Personnel Medical Form Checklist:

Have You:

• Made an appointment with your physician for a physical examination?
• Completed all asterisked areas on both sides of the Personnel health form?
• Remembered to bring the form with you to the physician at the time of your appointment?
• Made arrangements to return the completed form to the school nurse?

Has Your Physician:

• Remembered to complete all medical information areas of the Personnel Health Form?
• Submitted documentation of immunization record?
• If immunization record not available/ infectious diseases blood titres, Rubella, measles, mumps. Varicella.
• Administered the P.P.D. Mantoux (T.B. test) test? (Nurse or M.D. reads results in 48-72 hours.)
• Tetanus toxoid booster within past 10 years?
• Signed and dated the back of the form?