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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?

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