By submitting this form, the parent/guardian understands that their child may be excluded from school in the case of a vaccine-preventable disease outbreak or exposure. Illinois law does not allow for exemptions based on personal or philosophical beliefs. The form is to be signed by the health care provider who was responsible for performing the child's health examination. A statement must be included on the form detailing the religious beliefs that prevent the child from receiving each required vaccination. Each immunization that an exemption is being requested for must be checked in this form. Parents/guardians who object to their child being immunized for religious reasons must submit a Certificate of Religious Exemption. Religious Objection to Immunizations and/or examinations The student will be placed on the school’s susceptible list and is subject to immediate exclusion if exposed to a vaccine-preventable disease. The note must include the student’s medical condition that causes the contraindication. If a primary care provider finds that a student should not receive an immunization based on the student's current health status, a written note to this effect is to be submitted to the school. The use of laboratory evidence for proof of immunity only applies to the following mandated immunizations: Measles, Rubella, Mumps, Hepatitis B, and Varicella. If the primary care provider states a child is immune to a disease, the provider must submit the laboratory documentation including laboratory results of the child’s immunity to the school health office. If upon review by the Illinois Department of Public Health, the student is not considered to be in compliance, the student will be subject to the exclusion protocol of the state. While waiting for this review, the student is considered to be in compliance but unprotected. This statement with a signed and completed release of records form must be submitted to the regional immunization consultant for the Illinois Department of Public Health for review and consideration. If a healthcare provider believes a child is protected against a disease according to a different immunization schedule, the healthcare provider may state in writing the reasons for that belief and certify that he/she believes the specific immunization in question is not indicated at that time. If you need assistance with this process, contact your school’s health office as quickly as possible after registration. Lack of compliance with Section 27-B f the Illinois School Code relating to physical examination and immunization mandates will result in a student's exclusion from school until these requirements are completed. Indian Prairie School District 204 allows thirty days for the transfer of the above health information or for you to complete the examination and immunization requirements. Once the health office has a copy of the immunization records, the information will be reviewed, and the parent/guardian will be informed in writing of any deficiencies and the timeline for remediation. If you do not have a comprehensive immunization record for your child, check with your child’s prior school, and request a copy of the immunization records which were on file. The parent/guardian is required to complete and sign the Health History portion of the form.Īt the time of the examination, the primary care provider should complete and verify the immunization status for the student. The form must be completed by a physician licensed to practice medicine in the United States. The examination shall not have been given more than one year prior to the first day of attendance. Physical Examination and Immunization RequirementsĪll students entering preschool, kindergarten, sixth and ninth grades and those entering the district from out of state or from other countries are required to present documentation of a completed physical examination on the Illinois Certificate of Child Health Examination form.
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