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Health Forms and Emergency Action Plans

Health requirements for Mattoon Community Unit School District 2

It’s not too early to make sure your child is up to date with their health exams and immunizations for the upcoming school year.  Children entering the Mattoon school system for the first time or advancing to certain grade levels must provide proof of required immunizations and health exams at registration in August.  

Mattoon School district requires that all children needing mandated physical examinations and immunizations. For more information, contact Vicky Wright, district nurse at 217-238-7815.  (Title 77: IL Public Health, Part 665.240 Child Health Examination Code, Basic Immunization Minimum Immunization Requirements for Those Entering a Child Care Facility or School in Illinois).

Immunization abbreviations spelled out:

DPT, DTP, DTaP,  = Diptheria, Pertussis, Tetanus

Polio (IPV, OPV)  = Inactivated poliovirus vaccine, Oral poliovirus vaccine

MMR = Measles, Rubella, and Mumps

Hepatitis B = Hepatitis B

Varicella = Chickenpox

HIB = Haemophilus Influenzae Type B

Tdap = Tetanus, Diptheria, acellular pertussis (pertussis=whooping cough)

MCV = Meningococcal (Meningitis)

PCV = Invasive Pneumococcal disease      

Specific health and immunization requirements for Mattoon student as various grade levels or entry points in the District include:



Physical Exam 

4 DPT immunizations

3 Polio immunizations

1 MMR immunization

All 3 Hepatitis B immunizations

1 varicella immunization after 1st birthday

1 Hib immunization, at least one dose after 15 months of age

Pneumococcal, Children 24-59 months without series must have one dose after 24 months of age

 Lead screening



Physical Exam

Eye Examination

Dental Examination

4 or more doses of DPT with the 4th dose received on or after the 4th birthday

4 doses of Polio combination of IPV and OPV, or 3 doses of all OPV or IPV The last dose of Polio must be on or after the 4th birthday

2 doses of MMR

 2 doses of varicella

 Lead Screening


Second grade

Dental examination must be completed by May 15 of the school year. Therefore, Dental exams can be done during the school year by the child’s family dentist anytime during the summer break or during the school year up until May 15.   Sarah Bush Lincoln Dental will offer free dental exams to all District students with signed permission.  Please look for the permission forms at registration.      


Sixth grade

Physical Exam

 Dental Exam (same note as for 2nd grade)

 Tdap immunization

 Hepatitis B, 3 doses

2 varicella immunization



Ninth grade

Physical Exam


2 varicella immunizations

MCV, one dose after 11 years of age


Twelfth grade

MCV, 2 doses of the meningococcal vaccine at school entry; 2nd dose must be administered on or after 16th



Meningitis is a serious and possibly fatal bacterial infection that most often causes severe swelling of the tissue around the brain and spinal cord (meningitis) or a serious blood infection (meningococcemia). To protect your child from this disease the Illinois Department of Public Health (IDPH) requires that:

Any child entering the 6th grade shall show proof of having received one dose of meningococcal conjugate vaccine on or after the 11th birthday. The children entering 6th grade will receive this notice with their physical examination form.

Any child entering the 12th grade shall show proof of having received two doses of meningococcal conjugate vaccine prior to entering the 12th grade. The first dose shall have been received on or after the 11th birthday, and second dose shall have been received on or after the 16th birthday. If the first dose is administered when the child is 16 years of age or older, only one dose is required.

You child will need the meningitis vaccine by start of school in August. The school nurse will ask for proof of receiving the immunization at registration.

Health Forms

Preschool Requirements Page 1

Preschool Requirements Page 2

Kindergarten Requirements Page 1

Kindergarten Requirements Page 2

Kindergarten/Second/Sixth-Dental Form

SBLHC Dental Program (Optional)

SBLHC-Dental-Form (Optional)

Sixth Grade Physical Requirements

Ninth Grade Physical Requirements

Exam Form Updated

Registration Health Record

School Medication Authorization Form


Hearing and Vision Testing Schedule 2019-2020

Hearing Testing Schedule 2019-2020

Vision Testing Schedule 2019-2020


Emergency Action Plans And Forms

Dear families:

    At school we strive to protect the wellbeing of our students, especially those with special health problems.  The Emergency Action Plans listed below will enable school personnel to better provide for your child's wellbeing.

    Because of this commitment, it is important that parents or guardians share certain confidential information about the student's health problem.  This information will be used to plan for the care and management of the student's health condition.  It will be shared with those members of the professional school staff who have direct responsibility for the student when in school or participating in school activities.  In addition, we ask you to help us update the plan on an annual basis.

    If your child has a chronic health problem or a health condition that may create a need for emergency or supportive care during the school day, please complete the appropriate Action Plan and return it to the health office.  The school nurse is available to assist you in completing the form or answering any questions that you may have concerning the use of the information requested.

    It is important that you notify the school nurse during the school year of any changes in your child's health status, medications, or treatments so that the student's emergency action plan can be adjusted.  Parent-school communication is vital to the success of the program and the safety of our students.

    Thank you for assisting us in providing a successful school experience for all students with special needs or chronic health problems.

Mattoon School District Nurses


Asthma Action Plan Letter to Families

Asthma Medication Inhaler

Asthma Medication Nebulizer

Asthma Action Plan

Action Plan Consent Form

IDPH Asthma Action Plan

Medical Action Plan

Allergy and Anaphylaxis Emergency Plan 

Anxiety Action Plan

Cardiac Care Plan

Severe Bee Sting Allergy without EpiPen

Student Medical Information

Seizure (Parent Questionnaire)

Seizure Action Plan

Authorization to Provide Diabetes Care

Diabetes Medical Management Plan

Action Plan for High Blood Sugar

Action Plan for Low Blood Sugar




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Mattoon Community Unit School District 21701 Charleston AvenueMattoon, IL  61938

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