APPENDIX A FORMS FOR SCHOOL SPINAL SCREENING


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1 APPENDIX A FORMS FOR SCHOOL SPINAL SCREENING 32

2 SAMPLE PRE-SCREENING LETTER TO PARENTS Dear Parent/Guardian: Our school will do spinal screenings on. State law requires that schools must screen students for abnormal spinal curvature in accordance with the following schedule: Girls will be screened two times, once at age 10 (or fall semester of grade 5) and again at age 12 (or fall semester of grade 7). Boys will be screened one time at age 13 or 14 (or fall semester of grade 8). Trained screeners will check your child for signs of spinal problems like scoliosis. Catching a spinal problem early can make the treatment much easier. Not treating spinal problems can lead to serious health problems. The screening is simple. Screeners will look at your child s back while he or she stands and bends forward. Important Recommendations: Students should bring shorts to school for the exam. Girls should wear a thin t-shirt or a sports bra or a two-piece swimsuit top underneath their shirt on exam day. If girls are wearing a sports bra or a two-piece swimsuit top underneath their shirt, it is recommended they remove their shirt for the screening. Boys and girls will be screened separately and one at a time. The school will send you a letter if your child does not pass the screening. The letter will tell you how to follow up with a doctor. This screening is not a medical exam. Your child still needs to see a doctor for checkups. If you do not wish to have your child screened for religious reasons, you must submit an exemption to the school no later than. Thank you for your cooperation. Sincerely,. 33

3 CARTA DE MUESTRA PARA LOS PADRES ANTES DE LA EVALUACIÓN Estimado padre de familia o tutor: Nuestra escuela llevará a cabo revisiones de la columna vertebral el. La legislación estatal estipula que todas las escuelas deben examinar a los estudiantes en busca de curvaturas anormales de la columna vertebral. Las escuelas deben seguir el siguiente calendario de exploración clínica de la columna: Las niñas serán examinadas dos veces, una a la edad de 10 años (o en el semestre de otoño de 5. grado) y otra a la edad de 12 años (o en el semestre de otoño de 7. grado). Los varones serán examinados una vez a la edad de 13 o 14 años (o en el semestre de otoño de 8. grado). Examinadores capacitados revisarán a su hijo en busca de problemas de la columna vertebral, como la escoliosis. Detectar un problema de la columna vertebral a tiempo puede hacer que el tratamiento sea mucho más fácil. Dejar un problema de la columna vertebral sin tratar puede dar lugar a graves problemas de salud. La revisión es muy simple. Los examinadores observarán la espalda de su hijo o hija al estar de pie y doblar el cuerpo hacia adelante. Recomendaciones importantes: Los estudiantes deben llevar pantalones cortos a la escuela el día del examen. Las chicas deben llevar una camiseta delgada o un sostén deportivo o la parte de arriba de un traje de baño de dos piezas debajo de la blusa el día de la revisión. Si las chicas llevan un sostén deportivo o la parte de arriba de un traje de baño de dos piezas debajo de la blusa, se recomienda que se quiten la blusa para la revisión. Los chicos y las chicas serán examinados de manera separada, y uno a la vez. Si su hijo no pasa la revisión, la escuela le enviará una carta. Esta carta le dirá cómo dar seguimiento al caso con un doctor. Esta revisión no es un examen médico. Su hijo aún necesita ver a un doctor para que le haga más revisiones. Si usted no desea que se le haga la revisión a su hijo por razones de tipo religioso, debe enviar a la escuela una solicitud de exención a más tardar el. Muchas gracias por su cooperación. Atentamente,. 34

4 AFFIDAVIT OF RELIGIOUS EXEMPTION I,, understand that Texas law requires all (Parent or Guardian) public and private schools to screen students for abnormal spinal curvature in accordance with the following schedule: Girls will be screened two times, once at age 10 (or fall semester of grade 5) and again at age 12 (or fall semester of grade 7). Boys will be screened one time at age 13 or 14 (or fall semester of grade 8). I ask that not be screened because it is against our (Name of Student) religious beliefs. (Parent or Guardian) 35

5 DECLARACIÓN JURADA DE EXENCIÓN RELIGIOSA Yo,, quedo enterado de que la legislación estatal (padre, madre o tutor) estipula que todas las escuelas públicas y privadas deben examinar a los estudiantes en busca de curvaturas anormales de la columna vertebral. Las escuelas deben seguir el siguiente calendario de exploración clínica de la columna: Las niñas serán examinadas dos veces, una a la edad de 10 años (o en el semestre de otoño de 5. grado) y otra a la edad de 12 años (o en el semestre de otoño de 7. grado). Los varones serán examinados una vez a la edad de 13 o 14 años (o en el semestre de otoño de 8. grado). Solicito que no sea evaluado(a) porque va en contra de nuestras (nombre del estudiante) creencias religiosas. (padre, madre o tutor) 36

6 SCHOOL SPINAL SCREENING WORKSHEET SCHOOL/DISTRICT: R - Roundback S - Sway back ABNORMALITY DETECTED CURRENTLY UNDER TREATMENT RESCREENED RESCREEN CONFIRMED FINDINGS SCOLIOMETER READINGS (OPTIONAL) FAMILY CONTACTED REFERRED FOR EXAMINATION DIAGNOSIS & TREATMENT REPORT RECEIVED ADDITIONAL FOLLOW-UP REQUIRED SCREENER(S): DATE OF SCREENING: GRADE/AGE: A - Head B - Shoulder C - Spine D - Scapula E - Waist F - Hips 1 3 G - Lumbar hump STUDENT NAME M/F Y/N Y/N Y(DATE)/N Y/N / Y(DATE)/N Y/N Y(DATE)/N Y/N FILLING OUT THE SCHOOL SPINAL SCREENING WORKSHEET: This form is to assist with re-screening and follow-up by providing a place to indicate and reference your initial findings. This form allows you to note the student s position in which a possible abnormality was found, and section(s) of the body indicating that abnormality. Each of the screening positions has a corresponding numbered column. Sections of the body and some of the conditions you may find have corresponding letters. In the appropriate column, place letters to indicate the sections of the body showing a possible abnormality. For example, if one shoulder appears higher than the other when viewing a student in position 1, place a B in column 1 under that student s name. 37

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8 SPINAL SCREENING PROGRAM PARENT NOTIFICATION AND REFERRAL STUDENT: BIRTH DATE: ADDRESS: SCHOOL: SCHOOL TELEPHONE: Dear Parent/Guardian: Recently our school screened your child for spinal problems. Your child s screening shows that he or she has signs of a possible spinal problem. It is important for you to have your child s spine checked by a doctor. Catching a spinal problem early can make the treatment much easier. Not treating spinal problems can lead to serious health problems. Please take your child to the doctor as soon as possible. Bring this form with you when you go and ask the doctor to fill it out. After your child sees a doctor, please return this form to school. Please let us know if you have questions or cannot pay for a doctor. Thank you for your cooperation: School Screening Findings: L R L R High shoulder Rib hump Shoulder blade stands out more than the other Obvious curve of spine in lower back Obvious curve of the spine in area of rib cage Hip higher than the other side Round back Other: School Screener s Name & Title: Date: Professional Examination Report: Diagnosis: Recommendations: No Treatment Treatment: Observation Brace Surgery Other (please describe): Referral (please describe): Activity Limitation (if any, please describe): Additional Comments: Return Appointment: No Yes Return Date: Doctor s signature or hand stamp Date Doctor s Mailing Address/Phone: For school use: This form completed and received by school (name/date): This form not returned to school (reason): 39

9 PROGRAMA PARA EXAMEN DE LA COLUMNA VERTEBRAL NOTIFICACIÓN A A LOS PADRES Y RECOMENDACIÓN CON ESPECIALISTA ESTUDIANTE: FECHA DE NACIMIENTO: DIRECCIÓN: ESCUELA: TELÉFONO DE LA ESCUELA: Estimado padre/madre/tutor: Nuestra escuela evaluó recientemente la columna vertebral de su niño o niña. La evaluación mostró signos de un posible problema en la columna vertebral. Es importante que un médico examine la columna vertebral de su niño(a). Detectar de manera temprana los problemas de la columna vertebral hace que sea mucho más fácil tratarlos. No tratar los problemas de la columna puede conducir a problemas de salud graves. Por favor lleve a su niño(a) al médico lo más pronto posible. Lleve este formulario a la consulta y pídale al médico que lo llene. Después de que el médico vea a su niño(a), por favor entregue este formulario nuevamente a la escuela. Por favor avísenos si tiene alguna pregunta o si no puede pagar la consulta de un médico. Muchas gracias por su cooperación. RESULTADOS DEL EXAMEN Izq. Der. Izq. Der. [ ] [ ] Hombro alto (high shoulder) [ ] [ ] Protuberancia en las costillas (rib hump) [ ] [ ] Omóplato que sobresale más que el otro (shoulder blade stands out) [ ] [ ] Curvatura obvia de la espina en la parte baja de la espalda (obvious curve of spine in lower [ ] [ ] Curvatura obvia de la espina en el área de back) la caja torácica (obvious curve of spine in rib cage area) [ ] [ ] Una cadera más alta que la otra (one hip higher) [ ] Espalda encorvada (round back) Otro: Nombre y cargo de la persona que examinó en la escuela: Fecha: PROFESSIONAL EXAMINATION REPORT: Diagnosis: Recommendations: No Treatment Treatment: Observation Brace Surgery Other (please describe): Referral (please describe): Activity Limitation (if any, please describe): Additional Comments: Return Appointment: No Yes - Return Date: Doctor s signature or hand stamp Date Doctor s Mailing Address/Phone: For school use: This form completed and received by school (name/date): This form not returned to school (reason): 40

10 SEE OTHER SIDE FOR INSTRUCTIONS & LATE EXAM RESULTS SPINAL SCREENING REPORT (form M-51) NUMBER NAME OF SCHOOL DISTRICT OR SCHOOL CITY CONTACT (name/title/phone) COUNTY (10 DIGIT PEIMS/TEA IS NUMBER) STUDENT SPINAL SCREENING Grade(G)/Age(A) Sex (F or M) G5F G7F G8M A10F A12F A13M A14M Under Prior Treatment (Do not screen) Screened Rescreened Referred RESULTS OF REFERRALS ONLY PHYSICIAN DIAGNOSIS Normal Scoliosis Kyphosis Other Observation Only TREATMENT PLAN Orthosis Bracing Operation Surgery Other Results Unavailable Totals A B C D E F G H I J K L M Date SUBMIT COMPLETED FORM TO DSHS BY JUNE 30 For questions about completing this form contact the DSHS Spinal Screening Program at M-51 Revised 09/

11 INSTRUCTIONS FOR THE SPINAL SCREENING REPORT (FORM M-51) School districts, private school systems, and charter schools: use this form to report cumulative totals of the spinal screenings conducted at each of your campuses. Individual public/private school campuses within a district/system: this form is useful for reporting campus totals to main offi ce. The main offi ce enters cumulative totals of all campuses onto one form and submits that form to DSHS. STUDENT SPINAL SCREENING (Columns A - D) Age: Enter numbers under the respective students grade(g) or Age(A) and sex (F or M). (A) Under prior treatment: Enter number of students who have already received professional treatment for a spinal abnormality. Do not screen these students and do not enter their diagnosis or treatment on the report form. (B) Students screened: Enter number of students screened. (C) Rescreened: Enter number of students that received a second screening as result of a possible abnormal fi nding during the initial screening. (D) Referred: Enter number of rescreened students above whose parents were given a spinal screening parent notifi cation and referral for a professional examination. RESULTS OF REFERRALS ONLY (Columns E - M) This section is for recording the results of the professional exams of those students referred. Do not enter your assessment of the condition. If results are not available, indicate that in Column M. PHYSICIAN DIAGNOSIS (Columns E - H) (E) Normal: Nu mber of students determined by their physician to have normal curvature. (F) Scoliosis: Number of students that received a diagnosis of scoliosis from their physician. (G) Kyphosis : Number of students that received a diagnosis of kyphosis from their physician. (H) Other: Num ber of students that received a diagnosis for a condition not listed above. TREATMENT PLAN (Columns I - M) Mark only one treatment for each student. If a student receives multiple treatments, mark only the treatment that appears furthest to right on this form s treatment columns. (I) Observation only: Enter number of students to be observed only at this time. (J) Bracing: En ter number of students for whom a brace has been prescribed. (K) Surgery: E nter number of students for whom surgery has been indicated. (L) Other: Ent er number of students receiving a treatment not indicated above. (M) Results una vailable: Enter number of referred students for whom professional exam results are unavailable. Results should be submitted next year on the LATE EXAM RESULTS table. DOUBLE CHECK YOUR MATH: Sum of Columns E, F, G, H, & M should equal sum of Column D. Make sure you did not enter diagnosis/treatment for students under prior treatment (Column A). LATE EXAM RESULTS Use this table to record the results of referrals (if any) that were made the last school year, but returned too late to be included on last year s spinal screening report form. DIAGNOSIS TREATMENT Grade(G)/Age(A) Sex (F or M) Normal Scoliosis Kyphosis Other Obser vation Br acing Sur ger y Other G5F G7F G8M A10F A12F A13M A14M Totals E F G H I J K L 42

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