has exhausted all other means and does not have sufficient income to provide the child with an eye examination.

b) The Eye Examination Waiver Form shall be submitted to the school by October 15 of the school year. If the Eye Examination Waiver Form is not submitted by October 15, the school may hold the child's report card until the Eye Examination Waiver Form is submitted.

(Source: Added at 33 Ill. Reg. 8459, effective June 8, 2009)

SUBPART G: DIABETES SCREENING

Section 665.700 Diabetes Screening Requirement

A diabetes screening shall be included as a required part of each health examination. Diabetes testing is not required, but is recommended. (Section 27-8.1 of the School Code) Diabetes screening is the assessment of an asymptomatic individual for risk factors for the purpose of identifying whether the individual is likely to have diabetes. Diabetes testing is the performance of diagnostic tests (e.g., glucose tolerance test), in a health care setting, on an individual who exhibits signs or symptoms of diabetes.

(Source: Added at 29 Ill. Reg. 18127, effective October 24, 2005)

Section 665.710 Diabetes Screening

a) A diabetes screening shall include an assessment of whether a child is overweight (see Section 665.720) and an assessment of the following risk factors:

1) Family history of type 2 diabetes in first and second degree relatives;

2) Member of an ethnic minority group, including American Indians, African Americans, Hispanic Americans, Asian/South Pacific Islanders; and

3) Signs of insulin resistance or conditions associated with insulin resistance, including acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovarian syndrome.

b) Results of the diabetes screening shall be documented on the Certificate of Child Health Examination form.

(Source: Added at 29 Ill. Reg. 18127, effective October 24, 2005)

Section 665.720 Testing Recommendations

a) The Consensus Panel of the American Diabetes Association (ADA) recommends that if an individual is overweight and has any two of the risk factors identified in Section 665.710, diabetes testing should be done every two years, starting at age 10 years or at the onset of puberty, if it occurs at an earlier age.

b) A child shall be considered to be overweight if one of the following exists:

1) BMI > 85th percentile for age and sex; or

2) Weight for height > 85th percentile; or

3) Weight > 120 % of ideal weight for height.

c) Clinical judgment should be used in deciding whether to test for diabetes in children who do not meet these criteria.

(Source: Added at 29 Ill. Reg. 18127, effective October 24, 2005)

Section 665.APPENDIX A Illinois Department of Public Health Eye Examination Report

Section 665.APPENDIX A Illinois Department of Public Health Eye Examination Report

State of Illinois

Eye Examination Report

Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides eye examinations be submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school for other children. The examination must be completed within one year prior to the first day of the school year the child enters the Illinois school system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school.

Student Name:

(Last)

(First)

(Middle Initial)

Birth Date:

Gender:

Grade:

(Mo.)

(Day)

(Yr.)

Parent or Guardian:

(Last)

(First)

Phone:

(Area Code)

Address:

(Number)

(Street)

(City)

(Zip Code)

County:

To Be Completed By Examining Doctor

Case History

Date of Exam:
Ocular History:	q Normal	or Positive for:
Medical History:	q Normal	or Positive for:
Drug Allergies:	q NKDA	or Allergic to:
Other Information:

Examination

	Distance			Near
	Right	Left	Both		Both
Uncorrected Visual Acuity:	20 /_______	20 /_______	20 /_______		20 /_______
Best Corrected Visual Acuity:	20 /_______	20 /_______	20 /_______		20 /_______

Was refraction performed with dilation? q Yes q No

	Normal	Abnormal	Not Able to Assess	Comments
External Exam (lids, lashes, cornea, etc.)	q	q	q
Internal Exam (vitreous, lens, fundus, etc.)	q	q	q
Pupillary Reflex (pupils)	q	q	q
Binocular Function (stereopsis)	q	q	q
Accommodation and Vergence	q	q	q
Color Vision	q	q	q
Glaucoma Evaluation	q	q	q
Oculomotor Assessment	q	q	q
Other:_____________________________	q	q	q

NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.

Diagnosis

q Normal	q Myopia	q Hyperopia	q Astigmatism
q Strabismus	q Amblyopia	Other: ___________________________________

Recommendations

1.	Corrective Lenses:	q No	q Yes, glasses or contacts should be worn for:
			q Constant Wear			q Near Vision		q Far Vision
			q May Be Removed for Physical Education/Recess
2.	Preferential Seating Recommended:	q No	q Yes	Comments:
3.	Recommend Re-examination:		q 3 months		q 6 months		q 12 months
			q Other
4.
5.

Print Name:		Lic. No.:
	Optometrist or Physician (such as an ophthalmologist) Who Provided the Eye Examination
	qMD qOD qDO
Address:			Consent of Parent or Guardian I agree to release the above information on my child or ward to appropriate school or health authorities.

Phone:

Signature:			(Parent's or Guardian's Signature)
	Optometrist or Physician (such as an ophthalmologist) Who Provided the Eye Examination		Date
	qMD qOD qDO
Date:

(Source: Amended at 33 Ill. Reg. 8459, effective June 8, 2009)

Section 665.APPENDIX B Vaccination Schedule for Haemophilus influenzae type b Conjugate Vaccines (Hib) (Repealed)

(Source: Repealed at 41 Ill. Reg. 2973, effective February 27, 2017)

Section 665.APPENDIX C Illinois Department of Public Health Eye Examination Waiver Form

State of Illinois

Department of Public Health

EYE EXAMINATION WAIVER FORM

Please print:

Student's Name: Last First Middle		Birth Date: (Month/Day/Year)
Address: Street City ZIP Code		Telephone:
Name of School:	Grade Level:	Gender: Male Female
Parent or Guardian:	Address (of parent/guardian):

I am unable to obtain the required eye examination because:

q My child is enrolled in medical assistance/ALL KIDS, but we are unable to find a medical doctor who performs eye examinations or an optometrist in the community who is able to examine my child and accepts medical assistance/ALL KIDS.

q My child does not have any type of medical or vision/eye care coverage, my child does not qualify for medical assistance/ALL KIDS, there are no low-cost vision/eye clinics in our community that will see my child, and I have exhausted all other means and do not have sufficient income to provide my child with an eye examination.

q Other undue burden or a lack of access to an optometrist or a physician who provides eye

examinations:

Signature

Date

(Source: Added at 33 Ill. Reg. 8459, effective June 8, 2009)

Section 665.APPENDIX D Illinois Department of Public Health Dental Examination Form

Illinois Department of Public Health

PROOF OF SCHOOL DENTAL EXAMINATION FORM

To be completed by the parent (please print):

Student's Name: Last First Middle		Birth Date: (Month/Day/Year) / /
Address: Street City ZIP Code		Telephone:
Name of School:	Grade Level:	Gender: Male Female
Parent or Guardian:	Address (of parent/guardian):

To be completed by dentist:

Oral Health Status (check all that apply)

q Yes q No	Dental Sealants Present
q Yes q No	Caries Experience / Restoration History − A filling (temporary or permanent) OR a tooth that is missing because it was extracted as a result of caries OR missing permanent 1^st molars. Include both treated and untreated decay.
q Yes q No	Untreated Caries − At least ½ mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present.
q Yes q No	Soft Tissue Pathology
q Yes q No	Malocclusion

Treatment Needs (check all that apply)

q	Urgent Treatment − abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection or swelling
q	Restorative Care − amalgams, composites, crowns, etc.
q	Preventive Care − sealants, fluoride treatment, prophylaxis
q	Other − periodontal, orthodontic
q	Please note

Signature of Dentist

Date of Exam

Address:		Telephone
Street	City		Zip Code

(Source: Added at 33 Ill. Reg. 8459, effective June 8, 2009)

Section 665.APPENDIX E Illinois Department of Public Health Dental Examination Waiver Form

Illinois Department of Public Health

DENTAL EXAMINATION WAIVER FORM

Please print:

Student's Name: Last First Middle		Birth Date: (Month/Day/Year) / /
Address: Street City ZIP Code		Telephone:
Name of School:	Grade Level:	Gender: Male Female
Parent or Guardian:	Address (of parent/guardian):

I am unable to obtain the required dental examination because:

q My child is enrolled in the free or reduced lunch program and is not covered by private or public dental insurance (medical assistance/ALL KIDS).

q My child is enrolled in the free or reduced lunch program and is ineligible for public insurance (medical assistance/ALL KIDS).

q My child is enrolled in medical assistance/ALL KIDS, but we are unable to find a dentist or dental clinic in our community that is able to see my child and will accept medical assistance/ALL KIDS.

q My child does not have any type of dental insurance, and there are no low-cost dental clinics in our community that will see my child.

Signature

Date

(Source: Added at 33 Ill. Reg. 8459, effective June 8, 2009)

Section 665.APPENDIX F Vaccination Schedule for Pneumococcal Conjugate Vaccines (PCV13) (Repealed)

(Source: Repealed at 41 Ill. Reg. 2973, effective February 27, 2017)