216-RICR-20-10-4. School Health Programs (version Periodic Refile, 01/02/2002 to 11/16/2003)

RULES AND REGULATIONS FOR SCHOOL HEALTH PROGRAMS (R16-21-SCHO) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS Department of Elementary and Secondary Education Department of Health January 1964 AS AMENDED: March 1979 December 1980 May 1989 December 1989 March 1993 January 1996 December 1998 December 1999 December 2000 January 2002 (re-filing in accordance with the provisions of section 42-35-4.1 of the Rhode Island General Laws, as amended) i INTRODUCTION These Rules and Regulations for School Health Programs (R16-21-SCHO) are promulgated pursuant to the authority conferred under RIGL Chapters 16-21, 35-4, and 23-1-18(4) and are established for the purpose of adopting minimum standards pertaining to school health programs. Amendments were also promulgated in January 1996 for the purpose of addressing cases of anaphylaxis among students in Rhode Island schools. Anaphylaxis is a medical condition which requires immediate attention. Because children spend a significant portion of their time at school, it is crucial that school personnel are trained to respond effectively to cases of anaphylaxis. In the development of these amended regulations, consideration was given to: (1) alternative approaches; (2) overlap or duplication; and (3) significant economic impact on small business as defined in RIGL Chapter 42-35 which may result from the amended regulations. Based on information available, no alternative approach, overlap or duplication was identified. The need to provide for medical emergencies by adopting minimum standards for school health programs overrode any economic impact which may be incurred. Consequently, these regulations are adopted in the best interest of students in this state. Professional staff at the Departments of Health and Education shall be available to provide guidance on the implementation of these rules and regulations, as needed. These Rules and Regulations for School Health Programs (R16-21-SCHO) shall supersede all previous rules and regulations pertaining to school health programs and the health and safety of pupils and promulgated by the Departments of Education and Health and filed with the Secretary of State. ii TABLE OF CONTENTS Page PART I DEFINITIONS & GENERAL REQUIREMENTS 1 1.0 Definitions 1 2.0 General Requirements 6 PART II HEALTH EDUCATION 8 3.0 Administration of the Health Education Program 8 4.0 Health Education Curriculum 9 5.0 Mandated Health Instructional Outcomes: Required Content Areas 9 PART III HEALTH SERVICES 12 6.0 Responsibility for Services 12 7.0 School Personnel 12 8.0 Health Examinations 16 9.0 Vision Screening 17 10.0 Hearing Screening 19 11.0 Speech/Language Screening 21 12.0 Scoliosis Screening 22 13.0 Dental Health Screening 23 14.0 Health Records 24 15.0 Notification of Parents 26 16.0 School Reporting Requirements 27 17.0 First Aid and Emergencies 27 18.0 Medication Administration 31 19.0 Immunization and Testing for Communicable Diseases 34 PART IV HEALTHFUL SCHOOL ENVIRONMENT 35 20.0 Standards for School Buildings and Approval 35 21.0 New Construction (School Building)/General Requirements 35 22.0 Existing School Buildings/General Requirements 36 23.0 Asbestos 37 24.0 Lead 38 25.0 Radon 38 26.0 Food Service 39 27.0 Health Room 41 28.0 Sanitation 42 29.0 Housekeeping 43 30.0 Swimming Pools 43 31.0 Water Supply 43 32.0 Tobacco 43 33.0 Weapons and Firearms 44 34.0 Alcohol and Other Drugs 44 35.0 Recreational Facilities 44 36.0 Laboratories, Shops and other Special Purpose Areas 45 37.0 Vehicular and Pedestrian Traffic Safety 45 38.0 Asset Protection 45 PART V ENFORCEMENT & SEVERABILITY 46 39.0 Enforcement 46 40.0 Severability 46 REFERENCES 47 1 PART I DEFINITIONS AND GENERAL REQUIREMENTS (R16-21-SCHO) Section 1.0 Definitions Wherever used in these rules and regulations the terms listed below shall be construed as follows: 1.1 "Anaphylaxis" refers to a potentially fatal, acute allergic reaction to a substance (such as stinging insects, foods and medications) that is induced by an exposure to the substance. Manifestations of anaphylaxis may be cutaneous (such as hives, itchiness, swelling), cardiorespiratory (swelling of tongue, throat, wheezing, difficulty breathing, low blood pressure), central nervous system (lethargy, coma) and others. 1.2 "Audiologist" means an individual licensed in this state in accordance with the Rules and Regulations for Licensing Speech Pathologists and Audiologists (R5-48-SPA) of reference 9 who specializes in preventing, identifying, and assessing hearing disorders, as well as providing audiologic treatment including hearing aids and other assistive listening devices. 1.3 "Audiometric aide" means an individual registered in this state in accordance with the Rules and Regulations for Licensing Speech Pathologists and Audiologists (R5-48-SPA) of reference 9. 1.4 "Certified health educator" means an individual who holds the appropriate certification as a health educator in accordance with the requirements of the Rhode Island Department of Elementary and Secondary Education. 1.5 "Certified school nurse-teacher" means an individual who is licensed as a professional (registered) nurse in this state pursuant to Chapter 5-34 of the RIGL and is certified by the Rhode Island Department of Elementary and Secondary Education as a Certified School Nurse-Teacher. 1.6 "Community" means any city, town or regional school district established pursuant to state law and/or the Department for Children, Youth, and Families and any school operated by the state Department of Elementary and Secondary Education; provided, however, that the Department for Children, Youth and Families shall not have those administrative responsibilities and obligations as set forth in Chapter 2 of Title 16 ("Education"); provided, however, the member towns of the Chariho Regional High School District, created by Chapter 55 shall constitute separate and individual communities for the purpose of determining and distributing said Foundation Level School support including state aid for non-capital excess expenses for the special education of handicapped children provided for in Chapter 16-24-6 of the RIGL for all grades financed in whole or in part by said towns irrespective of any regionalization pursuant to Chapter 16-7 of the RIGL entitled, "Foundation Level School Support." 1.7 "Confidential health care information" means all information relating to a patient's health care history, diagnosis, condition, treatment or evaluation obtained from a health care provider who has treated the patient. 2 1.8 "Controlled substance" means a drug, substance, or immediate precursor in schedules I--V of Chapter 21-28-1.02 of the RIGL. 1.9 "Dental hygienist" , as used herein, means an individual licensed to practice dental hygiene in the United States. 1.10 "Dentist", as used herein, means an individual licensed in the United States to practice dentistry. 1.11 "Education record" means those records that are: 1. directly related to a student; and 2. maintained by an educational agency or institution or by a party acting for the agency or institution. 1.12 "Emergency" means a medical or psychological condition where the absence of immediate intervention could reasonably be expected to result in placing the student's health (or another student's health) in serious jeopardy; serious impairment to bodily or psychological functions; or serious dysfunction of any bodily organ or part. 1.13 "Epinephrine auto-injectors" refers to any device that is used for the automatic injection of epinephrine into the human body to prevent or treat anaphylaxis. 1.14 "Eye care provider", as used herein, means an individual licensed in the United States to practice optometry or medicine (i.e., ophthalmology). 1.15 "Follow up" means the contact with a student, parent as defined herein, and/or service provider to verify receipt of services, provide clarification and determine the need for additional assistance. 1.16 The “governing body” means the body or board or committee or individual, or the designated agent(s) or designee(s) of the aforementioned, responsible for, or who has control over, the administration of any elementary or secondary school, public or non-public, in the state of Rhode Island. 1.17 "Health" is the quality of a person's physical, psychological, and sociological functioning that enables him or her to deal effectively with self and others in a variety of situations. 1.18 "Health care provider/agency" means any person/agency licensed by this state to provide or otherwise lawfully able to provide health care services, including, but not limited to, a physician, chiropractor, hospital, intermediate care facility or other health care facility, dentist, dental hygienist, nurse, nurse practitioner, optometrist, podiatrist, pharmacist, physical therapist, psychiatric/clinical social worker, mental health counselor, or psychologist and any officer, employee or agent of that provider acting in the course and scope of his/her employment or agency related to or supportive of health services. 1.19 "Health education" means comprehensive sequential K through 12 instruction that builds a foundation of health knowledge, develops the motivation and skills required of students to cope with challenges to health and provides learning opportunities designed to favorably influence health attitudes, 3 practices and behavior that will impact lifestyles, educational performance and achievements and long range health outcomes and is in accordance with the requirements of section 3.4 herein. 1.20 "Hearing impairment" means an impairment in hearing, whether permanent or fluctuating, that affects a student's educational performance. 1.21 “Individualized health services” means services provided to individual students who attend school within the community which are specific to the health needs of the individual student, such as medication administration, and are not included in the health examination/screenings, record keeping and reporting requirements described in section 6.1.1 herein. 1.22 “Local education agency” means an educational agency at the local level that exists primarily to operate schools or to contract for educational services for elementary and secondary public and non- profit private schools. For non-profit private schools, this includes the building owner. 1.23 "Mandated instructional outcomes" are statements which indicate what health knowledge and skills students should have at the completion of a specific health unit. 1.24 "Medication" means a prescription substance regarded as effective for the use for which it is designed in bringing about the recovery, maintenance or restoration of health, or the normal functioning of the body. 1.25 "Parent" means a natural parent, a legal guardian or an individual acting as a parent in the absence of a parent or a legal guardian. 1.26 "Physician", as used herein, means an individual licensed in the United States to practice allopathic or osteopathic medicine. Chiropractic physicians licensed under the provisions of Chapter 5-30 of the Rhode Island General Laws, as amended, shall be entitled to the same services of the laboratories of the Department of Health and other institutions, and shall be subject to the same duties and liabilities, and shall be entitled to the same rights and privileges in their professional calling pertaining to public health which may be imposed or given by law or regulations upon or to physicians qualified to practice medicine by section 5-37-2 of the Rhode Island General Laws, as amended; provided, however, that chiropractic physicians shall not write prescriptions for drugs for internal medication nor practice major surgery. 1.27 “Population-based health services” means services provided to all students attending school within the community which are not focused on the individual health needs of the particular student but are provided to all students as part of the health examination/screenings, record keeping and reporting requirements described in section 6.1.1 herein. 1.28 "Prescription" means an order for medication signed by a licensed practitioner with prescriptive authority or transmitted by the practitioner to a pharmacist by telephone, facsimile, or other means of communication and recorded in writing by the pharmacist. 4 1.29 "Record" means any information recorded in any way, including, but not limited to, handwriting, print, tape, computer diskette, film, microfilm, and microfiche. 1.30 “RIGL” means Rhode Island General Laws, as amended. 1.31 "School" means all public or privately supported schools for students in grades Kindergarten (K) through 12 in Rhode Island. In addition, a preschool program operated by or within an approved school (per the requirements of section 2.1 herein) shall be considered a "school" for the purposes of the rules and regulations herein. 1.32 "School personnel" means all persons employed directly by the school or under contract to the school. 1.33 "Scoliosis screening" means screening for detection of an abnormal curvature of the spine, as defined by current American Academy of Orthopaedic Surgeons and Scoliosis Research Society standards. 1.34 "Self-administration" of medication means that the student uses the medication in the manner directed by the health care provider, without additional assistance or direction. 1.35 "Self-carry" means that the student carries medication on his/her person, in the event that self- administration is necessary, with safety to him/herself and other students. 1.36 "Speech or language impairment" means a disorder in articulation, language, voice and/or fluency that adversely affects the student's educational performance. A speech and language impairment may range in severity from mild to severe; it may be developmental or acquired. A speech and language impairment may be the result of a primary disabling condition or it may be secondary to other disabling conditions. A dialect is a variation of a symbol system used by a group of individuals that reflects and is determined by shared regional, social or cultural/ethnic factors and is not considered to be a disorder of speech. 1.37 "Speech/language pathology" includes identification of students with speech or language impairments; diagnosis and appraisal of specific speech or language impairments; referral for medical or other professional attention necessary for the habilitation of speech or language impairments; provision of speech and language services for the habilitation or prevention of communicative impairments; and counseling and guidance of parents, children and teachers regarding speech and language impairments. 1.38 "Speech/language pathologist" means a professional who identifies, assesses, diagnoses, prevents, and treats speech, voice, language, communication, and swallowing disorders. 1.38.1 "Certified speech/language pathologist" means a speech/language pathologist certified by the Rhode Island Department of Elementary and Secondary Education to perform speech- language pathology services for the public school system. 5 1.38.2 "Licensed speech/language pathologist" means a speech/language pathologist licensed by the Rhode Island Board of Examiners in Speech Pathology and Audiology to perform speech- language pathology services in all settings outside the public school system. 1.39 "Speech/language pathology aide" means an individual registered in this state in accordance with the Rules and Regulations for Licensing Speech Pathologists and Audiologists (R5-48-SPA) of reference 9. 1.40 "Student" means any individual who is or has been enrolled at an educational agency or institution and regarding whom the agency or institution maintains educational records. 1.41 "Vision screening," as used herein, means a limited series of tests to identify individuals who may have a vision or eye health problem. 1.42 "Visual impairments" include: a) "Partial sight" means a visual acuity ranging from 20/70 to 20/200 in the better eye after refraction, or a significant loss of fields of vision in both eyes as a result of, but not limited to, hemeralopia, glaucoma, retinitis pigmentosa, retinoschisis, or diabetes retinopathy that, with correction, affects a student's educational performance. b) "Blindness" means a visual acuity ranging from a central visual acuity of 20/200 or less in the better eye after refraction, or a peripheral field of vision that subtends an angle no greater than twenty (20) degrees that, even with correction, affects a student's educational performance. 6 Section 2.0 General Requirements 2.1 All schools that are approved pursuant to RIGL sections 16-19-1 and 16-19-2 shall have a comprehensive school health program consisting of health education, health services and a healthful school environment, approved by the State Commissioner of Elementary and Secondary Education and the Director of Health in accordance with RIGL section 16-21-7. The health education program (curriculum and personnel) for non-public schools shall be consistent with the provisions of section 3.1 herein. 2.2 Each community, school district and appropriate non-public school authority (e.g. the superintendent, the headmaster, or the principal) shall be responsible for a comprehensive school health program (health education, health services, healthful school environment) and shall develop a manual of procedures (protocols) governing health education, health services and a healthful school environment. This manual shall be available at the Superintendent's office and at each school, both public and non- public, within the district. Such procedures shall pertain to no less than the statutory and regulatory requirements herein and shall furthermore include provisions pertaining to, but not limited to, the following: 2.2.1 The education of children infected with HIV/AIDS, based on the most current Rhode Island Department of Elementary and Secondary Education and the Rhode Island Department of Health Policy Guidelines on Infected Students and Employees. 2.2.2 Substance abuse, based on the Model Policy for Tobacco, Alcohol, and Other Illicit Drug Use promulgated by the Rhode Island Substance Abuse Policy Task Force and the Rhode Island Department of Elementary and Secondary Education; 2.2.3 The use of alcohol and tobacco products on school premises and at authorized school activities; 2.2.4 Suicidal behavior; 2.2.5 The prevention and management of injuries and violent behaviors for the protection and safety of students on school premises and at authorized school activities; and 2.2.6 Provisions regarding the three (3) statutory waivers for exclusion of a child from certain areas of the health education curricula (see sections 5.1.7.2 sexuality and family life; 5.1.8.2 HIV/AIDS; and 5.1.12.1 the characteristics, symptoms or treatment of disease). 2.3 Each community, school district and appropriate non-public school authority (e.g., the superintendent, the headmaster, or the principal) shall be responsible to provide an adequate number of personnel for a school health program (health education, health services and environmental health) in accordance with the statutory and regulatory requirements therein. 2.3.1 Such personnel shall include no less than a school physician, dentist, certified school nurse- teacher and personnel as set forth in section 3.3 herein. 7 2.4 The superintendent of each school district, and the appropriate non-public school authority (e.g., the headmaster or principal) shall designate an individual(s) or committee to be accountable for the school or school district health program (health education, health services and a healthful school environment). The names of this/these individual(s) shall be included in the annual report (see section 2.5 herein). 2.5 A report pertaining to the district’s school health program (health education, health services and a healthful school environment) shall be submitted to the state Commissioner of Elementary and Secondary Education and the state Director of Health by the responsible school authority of public (the district superintendent) and non-public schools (the principal or headmaster). Such report (prepared with input from district school improvement teams, when appropriate) shall be submitted to the Commissioner of Elementary and Secondary Education and the Director of Health on forms provided by the Rhode Island Departments of Elementary and Secondary Education and Health, no later than sixty (60) days from a date established by the Departments of Education and Health. 2.6 Any person who has reasonable cause to know or suspect that any child has been abused or neglected shall report such information to the proper authorities at the Department of Children, Youth and Families, in accordance with the requirements of Chapter 40-11 of the RIGL and the Guide to Identifying and Reporting Child Abuse in the Schools, Rhode Island Department of Elementary and Secondary Education. 2.7 No requirement of the rules and regulations herein shall be construed as requiring a certified school nurse-teacher or other licensed health care provider to act in a manner contrary to the provisions of the laws and regulations governing the practice of said profession. 2.8 Nothing in these rules and regulations herein is meant to preclude any student or the parents of any student from pursuing their rights to appropriate educational services and accommodations guaranteed by federal and state laws. 8 PART II HEALTH EDUCATION (R16-21-SCHO) Section 3.0 Administration of the Health Education Program 3.1 Health education as defined in section 1.11 herein shall be provided in grades K through 12 in all schools approved by the Rhode Island Department of Elementary and Secondary Education in accordance with the standards herein. The health education program (curriculum and personnel) of non-public schools shall be approved if deemed substantially equivalent. 3.2 Pursuant to the provisions of RIGL section 16-1-5(14), the Rhode Island Department of Elementary and Secondary Education in conjunction with the Department of Health shall provide both guidance and technical assistance in the development and adoption of school health education curricula for the provision of comprehensive school health education in accordance with the statutory and regulatory requirements herein. 3.3 An appropriately certified health educator shall be designated by the superintendent of school districts and by the appropriate non-public school authority (e.g. the superintendent, the headmaster or the principal) to administer the health education program. Pursuant to the certification requirements of the Rhode Island Department of Elementary and Secondary Education and the provisions hereunder, teachers providing health education shall consist of: 3.3.1 at the secondary level: certified school nurse-teachers, health and physical education teachers or health educators, all of whom must hold appropriate certification as health educators in accordance with the requirements of the Rhode Island Department of Elementary and Secondary Education. 3.3.2 at the elementary level: certified school nurse-teachers, health and physical education teachers or health educators, all of whom must hold appropriate certification as health educators in accordance with the requirements of the Rhode Island Department of Elementary and Secondary Education, or any certified elementary teacher. 3.4 Health education instruction shall consist of a comprehensive health education program in accordance with the Mandated Health Instructional Outcomes of section 5.0 herein, which conforms to the statutory provisions of RIGL section 35-4-18, the curriculum requirements of the Rhode Island Department of Elementary and Secondary Education and other statutory and regulatory requirements herein. 3.5 Pursuant to the provisions of RIGL section 16-22-4, all children in grades one (1) through twelve (12) attending public schools or such other schools as are managed and controlled by the state, shall receive therein instruction in health and physical education as prescribed and approved by the Rhode Island Department of Elementary and Secondary Education during periods which shall average at least twenty (20) minutes in each school day. No non-public instruction shall be approved by any school committee for the purposes of RIGL Chapter 16-19 as substantially equivalent to that required by law 9 of a child attending a public school in the same city and/or town unless instruction in health and physical education similar to that required in public schools is given. 3.6 Planned and ongoing in-service programs shall be established to update health educators and other relevant personnel in their knowledge of health and teaching skills, and to obtain their input regarding health curriculum, assessment and improvement. These shall be consistent with the provisions of RIGL section 35-4-18 entitled, "An Act Relating to Health Education and Substance Abuse Prevention", and RIGL sections 16-1-5(14), 16-22-12, and 16-22-14 pertaining to substance abuse, alcohol, suicide and such other relevant laws. 3.7 Provisions shall be made for the participation by representatives from parent groups, community agencies, professional organizations, health agencies, business, educational institutions and such other groups, to actively involve them in the planning and the implementation of the school health education program. 3.8 Teaching and learning materials that relate directly to the mandated health instructional outcomes of section 5.0 herein and methods for each grade level shall be made available by the local school authorities to teaching staff (health educators) and students in the classroom. Section 4.0 Health Education Curriculum 4.1 The health education curriculum shall: 4.1.1 be sequential and comprehensive for grades Kindergarten-12; 4.1.2 be aligned with the Rhode Island health education standards; 4.1.3 include standards-based goals, objectives, examples of teaching and learning strategies and materials, and assessment; 4.1.4 address the mandated health instructional outcomes (section 5.0 herein); and, 4.1.5 be developmentally appropriate so that all students can achieve high standards. 4.2 A curriculum team consisting of representatives from the school district teaching and administrative staff, parents, and community members shall periodically review and revise, as necessary, the health education curriculum. The health education curriculum of each school district shall be available for review by the Rhode Island Department of Elementary and Secondary Education upon request. 4.3 All student progress toward the achievement of the standards shall be assessed at three grade levels using the state performance assessment. Districts may also establish health education assessment programs. Section 5.0 Mandated Health Instructional Outcomes: Required Content Areas 10 5.1 The health education curriculum shall be based on the health education standards of the Rhode Island Health Education Framework: Health Literacy for All Students and consistent with the mandated health instructional outcomes therein. These outcomes shall pertain to no less than the following topics appropriate to grade or developmental level: 5.1.1 Alcohol, Tobacco and Other Substance Abuse: the causes, effects, treatment and prevention of the use of tobacco and abuse of alcohol and other drugs pursuant to RIGL sections 16-2-3, 16-22-12, and 16-1-5(14); 5.1.2 Cardiopulmonary Resuscitation (CPR): the procedures and proper techniques for CPR and the Heimlich Maneuver, pursuant to RIGL sections 16-22-15 and 16-22-16; 5.1.3 Child Abuse: the signs, symptoms and resources available for assistance; 5.1.4 Community Health: the significance of the relationship between the individual and the community, and the impact that individual health has on the community’s health within a framework of geographical, social, cultural, and political factors; 5.1.5 Consumer Health: the factors involved in decision-making, selecting, evaluating, accessing and utilizing health information, products and services; 5.1.6 Environmental Health: environmental factors that affect the health of individuals and society, strategies to minimize the negative effects of the environment on the community and its members, and the importance of protecting and improving all aspects of the environment; 5.1.7 Family Life and Sexuality: the responsibilities of family membership and adulthood, including issues related to reproduction, abstinence, dating, marriage, and parenthood as well as information about sexually transmitted diseases, sexuality and lifestyles. Pursuant to RIGL section 16-22-18, courses in family life or sex education within this state shall include instruction on abstinence from sexual activity and refraining from sexual intercourse as the preferred method for the prevention of pregnancy and sexually transmitted diseases; 5.1.7.1 Pursuant to RIGL section 16-22-18, upon written request to the school principal, a pupil not less than eighteen (18) years of age or a parent of a pupil less than eighteen (18) years of age, within one week following the date the request is received, shall be permitted to examine the health and family life curriculum program instruction materials at the school in which his/her child is enrolled. 5.1.7.2 A parent may exempt his/her child from the program by written directive to the principal of the school. No child so exempted shall be penalized academically by reason of such exemption. 5.1.8 HIV (Human Immunodeficiency Virus)/AIDS (Acquired Immune Deficiency Syndrome): the causes, effects, treatment, and prevention, including abstinence as a preferred prevention method of this disease, pursuant to RIGL section 16-22-17; 11 5.1.8.1 Pursuant to RIGL section 16-22-17, upon written request to the school principal, a pupil not less than eighteen (18) years of age or a parent of a pupil less than eighteen (18) years of age, within one week following the date the request is received, shall be permitted to examine the HIV/AIDS curriculum program instruction materials at the school in which his/her child is enrolled. 5.1.8.2 A parent may exempt his/her child from the program by written directive to the principal of the school. No child so exempted shall be penalized academically by reason of such exemption. 5.1.9 Human Growth and Development: growth and development as a process of natural progression influenced by heredity, environment, culture, and other factors and which encompasses the continuum from conception to death; 5.1.10 Mental Health: the emotional, behavioral, and social factors that influence both mental and physical health; 5.1.11 Nutrition: the role of nutrition in the promotion and maintenance of good health; 5.1.12 Prevention and Control of Disease: the causes, effects, treatment, and prevention of chronic and communicable diseases. 5.1.12.1 A child may be excluded from instruction because of religious beliefs in accordance with RIGL section 16-21-7, whereby no instruction in the characteristics, symptoms, or treatment of disease shall be given to any child whose parent or guardian shall present a written statement signed by them stating that such instructions should not be given such child because of religious beliefs. 5.1.13 Physical Activity: the relationship of physical activity to health and physical fitness; 5.1.14 Safety and Injury Prevention: the causes, effects, treatment, and prevention of behaviors that can result in unintentional or intentional injury; and 5.1.14.1 Suicide Prevention: the causes, effects, and treatment of behaviors related to suicide, pursuant to RIGL section 16-22-14. 12 PART III HEALTH SERVICES Section 6.0 Responsibility for Services Population-Based Health Services 6.1 In accordance with Chapter 16-21-9 of the RIGL, each community shall provide adequate and appropriate personnel to conduct mandated population-based health services, as described herein, for all school children attending public and non-public schools within its geographical boundaries. 6.1.1 Said services shall include no less than the following components: 6.1.1.1 health examinations/screenings (as described in sections 8.0; 9.0; 10.0; 11.0; 12.0; and 13.0 herein); 6.1.1.2 record keeping requirements in accordance with sections 14.0, 15.0, 16.0, and 17.0 herein; 6.1.1.3 reporting and management of any school-based communicable, environmental, or occupational disease as directed by a physician and in accordance with section 15.0 herein. Individualized Health Services 6.2 Each public and non-public school shall provide adequate and appropriate personnel and/or equipment to render individualized health services to all students enrolled in the school. At a minimum, said services shall include those ordered by a physician, such as medication administration. 6.2.1 All personnel rendering individualized health services to students shall be duly licensed and/or certified in Rhode Island in accordance with all applicable state laws and regulations. 6.2.2 All medications shall be administered in keeping with safe standards of health care practice and in accordance with all applicable state and federal laws and regulations. 6.3 Pursuant to the provisions of section 23-13-26 of the RIGL ("Technology-dependent Children"), certified school nurse-teachers who provide direct care for technology-dependent children, shall provide such care according to the current edition of guidelines found in the publication entitled Children and Youth Assisted by Medical Technology: A Medical Primer of reference 10 and the Guidelines for Children with Special Health Care Needs in the School Setting in Rhode Island. 6.3.1 Each facility in which technology dependent children are treated shall have a current copy of said guidelines, which shall be accessible to the certified school nurse-teacher. Section 7.0 School Personnel 13 The school superintendent with the advice and consent of the school committee of each community, school district or appropriate non-public school authority (e.g., superintendent, headmaster or principal) shall arrange for the appointment of all school health personnel necessary to implement the health services requirements described herein, pursuant to the requirements of RIGL Chapter 16-21. 7.1 School Physician Each community shall provide for the appointment and provision of direct and/or consultative services of a school physician(s) as specified in section 16-21-9 of the RIGL, to make examinations of the health of the school children, who shall report any deviation from the normal, and for the preservation of records of the examinations of the children. 7.1.1 Qualifications and General Duties 7.1.1.1 The community's school physician(s) shall be licensed to practice allopathic or osteopathic medicine in Rhode Island in accordance with Chapter 5-37 of the RIGL. 7.1.1.2 The school physician shall be qualified by virtue of training and experience to assume the role of a school health consultant (e.g., develops school health protocols, provides in-service training for school nurses) and/or primary care provider (e.g., performs physicals, examines outbreak cases) for a wide range of comprehensive school health services. 7.1.1.3 The school physician shall have knowledge of all state and local laws, regulations and protocols affecting schools. The school physician shall participate actively to ensure implementation of all such laws, regulations and protocols in collaboration with the school’s administrative authorities and school health personnel. 7.1.1.4 The school physician shall establish a contract with the school system defining mutually agreed upon expectations and objectives and shall provide a regular report (a minimum of one (1) per year) on consultation and/or direct service activities rendered to the school system. 7.1.1.5 As a condition for approval of a community's school health program by the Commissioner of Elementary and Secondary Education and the Director of Health, that community's school health service plans, protocols and programs (except those developed and provided by the school dentist[s]) shall have received the prior approval of the community's school physician(s). 14 7.1.1.5.1 At a minimum, these plans shall be reviewed on an annual basis by the school physician and shall include provisions for: 1. the delivery of health services in the school environment (including screenings); 2. consultations; 3. furnishing information on health-related matters; 4. review of standing orders, protocols and procedures; and 5. reporting and management of infectious diseases and outbreaks, in accordance with the most current Department of Health recommendations related to infection control in the school environment. 7.2 Certified School Nurse-Teachers 7.2.1 Qualifications Certified school nurse-teacher personnel shall be certified by the state Department of Elementary and Secondary Education and licensed as registered nurses in accordance with section 1.5 herein. 7.2.2 General Duties In accordance with section 6.1 herein, a certified school nurse-teacher shall provide population-based health services to school children in public and non-public schools in the community. In accordance with section 6.2 herein, a certified school nurse-teacher shall provide individualized health services to all public school children in the community. This requirement shall not be construed as prohibiting certified school nurse-teachers from providing individualized health services to students in non-public schools. 7.2.3 Exemption from Certified Nurse-Teacher Requirement 7.2.3.1 In accordance with the Standards for Approval of Non-Public Schools in Rhode Island issued by the Rhode Island Department of Elementary and Secondary Education, non-public schools are authorized to employ registered nurses licensed in Rhode Island for the purpose of providing individualized health services, including dispensing medications, to students in the school setting. 7.2.3.2 These registered nurses licensed in Rhode Island (cited in section 7.2.3.1 above) are construed to be “substantially equivalent” in their qualifications only for the purpose of providing individualized health services, including dispensing medication, to students in the school setting, not for carrying out the population-based health services and other requirements of the school health program as described herein. 7.3 Dentist/Dental Hygienist 7.3.1 Qualifications 15 The school dentist(s)/dental hygienist for a community shall be licensed to practice dentistry/ dental hygiene, respectively, in Rhode Island in accordance with Chapter 5-31.1 of the RIGL. 7.3.2 General Duties 7.3.2.1 Each community shall provide for dental screenings by a dentist or a licensed dental hygienist with at least three (3) years of clinical experience as specified in section 16-21-9 of the RIGL who shall report any suspected deviation from the normal and for the preservation of records of the screenings of the children. 7.3.2.2 Each community as defined in section 16-7-16 of the RIGL shall only contract with a licensed dentist for the provision of the dental screening services required herein. Dental hygienists performing the dental screenings pursuant to the provisions of section 16-21-9 of the RIGL shall do so under the general supervision of the dentist liable and responsible under the contract with the community. (For a definition of “general” supervision, see the Rules and Regulations Pertaining to Dentists, Dental Hygienists and Dental Assistants (R5-31-DHA) promulgated by the Rhode Island Department of Health). 7.3.2.3 Each school dentist or dental hygienist as specified in section 13.1.1 herein may perform any of the required dental screenings of school children in his/her district. Each dentist shall also examine children referred to him/her by the administrator, certified school nurse-teacher, or physician for suspected dental disease. 7.3.2.4 The school dentist and dental hygienist, when applicable, shall be qualified by virtue of training and experience to assume the role of a school health consultant (e.g., develops school health protocols, provides in-service training for school nurses or dental hygienists) and/or service provider in accordance with the Rules and Regulations Pertaining to Dentists, Dental Hygienists and Dental Assistants (R5-31-DHA) promulgated by the Rhode Island Department of Health. 7.3.2.5 The school dentist and dental hygienist, when applicable, shall have knowledge of all relevant state and local laws, regulations and protocols affecting schools. The school dentist and dental hygienist, when applicable, shall participate actively to ensure implementation of all such laws, regulations and protocols in collaboration with the school’s administrative authorities and school health personnel. 7.3.2.6 The school dentist shall establish a contract with the school system defining mutually agreed upon expectations and objectives and the dentist and/or dental hygienist, when applicable, shall provide a regular report (a minimum of one (1) per year) on consultation and/or direct service activities rendered to the school system. 7.3.2.7 Except in emergency circumstances, referral by a dentist or dental hygienist of children screened pursuant to the provisions of section 16-21-9 of the RIGL to a dental practice by which the dentist or dental hygienist is employed and/or which 16 the dentist owns shall be strictly prohibited. In the event that a referral has been made in violation of this provision, the community shall terminate its contract with the dentist. In the case of an egregious violation of the referral prohibition contained herein, such conduct shall be reported to the Board of Dental Examiners at the Rhode Island Department of Health. (See also section 13.3.3 herein for follow-up and documentation requirements). i) Referrals by a dentist or a dental hygienist to non-profit dental programs that provide oral health services on a reduced or sliding fee scale basis are exempt from the provisions of section 7.3.2.7 herein (above). Section 8.0 Health Examinations 8.1 General Health Examination Requirements 8.1.1 Every student who has not been previously enrolled in a public or non-public school in this state shall have a medical history and physical examination completed. This examination shall be conducted in the twelve (12) months preceding the date of school entry, but if not, it shall be completed within six (6) months of school entry. 8.1.1.1 Said general health examination shall be a complete, age-appropriate history and physical examination, assessing the health and well-being of the child and evaluating any challenges to the child’s success in school and school-related activities. 8.1.2 Annual immunization surveys of all new entrants and transfer students (on forms acceptable to the Director) are required by the Director of Health and shall be submitted to the Department of Health by a date determined by the Department of each year. 8.1.3 In addition, a second general health examination and health clearance will be required upon entry to the seventh (7th) grade. This general health examination may be performed during the sixth (6th) grade, but no later than six (6) months after entry into the seventh (7th) grade. 8.1.3.1 Said general health examination shall be a complete, age-appropriate history and physical examination, assessing the health and well-being of the child and evaluating any challenges to the child’s success in school and school-related activities. 8.1.4 These general health examinations shall be conducted by the student's family physician, a physician's assistant under the physician's supervision, or a certified registered nurse practitioner who may collaborate with the physician. 8.1.4.1 If there is no evidence that the appropriate general health examination has been performed, the school system shall make provisions for said examination by the end of the school year in which it is required. 17 8.1.5 For students suspected or identified as having special health needs, referrals by a certified school nurse-teacher shall be made as specified herein or in the Regulations of the Board of Regents Governing the Special Education of Students with Disabilities of reference 11. 8.2 Each school system may require additional health examinations, in order to ensure the mental and physical health of each child to participate in classroom, athletic, or special activities sponsored or conducted by the school. Lead Screening 8.3 In accordance with the requirements of Chapter 23-24.6-8 of the RIGL, each public and private nursery school and kindergarten shall, prior to initial enrollment of a child, obtain from a parent of the child evidence that said child has been screened for lead poisoning according to guidelines established under Chapter 23-24.6-7 of the RIGL, or a certificate signed by the parent stating that blood testing is contrary to that person’s beliefs. Documentation & Follow-up 8.4 General health examination results shall be documented in a standardized format with one (1) copy available from the Department of Health or in any such format that captures the same fields of information. One (1) copy of said form shall be provided to the appropriate certified school nurse- teacher and entered into the student's cumulative school health record. Electronic transmission of the information is acceptable, provided that the requirements of section 14.4 herein are met. 8.5 As appropriate, a care plan for health problems shall be developed in conjunction with the parent, student, certified school nurse-teacher, and other appropriate health care providers and maintained on each student, as needed. The plan shall be entered into the cumulative health record. Section 9.0 Vision Screening 9.1 General Vision Screening Requirements 9.1.1 Every student shall be given a vision screening at least upon entry to school and in the first (1st), second (2nd), third (3rd), fifth (5th), seventh (7th) and ninth (9th) grades. 9.1.1.1 If satisfactory evidence is presented to the school physician or certified school nurse-teacher that the same screening, or series of tests, as provided for herein, has been completed within the preceding six (6) months by the student's ophthalmologist, optometrist, or primary care provider, the student shall be exempt from this screening requirement for that school year. 9.1.2 The screening shall be completed in accordance with the schedule prescribed below: 18 Function Recommended Tests Referral Criteria Comments Distance Visual Acuity Snellen letters Snellen numbers Tumbling E HOTV Picture tests è Allen figures è LH test For Ages 3--5 Years: 1.Less than 4 of 6 correct on 20 foot line with either eye tested at 10 feet monocularity (i.e., less than 10/20 or 20/40) OR 2. Two-line difference between eyes, even within the passing range (i.e., 10/12.5 and 10/20 or 20/25 and 20/40) For Ages 6 and Older: 1. Less than 4 of 6 correct on 15 foot line with either eye tested at 10 feet monocularity (i.e., less than 10/15 or 20/30) OR 2. Two-line difference between eyes, even within the passing range (i.e., 10/10 and 10/15 or 20/20 and 20/30) 1. Tests are listed in decreasing order of cognitive difficulty. The highest test that the child is capable of performing should be used. In general, the Tumbling E or the HOTV test should be used for ages 3 through 5 years and Snellen letters or numbers for ages 6 years and older. 2. Testing distance of 10 feet is recommended for all visual acuity tests. 3. A line of figures is preferred over single figures. 4. The nontested eye should be covered by an occluder held by the examiner or by an adhesive occluder patch applied to the eye. The examiner must ensure that it is not possible to peek with the nontested eye. Near Visual Acuity Snellen visual acuity or equivalent J-5 or worse Ocular Alignment Random Dot E Stereotest at 40 cm (100 secs of arc) Less than 4 of 6 correct Color vision Any standard developmentally- appropriate isochromatic color vision test Failure under conditions specified by the manufacturer Tested only once at school entry age or upon initial screening 9.2 Personnel & Training Requirements 9.2.1 The school vision screening shall be given by a certified school nurse-teacher, trained in the administration of these tests. 9.2.2 Trained volunteers or other school personnel who are directly supervised on-site by certified school nurse-teachers may be utilized in the vision screening program. 19 9.3 Follow-up & Documentation Requirements 9.3.1 A child failing the screening shall be given a retest on a different day (but within one month) before the parents are notified of the results of the test. 9.3.1.1 Students who fail the screening criteria set shall be re-screened by the certified school nurse-teacher. 9.3.2 Parents of those students who fail to meet the minimal visual requirements on the second screening shall be notified, in accordance with the requirements of section 15.0 herein, in order to arrange for a comprehensive vision examination by an eye care professional. 9.3.3 If the corrected visual acuity of the child is found to be in the range of 20/70--20/200 in the better eye after rescreening, the licensed health care provider in charge of the screening shall, within 30 days, report the result of the screening to the administrator of the Division of Services for the Blind and to the Special Education Supervisor, indicating that specialized services may be indicated. 9.3.3.1 Students identified with a visual impairment shall be referred for specialized services and follow-up in accordance with the provisions of section 4.0 of the Regulations of the Board of Regents for Elementary and Secondary Education Governing the Special Education of Students with Disabilities. 9.3.4 A student's vision screening results shall be recorded in the "Vision Screening" section of the school health record. Section 10.0 Hearing Screening 10.1 General Hearing Screening Requirements 10.1.1 Beginning with the first year of enrollment, school children shall be given a hearing screening test by a properly trained and qualified person in the manner and at such intervals as comports with current guidelines of the American Speech-Language-Hearing Association (ASHA). 10.1.2 Students who failed the hearing screening tests in previous years, repeat a grade, have a history of hearing difficulty or pathology, are enrolled in curricular or extracurricular activities where there is exposure to noise levels that meet or exceed current Occupational Safety and Health Administration (OSHA) standards of reference 23 herein, or are suspected by school personnel of a hearing loss shall be screened as often as is necessary. 10.1.3 The "passing" criteria for the hearing screening test shall be in accordance with the current guidelines of the American Speech-Language-Hearing Association (ASHA) of reference 12. 20 10.1.4 Any student who provides documentation from a parent that a hearing screening test has been performed in accordance with section 10.3.1 herein shall be exempt from this screening requirement. 10.1.4.1 In the absence of this documentation from the parent, the school shall make provisions for the screening. 10.2 Equipment All equipment utilized in the hearing screenings shall be calibrated according to current national standards, as described in references 12--14 herein. 10.3 Personnel Requirements 10.3.1 A certified school nurse-teacher shall be responsible for coordinating the requirements of this section. Personnel who may perform the screening requirements of this section include: an audiologist, speech language pathologist, certified school nurse-teacher, audiometric aide under the supervision of a licensed audiologist, or a speech/language pathology assistant under the supervision of a certified speech language pathologist. 10.3.2 Any supporting personnel utilized by an audiologist/speech language pathologist in the hearing screening program shall meet the requirements outlined in the Rules and Regulations for Licensing Speech Pathologists and Audiologists (R5-48-SPA) of reference 9. 10.4 Follow-up & Documentation Requirements 10.4.1 A child who does not meet the "passing" criteria shall be given a retest on a different day (but within four (4) to six (6) weeks of the previous test ). 10.4.2 The parent of a student who does not meet the "passing" criteria on the second hearing screening shall be notified, in accordance with the requirements of section 15.0 herein, in order to arrange for a comprehensive medical and/or audiological evaluation. 10.4.3 Children identified with a potentially educationally-significant hearing impairment shall be referred by the certified school nurse-teacher for in-school supportive services, Teacher Support Teams, or other educational accommodations, as appropriate or as specified in the Regulations of the Board of Regents for Elementary and Secondary Education Governing the Special Education of Students with Disabilities of reference 11. 10.4.4 A student's hearing screening results shall be entered into his/her school health record by the certified school nurse-teacher or the person performing the screening. 10.4.4.1 At a minimum, the following components shall be noted in the record: 21 10.4.4.1.1 date screening completed; 10.4.4.1.2 screening results; 10.4.4.1.3 follow-up plan, as indicated. Section 11.0 Speech/Language Screening 11.1 General Speech/Language Requirements 11.1.1 Every elementary school student who has not been previously screened for speech/language impairments shall be screened for speech and language impairments by a trained and qualified person (as described in sections 11.2.1 and 11.2.2 below). Any student may be screened on an “as needed” basis. 11.1.1.1 For those students who have been previously screened, results of said screening shall be transferred to each new school in accordance with the requirements of section 14.3 herein. 11.1.2 Any student who has never been previously enrolled in a Rhode Island school who provides documentation from a parent that a speech screening has been performed by a certified and/or licensed speech language pathologist shall be exempt from this screening requirement. 11.1.2.1 In the absence of this documentation from the parent, the school shall make provisions for the screening. 11.1.3 A speech/language screening shall consist of an assessment of the following: 11.1.3.1 articulation; 11.1.3.2 voice characteristics; 11.1.3.3 fluency (e.g., stuttering) and; 11.1.3.4 receptive/expressive language skills. 11.2 Personnel Requirements 11.2.1 A Rhode Island Department of Elementary and Secondary Education-certified speech language pathologist shall be responsible for implementing the requirements of this section. 11.2.2 Any support personnel (e.g., a speech/language pathology assistant) utilized by a speech/language pathologist shall meet the training and supervision requirements outlined in the Rules and Regulations for Licensing Speech Pathologists and Audiologists (R5-48- SPA) of reference 9. 22 11.3 Instruments 11.3.1 A school's speech screening program may be conducted utilizing commercially available kindergarten/elementary school level screening instruments. 11.3.2 In developing techniques for screening students ages eight (8) and above, informal items may be adapted from available tests. This informal screening would not provide standardized procedures but would yield an acceptable method of screening to determine the need for further testing. 11.4 Follow-up & Documentation Requirements 11.4.1 A student who does not pass the speech/language screening shall be referred immediately for a comprehensive speech/language evaluation. The parent of any child who does not pass the speech screening shall be notified of the findings, in accordance with the requirements of section 15.0 herein. 11.4.2 The speech language pathologist or the certified school nurse-teacher shall enter the results into the student's school health record. 11.4.2.1 The following components shall be noted in the record: 11.4.2.1.1 date screening completed; 11.4.2.1.2 screening results (i.e., pass/fail); and 11.4.2.1.3 follow-up plan for a student who does not pass. Section 12.0 Scoliosis Screening 12.1 General Scoliosis Screening Requirements 12.1.1 No school-based scoliosis screening shall be conducted before students are introduced to the nature of the condition, its effects, and the nature of the scoliosis screening procedure. 12.1.2 The school health program shall provide for the yearly screening or examination for scoliosis of all school children in grades six (6) through eight (8) and the preservation of records of the screening or examinations of those children. 12.1.3 The parent of any such child may have the screening or examination conducted by a private physician and the results thereof shall be made available to the local school department. If these results are made available to the local school department, the student shall be exempt from the requirements of this section. 23 12.1.4 The screening of male and female pupils shall be conducted separately and individually. A private, well-lit screening area should be available. 12.1.5 The test shall not be required of any student whose parents object on the grounds that the test conflicts with their religious beliefs. 12.2 Personnel Requirement The screening shall be conducted by a certified school nurse-teacher, in accordance with the requirements of Chapter 16-21-10 of the RIGL. 12.3 Follow-up and Documentation Requirements 12.3.1 In accordance with the requirements of section 15.0 herein, the certified school nurse-teacher shall be responsible for notifying the parent of any child who is found to have positive signs or symptoms of scoliosis, based upon current standards published by the American Academy of Orthopaedic Surgeons or the Scoliosis Research Society, in order to arrange for further evaluation or treatment, as indicated. 12.3.2 A student's scoliosis screening results shall be documented in the student health record. Section 13.0 Dental Health Screening 13.1 General Dental Health Screening Requirements 13.1.1 Every student who has not been previously enrolled in a public or non-public school in this state shall be given a dental screening by a licensed dentist or a licensed dental hygienist with at least three (3) years of clinical experience. Thereafter, every student shall be given an annual dental screening by a licensed dentist or dental hygienist through the fifth (5th) grade and shall be screened at least once between the seventh (7th) and tenth (10th) grades. 13.1.1.1 Provided, however, that dental screenings for children in kindergarten, third and ninth grades shall only be performed by a licensed dentist. 13.1.2 Students who are screened by private dentists/dental hygienists and who provide written documentation of the screening being performed at the prescribed intervals (as in section 13.1.1 above) shall be exempt from the requirements of this section and shall not be screened. 13.1.3 In order to screen for tooth decay and gum disease, the school dental screening shall consist of an inspection of the student's mouth, according to the referral criteria described below. These screenings shall be totally non-invasive. 24 Condition Screened Referral Criteria Soft tissue 1. Gross gingival inflammation 2. Soft tissue lesions (e.g., fistulas and abscesses) 3. Plaque-related lesions Gross Orthodontic 1. Age appropriateness of tooth eruption (e.g., missing or blocked laterals or canines) 2. Crossbites (e.g., posterior and anterior) 3. Space management (e.g., severe crowding) Dentition 1. Suspicious areas (e.g., cavities) 2. Deep pit and fissures 13.1.4 Equipment to perform the screening requirements of section 13.1.3 (above) shall include: a mirror, cotton rolls, a light source, and non-latex disposable gloves. 13.2 The initial dental screening preferably should be conducted by the child's family dentist/dental hygienist within the six (6) months preceding the date of school entry, and the succeeding screenings should be conducted by him/her at any time during the school year (including vacations) for which the screening is required. 13.2.1 The written results of all such screenings shall be made available to the school. 13.3 Follow-up and Documentation Requirements 13.3.1 When a school dental screening has revealed that a dental problem may exist, the parent shall be notified so that a dental visit may be arranged. 13.3.2 A student's dental screening results shall be documented on the school health record. 13.3.3 Each community shall provide to parents or custodians of children who require professional or skilled treatment a list of both dental practices in the community which accept patients insured by Medical Assistance and/or RIte Care and dental practices which provide services on a sliding scale basis to uninsured individuals. 13.3.3.1 In accordance with section 16-21-9(d) of the Rhode Island General Laws, as amended, the Rhode Island Department of Human Services shall provide each community with a list containing the addresses and telephone numbers of both dental practices which accept patients insured by Medical Assistance and/or RIte Care and dental practices which provide services on a sliding scale basis to uninsured individuals. Section 14.0 Health Records 14.1 The complete, cumulative school health record for each student shall be maintained by the certified school nurse-teacher, or other appropriate school authority, at the school in which the student is 25 enrolled. The student's cumulative health record is confidential and subject to the provisions of Chapter 5-37.3-1 of the RIGL, ("Confidentiality of Health Care Information Act" of reference 5), and other applicable state and federal laws and rules and regulations. The record shall be stored in an appropriately secured location with convenient access by the school nurse and shall be used only in connection with the provision of treatment to the student. The record shall be maintained by the school for a minimum of five (5) years after the student turns eighteen (18) years of age or five (5) years after the student leaves the school district. 14.1.1 Such records shall include information regarding: 14.1.1.1 immunization status and certification; 14.1.1.2 health history, including chronic conditions and treatment plan; 14.1.1.3 screening results and necessary follow-up; 14.1.1.4 health examination reports; 14.1.1.5 documentation of traumatic injuries and episodes of sudden illness referred for emergency health care (see also requirements in "First Aid and Emergencies" section 17); 14.1.1.5.1 For a student with documented anaphylaxis, the parental authorization of a student's treatment for allergies and the physician's order to administer an epinephrine auto-injector shall be entered into the student's health record. 14.1.1.6 documentation of any nursing assessments completed; 14.1.1.7 documentation of any consultations with school personnel, students, parents, or health care providers related to a student's health problem(s), recommendations made, and any known results; 14.1.1.8 documentation of the health care provider's orders, if any, and parental permission to administer medication or medical treatment to be given in school by the certified school nurse-teacher. 14.2 Appropriate steps shall be taken for the protection of all student health records, including the provisions for the following: 14.2.1 securing records at all times, including confidentiality safeguards for electronic records; 14.2.2 establishing, documenting and enforcing protocols and procedures consistent with the confidentiality requirements described herein; 26 14.2.3 training school personnel who handle student school health records in security objectives and techniques. 14.3 Whenever a student transfers to another school building or school system in Rhode Island, the original copy of the complete, cumulative school health record shall be transferred at the same time to the health personnel of the school building or school system to which the student is transferring. If the student transfers to a school system outside the state of Rhode Island, a photocopy of the complete, cumulative school health record shall be transferred at that time and in accordance with the requirements of this section. This record shall be sealed in an envelope marked "confidential" and sent to a health care professional authorized to receive said confidential health care information at the new school or handed to the parent, as appropriate. A copy of the record (or the original) shall be maintained by the sending community for a minimum of five (5) years after the student turns eighteen (18) years of age. 14.4 Confidentiality 14.4.1 Any school personnel, including health care providers, who maintain cumulative school health records containing confidential health care information shall be responsible for ensuring full confidentiality of this information as provided in section 5-37.3-4 of the RIGL ("Health Care Information Act" reference 5) and other applicable state and federal laws and rules and regulations. 14.4.2 Any school personnel, including health care providers, who release confidential health care information from cumulative school health records in accordance with section 5-37.3-4 of the RIGL ("Health Care Information Act" of reference 5) and other applicable state and federal laws and rules and regulations, shall document each such release in the applicable cumulative school health records by indicating the following: 14.4.2.1 the date of release; 14.4.2.2 a description of the information released; 14.4.2.3 the name(s) of the person(s) to whom the information was released; 14.4.2.4 the reason for the release of information. 14.4.3 Violations Pertaining to Confidentiality: Any person suspected of violating the Health Care Information Act shall be reported to the Attorney General's Office for prosecution and any subsequent penalties, in accordance with statutory provisions. Section 15.0 Notification of Parents 15.1 Parents and/or guardians shall be notified, according to established local school district procedures, of any suspected deviation from normal or usual health found as a result of a screening test (e.g., vision 27 screening), health examination, and/or school personnel observation, in accordance with all applicable state and/or federal laws and regulations. 15.2 Each school district shall develop procedures or protocols for documenting and implementing a follow-up and referral plan for students identified as needing additional services. Section 16.0 School Reporting Requirements 16.1 In accordance with the Rules and Regulations Pertaining to the Reporting of Communicable, Environmental and Occupational Diseases of reference 2, the basic responsibility for reporting communicable, environmental and occupational diseases lies with: 1. physicians licensed in accordance with Chapter 5-37 of the RIGL who are attending the case or suspected case; 2. laboratories; 3. other authorized health professionals working under the auspices of a physician; and 4. other health care professionals authorized by law or regulation to practice independently (e.g., registered nurse practitioners). In the school setting, this requirement encompasses certified school nurse-teachers directed by a physician to report in accordance with the regulatory requirements cited above. 16.1.1 Licensed health care facilities that operate school-based health clinics shall report communicable, environmental and occupational diseases in accordance with the Rules and Regulations for the Licensing of Organized Ambulatory Care Facilities of reference 16 and the Rules and Regulations Pertaining to the Reporting of Communicable, Environmental and Occupational Diseases of reference 2. 16.2 In accordance with the Rules and Regulations Pertaining to the Reporting of Communicable, Environmental and Occupational Diseases, any health care provider (e.g., school physicians, certified school nurse-teachers, school dentists/dental hygienist) having knowledge of any outbreak or undue prevalence of infectious or parasitic disease or infestation (based upon his/her professional judgment), whether listed in said regulations or not, shall promptly report the facts to the Department of Health. Exotic diseases and unusual group expressions of illness that may be of public health concern should also be reported immediately. Section 17.0 First Aid and Emergencies 17.1 Each school shall have written protocols and standing orders available in the event of injuries and acute illnesses, including anaphylaxis. 17.1.1 These written protocols and standing orders shall be prepared, dated, signed, reviewed and updated, as appropriate, but at least on an annual basis by the school physician(s). 17.1.1.1 No requirement herein shall be construed as prohibiting the issuance of a standing order by a school physician for the administration of an epinephrine auto-injector by a school nurse to a student who has not been previously medically identified for the prevention or treatment of anaphylaxis. This standing order shall be reviewed in accordance with section 17.1.1 above. 28 17.1.2 These emergency written protocols shall be reviewed annually by all school personnel who might be involved in managing an emergency in a school, including anaphylaxis, prior to the arrival of more fully trained persons. Said personnel shall be identified by the school principal, or other designated school authority, as needing to review these emergency written protocols on an annual basis. First Aid Training: Basic First Aid Training 17.2 In-service basic first aid training shall be provided for school personnel who might be involved in managing an injury or other medical emergency. Said personnel shall be identified by the school principal, or other designated school authority, and listed in the emergency protocol described in sections 17.1.1 and 17.1.2 above. Subjects to be covered shall include, but not be limited to: control of major bleeding, use of universal precautions, management of ocular trauma and emergencies, management of burns, accessing the "911" emergency medical system, proper application and removal of disposable gloves and equipment, and movement and transportation of an injured person. No less than two (2) hours of basic first aid training shall be required of all designated school personnel during every school year. 17.2.1 The school principal, or other authorized school personnel, shall maintain a record-keeping system documenting that the basic first aid training (as above) has been provided to all designated school personnel. 17.2.2 The training shall be delivered by a certified school nurse-teacher, or other designated instructor, utilizing a training curriculum that adheres to standards established by a nationally- recognized body. 17.2.3 Students engaged in potentially hazardous tasks (including, but not limited to, activities during normal school hours in science laboratories, industrial arts, physical education, and family/consumer science classes) should be directly supervised by teachers or instructors who are trained, as outlined in section 17.2 (above) in the administration of basic first aid, and who have posted and discussed safety rules with the students. First Aid Training: Basic First Aid and Cardiopulmonary Resuscitation Training 17.3 At all times, during normal school hours at on-site school-sponsored activities, each school shall have available at least one (1) person other than the certified school nurse-teacher who is trained, competent and responsible for the administration of basic first aid, child/adult cardiopulmonary resuscitation (CPR), including emergency procedures for obstructed airways (choking) and drowning, and administration of the epinephrine auto-injector. First Aid Training: Anaphylaxis 29 17.4 Training shall be provided for school personnel who might administer an epinephrine auto-injector in a case of anaphylaxis. Subjects to be covered shall include (but not be limited to): signs and symptoms of anaphylactic shock, proper epinephrine auto-injector administration, adverse reactions, accessing the "911" emergency medical system, and preparation for movement and transport of the student. Response to and Treatment for Anaphylaxis 17.5 To prevent or treat a case of anaphylaxis (as defined in section 1.1 herein), the certified school nurse- teacher or trained school personnel shall administer the epinephrine auto-injector to an identified student. Certified school nurse-teachers shall administer the epinephrine auto-injector in accordance with standard nursing practice. 17.6 In the event of a suspected case of anaphylaxis, school personnel may administer an epinephrine auto- injector to a medically identified student when authorized by a parent/guardian and when ordered by a physician or other licensed prescriber. 17.7 School health programs shall develop and adopt a procedure for addressing incidents of anaphylaxis and the use of the epinephrine auto-injector on previously medically identified students. Such procedures shall pertain to no less than the requirements described herein and shall include the following: 17.7.1 Parents shall provide a physician's or other licensed prescriber's order, parent authorization, and filled prescription(s) (i.e., the epinephrine auto-injector(s)) notifying the school of the student's allergy and the need to administer the epinephrine auto-injector in a case of anaphylaxis. 17.7.2 School administrators shall communicate the required medical information from the parent to the appropriate school personnel, including the certified school nurse-teacher, teachers and food service workers. 17.7.3 The school physician shall review these procedures on an annual basis, in accordance with the requirements of section 7.1, above. 17.7.4 Such procedures shall stipulate that the epinephrine auto-injector be used only upon the student for whom it was prescribed, in accordance with the provisions of Chapter 21-28.3, "Drug Abuse Control," of the RIGL. 17.7.5 Such procedures shall provide for the development of an individualized emergency plan for a student at risk for anaphylaxis. 17.7.6 Procedures for accessing the community's emergency medical system (i.e., "911") shall be included in these procedures. 30 17.8 Students who are treated for anaphylaxis at the school shall be transported by a licensed ambulance/rescue service promptly to an acute care hospital for medical evaluation and follow-up. 17.9 If appropriate, a child identified as being at risk for anaphylaxis should carry the epinephrine auto- injector with him at all times. If this is not appropriate, the epinephrine auto-injector shall, if necessary for the student’s safety, as determined by the physician, or other licensed prescriber, be available in the classroom, cafeteria, physical education facility, health room and/or other areas where the epinephrine auto-injector is most likely to be used. Reasonable provisions shall be made for the availability, safekeeping and security of the epinephrine auto-injector. The school shall develop protocols and procedures related to the availability, safekeeping and security of the epinephrine auto-injector. Role of Lay Personnel in Emergency Care 17.10 School personnel who have been trained in accordance with sections 17.2, 17.3, and/or 17.4, (above) are authorized to administer the epinephrine auto-injector to an identified student. If trained school personnel are not available, any willing person may administer the epinephrine auto-injector to a medically identified student. None of the requirements of this section shall preclude the self- administration of an epinephrine auto-injector by a medically identified student. Good Samaritan Provisions 17.10.1 No school teacher, school administrator, school health care personnel, or any other school personnel shall be liable for civil damages which may result from acts or omissions in the use of the epinephrine auto-injector which may constitute ordinary negligence. This immunity does not apply to acts or omissions constituting gross negligence or willful or wanton conduct. 17.10.2 No person who voluntarily and gratuitously renders emergency assistance to a person in need thereof shall be liable for civil damages which result from acts or omissions by such person rendering the emergency care, which may constitute ordinary negligence. This immunity does not apply to acts or omissions constituting gross negligence or willful or wanton conduct. 17.11 Follow-up & Documentation Requirements 17.11.1 Following a traumatic injury, an episode of anaphylaxis, or other emergency situation, a written report shall be completed and filed in the student health record and verbal notification made to the student's parents as soon as possible by the school principal or a person delegated by him/her. 17.11.2 Following a minor injury, the certified school nurse-teacher, or other appropriate school authority, shall make a notation of the minor injury in a log book maintained by the school specifically for this purpose. At a minimum, the following items shall be noted: 31 17.11.2.1 date and time of injury; 17.11.2.2 location where injury occurred; 17.11.2.3 chief complaint; 17.11.2.4 treatment administered; 17.11.2.5 disposition (e.g., back to class); 17.11.2.6 signature of responder. 17.11.3 For each student, emergency information shall be documented and updated on an annual basis. Such emergency information shall include no less than the following: 17.11.3.1 name and telephone number of the student's parent and additional contact person(s) in the event of an emergency; 17.11.3.2 name and telephone number of the family physician or primary care provider; 17.11.3.3 health insurance (optional); 17.11.3.4 known allergies (including drug, food, insect bite and chemical allergies); 17.11.3.5 medical conditions that may need attention (e.g., past surgeries, heart problems, seizure disorders, nosebleeds, diabetes); 17.11.3.6 current, routine prescription medications. 17.11.4 Protocols or procedures shall be developed to require an individualized emergency plan for a student at risk for anaphylaxis, asthmatic conditions and/or any other medical emergencies, as defined in section 1.12 herein. Section 18.0 Medication Administration The provisions of this section shall go into effect on July 1, 2000. Each public school district or non-public school authority shall develop protocols or procedures related to medication administration in schools that include, at a minimum, the following provisions: 18.1 A certified school nurse-teacher shall administer medication(s) to student(s) within the public school setting except as provided in sections 18.9, 18.10, or 18.11 herein. Such a certified school nurse- teacher shall be licensed in Rhode Island in accordance with the requirements of Chapter 5-34 of the RIGL. He/she shall also be certified in accordance with the provisions of Chapter 16-21-8 of the RIGL. 32 18.2 A certified school nurse-teacher or other registered nurse shall administer medication to student(s) in a non-public school except as provided in sections 18.9, 18.10, or 18.11 herein. Such a registered nurse shall be licensed in Rhode Island in accordance with the requirements of Chapter 5-34 of the RIGL. 18.3 No lay person, other than a parent, shall administer medication to a student in the school setting. Exceptions: sections 17.5, 17.6, 17.10 herein (related to the administration of epinephrine). Provisions Related to Nurse Administration 18.4 Each dose of medication administered by a certified school nurse-teacher or other registered nurse shall be documented. Documentation shall include: date, time, dosage, route of administration and the signature of the certified school nurse-teacher or other registered nurse administering the medication or supervising the student in self-administration. In the event a dosage is not administered as ordered, the reason(s) therefore shall be noted. 18.5 All medications to be administered by the certified school nurse-teacher or other registered nurse, as provided herein, shall be kept in a secured cabinet. 18.6 A licensed provider's (with prescriptive privileges) order shall be obtained and verified by the certified school nurse-teacher or other registered nurse for all medications to be administered by the certified school nurse-teacher or registered nurse, including school physician standing orders. Verbal orders to the nurse and facsimile transmissions may be accepted. Verbal orders shall be followed up by a written order from the licensed prescriber within three (3) working days. Upon receipt, the orders shall be confirmed with the parent by the nurse. 18.7 For prescription medications, all parent authorizations and licensed provider’s orders shall be renewed no less than annually by the certified school nurse-teacher or other registered nurse. Controlled Substances 18.8 No controlled substance shall be in the possession of or administered by anyone other than a certified school nurse-teacher, other registered nurse, licensed prescriber, or parent of the child for whom the medications have been prescribed. A student may deliver his/her own medication to school in accordance with protocols or procedures developed by the school but may not self-administer the controlled substance while on school property. Exception: see section 18.11 herein. Prescription Medications 18.9 All school districts or authorities shall develop protocols or procedures to permit students to self-carry and/or self-administer prescription medication if the student, parent, certified school nurse-teacher or registered nurse, and licensed prescribing health care provider enter into a written agreement that specifies the conditions under which the prescription medication must be self-carried and/or self- administered. The school principal shall be informed of the existence of said agreement. 33 18.9.1 The protocols or procedures related to student self-administration of prescription medications shall include provisions for the following: 18.9.1.1 All medications shall be stored in their original prescription-labeled containers. 18.9.1.2 A licensed health care prescriber’s written order shall be provided. 18.9.1.3 A written parent authorization shall be obtained and verified by the certified nurse-teacher or other registered nurse. 18.9.2 A student shall be prohibited from sharing, transferring, or in any way diverting his/her own medication(s) to any other person. 18.9.3 No school teacher, school administrator, or school health personnel, or any other school personnel shall be liable for civil damages which may result from acts or omissions which may constitute ordinary negligence when a student self-carries and/or self-administers his/her own medication(s) in accordance with these rules and regulations. This immunity does not apply to acts or omissions constituting gross negligence or willful or wanton conduct. Inhalers 18.10 Each school district shall develop a procedure to allow children to carry and use prescription inhalers while in school or at a school sanctioned function or event, when prescribed by a licensed individual with prescriptive privileges. Children who need to carry said inhalers shall provide the school with medical documentation that the inhaler has been legitimately prescribed and that the child needs to carry it on his/her person due to a medical condition. But no child shall be disciplined solely for failure to provide such documentation in advance. 18.10.1 No school teacher, school administrator, or school health personnel, or any other school personnel shall be liable for civil damages which may result from acts or omissions in the use of prescription inhalers by children which may constitute ordinary negligence. This immunity does not apply to acts or omissions constituting gross negligence or willful or wanton conduct. Medication Administration at Off-site School-sponsored Activities 18.11 Each school district or non-public school authority shall develop a procedure or protocol to allow students to self-carry and self-administer a day’s supply of medication, including a controlled substance, during an off-site school-sponsored activity. Said medication shall be supplied by the parent and shall be stored and transported in a properly labeled container. 18.11.1 Said medication shall be supplied by the parent with a parent’s written authorization for use of the medication during the off-site school-sponsored activity and shall be stored and transported in its original prescription-labeled container (in the case of a prescription medication) or its manufacturer-labeled container (in the case of a non-prescription medication). 34 18.11.2 In the case of a prescription medication, a licensed health care prescriber’s written order shall be provided, if it is not already on file in the school. 18.11.3 A student shall be prohibited from sharing, transferring, or in any way diverting his/her own medication(s) to any other person. 18.11.4 No school teacher, school administrator, or school health personnel, or any other school personnel shall be liable for civil damages which may result from acts or omissions which may constitute ordinary negligence when a student self-carries and/or self-administers his/her own medication(s) in accordance with these rules and regulations. This immunity does not apply to acts or omissions constituting gross negligence or willful or wanton conduct. Section 19.0 Immunization and Testing for Communicable Diseases 19.1 Pursuant to the Rules and Regulations Pertaining to Immunization and Testing for Communicable Diseases of reference 3, public and non-public schools in this state must adopt, at a minimum, the standards for immunization and communicable disease testing described therein. 19.2 It shall be the responsibility of the administrative head of any public or non-public school to secure compliance with the rules and regulations of reference 3. 35 PART IV HEALTHFUL SCHOOL ENVIRONMENT (R16-21-SCHO) Section 20.0 Standards for School Building(s) and Approval 20.1 Pursuant to RIGL section 16-21-3, the State Building Codes Standards Committee, the State Fire Marshall, the State Health Department, and the Department of Labor and Training, Division of Occupational Safety shall determine whether the school buildings in the several cities and towns or on state property conform to appropriate state and federal laws and regulations within their respective jurisdiction. 20.1.1 Furthermore, it shall be the responsibility of each local fire chief, local building inspector, the Director of the state Department of Health, and the Director of the state Labor and Training Department to determine and notify each local school superintendent or non-public school official by August 1 of each year as to whether the public and non-public nursery, elementary and secondary school buildings conform to appropriate state and federal laws and regulations within their respective jurisdiction. 20.1.2 In the case of those schools on state property, it shall be the responsibility of the State Building Commissioner, the State Fire Marshall, the Director of the state Department of Health, and the Department of Labor and Training to notify the department director responsible for the operation of the school as to whether these schools conform to appropriate state and federal laws and regulations. 20.2 Pursuant to RIGL section 16-21-3.1, it shall be the responsibility of the school administrator, the non- public school official, in the case of state operated schools, the responsibility of the director of the state operated school, to ensure that schools are not opened until notification is received from the aforementioned agencies that the schools are in compliance with their respective codes. 20.2.1 Neglect by any superintendent, non-public school official, or director of any state operated school to comply with the statutory provisions of section 20.2 above shall be subject to the sanction as set forth in RIGL section 16-21-3.1. Section 21.0 New Construction, Renovation or Conversion of Existing Buildings to Schools General Requirements 21.1 All new construction or the alteration, extension, or modification of an existing building(s) shall be subject to all applicable federal, state and local laws, codes, regulations, and ordinances, including but not limited to the following regulatory provisions enforced by the specific agency: 21.1.1 SBC-1 State Building Code, et al, RIGL Chapter 23-27.3, R.I. State Building Code Standards Committee; 21.1.2 The federal and state accessibility for persons with disability standards: 36 21.1.2.1 RIGL Chapter 37-8-15, “Access for People with Disabilities”; 21.1.2.2 The Federal Rehabilitation Act of 1973, as amended, (29 U.S.C. § 791 et seq.) section 504, 34 Code of Federal Regulations, Part 104, Program Accessibility for Persons with Disabilities and the Americans with Disabilities Act of 1990 (42 U.S.C. § 12101 et seq.), 28 Code of Federal Regulations, Parts 35 and 36, Accessibility for Persons with Disabilities in Public Entities and Public Accommodations; 21.1.2.3 SBC-15 Accessibility for Individuals with Disabilities in State and Local Government Facilities, R.I. State Building Commissioner; 21.1.2.4 SBC-16 Accessibility for Individuals with Disabilities, R.I. State Building Commissioner; 21.1.2.5 RIGL section 42-26-13 Open Meetings--Accessibility for Persons with Disabilities; SBC-17 Accessibility of Meetings for Persons with Disabilities, R.I. State Building Commissioner. 21.1.3 The Code of Federal Regulations, Title XXIX, General Industry Standards 1910 and 1926, Construction, Division of Occupational Safety, Rhode Island Department of Labor and Training; 21.1.4 Section 7, Chapter 10 of the Rhode Island Fire Prevention Code, Rhode Island State Fire Marshal’s Office; and, 21.1.5 Such other applicable statutory and regulatory provisions. 21.2 All architectural plans for school construction, renovations, or conversions shall be submitted to the appropriate staff at the Rhode Island Department of Elementary and Secondary Education, the Governor’s Commission on Disabilities, the State Building Commissioner and all other state or local agencies as appropriate prior to construction for review for compliance with all applicable federal, state and local laws, codes, regulations and ordinances. 21.2.1 All architectural plans for new school construction submitted for approval on or after July 1, 2000 shall include provisions for a health room that includes, at a minimum, a private toilet, hand washing facilities, a private area for consultation, and a waiting area. Section 22.0 Existing School Buildings/General Requirements 22.1 All existing structures shall comply with all applicable federal, state and local laws, codes, regulations, and ordinances including but not limited to the following regulatory requirements enforced by the specified agency: 37 22.1.1 SBC-13 State Building Code Standards for Existing Schools, R.I. State Building Code Standards Committee through the local building officials or the State Building Commissioner; 22.1.2 Where applicable, the federal and state accessibility for persons with disability standards: 22.1.2.1 RIGL Chapter 37-8-15, “Access for People with Disabilities”; 22.1.2.2 The Federal Rehabilitation Act of 1973, as amended, (29 U.S.C. § 791 et seq.) section 504, 34 Code of Federal Regulations, Part 104, Program Accessibility for Persons with Disabilities and the Americans with Disabilities Act of 1990 (42 U.S.C. § 12101 et seq.), 28 Code of Federal Regulations, Parts 35 and 36, Accessibility for Persons with Disabilities in Public Entities and Public Accommodations; 22.1.2.3 SBC-15 Accessibility for Individuals with Disabilities in State and Local Government Facilities, R.I. State Building Commissioner; 22.1.2.4 SBC-16 Accessibility for Individuals with Disabilities, R.I. State Building Commissioner; 22.1.2.5 RIGL section 42-26-13 Open Meetings--Accessibility for Persons with Disabilities; SBC-17 Accessibility of Meetings for Persons with Disabilities, R.I. State Building Commissioner. 22.1.3 The Code of Federal Regulations, Title XXIX, General Industry Standards 1910 and 1926, Construction, Division of Occupational Safety, R.I. Department of Labor and Training; 22.1.4 RIGL Chapter 23-28.12 and section 7, Chapters 1 through 8 and Chapters 24 through 43 of the current Rhode Island Fire Prevention Code, Rhode Island State Fire Marshal’s Office; and, 22.1.5 Such other applicable statutory or regulatory requirements. Section 23.0 Asbestos 23.1 School buildings shall be subject to the provisions of RIGL Chapters 23-24.5 and the Rules and Regulations for Asbestos Control, promulgated by the Rhode Island Department of Health. 23.2 Such requirements, as stipulated in the regulations cited in section 23.1 (above) include, but are not limited to, the following: 23.2.1 All schools shall be inspected for asbestos-containing building materials (ACBM). Identified ACBM shall be assessed and the appropriate response actions (repair, encapsulation, removal) shall be implemented in accordance with the regulations cited in section 23.1(above). 38 Any uninspected building acquired for use as a school building shall be inspected within thirty (30) days after commencement of such use. 23.2.2 Each local education agency (LEA) with ACBM shall have implemented an effective and ongoing operations and maintenance program as part of a management plan to include no less than the following: 23.2.2.1 a designated person trained to oversee asbestos activities and to ensure regulatory compliance; 23.2.2.2 a two (2) hour awareness training for all members of the maintenance and custodial staff working in buildings with ACBM; 23.2.2.3 a sixteen (16) hour training for all members of maintenance and custodial staff who may conduct activities that will disturb asbestos. Such trained staff may be licensed by the Department of Health to perform spot repairs, as defined in the regulations cited in section 23.1(above); 23.2.2.4 periodic surveillance, but no less than every six (6) months; 23.2.2.5 reinspection every three (3) years by a certified inspector and management planner; 23.2.2.6 annual notifications to workers and building occupants, or their parents, regarding asbestos inspections and response actions; 23.2.2.7 mechanism(s) for informing contractors involved in remodeling or construction projects regarding the location of ACBM prior to starting any projects; 23.2.2.8 documentation of all inspection, reinspections, response actions, training, and notifications to be included with the management plan maintained at each school with ACBM and at the LEA administrative office. 23.2.3 All asbestos abatement projects larger than a spot repair shall not be initiated without prior approval of an asbestos abatement plan by the Department of Health. The plan shall be prepared by a certified project designer and performed by a licensed asbestos abatement contractor. Section 24.0 Lead 24.1 Schools serving children under the age of six (6) years (e.g., kindergartens, day care sites) shall be subject to the provisions of RIGL Chapter 23-24.6 as well as the Rules and Regulations for Lead Poisoning Prevention (R23-24.6-PB) promulgated by the Rhode Island Department of Health. Section 25.0 Radon 39 25.1 School buildings shall be subject to the provisions of RIGL Chapter 23-61 and the Rules and Regulations for Radon Control, promulgated by the Department of Health. 25.2 Such requirements, as stipulated in the regulations cited in section 25.1(above), shall include, but are not limited to, the following: 25.2.1 All schools shall be tested for radon in the air to identify structures in which the potential exists for elevated radon concentrations. 25.2.1.1 Schedules for initial short term testing shall be submitted to the Department of Health confirming that all initial and short term testing has been completed in accordance with the regulations cited in section 25.1 (above). 25.2.1.2 All short term results shall be reported to the Department of Health within thirty (30) days of receipt of results. 25.2.2 Measurement protocols, as outlined in the regulations cited in section 25.1 herein, shall include no less than the following: 25.2.2.1 Measurements shall be taken by a certified radon measurement consultant; 25.2.2.2 Measurements shall be taken with acceptable measurement devices and analyzed by certified laboratories; 25.2.2.3 Short term measurements shall be taken during the months of October through March, and shall be left in place for a minimum of forty-eight (48) hours in closed building conditions. 25.2.3 Follow-up measurements shall be required when short term measurements are greater than or equal to four (4) picocuries per liter (pCi/L) to determine if areas exceed the indoor air standard of four (4) pCi/L as an annual average. Testing protocols are outlined in the regulations cited in section 25.1 (above). 25.2.4 Mitigation systems shall be installed to reduce areas of school buildings that have radon levels of four (4) pCi/L or greater on an annual average. Installations of radon mitigation systems shall only be performed by individuals licensed as radon mitigation specialists. 25.2.5 Post-mitigation measurements shall be taken in all mitigated areas by a certified radon measurement consultant to ensure the effectiveness of the mitigation system. Section 26.0 Food Service 26.1 Food service in all schools, including food service facilities, shall comply with the following statutory and regulatory provisions relating to food protection including, but not limited to: 40 26.1.1 RIGL Chapter 21-27 and section 23-1-31; 26.1.2 Food Code (R23-1,21-27-FOOD), Rhode Island Department of Health, Office of Food Protection, 1994; 26.1.3 Rules and Regulations Pertaining to Sanitary Standards for Manufacture, Processing, Storage, and Transportation of Ice, Rhode Island Department of Health; 26.1.4 Regulations Pertaining to the Sale of Foods and Beverages through Vending Machines (R23-1-VM), Rhode Island Department of Health; 26.1.5 Rules and Regulations Pertaining to Certification of Managers in Food Safety (R21-27- CFS), Rhode Island Department of Health. 26.2 No less than one (1) person certified as a manager in food safety within each school shall be designated to supervise all food preparation personnel to ensure food safety. 26.3 No person shall be in the food service area (i.e., work as a food handler) who may be a health hazard to others. 26.3.1 Food employees and food employee applicants are required to report, to the person in charge, information about their health and activities (such as consuming food implicated in a food borne outbreak) as they relate to diseases that are transmissible through food and active cases of tuberculosis or measles. 26.3.2 The person in charge shall exclude a food employee from a food service facility if the food employee is diagnosed with Salmonella typhi, Shigella spp., Escherichia coli 0157:H7, or Hepatitis A virus infection, confirmed through laboratory testing, even if asymptomatic. 26.3.3 Symptoms and signs indicating exclusion or restriction from the food service area pursuant to requirements of the Food Code (R23-1, 21-27-FOOD) include but are not limited to: 26.3.3.1 diarrhea, fever, vomiting, jaundice, or abdominal cramps; 26.3.3.2 respiratory tract infections; 26.3.3.3 open or infected cuts, burns, sores, or other infected skin conditions on the hands, wrists or exposed portions of the arms, or on other parts of the body, unless the lesion is covered by a dry, durable, tight-fitting bandage; and 26.3.3.4 any other condition and/or communicable disease with the potential for causing foodborne illness during the infectious period. 41 26.4 Hand washing Facilities: lavatory facilities shall be readily accessible to food handlers to enable them to wash their hands before starting work and as often as may be necessary while working in the food service areas. 26.4.1 Consistent with the Rhode Island Food Code, the lavatory facilities used by food service personnel shall be equipped with soap dispensers (liquid or powder soap) or bar soap, a nailbrush, and either an adequate supply of disposable towels stocked at all times or a heated- air hand drying device. 26.4.2 The lavatory facilities used by food service personnel shall be accessible to persons with disabilities in accordance with all applicable local, state, and federal laws and regulations. 26.5 Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single use non-latex gloves, or dispensing equipment. 26.6 In accordance with the Rhode Island Food Code, each school serving hot potentially hazardous foods shall have a written plan for assessing, monitoring, and controlling foodborne disease hazards within the facility. The plan shall include, but not be limited to, monitoring of food temperatures at the shipping and receiving end for satellite feeding operations and a plan for the restriction and exclusion of ill personnel. Section 27.0 Health Room 27.1 As of July 1, 2001, existing schools shall have a designated health room(s) to be utilized for health services. The room(s) shall be equipped with no less than the following accommodations: Within the health room: 27.1.1 hand washing facilities, including warm (not to exceed 120°F [49°C]) and cold running water, soap dispensers and soap (liquid or powdered), and either disposable towels or a heated-air hand drying device; 27.1.2 a cot or other suitable area for reclining, with accommodations for privacy; 27.1.3 all supplies necessary for the disposal of biohazardous waste, including but not limited to, a sharps container that shall be managed in accordance with the requirements of reference 24 herein; 27.1.4 a secure medication storage area, including a locked storage site for controlled substances; 27.1.5 a telephone; 42 Either within or adjacent to the health room: 27.1.6 a toilet; 27.1.7 a secure refrigerator for exclusive use of medications and health supplies (e.g., ice packs); 27.1.8 a secure cabinet for medical record storage; 27.1.9 an area for students to comfortably await services; Either within or accessible to the health room on the same floor of the building: 27.1.10 a private area for consultations that ensures that confidentiality is maintained. Section 28.0 Sanitation Facilities 28.1 The premises of each school shall include an appropriate number of hand washing facilities, toilets, and drinking fountains for all students and school personnel that shall be maintained in a working and sanitary condition as determined by the Rhode Island Department of Health and in accordance with the Code of Federal Regulations of the Division of Occupational Safety, R.I. Department of Labor and Training of section 22.1.3 herein. 28.1.1 Hand washing facilities: In addition, hand washing facilities shall have cold and warm (not to exceed 120°F [49°C]) running water and be stocked at all times with soap dispensers and soap (liquid or powdered) and either disposable towels or a heated-air hand drying device. 28.1.2 Toilets: At a minimum, the following ratios of accessible toilets to students shall apply: Type of School Minimum Ratio of Toilets per Student Boys Girls Elementary School 1:40 1:35 Secondary School 1:75 1:45 Urinals 1:30 28.1.3 Showers: In those schools where shower facilities are in use, they shall be properly cleaned and maintained and supplied with cold and warm (not to exceed 120°F [49°C]) running water. 28.1.4 All sanitation facilities shall be accessible to persons with disabilities in accordance with all applicable local, state and federal laws and regulations. 43 Section 29.0 Housekeeping 29.1 Each school shall maintain a comprehensive list of all solutions, compounds and other products used in and around the school for cleaning and maintenance. This list shall include, but not be limited to, cleaning products used in all parts of the school, lawn care products used on school grounds, and products used to maintain facilities such as swimming pools. Said list shall be kept in a readily accessible location, such as the school administrative office, shall be updated regularly, and shall be provided to any individual upon request. Section 30.0 Swimming Pools 30.1 Swimming pools shall be subject to the statutory provisions of RIGL Chapter 23-22 and any other applicable law relating to swimming pools and the Rules and Regulations for the Licensing of Swimming and Wading Pools, Hot Tubs and Spas promulgated by the Department of Health. Section 31.0 Water Supply 31.1 Each school building shall be furnished with an adequate supply of potable water meeting the standards set forth in Rhode Island's public drinking water regulations entitled, Rules and Regulations Pertaining to Public Drinking Water (R46-13-DWQ) of the Rhode Island Department of Health. 31.1.1 Potable water shall be supplied to all food service areas, lavatories, janitorial and shower areas. 31.1.2 An adequate supply of potable drinking water shall be available for consumption through a sufficient number of well-maintained and accessible sources and in accordance with sections 404 and 411 of the Rhode Island Plumbing Code (SBC-3). 31.2 A community water system shall be used as the source of supply where available. 31.2.1 Where a community water system is unavailable the water supply system utilized by the school must meet the requirements of RIGL Chapter 46-13 and the Rules and Regulations Pertaining to Public Drinking Water (R46-13-DWQ) of the Rhode Island Department of Health. 31.3 All proposed school water systems or proposed alterations to existing school water systems shall be approved by the Department of Health. Section 32.0 Tobacco 32.1 Schools shall be subject to the provisions of RIGL Chapter 23-20.6, "Smoking in Public Places", RIGL Chapter 23-20.7, "Workplace Smoking Pollution Control Act", and RIGL Chapter 23-20.9, entitled, "Smoking in Schools." 44 32.1.1 Pursuant to the requirements of RIGL Chapter 23-20.9-5, the governing body of each school in Rhode Island shall be responsible for the development of enforcement procedures to prohibit tobacco product usage by any person utilizing school facilities. All facilities, including school grounds, used by a school, whether owned, leased or rented, shall be subject to the provisions of said Chapter. Enforcement procedures shall be promulgated and conspicuously posted in each building. 32.1.2 The requirements of section 31.1.1 (above) and of RIGL Chapter 23-20.9-5 shall not modify, or be used as a basis for modifying, school policies or regulations in effect prior to the passage of said Chapter if the existing policies or regulations prohibit tobacco product usage in said school. 32.1.3 All school areas where tobacco product usage is prohibited shall be clearly marked with “nonsmoking area” signs with bold block lettering at least three inches (3") high stating, “Tobacco-Free School - Tobacco Use Prohibited.” There shall be at least one (1) “nonsmoking area” sign, in conformance with the above, at every building entrance and in other areas as designated by the governing body. Signs shall also be posted in every school bus and every school vehicle. Signs as detailed above shall be provided, without charge, by the Department of Health. Section 33.0 Weapons and Firearms 33.1 All schools shall have policies prohibiting possession of firearms and other weapons and imposing penalties for such possession in conformity with RIGL 16-21-18 and the “Gun Free Schools Act”, 20 U.S.C.A. § 8921 et seq. Section 34.0 Alcohol and Other Drugs 34.1 All schools shall have policies regarding possession of alcohol and other drugs and shall have on-going prevention activities and programs as supported by the “Safe and Drug Free Schools Act”, 20 U.S.C.A. § 7101 et seq. Section 35.0 Recreational Facilities 35.1 All recreation facilities and areas, including gymnasiums, playgrounds, and athletic fields shall be maintained and operated in a safe manner at all times, including, at a minimum, the following provisions: 35.1.1 As of July 1, 2002, playground surfaces and equipment shall meet all applicable standards of the most recent version of the Handbook for Public Playground Safety issued by the U.S. Consumer Products Safety Commission. 35.2 In accordance with section 36 Code of Federal Regulations, Part 1191, recreational facilities, athletic fields and playgrounds shall be accessible to persons with disabilities. 45 35.3 Adequate, convenient, and well-maintained changing areas and facilities shall be provided for secondary school students, as needed. Section 36.0 Laboratories, Shops and Other Special Purpose Areas 36.1 Special purpose areas of school facilities that shall include, but not be limited to, the cafeteria, home economics laboratory, industrial arts and vocational laboratories, art rooms, and science laboratories shall be in compliance with the following provisions: 36.1.1 The Code of Federal Regulations, Title XXIX, General Industry Standards 1910 and 1926, Construction, Division of Occupational Safety, Rhode Island Department of Labor and Training; 36.1.2 RIGL Chapter 16-7-24, entitled “Minimum Appropriation By a Community for Approved School Expenses”; 36.1.3 The Basic Educational Program Manual, Rhode Island Department of Elementary and Secondary Education. Section 37.0 Vehicular and Pedestrian Traffic Safety 37.1 Each school shall develop written procedures or protocols, the goal of which shall be to reduce the risk of motor vehicle injuries and exposure to motor vehicle exhaust fumes among students. These procedures shall be reviewed annually by school representatives and local police authorities and shall address no less than the following issues: 37.1.1 Arrival and departure areas for busses, private automobiles, bicyclists, and pedestrians; 37.1.2 Parking and idling locations for motor vehicles, including busses; 37.1.3 Signage and crosswalks; 37.1.4 Traffic flow on and adjacent to school grounds; and, 37.1.5 Emergency procedures. Section 38.0 Asset Protection 38.1 Each public school shall be subject to the provisions of RIGL Chapter 16-7.1, entitled “The Rhode Island Student Investment Initiative”, requiring all public school districts to provide an annual asset protection plan to the Commissioner of Elementary and Secondary Education. 46 PART V ENFORCEMENT & SEVERABILITY Section 39.0 Enforcement 39.1 Pursuant to the provisions of section 16-5-30 of the RIGL, the Commissioner of Elementary and Secondary Education may for violation or neglect of law or for violation or neglect of rules and regulations in pursuance of law by any city or town or city or town officer or school committee, order the General Treasurer to withhold the payment of any portion of the public money that has been or may be apportioned to the city or town. 39.2 The General Treasurer upon the receipt in writing of the order shall hold the public money due the city or town until such time as the Commissioner by writing requests the withheld funds for the purposes of eliminating the violation or neglect of law or regulation that caused the order to be issued, or the Commissioner of Elementary and Secondary Education shall notify the Treasurer that the city or town has complied with the order as the Department shall make in the premises, in which case payment shall be made to the town forthwith. 39.3 The Board of Regents for Elementary and Secondary Education shall report to the General Assembly annually all infractions of school law which shall be brought to its attention, with a record of such action as the Department shall have taken in each instance. Section 40.0 Severability 40.1 If any provision of these rules and regulations or the application thereof to any facility or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of the regulations which can be given effect, and to this end the provisions of the regulations are declared to be severable. 47 REFERENCES 1. American Academy of Pediatrics. "Anaphylaxis at School: Etiologic Factors, Prevalence, and Treatment." Pediatrics, 91:2, 516 (February 1993). 2. Rules and Regulations Pertaining to Reporting of Communicable, Environmental and Occupational Diseases (R23-5,6,10,11, 23-24.6-CD/ERD)(R23-24.5-ASB), Rhode Island Department of Health, April 1996 and subsequent amendments thereto. 3. Rules and Regulations Pertaining to Immunization and Testing for Communicable Diseases (R23-1-IMM), State of Rhode Island and Providence Plantations, Department of Health, November 1998 and subsequent amendments thereto. 4. "Good Samaritan--Immunity from Liability", Chapter 9-1-27.1. of the RIGL. 5. "Confidentiality of Health Care Information Act", Chapter 5-37.3-1. of the RIGL. 6. ADA Compliance with the Americans with Disabilities Act: A Self-Evaluation Guide for Public Elementary and Secondary Schools. Washington, D.C.: U.S. Department of Education, Office for Civil Rights. ISBN # 0-16-048098-1. Available from the U.S. Government Printing Office (202) 512-1800. 7. Handbook for Public Playground Safety, U.S. Consumer Products Safety Commission, Washington, D.C. 20207. U.S. Government Printing Office Publication #325, 1997. 8. The Basic Educational Program Manual, 1989, available from the Rhode Island Department of Elementary and Secondary Education (telephone: 401.222.4600 ). 9. Rules and Regulations for Licensing Speech Pathologists and Audiologists (R5-48-SPA), State of Rhode Island and Providence Plantations, Department of Health, September 1999 and subsequent amendments thereto. 10. Porter, Stephanie. Children and Youth Assisted by Medical Technology: A Medical Primer. Boston, MA: Paul H. Brooks Publishing Company, 1997. (stock #2363 To order a copy, call: 1- 800-638-3775). 11. Regulations of the Board of Regents for Elementary and Secondary Education Governing the Special Education of Students with Disabilities, State of Rhode Island & Providence Plantations, Department of Elementary & Secondary Education, August 1992 and subsequent amendments thereto. 12. American Speech-Language-Hearing Association (1990). Guidelines for Screening for Hearing Impairments and Middle Ear Disorders. ASHA, 32 (suppl. 2), 17--24. 48 13. American National Standards Institute (1970). Specifications for Audiometers (ANSI 3.6-1969). New York: ANSI. 14. American National Standards Institute (1988). Specifications for Instruments to Measure Aural Acoustic Impedance and Admittance (Aural Acoustic Immittance) (ANSI 3.39-1987). New York: ANSI. 15. "Family Educational Rights and Privacy", 34 Code of Federal Regulations, Part 99, pp. 300-- 312, July 1, 1995 edition. 16. Rules and Regulations for the Licensing of Organized Ambulatory Care Facilities, Rhode Island Department of Health, January 2000 and subsequent amendments thereto. 17. Rules of the Department of Health and Rehabilitative Services, Chapter 10D-84, Florida Administrative Code, School Health Services, State Health Office, Tallahassee, Florida. 18. Spinal Screening Guidelines for School Nurses, National Association of School Nurses, Inc. Scarborough , Maine: April 1987. 19. The Comprehensive School Health Manual, Massachusetts Department of Public Health, January 1995. 20. “Screening Prior to Child Care or School Enrollment”, Chapter 23-24.6-8 of the RIGL. 21. “Screening by Health Care Providers”, Chapter 23-24.6-7 of the RIGL. 22. Standards for Approval of Non-Public Schools in Rhode Island, Rhode Island Department of Elementary and Secondary Education, School Approvals Division. 23. Occupational Safety and Health Administration (OSHA): Occupational Noise Exposure Standard, 29 Code of Federal Regulations section 1910.95(c). July 1, 1997 edition, p. 201. 24. Rules and Regulations Governing the Generation, Transportation, Storage, Treatment, Management and Disposal of Regulated Medical Waste in Rhode Island (DEM-DAH-MW- 01-92), Rhode Island Department of Environmental Management, June 1994 and subsequent amendments thereto. October 17, 2001 school health regs-refiling-jan02.doc