The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
250 Washington Street, Boston, MA 02108-4619

MITT ROMNEY
GOVERNOR
KERRY HEALEY
LIEUTENANT GOVERNOR
RONALD PRESTON
SECRETARY
CHRISTINE C. FERGUSON
COMMISSIONER	

TO:		School Nurse and School Physicians

FROM:	Anne H. Sheetz
		Director of School Health Services

DATE:		November 22, 2004

SUBJ:		Health Care Provider's Examination: School Health Record

MEMORANDUM
______________________________________________________________________

Massachusetts General Law, Chapter 71, section 57 requires that each student have a physical examination at certain intervals.  After completion, the Massachusetts Health Care Provider's Examination Form must be shared with the school to become part of the student's school health record.  During the past year, the Massachusetts Department of Public Health has collaborated closely with school physicians, pediatricians and nurses to update the existing form.  The goal of this process was to identify information needed by the school to protect the health and safety of the student and to meet certain legal requirements.  Another goal was to create a single-page document for ease of implementation.   

Attached is the revised Health Care Provider's Examination Form. When completed, this form, with the student's complete record/certificate of immunizations, should be given to the school nurse and placed in the student's health record.  We would suggest that you consider copying the certificate of immunizations on the back of the Health Care Provider's Examination form to ensure that it is completed as part of this record.

Providers are advised to include that information necessary for the health and safety of the student in the school setting.  If a provider wishes to use a different form or format, this is acceptable, provided the content of the Massachusetts Health Care Provider's Form is included. In addition, the following should be attached as appropriate:

•	Additional detailed information to facilitate the care of the student in the school setting;
•	A separate provider's order form for each medication or treatment to be administered in the school; and
•	If a child has asthma, a Massachusetts Asthma Action Plan.

Schools may wish to share the Health Care Provider's Examination Form and this letter with local primary care providers as soon as possible. 

We hope this revised Health Care Provider's Examination Form proves useful to you.   Thank you.