V" ‘V'; ; ■ I tKfre Commontoealtlj of iflasaatfmsettsi 
HEALTH IN THE SCHOOLS 
A MANUAL OF THE SCHOOL HEALTH PROGRAM 
MASSACHUSETTS DEPARTMENT OF EDUCATION 
with the collaboration of 
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH 
John J. Desmond, Jr., 
Commissioner, Department of Education 
Vlado A. Getting, M.D., D.P.H., 
Commissioner, Department of Public Health FOREWORD 
On December 30,1930, the Division of Child Hygiene 
of the Massachusetts Department of Public Health 
published “A Handbook on School Hygiene”, which 
was planned to serve as reference material for adminis- 
trators, medical officers, public health nurses, and 
others working for the health of the school child. The 
revision in 1940 of this Handbook was published under 
the new title “The Guide to the School Health 
Program.” 
Today’s manual “Health in the Schools” is a second 
revision of “The Guide to the School Health Program.” 
It is produced under the sponsorhip of the Massachu- 
setts Departments of Health and Education. 
“Health in the Schools” has been prepared by a 
group of specialists in the field of school health. Col- 
laboration and approval between the Department of 
Public Health and the Department of Education was 
attained through the Massachusetts School Health 
Council, a body composed of staff members of each 
department. 
Commissioner of Education 
Commissioner of Public Health 
January 18, 1949 TABLE OF CONTENTS 
Page 
Foreword 
Introduction 7 
School HealtliServices 11 
Planning 
Evaluation 
Initiation 
Administration 
School Health Program—Personnel Qualifications 12 
Teachers 
Health Coordinators 
Physicians 
Nurses 
Dentists 
Dental Hygienists 
Vision and Hearing Testers 
Lunchroom Personnel 
Custodians 
Personnel—Functions and Duties 19 
Superintendents 
Principals 
Coordinators of School Health 
Teachers 20 
Conditions to be noticed in observation of pupils 21 
Health Education by 22 
Vision testing by 23 
Hearing testing by 24 
Detection of Mental Problems and Retardation by 25 
Measurements of Growth by 26 
Physicians 26 
Family Physicians 27 
Examinations—Procedure Prior to 27 
Attendance of Parents at 
Procedure during 
Procedure following Examination 
Examination of Athletes 30 
Examination for Work Certificates 30 
Communicable Disease Control 31 
Accident Prevention 31 
Other Duties 31 
Guidance to Teachers 
School Nurse—Duties of 31 
At Examinations 
Guidance of Teachers 
Emergencies at Schools 
Environmental Information 
School Environment 34 
Health Instruction 34 
Supervision of Nurse 35 
4 Page 
Lunchroom Personnel 35 
School Lunches 
Lunchroom Manager 36 
Custodian—Duties of 37 
Bus Driver—Duties of 38 
First Aid . 39 
Communicable Disease Control 40 
Immunizations 
Preventive Measures within School 
Return to School following Absence 41 
Health Education 41 
Dental Health 43 
Dental Hygienist 46 
Dental Service Programs 
Bibliography 
Mental Health 48 
Problems—Symptoms 49 
Practical Guideposts 51 
Bibliography 52 
Environment 52 
Seating 
Lighting 
Intensity Standards 53 
Maintenance 
Use of Existing Facilities 54 
Room Finish 55 
Luminaries—Lighting Units 56 
Heating and Ventilation 
Sanitation 
Handwashing Facilities—Standards . 56 
T oilets—Standards 
Rest Rooms 57 
Health Room 
Cubicles 
Lunchroom 58 
Playground 
Equipment for Health Room 59 
Services offered by Massachusetts Departments of 
Public Health, Mental Health and Education 60 
Equipment for Vision and Hearing Testing 60 
Physically Handicapped Children 61 
Sight Saving Classes 
Lip Reading Classes 62 
Vocational Rehabilitation 64 
Sources of Additional Information 
5 Page 
General Laws Relating to School Hygiene 66 
Maintenance of Public Schools and Subjects of Study. Ch. 71, Sec. 1 
Handicapped Children. Ch. 71, Sec. 42 66 
Act Relative to Education of Handicapped. Ch. 71, Sec. 46A .... 67 
Provision of Eyeglasses. Ch. 40, Sec. 5 
Payment of hospital Expenses resulting from playing injuries. Ch. 40A (1947) 
Instruction in Lip Reading. Ch. 69, Sec. 29 68 
Medical and Nursing Service. Ch. 71, Sec. 53 69 
Sec. 53 B. Certain Towns Exempt 70 
Physical Examinations of Pupils, Teachers and Janitors. Ch. 71, Sec. 54 
Return to School after Contagious Disease. Ch. 71, Sec. 55 70 
Handling of Children Showing Signs of 111 Health. Ch. 71, Sec. 56 . . .71 
Testing Vision and Hearing. Ch. 71, Sec. 57 72 
Lunches. Ch. 71, Sec. 72 72 
Vaccination. Ch. 76, Sec. 15 
Vaccination. Ch. 76, Sec. 15 
Vaccination—Exemptions. Ch. Ill, Sec. 183 72 
Right to Attend School without Vaccination. R. L. 44, Sec. 6 .... 73 
Sanitation. Ch. 143, Sec. 42 
Employment of Children under Sixteen. Ch. 143, Sec. 60 
Issue of Employment Certificates. Ch. 149, Sec. 87 75 
Sec. 88 78 
Sec. 89 79 
Sec. 90 80 
Children’s Health Camps. Ch. Ill, Sec. 62A 81 
Sec. 62B 
Sec. 62C 
Sec. 62D 82 
Sec. 62E 
Sec. 62F 
Sec. 62G 83 
Sec. 62H 
Dental Certificate—Facsimile 84 
Dental Examination Request—Facsimile 
Evaluation Scale School Health 86 
6 INTRODUCTION 
The school health program is receiving increasing em- 
phasis in the field of public health. Within the past two 
years, committees made up of representatives of nation-wide 
public-health, educational, medical, dental, nursing, and 
nutrition organizations have published policies and program 
outlines in the field. State and local medical societies are 
showing increasing interest in the school medical program. 
We are challenged to improve and to extend school health 
services. The graduates of Massachusetts schools must not 
only be well informed; they must be healthy, happy, and 
confident citizens. 
An effective health program must start at the beginning 
of fife and continue throughout its duration. Thus, school 
health is not a separate entity, but it is a part of a complete 
public health program. On the one hand it is dependent 
upon the care which the child receives in the home through 
the intelligence and co-operation of the parents. On the 
other hand, it is dependent upon the health facilities offered 
by the community. It involves many people—children, 
parents, superintendents of schools, health officers, princi- 
pals, teachers, physicians, nurses, dentists, health educators, 
nutritionists, physical educators, psychologists, social work- 
ers, custodians, public and private organizations, the press, 
and radio. These varied elements must be welded into a 
team which will produce a balanced program. 
The program of each community will be individual. The 
needs in each case must be determined by a free interchange 
of ideas between the personnel concerned, guided by school 
and community leaders. If requested, guidance may also 
be obtained from the Massachusetts Departments of Public 
Health, of Mental Health, and of Education. It is desirable 
that there be school and community planning through a 
Community Health Council composed of representatives of 
7 the schools, public health authorities, the county medical 
and dental societies, and other organizations interested in 
and concerned with health. 
Each school system and any large school within that 
system should establish an advisory health council of its own 
to provide leadership and direction for its health service and 
health education program, and to co-operate with the com- 
munity health council through duly appointed representa- 
tives. 
In addition to the professional, school, and health staff 
members, guest consultants from time to time (depending 
on the topic of the meeting), may include: representatives 
of local civic groups such as the Parent-Teacher Association, 
members of the fire, police, and sanitary departments, 
officers of the student council, and service squads. 
For each such council there must be administrative leader- 
ship. There must be one person who has a definite responsi- 
bility for the total school health program, for co-operation 
with the medical and dental professions and with community 
health agencies, public and private. As has been empha- 
sized this school health program concerns not only the school, 
but also the home, and the community groups. Active par- 
ticipation and co-operation of all is necessary for the realiza- 
tion of an adequate health service program. All schools 
should have a school physician who will function as a school 
medical adviser. There should be periodic evaluations of the 
school health services to determine the progress toward the 
program ideals, to record the accomplishments, the weak- 
nesses, or the obstacles, which hinder the proper functioning 
of the services. One of the purposes for which the school 
health program is planned is the promotion of health con- 
sciousness in the pupils and in the school staff. This may 
be accomplished by repeated health appraisals, by special 
health services such as vision and hearing testing, and by 
a sustained drive to maintain a healthy school environment. 
For this purpose also, health education should be integrated 
8 in the school curriculum with instruction in the functions 
and limitations of the community health resources. 
Materials used for evaluation will include the regular 
reports from the staff, and a summary of the pupil’s health 
appraisal and health practices at the end of the school year. 
The “School Health” section of the “Evaluation Schedule” 
compiled by the American Public Health Association may 
be used as a foundation for problem analysis. Under the 
guidance of the superintendent of schools, with the help of 
educators and school health specialists, the evaluation 
should be done by all members of the staff who have con- 
tributed to the school health services. The School Health 
Council or Committee might be helpful in solving problems 
resulting from this study. Consultation services for evalua- 
tion are available from the State Departments of Public 
Health and of Education. 
9 THE SCHOOL HEALTH SERVICES 
In a literal sense the school health services commence with 
the registration of the entering child. In a more practical 
sense the school is and should be concerned with the health 
of the pre-school child. Complex post-natal influences 
make themselves felt in the problems of school life. For the 
critical moment of the first school year the child should be 
free of all remediable physical defects, he should be emotion- 
ally confident, and tranquil. 
The initiative for planning the registration of entering 
children is the responsibility of the school superintendent. 
For the good health of all of his registrants he depends upon 
two powerful collaborators. One is the family physician 
whose supervision begins at birth and extends through the 
school years. The card which he fills out for his young 
patient, and submits to the superintendent at entrance is the 
report of his stewardship for the first five years—the five 
year result of his periodic appraisals of the child’s health 
and of his treatment. The other collaborator is the com- 
munity-sponsored Child-Health Conference which should 
complement the work of the family physician. Should the 
community be without such a conference the superintendent 
may well regard it as one of his prime responsibilities to 
organize one. Consultant and demonstration services are 
available from the Massachusetts Department of Public 
Health. 
The Child-Health Conference, or the Well Child Con- 
ference as it is sometimes called, is staffed by a physician 
and a nurse. Additional staff members including dentists, 
dental hygienists, nutritionists and social workers may be 
obtained as for instance, from the District Health Office. 
Public and private facilities may be available for the cor- 
rection of any ailment whether the pre-school child is super- 
vised by his family physician or by the community health 
organization. 
11 For the early and complete registration of entering school 
children the superintendent of schools depends upon pub- 
licity. One source is the older children of the family who 
are already familiar with school routine. He may use news- 
paper, radio, and film publicity. He may address parent- 
meetings and he may give notice to local medical and dental 
societies. Registration may be started in the early spring 
in the school building in the district in which the child lives. 
The registration staff is usually made up of first grade or 
kindergarten teachers, nurses and volunteers. 
Necessary materials are the registration blank, the notice 
to parents, and the State Health Record form completed by 
the child’s physician and dentist or by the staff of the Child 
Health Conference and N.O.P.H.N. record forms. 
SCHOOL HEALTH PROGRAM- 
PERSONNEL QUALIFICATIONS 
The superintendent has the responsibility of selecting his 
personnel. He will have in mind that all school personnel 
should maintain good health. It is recommended that they 
be examined before employment and have periodic exami- 
nations by private physicians or by the school physician. 
Chest X-rays should be part of such examinations. These 
may be done free of charge at state sanatoria or at clinics. 
Since the teacher plays a major role in the school health 
program, the school department should select teachers who 
possess good physical and mental health. A teacher should 
look well, should be well, and should be emotionally stable. 
To qualify for health teaching, an applicant should be 
trained in the basic sciences and in health education and 
should have taught, under supervision, the subject of health. 
Teachers who have not had this preparation should be re- 
quired to take in-service courses in basic sciences and health 
education methods. The health rating of prospective teach- 
ers who are entering work directly from teachers’ colleges 
12 may be obtained from the Massachusetts Department of 
Education. 
The Health Co-ordinator 
School health services are under the overall administra- 
tion of the superintendent of schools. However, because of 
the increasing complexity of the school health program and 
the need for its integration with the total education program 
and with the total community health program, he usually 
finds it advisable, either for the entire school system or for 
each school, to assign, to one individual, the responsibility 
for health co-ordination. This individual is variously called 
the health educator, health co-ordinator, or health con- 
sultant. The title is not important, but the job is. 
The need for co-ordination is accentuated by the fact that 
so many of the specialized health services are provided by 
personnel who visit the school only once or twice a week. 
The physician, the dentist, and the nurse, are all making 
vital contributions to the health of the children but their 
contacts with teachers are sporadic. It is easily seen that 
such a co-ordinator must be diplomatic, must have a back- 
ground of health knowledge, and must be capable of supply- 
ing leadership in the advisory school health council. 
The School Physician 
For the necessary qualifications of a school physician no 
standard will apply to all communities. It would be unreal- 
istic to require the same qualifications of a school physician 
in a small community as of a school phyisician in a large 
city. The smallest political units are the rural towns. 
Unable to provide the salary for even a part-time school 
physician these small communities may form a union ar- 
rangement such as the superintendency unions in Massa- 
chusetts, in order to secure the services of a full-time pro- 
fessional health officer who may serve also as school physi- 
13 cian. Larger units, or unions of larger units may secure a 
part-time or full-time school physician. The arrangements 
for employment, as well as the selection of personnel should 
encourage a consistently progressive school health program 
as distinguished from a static or regressive one.* 
The physician serving a school system must be licensed 
to practice in the State. He should have a pleasing person- 
ality, an interest in children, and a belief in his work. One 
who has been trained in pediatrics, if not a licentiate, is to 
be desired. Training and experience in public health work 
is a distinct advantage. Today the school physician has 
responsibilities of a much broader nature than the mere 
physical examination of pupils. These responsibilities as set 
forth by the Committee on Professional Education of the 
American Public Health Association (American Journal of 
Public Health, September, 1944) are in part as follows:— 
(Material in parentheses is ours.) 
(A knowledge of the principles by which) the growth and 
development of normal children (may be encouraged). (They 
include familiarity with) (1) diseases of children, (2) the 
values, methods, and limitations of advisory service to 
parents, teachers, school administrators, and pupils, con- 
cerning the promotion of optimum growth and development, 
(3) the over-all school program, (4) the types of adjustment 
which are possible and necessary for health reasons for some 
children, (5) the methods of co-ordinating the medical and 
nursing services and other school health work with class- 
room instructions, physical education, recreation, lunch- 
room and nutrition services, so that he may assist all school 
personnel to make their most effective contribution to opti- 
mum pupil health. He should also appreciate the facilities 
that are available for treatment in the community (chief of 
which is the private physician), and the technics for explain- 
ing to the parents, child, and teacher the reasons why good 
health practices are desirable and why treatment is neces- 
*The Department of Public Health offers consultation services to 
physician, to school administrator, and to school committee. 
14 sary. He should be aware of individual and community 
health problems which may be attacked through education 
and the place of the school as an integral part of the com- 
munity’s health resources. These responsibilities demand 
special educational qualifications over and above the M.D. 
degree. 
Thus far we have dealt with the single part-time, or full- 
time physician, working within communities of compara- 
tively small size. In a large school system there may be 
many physicians working under the general supervision and 
direction of a chief physician. In still larger school systems 
the chief physician may have one or more deputies, some 
of whom may have special titles, descriptive of their spe- 
cialized duties. 
The Director, Deputy, or Assistant Director of School 
Health—regardless of his actual title—will be ordinarily, a 
full-time employee of the Board of Education or of the 
Health Department, with a rank of, or equivalent to, an 
assistant superintendent if employed by schools or assistant 
health officer or deputy if employed by health departments. 
He establishes policies, selects other medical personnel, super- 
vises, guides and evaluates all medical phases of the school 
health program, and is responsible to the school superin- 
tendent or to the health officer, or to both. 
For the post of Director, or Deputy, or Assistant Director 
of School Health, the scope of modern school health activities 
requires a career man with special training both in educa- 
tion and in public health. In addition to being a well- 
trained physician with the qualifications listed above for the 
“School Medical Adviser” he will need the following special 
training and experience. 
Basic principles of public health including general phil- 
osophy of mass health protection, epidemiology, vital sta- 
tics, record systems and record keeping, environmental 
sanitation, and the principles of public health administra- 
tion; an understanding of school procedures and organiza- 
15 tion, the principles of educational supervision and adminis- 
tration, educational psychology, the administration of school 
health programs, including development of health education 
curricula, the organization and conduct of special classes 
such as speech correction, lip reading, and sight saving, and 
the development of school mental hygiene programs includ- 
ing mental testing. These are essentially the requirements 
for the Master of Public Health degree in most schools. 
Such qualifications are discussed in more complete detail in 
the American Journal of Public Health, Vol. 34; No. 9, 
September 1944. 
The Nurse—qualifications of 
The nurse working in the school, under supervision, 
should have good health, tact, a happy temperament, and a 
professional manner. She should be neat in appearance. 
She should have a knowledge of the principles of public 
health and of health education methods. She should be a 
registered nurse. Completion of a year’s program of study 
in public health nursing in an approved university previous 
to or within five years after appointment should be required. 
Minimum qualifications for the public health nurse working 
without supervision: 
Same as above with the addition of: 
Completion of a year’s program of study in public 
health. 
Nursing in an approved university program. 
At least one year’s experience under supervision in an 
approved public health nursing agency in which 
family health is emphasized and the school program 
included. 
Knowledge of child growth and development and under- 
standing of children. 
Knowledge of school organization and administration. 
Ability to organize and co-ordinate nursing service in the 
community. 
16 Ability to work with lay and professional groups in 
town or school health councils. 
An effort should be made by employing agencies to ap- 
point qualified personnel. Public health nurses with mini- 
mum qualifications should be encouraged to participate in 
educational programs offered by the State or by local 
agencies. It should be expected that in five years after 
appointment the year’s post-graduate study in public health 
nursing in an approved university shall have been com- 
pleted. It is increasingly desirable for the nurse to complete 
work for her baccalaureate degree, but it is imperative, if 
appointment is to be with status of teacher. When more 
than one nurse is employed, it is recommended that one be 
designated as senior. She should be responsible for public 
health nursing policies and procedures, acting as co-ordinator 
with other community nursing agencies, school personnel 
and employing agency. All nurses designated as supervisor 
or director of public health nursing in any agency should 
have a baccalaureate degree in public health nursing. * “The 
Public Health Nurse and School Health.” National Organ- 
ization for Public Health Nursing.—1790 Broadway, New 
York 19, N. Y. 
The Dentist—qualifications of 
The school dentist must be licensed to practice dentistry 
in Massachusetts. He should have (1) an interest in children 
and their dental problems, (2) experience in child dentistry, 
(3) sufficient patience and emotional stability to gain the 
confidence of children, (4) some knowledge of public health, 
and (5) a realization of the aims and psychological principles 
of modern education. Because of the lack of legislation per- 
mitting school committees to employ dentists to treat as 
well as to examine, neither dentists nor dental hygienists 
are a part of the regular school personnel in Massachusetts. 
*Obtained in part from American Association of School Adminis- 
trators, “Health in Schools”, Department of the National Education 
Association of the United States, 1201 Sixteenth St., N. W., Washing- 
ton, D. C. 
17 Dental Hygienist—qualification of 
A dental hygienist must be licensed to practice in Massa- 
chusetts. She should have tact, patience, emotional sta- 
bility, an interest in children, and an acquaintance with 
educational methods. 
QUALIFICATIONS OF OTHER PROFESSIONAL STAFF 
Personnel for Vision and Hearing Testing 
One person in each school system should be trained to test 
vision and hearing. 
Because of the arduous nature of the work, this person 
should possess good health, should have vision corrected to 
20/20 and should be under forty years of age. Other desir- 
able requirements are, general professional interest, affection 
for and patience and experience with children. 
Lunchroom Manager 
A trained lunchroom manager is preferred. She should 
know (1) food values, (2) how to buy economically, (3) how 
to prepare food and (4) how to serve food attractively. A 
knowledge of health education, of salesmanship, and of child 
psychology is desirable. In some schools the home eco- 
nomics teacher may be trained to supervise the lunchroom. 
Custodian 
The custodian should receive instruction in maintenance 
of sanitation, pest control, lighting, ventilation and temper- 
ature regulation. He should be alert for the prevention of 
accidents. He should have patience and a genuine interest 
in children. 
18 FUNCTIONS AND DUTIES OF SCHOOL PERSONNEL 
IN THE SCHOOL HEALTH PROGRAM 
The Superintendent 
The Superintendent administers the school health pro- 
gram. He is expected (1) to furnish leadership for school 
and community health programs, (2) to maintain standards 
of function and environment conducive to good health, (3) 
to assist in the development of health policies, with other 
members of his staff, and (4) to maintain standards of 
physical, mental, and emotional health among the personnel 
of the school system. The superintendent may delegate 
some duties to his school health co-ordinator or to his prin- 
cipals. It is essential that all phases of a school program be 
co-ordinated under one individual within the school adminis- 
tration. 
The School Principal 
The school principal is expected (1) to administer his 
school so as to maintain a healthy environment, (2) to give 
guidance and encouragement to his staff in matters of health 
and health education, (3) to observe and to maintain the 
health of his staff with the assistance of the school physician 
and nurse and (4) to give oversight and supervision to school 
health activities and take part in conferences. In the 
absence of nurse or physician the care of a school emergency 
may become the immediate responsibility of the school 
principal who then supervises first aid, notification of par- 
ents, and transportation home or to hospital, if necessary. 
The Co-ordinator of School Health 
Much has been and will be written concerning the func- 
tions of such a person. Since the final detail of his activities 
will be closely related to conditions in each individual school 
19 system we refer only in general terms to his functions. There 
are two main responsibilities: The first is to take over from 
principal or superintendent much of the burden of adminis- 
tering and co-ordinating the school health services, and the 
second is to supply leadership that is sustained and to a 
considerable degree “silent.” There is a strong need for 
such capable leadership if the advisory school health council 
is to operate in a useful manner. 
The Teacher—duties of 
Observation of Pupil’s Health 
Daily observation and daily checking of the health status 
of each child is a function of the teacher. If necessary, 
special guidance in observation methods may be given to 
the teacher by the principal, by the nurse, and by the physi- 
cian. Because of the daily opportunity, under varying con- 
ditions, to observe the child, individually and comparatively 
as a member of the class group, the teacher can better judge 
than the parents the health status of each child. 
The teacher-nurse conference is a means of supplying the 
teacher with guidance. Such conferences should be periodic 
and planned. The teacher should not await such planned 
conferences, however, to refer any child who appears to be 
under par in health, to the school nurse. By “under par in 
health” we mean not only children who are obviously 
acutely ill with rash, cough, fever or vomiting, but those 
who are unduly tired or listless, or who are doing poor 
scholastic work without obvious reason; who are absent fre- 
quently; who seem to need glasses; who hear poorly or who 
need dental care. The teacher’s report will permit the nurse 
to schedule her conferences according to urgency. The 
teacher should observe her pupils as a conscientious and 
intelligent parent would. She should write her observations 
and reasons for referral on the Teacher’s Health Card for 
that child and send the card to the nurse. 
20 In her observation of her pupils, the conditions which 
should be noted include: 
1. Eyes 
a. Sties or crusted lids 
b. Inflamed eyes 
c. Crossed eyes 
d. Repeated headaches 
e. Squinting, frowning, or 
scowling 
f. Protruding eyes 
g. Watery eyes 
h. Rubbing of eyes 
i. Excessive blinking 
j. Twitching of the lids 
k. Holding head to one 
side 
2. Ears 
a. Discharge from ears 
b. Earache 
c. Failure to hear ques- 
tions 
d. Picking at the ears 
e. Turning the head to 
hear 
f. Talking in a monotone 
g. Inattention 
h. Anxious expression 
i. Excessive noisiness of 
child 
3. Nose and Throat 
a. Persistent mouth 
breathing 
b. Frequent sore throat 
c. Recurrent colds 
d. Chronic nasal discharge 
e. Frequent nose bleeding 
f. Nasal speech 
g. Frequent tonsilitis 
4. Skin and Scalp 
a. Nits on the hair 
b. Unusual pallor of face 
c. Eruptions or rashes 
d. Habitual scratching of 
scalp or skin 
e. State of cleanliness 
f. Excessive redness of 
skin 
5. Teeth and Mouth 
a. State of cleanliness 
b. Gross visible caries 
c. Irregular teeth 
d. Stained teeth 
e. Offensive breath 
f. Mouth habits such as 
thumb sucking 
6. General Condition and 
Appearance 
a. Underweight — very 
thin 
b. Overweight — very 
obese 
c. Does not appear well 
d. Tires easily 
e. Chronic fatigue 
f. Nausea or vomiting 
g. Faintness or dizziness 
7. Growth 
a. Failure to gain regu- 
larly over 3 months 
period 
b. Unexplained loss in 
weight 
c. Unexplained rapid gain 
in weight 
21 8. Glands 
a. Enlarged glands at side 
of neck 
b. Enlarged thyroid 
9. Heart 
a. Excessive breathless- 
ness 
b. Tires easily 
c. Any history of “grow- 
ing pains” 
d. Bluish lips 
e. Excessive pallor 
10. Posture and Musculature 
a. Asymmetry of should- 
ers and hips 
b. Peculiarity of gait 
c. Obvious deformities of 
any type 
d. Anomalies of muscular 
development 
11. Behavior 
a. Overstudious, docile 
and withdrawing 
b. Bullying, over-aggres- 
sive and domineering 
c Unhappy and depressed 
d. Overexcitable uncon- 
trollable emotions 
e Stuttering or other 
forms of speech diffi- 
culty 
f. Lack of confidence, self- 
denial and self-cen- 
sure 
g. Poor accomplishment 
in comparison with 
ability 
h. Lying (imaginative or 
defensive) 
i. Lack of appreciation of 
property rights 
(stealing) 
j. Abnormal sex behavior 
k. Antagonistic, negativ- 
istic, continually 
quarreling 
False emphasis is often placed on perfect attendance. 
The health of the school child should be of paramount im- 
portance, not a perfect attendance record. 
Education in Health 
Health education should be integrated by the teacher into 
her regular program. It may be furthered in individual con- 
ferences with pupils, and with the parents. A knowledge of 
“her parents” and of environmental conditions is almost as 
essential to her success as a knowledge of her pupils. 
The teacher will need to consider curriculum adjustments 
for handicapped children. Such adjustments will usually be 
made after consultation with nurse or physician. 
22 Detection of Visual Defects 
(The latest figures obtainable from the U. S. Public 
Health Service show that 10,000,000 children in the United 
States ages 5-17 have some visual defect.) 
By law the examination of vision and hearing must be 
done by the teacher but it may be checked by physician or 
nurse. Markedly superior results will be obtained if a spe- 
cially trained person is employed to do all vision and hear- 
ing screening in the schools. Use of home-room teachers for 
screening purposes is not recommended. As an alternative, 
one person may be selected to do all the screening in one 
school building. This person may be employed by one town 
or city for the period of time necessary to complete the tests 
A superintendent may employ such an examiner. 
The new Massachusetts Vision Test requires special 
material. Schools desiring to use the improved form of the 
Test can purchase the needed equipment which is now avail- 
able in the form of a complete kit for testing vision. This 
Test may be obtained from the Welch-Allyn Company, 
Auburn, New York. Each District Health Office has a 
demonstration kit which is available to schools for a limited 
time. District Health Offices will also co-operate in furnish- 
ing training for local personnel in the proper use of the equip- 
ment. Snellen cards can be secured, without charge, from 
the Department of Public Health, Division of Maternal and 
Child Health, or Bureau of Health Information. These cards 
are larger, of sturdier material, and cost more than the card 
previously supplied. One card to a school building should 
be adequate. 
In connection with the school program of visual hygiene 
it is of particular importance to stress the difference between 
a school vision test and an eye examination. The former 
serves merely to detect children whose vision appears to 
deviate from normal and who, therefore, should have the 
benefit of an eye specialist’s attention. It should not be 
assumed that the school test provides a diagnosis. It is not 
23 to be expected that the findings from such an examination 
will always indicate the presence of a defect in the case of 
each child failing the school test. 
Schools desiring to adopt the new form of the vision test 
can secure information and instructions from the Division 
of Maternal and Child Health, Department of Public Health, 
and the Bureau of Health Information. By its use, some 
children with impaired vision can be detected who are gen- 
erally overlooked in the simple use of the Snellen card alone. 
The new test has been reported “Acceptable’ ’ by the Coun- 
cil on Physical Therapy of the American Medical Association 
and has received the endorsement of the Massachusetts 
Public Health Council. The teacher should watch for symp- 
toms of eye defects and check these on the form for “Teacher 
Observation.” Children who need glasses and who are 
financially unable to obtain them may secure them by apply- 
ing to their local Board of Health. (See law, page ii.) 
Detection of Hearing Impairment 
Although the teacher may call attention to the need for 
hearing tests in selected cases, mass testing is usually done 
by specially trained persons. The screening of hearing im- 
pairments in school children constitutes a unique school 
health responsibility since complex apparatus which is not 
otherwise accessible to children is required and available 
through the schools for successful detection. Ten per cent 
is a reasonable estimate of the incidence of hearing devia- 
tions from the normal in our school population. The best 
method for screening hearing is an individual pure tone test 
given with a discrete frequency audiometer. Unfortunately, 
this method is not practicable for a great majority of our 
schools since it is too time-consuming. 
State District Health Offices are equipped with Western 
Electric 4C audiometers which provide phonograph record 
speech tests for as many as forty children. 
24 State-owned equipment is available for loan to smaller 
communities which are unable to finance their own pur- 
chases. State District Health Offices are also equipped with 
pure tone audiometers which again are available for loan. 
Most State-owned equipment has been converted so that it 
may be used either for a group speech test or for a group 
pure tone test. The group pure tone test has recently been 
developed by the Division of Maternal and Child Health, 
Massachusetts Department of Public Health, and while still 
in the experimental stage, it gives promise of providing an 
answer to the problem of screening hearing satisfactorily on 
a mass basis. District Health Office personnel can furnish 
more details relative to this new method for testing hearing. 
The new method is termed The Massachusetts Hearing 
Test. 
Reference: “Syllabus of Audiometric Procedure in the 
Administration of a Program for the Conservation of Hear- 
ing of School Children.” Published by Douglas Printing 
Co., 109 North 18th Street, Omaha, Nebraska, for American 
Academy of Ophthalmology and Otolaryngology. (1945.) 
Mental Problems and Retardation 
The teacher usually calls attention first to the need for 
mental tests in selected children. Certain behavior prob- 
lems may be due to mental retardation, therefore, it is desir- 
able to test all maladjusted children. The Law (see page i) 
requires that the school committee shall annually ascertain 
the number of children three years or more retarded in 
mental development in attendance upon its public schools, 
or of school age and resident therein. The Massachusetts 
Department of Education gives consultation and super- 
vision for the formation of special classes for retarded chil- 
dren. Other observations such as absences and causes 
thereof and measurements of growth and development 
should be recorded by the teacher. 
25 Growth and Development 
Body build must be considered in relation to weight. 
Each child has his own yearly record of weight and height 
measurements kept by the teacher. 
The School Physician—duties of 
The school physician should realize that he and other 
members of the school staff are members of a team which is 
working not only for the better health of the child and of the 
community, but also for the education of the child, parent, 
and community, in the science of good health. He must 
diagnose the special needs of his community, which is the 
environment of the child, and work to improve them so that 
the children of his schools will not encounter experiences in 
the community contradictory to his health teachings. 
At this writing it is still necessary that annual examina- 
tions be carried out in the schools and of all children. Ex- 
cepted are those examined by their own physicians in a 
manner complying with the state requirements. It should 
be recognized that because of the example he sets to impres- 
sionable youngsters it is doubly necessary that whatever the 
school physician does in the schools must be done well. 
Therefore he must not undertake more than he can accom- 
plish with credit. To the children who are brought to his 
attention because of indications of illness, crippling defects 
or maladjustment, the greater amount of his time and effort 
is due. To the family physician and to available clinics or 
other approved medical agencies belongs the responsibility 
of any therapy which may be indicated. To the school 
physican and his staff belongs the guiding function. 
The limiting word “physical” should be dropped in de- 
scribing school examinations. These are more than physical, 
they are conference examinations. A “conference” exami- 
nation implies the presence and co-operation of a parent in 
all elementary grades. In the secondary schools the pres- 
26 ence of the parent is usually not desirable. It is better at 
these years to encourage feelings of self-responsibility so 
that such pupils will talk over their own problems with this 
physician of theirs. Should a physician find that he is not 
receiving the confidence of these older pupils he must pause 
and examine his methods—his own personality—for to be 
an adequate school physician the doctor must also be an 
acceptable counsellor. 
Well conducted examinations and health procedures are 
not to be expected of a school physician unless the school 
supplies the facilities such as examining rooms which afford 
at least cheer, light, quiet, and privacy. If necessary as 
is often the case in older school buildings such facilities can 
only be supplied by additions. Whatever their construction 
—whether pre-fabricated buildings or even Quonset huts— 
it is desirable that they be attached to the school building. 
This health examination can be an educational experience 
of lasting value in the child’s life. It is, also, an unequalled 
opportunity to the physician of presenting health informa- 
tion to parents. Furthermore, in discussing with the child’s 
teacher such recommendations as he needs to make, he finds 
himself with a third person to whom the experience is neces- 
sarily educational. Correcting misconceptions, dispelling 
superstitions, and instilling a desire for accurate scientific 
facts are fundamental contributions of physician to health 
education. 
Family Physician The school physician may at his discre- 
tion omit the re-examination of those children who are under 
the superivision of their own physician. The school health 
record card or other suitable record form containing similar 
information will be sent to the school by the family physician 
and his recommendations should be followed. 
Procedure Prior to School Examination 
School physician may meet with community physicians 
and dentists to enlist their support of the school health pro- 
27 gram. Superintendent, school physician, and nurse may 
designate grades to receive examinations. A yearly schedule 
should be available for school personnel, so that it may be 
included in the school calendar. If the physican cannot 
meet the schedule, he should provide a substitute, subject 
to the approval of the school superintendent and School 
Board. The health records are reviewed by nurse and 
teacher to ascertain if all pertinent data are recorded for 
physician’s information. Health teaching in the classroom 
should precede examinations. Teachers and nurse select 
pupils in other grades to be referred as previously detailed. 
Adequate space should be available within the school. If 
not available, it may be possible to use a community 
building. 
Attendance of Parents at His Examination 
Parents should be urged to attend the examination. Invi- 
tations to parents should be written in the classroom and 
taken home by the pupils. Personal interviews and accepted 
publicity methods should be used to encourage parents to 
attend examination. Few parents would think of sending 
a young child to their family physician without their per- 
sonal attendance, but experience has shown that it is often 
difficult to induce them to attend such an examination in 
the school. The Parent-Teacher Association can be of great 
assistance with this activity. The appointment system can 
prevent unnecessary waiting for mother and child, but it 
must be remembered that any practicing physician is sub- 
ject to emergencies which often intrude upon his schedule 
whether of school work or private practice. Without the 
presence of either or both parents the examination of a 
young child is not comprehensive, yet few children regularly 
receive the complete examination from their family physician 
which the school physician stands ready to give. The school 
physician must address himself to the problem of obtaining 
their attendance. Without going into all possible methods, 
it is here suggested that a personal visit by his nurse to the 
28 home previous to his examination will accomplish one of 
two important objectives: Either it will induce the actual 
attendance of parent at the examination or the nurse will 
be able to complete a form-questionnaire which will supply 
to the doctor most of the essential information for his under- 
standing of the child. Such an alternative is not as satis- 
factory as the actual attendance of parent because the 
information obtained can never be as complete, and the 
educational possibilities of such a conference will not have 
been received. It is better, however, than the mere physical 
examination which has been in vogue. Older children should 
be encouraged to take responsibility for their own physical 
and emotional status. 
Procedure During Examination 
The child should be undressed. Physician should review 
health card which will include history of illness, result of 
vision, hearing, and psychological tests, growth tests, growth 
record, and comments of nurse and teacher. Examination 
should cover all items on health card. (Coded according to 
State committee recommendations.) Physician should re- 
cord his findings and recommendations on card and discuss 
findings with parent or mature child and develop a plan for 
medical care, explaining how the result of uncorrected 
remediable defect may affect the child. He should discuss 
the need for remedial care with public health nurse and the 
public health nurse should assist parents to put into effect 
the plan for remedial care; she makes known to them the 
available community facilities. 
Procedure following Examination 
The physician will discuss special problems with the 
family physician. Recommendations from the family phy- 
sician on such problems should be recorded and followed. 
If a family physician requests that a student be excused from 
physical education his request must be honored. Some 
towns require such a request to be made on a special form. 
29 The nurse will give the child an appointment for re-examina- 
tion, if necessary, and she will arrange for a home visit or 
conference in school with parent, if medical care plans are 
not carried out. This activity should be co-ordinated with 
other public health nursing and school activities to prevent 
overlapping of services. Physician and nurse should discuss 
with the superintendent and teachers special problems in- 
volving environmental, emotional or physical classroom 
adjustments. It must be understood that the periodic 
health examination does not insure the maintenance of the 
health status found at the time of the examination, e.g., the 
pupil may develop an acute illness the day after the examina- 
tion. Therefore, constant watchfulness by parent and 
teacher is necessary. 
Examination of Athletes 
A special examination for students in upper grades who 
are entering competitive sports should be given early in the 
fall. A physician should be present at major games but 
this should not be considered as part of the program of the 
school physician as such, If the school physician feels that 
a student should not enter major sports his decision must 
stand. There should be close co-operation between the 
school physician and the physical education supervisor. 
Examination for Work Certificates 
The law requires that a physician, before issuing a cer- 
tificate, shall be familiar with: 
1. The nature of the proposed employment. 
2. The stresses and strains which it involves. 
3. The child’s physical condition. 
An unconditional certificate may be given; a temporary 
one; a certificate may be refused completely, or refused for 
one occupation, but given for another. The card must be 
filled in by the employer before being signed by the physician 
30 Control of Communicable Diseases 
In the control of communicable disease, the school physi- 
cian, working in co-operation with the other physicians of 
the community and with the local Board of Health exercises 
another potentially educational function. Among these 
control measures are smallpox re-vaccination; toxoid booster 
doses; and such other supplementary measures that should 
be initiated and organized by the school physician. He 
should also consider, from time to time, the advisiability of 
a tuberculosis survey, initiating and organizing it, if it 
seems warranted. Such recommendations as he may feel are 
desirable and educational should be explained to the teach- 
ers and to the community. The school physician should 
have a regular place on the agenda of all P.T.A. meetings, 
in his community. This provides an excellent opportunity 
to address the community. 
Accident Prevention 
School safety is the responsibility of the school physician. 
A clearly defined procedure, to be followed in the case of 
school emergencies, should be established, preferably after 
consultation with the superintendent, the principals, and 
his nursing staff. He is educating by example in these 
emergencies. Furthermore, in his talks to parents, he may 
point out special hazards that threaten any one of his schools, 
whether or not they are remediable. That school hazards 
are apt to be rather insignificant compared to those in the 
average home may be emphasized frequently. 
Other Duties 
Directly educational is his function of guiding teachers in 
systematic and continuous observation of the health of 
pupils so that deviations from normal will be promptly noted 
by the teachers and will be brought to his attention. Se- 
lected pupils will be brought by the school physician to the 
attention of consultants to determine in each individual case 
the advisability of special educational programs such as lip 
31 reading instruction, speech correction, and sight conserva- 
tion. He will determine the need for visiting teacher service, 
modified physical education, shortened school day, rest 
periods, and he will advise with teachers in constructing 
educational programs for the physically handicapped. He 
also is expected to give general supervision of sanitation and 
other environmental health factors within the school build- 
ings and grounds. This includes the safety of water, safety 
of food and milk supplies in the lunchroom and their safe 
treatment by food handlers; the proper disposal of sewage 
and wastes; sanitation of drinking fountains and wash 
rooms; proper lighting, heating and ventilation and safety 
of gymnasium and playground. For individual children 
the length of the school day, extra curricular activities, the 
length and frequency of recess periods, even the type of 
examinations and methods of marking may call for the spe- 
cific recommendations of the school physician. In the man- 
agement of certain children who may be called “difficult” 
the teacher may seek the physician’s advice. 
Professional Guidance to Teachers 
He offers professional guidance in the field of teachers’ 
health. The teacher’s mental as well as her physical health 
is of direct concern to her employer because of its effect on 
the quality of her work. The school physician conducts 
periodic health examinations and offers consultation to em- 
ployees with health problems. 
Duties of a School Nurse 
No other person concerned with the school health program 
knows the home and neighborhood of each child so inti- 
mately as does the public health nurse. Because one of her 
major activities is home visiting, she learns and understands 
what this environment is, and its relation to the child’s 
physical, emotional and mental health. She is, therefore, 
in an excellent position to act as liaison between school and 
32 home and other community agencies. She interprets the 
conditions in the home to the school personnel, and she 
helps the parents to understand the health services and 
health policies of the school. Through conferences with 
parents she explains the importance of maintaining a home 
environment that provides for the healthy development of 
their children. If there are difficult home problems she 
refers parents to the right community agency for help. To 
school personnel and parents she explains the use of com- 
munity health facilities. If these facilities are inadequate, 
she works toward their improvement and expansion through 
active membership on health committees and other com- 
munity contacts. 
The public health nurse assists the school physician to 
prepare and to conduct health examinations. The nurse 
and the teacher select the children who are most in need of 
examination, and they provide the physician with appro- 
priate data. The nurse encourages parents to be present at 
the examination, helps them and the school personnel to 
plan ways of securing the care recommended by the physi- 
cian, and of working out a suitable regimen that will lead 
the child to good health habits in and out of school. 
Because teachers have day-to-day contacts with school 
children, the public health nurse instructs the teachers in 
the importance of maintaining continuous observation of 
each child’s health and behavior. Through in-service edu- 
cation programs and individual conferences, she demon- 
strates to them the technics for conducting periodic screening 
tests—vision, hearing, weighing, and measuring. 
Emergencies in a school are generally referred to the 
nurse if the physician is not present, but her responsibility 
is limited to first aid. Further treatment is given by the 
child’s private physician or at a clinic as arranged by the 
family. Because an accident may occur when neither 
physician or nurse is present, a teacher or other person 
trained in first aid should always be present at school. 
33 To the public health nurse belongs the additional responsi- 
bility of co-ordinating all available information concerning 
the health facts of every boy or girl. She does this by 
making sure that there is a complete up-to-date health 
record, upon which is entered data given her by the teacher, 
and medical, dental, and other health personnel; also by 
providing teachers, parents, and other agencies with written 
reports as needed, and by keeping a daily report of activities 
from which monthly and annual narrative and statistical 
reports are prepared. 
In Health Instruction 
Instruction in health should be part of the total curriculum 
of the school. In addition, the best opportunities for teach- 
ing health frequently come in connection with other sub- 
jects. It is the teacher’s role to give classroom instruction 
in health, and the nurse’s role to act as consultant and 
advisor to the teacher. The nurse helps to plan the health 
curriculum, serves as a member of the school health council 
or planning group, and assists in the selection of authentic 
health education materials. She also makes a contribution 
by showing teachers how to relate health instruction to the 
specific needs of each child. 
In the School Environment 
As a member of the team concerned with school health, 
the nurse has a part in seeing that standards are maintained 
for school safety and sanitation. In this connection she 
gives attention to teacher-pupil relationships as they influ- 
ence mental, emotional, and physical health; to the school 
lunch; and to the health of school personnel. Nursing serv- 
ices should be provided to children of all ages in all schools 
—public, parochial and private. 
Each community works out the arrangement that best 
meets its needs. In some places boards of education employ 
public health nurses to give service to schools. In other 
34 communities, nursing service is provided by arrangement 
with the local health department or purchased by a board 
of education from the local visiting nurses association just 
as nursing service is purchased by small industries. Three 
out of every four public health nurses in the United States 
give service to schools. 
Supervision is Important 
Supervision is essential for the continual improvement of 
school nursing service, and for the professional growth and 
development of individual nurses. This is true even when 
the nurse serving the school meets all recommended quali- 
fications. 
Smaller school systems or organizations unable to pro- 
vide supervision may arrange to get it through a local or 
state health department or by purchasing it from a volun- 
tary agency such as a visiting nurse association. In addition 
to the qualifications necessary for the nurse in the school, 
the supervisor of school nursing also needs previous experi- 
ence in a school health program and preparation in the 
theory and practice of supervision. 
Lunchroom Personnel 
This varies according to locality. A trained lunchroom 
manager is preferred. A community nutritionist may super- 
vise if no trained manager or home economics teacher is 
available. The school nurse co-operates with the nutrition- 
ist, and in rural schools, may need to initiate the hot lunch 
program. The teachers should guide the pupils in choice of 
good school lunch. 
School Lunch 
The law (page iv) permits the School Committee to pre- 
pare and sell lunches. The responsibility for these lunches 
is divided between the home, to supply a home lunch or a 
packed lunch, or to supply money for lunch, and the school 
35 to allow sufficient time for lunch and to supply a hot lunch 
when necessary. The community also has the responsi- 
bility for subsidizing through private or public agencies the 
feeding of needy children. The organization of the lunch- 
room arrangements should be the function of a school lunch 
committee which forms the policies and is responsible for 
their execution. This committee should include a school 
committee member, the principal, the school nurse, a 
teacher, a student, the lunchroom manager or the home 
economics teacher and a parent. 
The Lunchroom Manager 
The lunchroom manager must organize and plan food 
services and supply education in nutrition. 
Food services are as follows: the planning of menus to 
conform with nutritional principles and patterns; the pur- 
chase of food supplies and the establishment of necessary 
specifications; the supervision, preparation and serving of 
all meals; the maintenance of high standards; the super- 
vision and direction of the duties of all personnel; the setting 
up of work schedules as a basis for efficient procedures and 
controls; the supervision of and execution of all financial 
records as required, including food costs control and monthly 
inventories; the establishment of adequate routines for 
sanitation and storage of food; the care, upkeep, and use 
of equipment, and other related duties. 
Her duties also include: 
The establishment of approved health standards of 
workers; recommending the nutrition education needed in 
the school; developing the educational use of the lunch- 
room through the food service by increasing the interest of 
children and parents; studying children to determine the 
desirable type and variety of food; consulting with school 
administrator, teachers and others in all problems con- 
cerned with the provision of food by the school; participat- 
36 ing in school and community health projects as opportunities 
arise and attending Massachusetts School Lunch Advisory 
Meetings at regular intervals. 
A Custodian 
Custodians have such an important part in the school 
health program that their interest and pride should be 
aroused and stimulated through representation in the group 
of health officials of a school system. In-service training is 
desirable. Just as the teacher by the nature of her work 
becomes the first person to notice in the individual child 
the signs of illness, so the school custodian by the nature of 
his work should be the first to become aware of and to re- 
move any menace to school safety. In all of his duties 
inside and outside the building he should be alert against 
fires and falls, against broken bottles and rails,—the bite of 
animals or the traffic death. 
The necessary safety measures that are beyond his skill 
should be reported at once to the principal. 
The suggestions which follow have been taken from the 
Report of the Committee on Custodial Care of School Prop- 
erty in Massachusetts and the State Department of Edu- 
cation. 
Classroom and corridor floors should be swept daily, oiled 
at least twice a year, and washed before each oiling. If it 
is found that an oiling twice or three times a year is not 
sufficient to keep the floors in satisfactory condition, either 
more frequent applications should be made or an oiled 
sweeping compound used to prolong the effects of the oil. 
A thorough scrubbing of floors should precede each oiling. 
Where the floors are not oiled they should be scrubbed more 
often, at least once a week, or oftener if the playground is 
muddy. The use of disinfectant in washing floors and furni- 
ture has little or no value. Its elimination furnishes an 
opportunity for a minor economy. No standard number of 
37 times for washing windows can be recommended because of 
variations in atmospheric conditions. It should be borne 
in mind that dust and dirt materially diminish the amount 
of light. Generally speaking windows are not washed fre- 
quently enough. School furniture should be washed at least 
twice a year. Sanitaries should receive a daily cleaning with 
hot water and soap powder. Every municipality should 
have regulations governing the work of custodians. Ordi- 
narily only men with experience in and knowledge of cus- 
todial work should be engaged. 
The School Bus Driver 
In addition to his responsibility to safely conduct pupils 
to and from the schools it is his duty to see that no factors 
exist which will endanger the health of the pupils while in 
his care. Because it may be necessary for students to walk 
substantial distances, in some areas, to meet the bus the 
driver should observe whether or not they are properly 
clothed for the weather conditions. If a pupil is not suitably 
clothed the driver should so report to the school authorities. 
Established schedules should be maintained to avoid un- 
necessary waiting. Waiting shelters should be provided 
wherever needed. The bus should be at a comfortable tem- 
perature, and heated during winter months. It should be 
ventilated, with assured safety from carbon monoxide 
fumes. Cleanliness should be maintained in the bus. Dirty 
conditions would be in conflict with school health teachings. 
To aid the driver, the pupil-trafiic-control should make a 
brief inspection before the pupils leave the bus. The bus 
driver should include in his daily routine, (1) sweeping the 
floor, (2) dusting the seats, (3) inspecting for breakage or 
damage, (4) cleaning windshield, side windows and mirrors, 
and (5) checking exhaust and heating apparatus to make 
certain that no monoxide gas is reaching the interior of the 
bus. 
38 FIRST AID 
First aid is the immediate care given at school in sudden 
illness or accident. A qualified person should be selected in 
each school to give such care. Standing orders for the first 
aid treatment of all emergencies should be prepared by the 
school physician. Such standing orders should be posted 
and maintained in a prominent and suitable spot which 
should be designated by the physician after conference with 
principal, health co-ordinator, and nurse. The school should 
provide facilities for emergency treatment. 
After-care is the responsibility of the family and the family 
physician. The doctor, nurse, principal, health co-ordinator 
or the selected qualified person mentioned above may report 
the accident or sudden illness to the parent. Except in the 
most minor matters it is not wise for the school to make 
recommendations for after-care. It is absolutely necessary, 
if the child is to be sent home, to make certain that a qualified 
person will be at home when the child arrives. This safe- 
guard may on no account be omitted. If the school repre- 
sentative is unable to reach such a person in the home an 
injured or sick child may be kept under school supervision 
or the family physician may be directly requested to assume 
the care of the patient. Parents should agree at the enroll- 
ment of their children in school to permit medical consulta- 
tion for serious accidents. Such a consultant would always 
be the family physician unless unavailable. 
Minor injuries such as cuts, bruises, or scratches may be 
cared for by the children themselves under the supervision 
of the qualified selected person mentioned above. They 
may use materials from the first aid kit. This should pro- 
vide a good teaching opportunity. Fire blankets should be 
kept in the chemistry laboratory, in the household art room, 
and wherever there is an open flame. A deluge shower is 
recommended in chemical laboratories. 
39 COMMUNICABLE DISEASE CONTROL 
Immunizations 
Children should be vaccinated against smallpox and im- 
munized against diphtheria during the preschool years. 
Tetanus toxoid immunization is also recommended. A 
booster dose of diphtheria toxoid should be given on entrance 
to primary and high school grades. Immunization is the 
function of the local Board of Health, not of the School 
Department. Any school children needing vaccination or 
immunization should be referred to their family physicians 
or, lacking them, to the local Board of Health. No unvac- 
cinated child may be admitted to school unless he presents 
a certificate signed by a registered physician exempting the 
child from vaccination because of his health. 
Preventive Measures in School 
The term “epidemic” means affecting a large number of 
persons in a community at the same time. It is generally 
agreed that schools should be kept open in time of epidemic. 
The public health nurse co-operates with the school physi- 
cian in the control of communicable disease by helping the 
teachers to recognize suspicious signs and symptoms, to 
understand protective measures, to record disease history 
and completed immunizations. It has already been pointed 
out that teachers should observe their children closely. 
Under epidemic conditions they should be especially alert 
to signs of illness and should know each non-immune child. 
If a child shows symptoms suggesting a communicable dis- 
ease he should be isolated and the school physician should 
be called. The superintendent or one delegated by him will 
see that the child is sent home as soon as arrangements can 
be made. (See First Aid.) The public health nurse assists 
with arrangements for isolation and care of sick children 
until called for by parents. Parents and children will be 
given pertinent information. 
40 The School department should notify the local Board of 
Health of all children excluded because of symptoms sug- 
gesting communicable disease. The law requires the local 
Board of Health to notify the School Department of re- 
ported cases of communicable disease in the community. 
Return to School After Communicable Disease or 
(Exposure to It) 
According to law a child may not return to school after 
exposure to or illness with a communicable disease unless he 
brings a certificate from the local Board of Health or the 
school physician. Certificates from the family physician 
are not legal unless the Board of Health designates private 
physicians as agents to issue such certificates. 
The community will be informed by the local Board of 
Health of accepted practice in the control of communicable 
disease. School health personnel will give instruction in the 
control of communicable disease in all contacts with parents 
and children. Parents and children should be encouraged to 
assume responsibility for recognizing the signs and symp- 
toms of communicable disease and the need for protecting 
others. 
HEALTH EDUCATION 
Health education is a general term covering a wide field 
of human experiences. It has been defined as follows: 
‘‘Health Education is the sum of all experiences which fav- 
orably influence habits, attitudes, and knowledge relating to 
individual, community and racial health.”* “The child is 
educated in health in all his experiences that in any way 
influence his habits, attitudes and knowledge relating to 
health, but the experiences he has that emerge from and are 
identified with school life are those of School Health Edu- 
*Fourth Year Book of the Department of Superintendence of the 
N.E.A. 
41 cation.”** Therefore, health education should be integrated 
in the entire school curriculum. 
Education for healthful school living may be divided into 
two major divisions as follows: factors influencing the estab- 
lishment of sanitary and safe school environment for the pro- 
tection of the child and factors influencing the establishment 
of an orderly and well-organized school day, so that the 
greatest learning may result for the child. The teacher will 
see the value of classroom learning experiences associated 
with healthful living in school, as one of the most effective 
avenues for teaching health. 
Health instruction includes the planning of educational 
experiences for the child so that he may acquire desirable 
health attitudes, practices and a sound, scientific background 
pertaining to personal and community health, thus becom- 
ing an intelligent self-directed citizen. Such learning experi- 
ences may include those associated with healthful living in 
school, those associated with school health examination, 
those which are associated with the general organization of 
all subject matter and the learning experiences which are 
organized and specific. 
Direct health instruction, with a definite weekly time 
allotment, is considered especially desirable after the third 
grade. Such direct health instruction should utilize all the 
best teaching procedures and motivations available. The 
health education textbook has an important and essential 
place in such instruction, but effective health teaching can- 
not be confined solely to the textbook, or to recitation type 
of teaching. The functional approach towards solving health 
problems as they occur in the actual life of the child is to be 
emphasized. 
Since many of the objectives of health teaching can not 
be achieved before the pupil is mature, there should be direct 
health instruction also in the secondary schools. The trend 
**Committee Report Health Education Section, Am. Phys. Ed. 
Assoc., Journal of Am. Assoc, for Health, Phy. Ed. and Rec. 
42 is towards the concentrated health courses, one in the junior 
high school and the other late in the senior high school 
period. It is desirable that such classes meet several times 
a week in order that a functional type of health instruction 
may be developed.* 
Parent education in matters of health is to be emphasized 
since it is recognized that the school health program can not 
be effective unless at the same time parents are being in- 
formed as to the objectives of the school health education 
program and its methods of procedure. Co-operation of all 
parent and civic groups of the community for the under- 
standing and appreciation of the school health program is 
essential. In addition, it is recommended that each class- 
room teacher should take responsibility for the co-ordination 
of the home with the specific health program she is develop- 
ing in the classroom. It is only through co-ordinated learn- 
ings in the home and in the school that the specific health 
objectives of each grade level may be achieved. Home, 
school, and community should be co-ordinated for health. 
As has been previously stated, it is the function of the 
Superintendent of Schools to administer the health program. 
Often administrative leadership is furthered by the appoint- 
ment within the school system of a supervisor or co-ordinator 
for the total school health program, of which health educa- 
tion is an integral part. In some systems the health program 
is co-ordinated under the direction of a school administrator 
in charge of all special services to children. 
DENTAL HEALTH 
The school committee may employ a dentist to do dental 
examinations but not to treat disease. Furthermore, laws 
do not permit school systems to administer dental clinics 
(General Laws, Chapter 111, Section 50). Clinic service 
may be administered by the board of health or by private 
*“Health Education”—N.E.A.—A.M.A., 1948 ed., p. 242. 
43 agency. In the same way, dental hygienists, when em- 
ployed by school committees, must be employed as teachers 
as there is no legislation allowing them to be employed as 
dental hygienists by the school department. The dental 
hygienist should perform dental inspections and dental pro- 
phylaxis when possible. Her work will be associated with 
education in oral hygiene for parent and pupil. She should 
also provide the teacher with material for health education. 
Dental health is a part of general health which presents a 
unique problem because of the large percentage of the popu- 
lation repeatedly affected each year. At least 95% of all 
school children in Massachusetts have experienced dental 
caries by the time of entrance into high school. One half of 
the teeth of the average pupil are attacked by time of high 
school graduation. This incidence of dental caries is one of 
the highest in the United States. 
Dental decay is found as early as two and one-half years 
of age. It is suggested that children attending preschool 
registration be given notification blanks to take to the 
dentist and that they be urged to present these to the teacher 
at the opening of school. In this way the certification of 
dental corrections may be presented along with that of vac- 
cination upon entering school. Immediately upon entrance 
to elementary school, attention should be directed towards 
the care of the permanent teeth. It is in this age group that 
care of the first permanent molars should begin as these teeth 
are so subject to decay that neglect can lead to their loss by 
extraction by age ten. 
Junior and Senior High School students have, for practical 
purposes, their complete permanent dentitions. Dental 
caries continues to be highly active in this group. Because 
many of the dental care and educational programs are dis- 
continued at the completion of elementary school, and be- 
cause of a change in responsibility for health matters, there 
results a degree of neglect sufficient to allow irreparable 
damage to permanent teeth. 
44 The Council on Dental Health of the American Dental 
Association states: “Dental Science has advanced to the 
point where decay of the teeth can be controlled. The fol- 
lowing four measures are necessary for its accomplishment: 
1. Regular visits to the dentist for examination. 
2. Early treatment of small cavities. Delay will be 
serious. 
3. Selection and consumption of a proper diet and tem- 
perance in the use of confections and sweetened 
beverages. 
4. Proper and regular cleaning of the teeth after eating. 
Your dentist can aid in teaching you a correct 
method.” 
Recent developments in fluoride therapy indicate that the 
procedure of topical application of sodium fluoride should 
be added to the above recommendations. 
It is recognized that good dental health is dependent 
chiefly on the accomplishments of the private dentists of 
the community. In an effort to make available the services 
of these practitioners to those children who can afford them, 
a form (see appendix, page xi) has been developed for class 
room distribution. When this card is sent home the parents 
are expected to bring the child to the family dentist within 
a reasonable length of time. Space on the card is provided 
for the dentist’s signature usually verifying one of three 
facts: (1) Treatment is needed and has been arranged priv- 
ately. (2) There is no need for further treatment at the 
time. (3) Treatment is needed but no provisions can be 
made for private care by the parent of the child. This type 
of notification is available from both state and local agencies. 
Its use thus far has been limited largely to those communi- 
ties where a sufficiently large number of participating 
private dentists exists and where their co-operation has been 
previously obtained. When the notification forms are dis- 
tributed in any classroom it is hoped that organized dental 
health instruction will immediately follow in order to teach 
45 pupil and parent the need for dental care. Instruction 
should be planned to extend into the home as much as possi- 
ble. Education of parents is needed for co-operation in 
carrying out dental care. Children in elementary grades 
should be instructed in proper dental practices. The value 
of the services and relationship with the family dentist 
should be taught the pupils. 
The Dental Certificate signed by the dentist verifying 
the correction of all existing dental defects is used to a con- 
siderable extent. About 100,000 are provided to the dentists 
annually in Massachusetts. The person in charge of the 
dental promotional program may collect these certificates 
and estimate the percentage of pupils receiving complete 
dental care. 
The School Dental Hygienist 
Fifteen percent of the registered dental hygienists in 
Massachusetts are employed in school dental programs. 
These hygienists are employed as dental inspectors and as 
teachers in oral hygiene. Many perform dental prophylaxis 
to a limited age group. When possible, these persons should 
have a pedagogical background in addition to their basic 
training in dental hygiene. The satisfactory effect of this 
type of program is evidenced in the high percentage of com- 
pletely treated cases. 
Dental Service Programs 
Boards of Health and private agencies may establish and 
maintain clinics for dental care. They must be licensed. 
The agency administering the clinic should set up the stand- 
ards for eligibility. When no clinic is available some means 
of supplying needed dental care to indigent children of all 
grades must be planned. 
The Massachusetts School Health Council composed of 
members of the staffs of the Departments of Education and 
46 of Public Health considers matters concerning the schools 
and various health personnel and they make the following 
recommendation: “Children who need medical or dental 
care, and who by necessity must make appointments with 
private doctors or dentists during the regular school hours, 
should be accorded the same privilege as that enjoyed by 
children who, with the approval of school authorities, attend 
clinics, i.e., excuse without absence.” 
Consultant service on all types of dental programs is 
available through the Dental Division of the Massachusetts 
Department of Public Health, 227 Commonwealth Avenue, 
Boston 16, Massachusetts. 
References 
The following materials are considered the most authentic 
dental references available and may be obtained from the 
American Dental Association, 222 East Superior Street, 
Chicago 11, Illinois. A current price list is available upon 
request. 
Dental Health Program for Elementary and Secondary Schools 
This manual outlines the important steps in developing 
and conducting school dental health programs. 
Teeth, Health and Appearance 
An unusually attractive book bound in cloth and con- 
taining over one hundred illustrations, fifty of them in 
color. This book is especially suited for elementary 
school libraries and reading tables. 
Your Child's Teeth 
A booklet prepared for parents, teachers, nurses, dental 
hygienists, dentists and physicians. The illustrated 
text provides comprehensive dental health information 
concerning children from preschool through high school 
age. 
47 Tommy’s First Visit to the Dentist 
A story of a real boy’s visit to a real dentist, told with 
pictures to help the preschool children understand what 
to expect on their first visit to the dentist. 
Pete Meshakee 
A sixteen page booklet on the customs, habits, and 
dental health of the Chippewa Indians. Includes a 
short Ojibwa English dictionary. Prepared especially 
for the 8 to 12 year old child. Recommended to inter- 
mediate grade teachers as supplementary reading. 
The Control of Dental Caries 
A concise explanation of the present knowledge of the 
cause and results of dental caries. An authentic state- 
ment for teaching use. 
Fluorine and Dental Caries Control 
A statement of the current position of fluorine in dent- 
istry. Excellent footnotes for additional references on 
the subject. A leaflet for teacher information. 
Dentistry as a Professional Career 
General information about the dental professions— 
dentistry, dental hygiene. Dental assisting-schools of 
training are listed as well as requirements for admission. 
MENTAL HEALTH 
Relationship between Education and Mental Hygiene 
Today education is thought of in terms of preparing the 
child for living. He goes to school not only to learn about 
the world in which he lives, but also to learn how to live 
in that world. Therefore, responsibility for the child’s 
physical, mental, social, and vocational success is inevitably 
accepted by the school with as much concern as is the matter 
48 of his education in the traditional academic subjects. 
Mental hygiene and education are collaborating to produce 
an individual with a well-rounded personality, who, in addi- 
tion to having acquired academic information, has the 
capacity for a successful adaptation to life. 
The principles of mental hygiene are being successfully 
utilized by alert educators. The understanding teacher 
realizes that the basis for a happy and successful adulthood 
is the development of a normal personality in the growing 
child. To that end, she tries to give him individual guidance 
and attempts to understand and to assist the process of his 
development. 
Next to the parent, the teacher is the most influential 
person in the child’s life. She is in a strategic position, not 
only to detect problems in the beginning, but also to play 
an important role in the correction of them. The matter 
of her personality is of real concern if she is to fulfill her 
obligations to the pupils. 
Problems Frequently Observed in Classroom that 
Indicate Need for Attention and Correction 
In every school there are children who are erratic in their 
school progress, perplexing in their behavior, and who pre- 
sent various types of personality defects. Influences within 
the child, the home, school, or neighborhood are often re- 
sponsible for these difficulties. The following list of symp- 
toms represents some of the more common manifestations 
of maladjustment in school children. Some of these have 
already been presented: fj 
1. Neurotic Traits Nail-biting 
Thumb-sucking 
Pencil-chewing 
Unestablished toilet habits 
Blinking 
Facial twitching 
Infantile speech 
49 2. Personality Difficulties Quarrelsomeness 
Pugnacity 
Fearfulness 
Shyness 
Excessive obedience 
Seclusiveness 
Day dreaming 
Restlessness 
Overactivity 
Distractibility 
3. Behavior Problems Temper tantrums 
Disobedience 
Destructiveness 
Lying 
Stealing 
Truancy 
Sexual misbehavior 
4. Educational Problems Inability to read (although child 
has been found to have adequate 
intelligence) 
Arithmetical disability 
Lack of application 
Speech disability 
When it is remembered that all of these are but symptoms 
—symptoms that indicate an underlying cause—it should 
encourage inquiry and the devising of means through which 
special guidance may be given to the child at an early date, 
thereby averting the development of more serious problems. 
Most children present problems at one time or another in 
the course of their development, and it is important to 
understand and to properly guide these deviations of con- 
duct in order to prevent permanent impairment of their 
personality. 
One should not expect teachers to diagnose and to treat 
personality and behavior disorders, but one does expect them 
to be able to apprehend these difficulties and to refer them 
to the proper resources for further study. The State De- 
partment of Mental Health has geographically placed Child 
50 Guidance Clinics throughout the state, to which children 
presenting any of the aforementioned problems may be 
referred. Owing to the difficulty of providing suitably 
trained and experienced personnel some of these have had 
to be discontinued. A list of such clinics is available through 
the Division of Mental Hygiene, 100 Nashua Street, Boston. 
To understand a child’s reactions, there must be a study 
of his physical and mental make-up, his home environment, 
the intelligence and stability of his parents, the nature of 
the community, and other environmental factors present in 
school or playground. 
A common cause of maladjustment of the child in school 
is poor personal adjustment of teacher. The attitude of 
such a teacher may produce such emotional tensions in the 
classroom as to affect unfavorably her young pupils. Other 
causes are poor home-child relationship, poor home-school 
relationship, poor individual teacher-child relationship and 
incorrect placement in grade. 
Practicable Mental Hygiene Guideposts 
Let the teacher view each child as an individual with 
needs to be served, particular capacities to be developed, 
and interests to be respected. She should appraise each 
child objectively, without bias or prejudice, and ascertain 
why he behaves as he does, e.g., What satisfaction does his 
behavior afford him? Why is life unsatisfactory to him? 
What methods used by his parents or teachers have resulted 
in these patterns of behavior? What combination of cir- 
cumstances has called forth this reaction in him? The 
teacher should try to know the child’s home, his position in 
it, and to make certain that the curriculum is suited to the 
child’s needs and capacity. She should aim to construct in 
the child a feeling of security. She should try to evaluate 
herself and her relationship to the child and when in doubt, 
she should refer the child to a Child Guidance Clinic. 
51 Bibliography 
Every day Problems of the Everyday Child—Douglas A. Thom, M.D. 
—Appleton Century Co. 
Mental Hygiene and Education—Mandel Sherman—Longmans, Green 
& Company. 
Mental Health Through Education—Carson W. Ryan—Commonwealth 
Fund, Oxford Univ. Press. 
Our Children—Child Study Association of America. 
Personality Adjustment of the Elementary School Child—National Edu- 
cation Association. 
ENVIRONMENT 
Classroom—Seating 
Chair backs should provide two transverse supports, the 
upper support above angles of shoulder blades, the lower 
support to conform to curve of lower back. They should 
provide below this, a space for lower part of back, seats 
should be adjustable or of a sufficient number of sizes to suit 
individual differences. There should be constant readjust- 
ment to keep pace with growth of children. The distance 
from the surface of the seat to floor shall be such that 
when lower leg is perpendicular the whole sole of the foot 
rests on the floor. The length of the seat should support 
three-quarters of the length of the upper leg. It should slope 
slightly backward and conform to the curves of the buttocks. 
The desk surface should be slightly inclined toward the 
body and wide enough to make possible the support of the 
hand while writing on the bottom lines of writing book or 
paper. A plumb line from the edge of the desk should fall 
from 1J/2 to 2 inches inward from edge of seat. 
Helpful suggestions may be obtained from Bancroft’s 
“Posture of School Children.” 
Lighting 
The results of research have consistently indicated the 
potential contributions to human efficiency and to welfare 
52 to be gained from the use of more and better lighting in 
the performance of visual tasks. Lighting should be pro- 
vided of such quality and quantity as to enable the eyes to 
accomplish their task with accuracy, speed, ease, and com- 
fort. It has also been learned that the presence of direct 
glare has a highly injurious action upon the vitamin supply 
of the eye. 
Intensity 
In determining lighting standards emphasis has lately 
been placed upon comfort more than upon foot candles as a 
sole guide. 
General—minimum of 30 foot candles. 
Sewing and drawing rooms—minimum of 50 foot 
candles. 
Hallways, stairways, locker rooms, toilets, auditoriums 
—10 foot candles minimum. 
Gymnasiums and playrooms, intensity determined by 
the use made of the room. 
Team games require well diffused light of high intensity. 
Maintenance 
Illumination deteriorates rapidly unless windows are kept 
clean and the wall and ceiling surface are maintained in 
good condition. As lamps age, they blacken and give less 
light. Dirt and dust reduce the reflecting and transmitting 
qualities of the lighting units. Provision should be made 
for a system of regular inspection, preferably with a light- 
meter, as a check against excessive and wasteful loss of 
illumination. 
Achievement of these goals will, in most instances, require 
the services of a skilled expert in illumination. Through the 
local light and power company an illuminating engineer can 
53 usually be secured who will act as a consultant on the tech- 
nical details involved in attaining desirable standards of 
illumination. 
Better Utilization of Existing Lighting Facilities 
Existing lighting installations in school buildings are often 
inadequate. Under such circumstances, it is necessary to 
make the most effective use of natural light that is possible. 
It is desirable to obtain even illumination throughout the 
classroom. An unshaded lower window area permits only 
about one-third of the amount of room illumination that an 
equal area of unshaded upper window will provide. Thus 
top sections of the windows best serve the rows of seats 
farthest from the windows. Windows should be cleaned 
frequently and should be unobstructed by pictures, curtains, 
shrubbery, decorations and plants. 
Two-way shades mounted at the midline of the windows 
and operating up and down independently will provide 
greater flexibility of adjustment than shades operating only 
one way. If one shade only must be used it should be 
mounted so that it can be raised from the bottom to the top 
of the window. Experiment with shade adjustment under 
various weather conditions to determine the arrangement 
best suited to giving light without introducing glare into 
the field of vision. 
Converting side and rear-wall blackboards into bulletin 
boards by covering them with a suitable material of light 
color will increase the fight intensity on pupils’ desks in the 
darker parts of the room and also reduce undesirable con- 
trasts. If it is preferable to have all blackboard space avail- 
able, white cloth window shades may be installed and kept 
down except when the blackboards are in use. The back 
of a map mounted on a portable stand may be used to reflect 
more fight on a particularly dark desk surface. This re- 
source, however, is apt to introduce an undesirable glare. 
54 Room Finish 
Ceilings and upper walls should be white, light cream, 
ivory, or bluish white of non-glossy finish. Minimum co- 
efficient of reflection 75%. Lower walls should be in light 
colors of non-glossy finish with a minimum co-efficient of a 
reflection 50%. Floors, desks, and chairs should be in light 
natural non-glossy finish. Surfaces, such as glass, which 
may be troublesome sources of reflected fight should be 
avoided. 
Luminaires (lighting units) 
Light should be well diffused. The contrast between the 
fight source and its background should not be greater than 
20 to 1 if the luminaire is visible. If of high brightness 
the luminaire should be 20°-30° above the eye level of the 
worker. Indirect fighting should be utilized if a fight source 
of high intensity is used. Direct fighting units should be of 
the enclosed globe type. The surface brightness of direct or 
semi-direct units should not exceed 2 foot candles per square 
inch. 
The level of illumination in the classroom may be raised 
and the windows’ glare may be avoided by turning indi- 
vidual desks at an angle which places the window just 
behind the child’s shoulder and at the same time avoids 
throwing the child’s shadow upon his desk. When seats 
and desks are fixed, it may be necessary to keep the shades 
drawn all the way on the front window or windows, and 
supplement daylight with artificial fight. Glass surfaces 
and other shiny, reflective surfaces which are the sources 
of objectionable glare, should be covered, eliminated or 
subdued. 
Pupils with impairment of vision should be seated where 
their work receives the best fight. 
Amer. Recog. Practices of School Lighting. 
111. Eng. Soc., 51 Madison Avenue, New York, New York. (1938) 
55 Heating and Ventilation 
The recommended temperature for classrooms is 68°. 
The thermometer should be on the level of children—not on 
an outside wall. A unit system of heating and ventilating 
permits suitable regulation of temperature in individual 
rooms. In rural schools the stove should be jacketed and 
fresh air supplied from outside space between stove and 
jacket. A foul air outlet must be maintained. Children 
should learn to keep temperature records. 
Sanitation 
The maintenance of standards is the responsibility of the 
Superintendent of Schools and of the principal of the 
building. 
Urban standards for drinking facilities require one bub- 
bler of a side stream or ring type for at least every 75 pupils. 
Such drinking facilities must be cleanly separated from sinks 
where there is handwashing. Rural standards require that 
the source of drinking water be tested once a year by the 
Massachusetts Department of Public Health. (No charge.) 
Water should be stored in closed container with bubbler or 
spigot. Individual drinking cups, preferably of paper or 
supplied from home, should be kept on hooks in a cabinet 
made for the purpose. 
Standards for Hand Washing Facilities (Urban) 
One bowl for 40-50 children should be located near the 
toilets. Soap—liquid or powdered—and paper towels should 
be kept in supply. Rural standards require a tank and sink 
unit or at least individual pails, liquid soap, and paper 
towels. 
Standards for Toilets 
Urban standards require 3 per 50 pupils. Where seats 
are used by lower grades only, they should be adapted to 
56 the size of the children. Urinals should be of porcelain. 
Floors, lower part of walls, and partitions of booths should 
be of nonabsorbent material. Ventilation should be by- 
blower type fan with an outside vent. Vent openings should 
be in water closets and urinal fixtures and in the walls of 
each water closet compartment. Rural standards for toilets 
require either the pit type, chemical type or the septic type. 
A pit type toilet must be made and kept insect proof. That 
is, its walls must be continued below ground surface to a 
distance of 18 inches or more. Its windows must be screened, 
its seats must be kept covered. The pits must be treated 
with chloride of lime and either ashes or earth. 
Rest Room for Teachers 
This should be attractively decorated and furnished, 
well lighted and ventilated, with at least one window, with 
comfortable chairs, couch, toilet, lockers for clothes, and 
facilities for heating water. 
Health Room 
The Health Room should be attractive. It should be on 
the first floor, with access to natural light and ventilation 
and it should be provided with outlets for artificial fights 
and for equipment, e.g., vision testing equipment. It is 
desirable that the location should be free from the noises of 
the gymnasium, playground, shop, and music room. It 
should be at least 24 ft. x 18 ft., the long dimensions being 
necessary for hearing and vision testing. 
Cubicles 
Examining rooms should be provided adjacent to the 
health room. They should measure 10 ft. x 8 ft. and should 
have at least one window but one which will permit privacy 
during the physical examination of child and conference with 
parent. The nurse’s office should measure 10 ft. x 8 ft. and 
be provided with at least one window. It should have a 
57 connecting door to examination room. In addition to its 
use as her office it may be used for parent-nurse conference, 
teacher-nurse conference, pupil-nurse conference and work- 
room for nurses. This cubicle should be equipped with 
hand-washing facilities with hot and cold running water, 
which may be used by doctor and nurse. Base plugs for 
electrical equipment are necessary. Furthermore, an isola- 
tion cubicle should be provided, measuring about 10 ft. x 6 
ft., to be used to separate children with undiagnosed illnesses 
from other children. 
The Lunch Room 
Should have adequate space and equipment for the prep- 
aration, serving and eating of food. It should be maintained 
in sanitary condition. It should be a comfortable, attractive 
place to eat lunch. 
The Playground 
It should be clean, attractive, safe, free of broken glass, 
of loose rocks and of pebbles. Because of automobiles, it 
should be fenced or walled. Play should be supervised at all 
times. Police protection should be provided at cross walks 
at the opening and the closing of all sessions. 
References—Janitor and the School Child—Metropolitan Life Insur- 
ance Company, 1 Madison Square, New York, N. Y. 
58 Equipment for Health Room 
Cot 
Pillow with waterproof covering 
Blanket (washable) 
Desk and desk chair 
Other chairs 
Wastepaper basket 
Table with washable top 
Hooks for hanging clothing 
Red Cross textbook on First Aid 
Supply of School Physical Record 
cards 
Supply of referral slips 
Files 
Screens 
Running water or hand basin and 
pitcher 
Soap 
Dressing pail 
Emesis basin 
Electric plate for heating water 
2 glass jars for holding tongue 
depressors and applicators 
Paper cups 
Paper towls 
Throat sticks 
Scale—Standard (with measuring 
rod) 
Vision and hearing test equip- 
ment and report forms 
Mirror—full length for health 
teaching 
Medicine cabinet with first aid 
equipment 
Wooden applicator and tooth- 
picks 
Sterile gauze 
Absorbent cotton 
Adhesive tape 
Prepared dressings 
Roller bandages of two widths 
Scissors 
Antiseptic 
Slings and splints 
Aromatic spirits of ammonia 
Safety pins 
Clinical thermometers 
Supply of accident report slips 
59 SERVICES OFFERED BY THE 
MASSACHUSETTS DEPARTMENTS OF PUBLIC HEALTH, 
MENTAL HEALTH AND EDUCATION IN RELATION 
TO THE SCHOOL HEALTH PROGRAM 
Upon request, there are available from the Massachusetts 
Department of Public Health, The Department of Mental 
Health and The Department of Education consultation 
services concerning: 
a. Administration and standards of the school health 
program. 
b. Examination of entering school children. 
c. Examination of school children. 
d. Health education in the schools. 
e. Public health nursing in the schools. 
f. Nutrition services and school lunches. 
g. The teacher’s contribution to the school health 
services. 
h. Communicable disease control. 
i. School sanitation. 
j. School health surveys. 
k. In-service training for teachers and nurses. 
l. Vision and hearing testing. 
m. Guidance service to school health personnel and 
parents. 
n. Dental services. 
Equipment for Vision and Hearing Testing 
Through the Massachusetts Department of Public Health 
each District Health Officer is equipped with audiometers 
and the Massachusetts Vision Test which may be loaned to 
small communities which do not provide their own. Re- 
quests would be sent to the District Health Office. 
Health Record forms and Notification of Defects may be 
obtained on request from the Bureau of Health Information 
60 of the Massachusetts Department of Public Health, State 
House, Boston. 
“Health in the Schools”, printed material for children and 
adults, outlines for health teaching and moving picture 
films may be obtained from the Bureau of Health Infor- 
mation of the Massachusetts Department of Public Health, 
State House, Boston. 
Physically Handicapped Children 
In accordance with Chap. 71, Sect. 46A, and under regu- 
lations prescribed by the Departments of Education and of 
Public Health, school committees are required to ascertain 
and to report on those children of school age who are physi- 
cally handicapped. It is mandatory upon the school com- 
mittees to provide instruction for all children of school age 
who are physically unable to attend school and who have 
been approved for such instruction by the Departments of 
Education and Public Health. Children able to attend 
school but who have vision, speech or other physical handi- 
caps which prevent normal educational growth and develop- 
ment must be given that special type of training recom- 
mended by the Department of Education. 
Regulations are provided by the Department of Educa- 
tion defining physically handicapped children to be reported, 
and the method and forms to be used in reporting them. 
The regulations also define the qualifications of teachers 
employed to teach those children who are unable to attend 
school and the minimum hours of instruction that may be 
given. Consultation service is provided by the Depart- 
ments of Education and of Public Health in cases where 
there is doubt as to the type of education or of medical care 
that a child should be receiving. 
Sight Saving Classes 
All children who go to Sight Saving Class must be recom- 
mended by an ophthalmologist. The following children are 
61 eligible for a Sight Saving Class: children with a visual 
handicap who have normal intelligence; children whom the 
ophthalmologist recommends because of eye condition; chil- 
dren who need to wear an occluder over the good eye in 
order to stimulate the vision in the poor eye; any child who 
has a progressive eye condition, even though the vision is 
better than 20-70; any child whose vision is 20-70 or less 
with best correction but not low enough for education in a 
school for the blind. 
Lip Reading Classes 
Hearing 
The latest figures obtainable from the United States 
Public Health Service show that 1,000,000 children in the 
United States, ages 5-17, have some hearing defect. 
Children are referred for lip reading who have: A moderate 
loss of speech range which does not improve in six months 
under the care of physician; defective speech because of loss 
in hearing; failing in school because of loss in hearing; if the 
better ear has a drop of 25 decibels or more in speech range. 
Vocational Rehabilitation 
Rehabilitation is defined as the restoration of the handi- 
capped to the fullest physical, mental, social, vocational, 
and economic usefulness of which they are capable. Voca- 
tional Rehabilitation connotes a plan with an employment 
objective as the final goal. 
Services from the Division of Vocational Rehabilitation, 
of the Massachusetts Department of Education, with head- 
quarters at 200 Newbury Street, Boston (and offices in 
Boston, Lowell, Springfield, Pittsfield, Worcester and New 
Bedford), in furthering training and education may provide 
a satisfactory transition from school to work for the young 
person who is handicapped. The Division of Vocational 
Rehabilitation offers services to any resident of Massachu- 
setts of legal employable age (16 years or over) who has a 
62 physical or mental disability which is a substantial employ- 
ment handicap and who reasonably may be expected to be 
fitted for remunerative employment. 
The Division offers a variety of services in fitting a handi- 
capped person for suitable employment. The service de- 
pends in each case on the individual and he is considered 
from the point of view of his own interests, aptitudes and 
physical or mental limitations. The services are: 
1. Thorough physical examinations. 
2. Necessary medical, surgical, psychiatric and hos- 
pital services. 
3. Necessary prosthetic devices, such as artificial limbs, 
hearing aids, braces and the like. 
4. Individual vocational counseling and guidance. 
5. Training for a job—in schools, on the job, by corre- 
spondence, or by tutor. 
6. Maintenance and transportation during rehabilita- 
tion, if necessary. 
7. Necessary tools and equipment. 
8. Placement on the right job. 
9. Follow-up to make sure the worker and the job are 
properly matched. 
Diagnostic services, both medical and vocational, indi- 
vidual counseling and guidance training, education, and 
placement on the job are available without investigation of 
the economic need of the applicant. It is necessary, how- 
ever, to determine economic need for the following services, 
surgical and medical treatment, psychotherapy, hospitaliza- 
tion, prosthetic appliances, instructional and training sup- 
plies, transportation and maintenance (if required) during 
rehabilitation. 
The program of physical restoration services is designed 
to help the medically indigent, who often postpone surgery 
and medical treatment because they are unable to pay for 
the service. Care for acute illness may not be furnished. 
These services are intended for conditions that are rela- 
63 lively stable, slowly progressive or chronic but amenable to 
treatment. It is the policy of this program to compensate 
physicians and hospitals of the patient’s choice in the same 
manner in which it compensates the schools and colleges 
for tuition. 
Sources of Additional Information 
Information regarding public and private agencies which 
offer aid in the care of children of all ages, and clinics for 
crippled children, blind and deaf children, tuberculosis 
clinics, and child guidance clinics may be obtained from the 
following District Health Offices of the Department of 
Public Health. 
Dr. Harold W. Stevens 
District Health Officer 
105 William Street 
New Bedford, Mass. 
(Vacancy) 
Acting District Health Officer 
1245 Hancock Street 
Quincy, Mass. 
Dr. Robert E, S. Kelley 
District Health Officer 
227 Commonwealth Avenue 
Boston, Mass. 
Dr. Walter J. Pennell 
District Health Officer 
367 Main Street 
Wakefield, Mass. 
(Vacancy) 
District Health Officer 
476 Main Street 
Worcester, Mass. 
Dr. Arthur E. Burke 
District Health Officer 
Central Avenue 
Ayer, Mass. 
Dr. Walter W. Lee 
District Health Officer 
Fernald Hall, University of Mass. 
Amherst, Mass. 
Dr. Charles E. Gill 
District Health Officer 
184 North Street 
Pittsfield, Mass. 
A list of agencies supplying educational material relating 
to health may also be obtained from these offices. 
Many of the school systems in Massachusetts have pre- 
pared attractive and useful pamphlets for distribution to 
parents of entering school children. The Division of Public 
Libraries, 200 Newbury Street, Boston, will gladly lend 
copies of these pamphlets to teachers, superintendents, and 
64 school boards, who are interested in preparing such material 
for their communities. 
Applications for vocational rehabilitation may be made to 
any office of the Division for the handicapped child by his 
parents, or by any other person or agency in his own behalf. 
It is not necessary to use any special form or blank. 
The vocational counselors of the Division are available 
for advice and guidance at any time the school or the 
parents wish to consult them. 
1. They are especially interested in handicapped chil- 
dren of legal employable age who may be leaving 
school. 
2. The vocational rehabilitation program, in addition 
to physical restoration provides a disabled person 
an opportunity to acquire skill leading to suitable 
employment. 
65 GENERAL LAWS—SCHOOL HYGIENE 
Distributed by the Massachusetts Department of Public Health 
Subjects of Study 
Chap. 71, Sec. 1. (As amended by chapter 222, Acts of 
1923.) Maintenance of Public Schools and Subjects of 
Study. Every town shall maintain, for at least one hundred 
and sixty days in each school year unless specifically ex- 
empted as to any one year by the department of education, 
in this chapter called the department, a sufficient number 
of schools for the instruction of all children who may legally 
attend a public school therein. Such Schools shall be taught 
by teachers of competent ability and good morals, and shall 
give instruction and training in orthography, reading, 
writing, the English language and grammar, geography, 
arithmetic, drawing, the history and constitution of the 
United States, the duties of citizenship, physiology, and 
hygiene, good behavior, indoor and outdoor games and 
athletic exercise. In connection with physiology and hy- 
giene, instruction as to the effects of alcoholic drinks and of 
stimulants and narcotics on the human system, and as to 
tuberculosis and its prevention, shall be given to all pupils 
in all schools under public control, except schools maintained 
solely for instruction in particular branches. Such other 
subjects as the school committee considers expedient may 
be taught in the public schools. 
Chap. 71, Sec. 42. (Amendment, 1941.) Handicapped 
Children. The school committee of every town shall annu- 
ally ascertain, under regulations prescribed by the depart- 
ment and the department of mental health, the number of 
children three years or more retarded in mental develop- 
ment in attendance upon its public schools, or of school age 
and resident therein. At the beginning of each school year, 
the committee of every town where there are ten or more 
such children shall establish special classes for their instruc- 
tion according to their mental attainments, under regulations 
66 prescribed by the departments. A child appearing to be 
mentally retarded in any less degree, may, upon request of 
the superintendent of schools of the town where he attends 
school, be examined under such regulations as may be pre- 
scribed by the department and the department of mental 
health. No child under the control of the department of 
public welfare or of the child welfare division of the insti- 
tutions department of the city of Boston, who is three 
years or more retarded in mental development within the 
meaning of this section, shall, after complaint made by the 
school committee to the department of public welfare or 
said division, be placed in a town which is not required to 
maintain a special class as provided for in this section. 
An Act Relative to the Education of Certain Physically 
Handicapped Children—Be it enacted, etc., as follows: 
Section 46A of chapter 71 of the General Laws, as most 
recently amended by chapter 357 of the Acts of 1946, is 
hereby amended by striking out the last sentence and 
inserting in place thereof the three following sentences:—■ 
On or before the fifteenth day of July in each year the town 
furnishing such instruction shall submit to the department 
an itemized statement of the following items of actual cost 
of instruction to children confined in hospitals, sanitaria, and 
similar institutions located therein for the preceding school 
year: teachers, textbooks, supplies and general control. The 
department shall determine the reasonableness of such cost, 
and shall, on or before the first day of September following, 
either notify said town that the cost is approved, or shall 
send to the town its own determination of reasonable cost. 
Such cost as approved or determined shall be divided by 
the pupil days of instruction given, and the result shall con- 
stitute the daily tuition for each pupil to be paid by the 
town where the parent or guardian has a legal residence to 
the town furnishing such instruction. 
Chap. 40, Sec. 5. (New paragraph inserted after para- 
graph 39 by chapter 28 of the Acts of 1935.) Appropriation 
67 of Money for Eyeglasses and Spectacles for Needy School 
Children. To provide eyeglasses and spectacles for school 
children eighteen years of age or under who are in need 
thereof and whose parents or guardians are financially un- 
able to furnish the same. Money so appropriated shall be 
expended under the direction of the mayor and city council 
of a city and the selectmen of a town. 
Chap. 40A. (Added 1947.) For the payment, by pro- 
viding insurance coverage or otherwise, of the reasonable 
hospital, medical and surgical expenses incurred by or in 
behalf of any student in any of its public schools by reason 
of injuries sustained by him or her while participating, or 
practicing or training for participation, in any game, meet 
or contest conducted or held as a part of or in connection 
with the physical education or athletic training program of 
its school department. Money so appropriated shall be ex- 
pended under the direction of the school committee. (Ap- 
proved June 13, 1947.) 
Chap. 69, Sec. 29. (Insertion of new section after Section 
28 by chap. 313 of Acts of 1938.) Instruction in Lip Read- 
ing for Certain School Children Whose Hearing is Defective. 
The school committee of any town, or any superintendency 
union or district, where there is in attendance in any public 
or private school any child under the age of eighteen whose 
hearing is defective may provide instruction in lip reading 
for such child. Such instruction shall be in addition to the 
regular school instruction and shall be for at least one hour 
per week during the time when such public schools are in 
session. 
School Organizations 
Chap. 71, Sec. 47. (As amended by chap. 199, Acts of 
1935.) Supervision of Athletic and Other School Organiza- 
tions. The committee may supervise and control all ath- 
letic and other organizations composed of public school 
pupils and bearing the school name or organized in con- 
68 nection therewith. It may directly or through an author- 
ized representative determine under what conditions the 
same may compete with similar organizations in other 
schools. Expenditures by the committee for the organiza- 
tion and conduct of physical training and exercises, athletics, 
sports, games and play, for providing proper apparatus, 
equipment, supplies, athletic wearing apparel and facilities 
for the same in the buildings, yards and playgrounds under 
the control of the committee, or upon any other land which 
it may have the right or privilege to use for this purpose, 
and for the employment of experienced athletic directors to 
supervise said physical training and exercises, athletics, 
sports, games and play, shall be deemed to be for a school 
purpose. 
Medical and Nursing Service 
Chap. 71, Sec. 53. (As amended by section 1, chapter 357, 
Acts of 1921.) Appointment of School Physicians and 
Nurses. The school committee shall appoint one or more 
school physicians and nurses, shall assign them to the public 
schools within its jurisdiction, shall provide them with all 
proper facilities for the performance of their duties and shall 
assign one or more physicians to the examination of children 
who apply for health certificates required by section eighty- 
seven of chapter one hundred and forty-nine, but in cities 
where the medical inspection hereinafter prescribed is sub- 
stantially provided by the board of health, said board shall 
appoint and assign the school physicians and nurses. The 
department may exempt towns having a valuation of less 
than one million dollars from so much of this section as 
relates to school nurses. 
Chap. 71, Sec. 53A. (Added by section 2. chapter 357, 
Acts of 1921.) District may employ School Physicians and 
Nurses. A superintendency district formed and conducted 
under the provisions of section sixty, or a superintendency 
union formed and conducted under the provisions of sections 
sixty-one to sixty-four, inclusive, may employ one or more 
69 school physicians and may employ one or more school 
nurses; determine the relative amount of service to be ren- 
dered by each in each town; fix the compensation of each 
person so employed; apportion the payment thereof among 
the several towns; and certify the respective shares to the 
several town treasurers. A school physician or nurse so em- 
ployed may be removed by a two thirds vote of the full 
membership of the joint committee. 
Chap. 71, Sec. 53B. (Added by section 2, chapter 357, 
Acts of 1921.) Certain Towns exempt. The towns com- 
prised in a superintendency district or union employing, to 
the satisfaction of the department, one or more school 
physicians and nurses in accordance with the provisions of 
section fifty-three A shall be exempt from the provisions of 
section fifty-three requiring the appointment of such persons. 
Physical Examination of Pupils, Teachers and 
Janitors 
Chap. 71, Sec. 54. Every school physician shall make a 
prompt examination of all children referred to him as pro- 
vided in this chapter, and such further examination of teach- 
ers, janitors and school buildings as in his opinion the pro- 
tection of the health of the pupils may require. Every such 
physician who is assigned to perform the duty of examining 
children who apply for health certificates shall make a 
prompt examination of every child who wishes to obtain an 
employment permit, as provided in section eight-seven of 
chapter one hundred and forty-nine, and who presents to 
said physician the pledge or promise of the employer, as 
provided in said section; and the physician shall certify in 
writing whether or not in his opinion such child is in suffi- 
ciently sound health and physically able to perform the work 
described in said pledge or promise. 
Chap. 71, Sec. 55. (As replaced by sec. 2, chap. 265, 
Acts of 1938.) Return to School After Infection with or 
Exposure to Contagion from a Disease Dangerous to the 
Public Health. A child infected, or in a household where 
70 a person is infected, with a disease dangerous to the public 
health as defined in accordance with section six of chapter 
one hundred and eleven, or in a household exposed to con- 
tagion from any such disease in another household, shall not 
attend any public school while he is so infected or remains 
in a household where such infection or exposure exists. A 
child returning to school after having been absent on account 
of such infection or exposure shall present a certificate from 
the board of health or its duly appointed agent that the 
danger of conveying such disease by such child has passed; 
provided, that if such a child returns to school without such 
a certificate, after having been absent on account of such 
infection or exposure, he shall immediately be referred to a 
school physician for examination and, if it is found by such 
physician upon such examination that such danger has 
passed, he may remain at school. 
Chap. 71, Sec. 55A. (As added by sec. 3, chap. 265, 
Acts of 1938.) Handling of Children Showing Signs of 111 
Health or Infection. A child showing signs of ill health or 
of being infected with a disease dangerous to the public 
health as defined in accordance with section six of chapter 
one hundred and eleven shall be sent home immediately, or 
as soon as safe and proper conveyance can be found, or shall 
be referred to a school physician, who may direct that such 
child be sent home. In the case of schools remotely situated, 
such other steps may be taken as will best effectuate the 
purpose of this section and ensure the safety of such child 
and of other pupils. The superintendent of schools shall 
immediately cause the board of health to be notified of all 
children excluded under this section by reason of any disease 
dangerous to the public health. 
Chap. 71, Sec. 56. (As substituted by sec. 4, chap. 265 
of the Acts of 1938.) Notification of Parents. If any child 
is found to be suffering from any disease or defect, or if any 
child is found to have any defect or disability requiring 
treatment, the school committee shall forthwith notify the 
parent or guardian of such child. 
71 Chap. 71, Sec. 57. The committee shall cause every child 
in the public schools to be separately and carefully tested 
and examined at least once in every school year to ascertain 
defects in sight or hearing, and other physical defects tend- 
ing to prevent his receiving the full benefit of his school 
work, or requiring a modification of the same in order to 
prevent injury to the child or to secure the best educational 
results, and to ascertain defects of the feet which might 
unfavorably influence the child’s health or physical effi- 
ciency, or both, during childhood, adolescence and adult 
years, and shall require a physical record of each child to be 
kept in such form as the department may prescribe. The 
tests of sight and hearing shall be made by the teachers, 
directions for which shall be prescribed by the department of 
public health, and the examinations of feet shall be made 
by the school physicians. 
Lunches 
Chap. 71, Sec. 72. Sale of Lunches to Pupils and Teach- 
ers. The school committee may prepare and sell lunches at 
one or more school buildings for the pupils and teachers of 
the public schools at such prices as it deems reasonable. 
Vaccination 
Chap. 76, Sec. 15. (As amended by sec. 5, chap. 287, 
Acts of 1938.) Vaccination. An unvaccinated child shall 
not be admitted to a public school except upon presentation 
of a physician’s certificate like the physician’s certificate 
referred to in section one hundred and eighty-three of chap- 
ter one hundred and eleven. 
Chap. Ill, Sec. 183. Exemptions . . . and any child 
presenting a certificate, signed by a registered physician 
designated by the parent or guardian, that the physician 
has at the time of giving the certificate personally examined 
the child and that he is of the opinion that the physical con- 
dition of the child is such that his health will be endangered 
72 by vaccination, shall not, while such condition continues, 
be subject to the two preceding sections. (Enforced vacci- 
nation by boards of health (see 181, 182). 
R. L. 44, Sec. 6 (as amended by 1906, 371, and by 1907, 
215) does not give an unvaccinated child presenting a cer- 
tificate that he is not a fit subject for vaccination an absolute 
right to attend school at all times. A regulation made dur- 
ing a time when smallpox was prevalent to “exclude from 
attendance all unvaccinated children and also all children 
who do not present a certificate of revaccination as required 
by the board of health, until such time as this (school) com- 
mittee may become satisfied that the imminent danger from 
contagion of smallpox in our town has ceased,” is a reason- 
able one. Hammond v. Hyde Park. 195 Mass. 29. 
The exemption under G. L., c. 76, sec. 15, and c. Ill, 
sec. 183, upon the presentation of the certificate therein 
described, of a child of school age from vaccination before 
being admitted to the public schools does not cover the 
entire period of the child’s attendance after the filing of the 
certificate; the certificate is limited to the period during 
which his physical condition is such that in the opinion of 
the certifying physician he is an unfit subject for vaccina- 
tion. Spofford v. Carleton, 238 Mass. 528. 
It has been further held that a regulation of the school 
committee requiring a renewal of such a certificate every 
two months, but providing that a pupil failing to renew such 
certificate should not be excluded from school until a period 
of two weeks had elapsed after failure to renew, conformed 
with the law and was valid. Spofford v. Carleton, 238 
Mass. 528. 
Sanitation 
Chap. 143, Sec. 42. Ventilation and Sanitation. Inspec- 
tion. Every public building as defined in section one, ex- 
cept schoolhouses in which public or private instruction is 
afforded to less than eleven pupils at one time, shall be kept 
73 clean and free from effluvia arising from any drain, privy or 
nuisance, shall be provided with a sufficient number of proper 
water closets, earth closets or privies, and shall be ventilated 
in such a manner that the air shall not become so impure as 
to be injurious to health. If it appears to an inspector (of the 
Department of Public Safety) that further or different heat- 
ing, ventilating or sanitary provisions are required in any 
such public building, in order to conform to the requirements 
of this section, and that such requirement can be provided 
without unreasonable expense, he may issue a written order 
to the proper person or authority, directing such heating, 
ventilating or sanitary provisions to be provided. A school 
committee, public officer or person who has charge of, owns 
or leases any such public building, who neglects for four 
weeks to comply with the order of such inspector, shall be 
punished by a fine of not more than one hundred dollars. 
The district health officers or such other officers as the de- 
partment of public health may from time to time appoint 
shall make such examinations of school buildings subject to 
this section as in the opinion of the department (Department 
of Public Safety) the protection of the health of the pupils 
may require. This section shall not apply to Boston. 
Employment of Children under Sixteen 
No person shall employ a child under sixteen years of age, 
other than a child over fourteen granted an employment 
permit by the superintendent of schools when such superin- 
tendent determines that the welfare of such child will be 
better served through the granting of such permit, or permit 
him to work in, about or in connection with any mercantile 
establishment or in any employment mentioned in section 
sixty, or as defined in section one, other than street trades 
as defined in sections sixty-nine to seventy-three, inclusive; 
provided, that pupils over fourteen in co-operative courses 
in public schools may be employed by any co-operating mer- 
cantile establishment or other co-operating employment as 
defined by section one upon securing from the superintendent 
74 of schools a permit covering any such co-operating employ- 
ment; and provided, further, that no permit shall be issued 
to any child under sixteen to work in, about or in connection 
with any manufacturing or mechanical establishment, fac- 
tory or workshop. Children between fourteen and sixteen 
who possess the educational qualifications set forth in sec- 
tion one of chapter seventy-six and are employed in private 
domestic service or service on farms shall be required to 
secure a permit issued by the superintendent of schools 
covering such employment. The person employing a child 
between fourteen and sixteen shall procure and keep on file, 
accessible to the supervisors of attendance of the town, to 
agents of the department of education, and to the depart- 
ment of labor and industries or its authorized agents or 
inspectors, the permit for employment issued to such child 
and shall keep a complete list of the names and ages of all 
children so employed. 
Chap. 149, Sec. 87. Issue of Employment Certificates. 
An employment certificate shall be issued only by the super- 
intendent of schools or by a person authorized by him in 
writing, or, where there is no superintendent of schools, by 
a person authorized in writing by the school committee of 
the town where the child to whom it is issued resides during 
his employment, or, if the child resides outside the Common- 
wealth, of the town where the child is to be employed; pro- 
vided, that no member of a school committee or other 
person authorized as aforesaid shall have authority to issue 
such certificate for any child then in or about to enter such 
person’s own employment or the employment of a firm or 
corporation of which he is a member, officer or employee. 
If an employment certificate is issued to a child under six- 
teen authorizing employment in a town other than that of 
his residence, a duplicate thereof shall be sent forthwith to 
the superintendent of schools of the town where the employ- 
ment is authorized. 
The person issuing an employment cetificate shall, before 
75 issuing it, receive, examine, approve and file the following 
papers, duly executed: 
(1) A pledge or promise, signed by the employer or by an 
authorized manager or superintendent, setting forth the 
character of the specific employment, the number of hours 
per day during which the child is to be regularly employed, 
and the name and address of the employer, in which pledge 
or promise the employer agrees to employ the child in 
accordance with this chapter, and to return the employment 
certificate as provided in the preceding section. 
(2) The school record of such child, filled out and signed 
as provided in the following section, except when such rec- 
ord may be waived thereunder. 
(3) A certificate, signed by a school or family physician, 
or by a physician appointed by the school committee, stat- 
ing that the child has been thoroughly examined by said 
physician, and in his opinion is in sufficiently sound health 
and physically able to perform the work which the child 
intends to do. 
(4) Evidence of age, showing that the child is fourteen, 
which shall consist of one of the following proofs of age: 
(a) A birth certificate, or a duly attested transcript 
thereof, made by a register of vital statistics or other officer 
charged with the duty of recording births. 
(b) A baptismal certificate, or a duly attested transcript 
thereof, showing the age and date of baptism of the child. 
(c) If none of the aforesaid proofs of age is obtainable, 
and only in such case, the person issuing employment cer- 
tificates may accept in lieu thereof a passport or a duly 
attested immigration record, or transcript thereof, showing 
the age of the child, or other official or religious record of 
the child’s age; provided, that it shall appear to the satis- 
faction of said person that the same is good and sufficient evi- 
dence of the child’s age. 
(d) If none of the aforesaid proofs of age is obtainable, 
and only in such case, the person issuing employment cer- 
76 tificates may accept in lieu thereof a record of age as given 
on the register of the school which the child first attended 
in the commonwealth; provided, that such record was kept 
for at least two years during the time when such child 
attended school. 
(e) If none of the aforesaid proofs of age is obtainable, 
and only in such case, the person issuing employment cer- 
tificates may receive the signed statement of the school 
physician, or of the physician appointed by the school com- 
mittee, stating that after examination it is the opinion of 
such physician that the child is at least fourteen. Such 
physician’s statement shall be accompanied by a statement 
signed by the child’s parent, guardian, or custodian, or, if 
such child has no parent, guardian, or custodian, by the 
signed statement of the next adult friend. Such signed 
statement shall contain the name, date and place of birth 
and residence of the child, and shall certify that the parent, 
guardian, custodian or next friend signing it is unable to 
produce any of the proofs of age specified in this section. 
Such statement shall be so signed in the presence of the 
person issuing the employment certificate. The person 
issuing employment certificates may, before issuing a cer- 
tificate, require the parent, guardian, custodian, or next 
adult friend of the child to appear and approve in writing 
the issuance of said certificate. 
A certificate relating to the age or place of birth of any 
child or to any other fact sought to be established in relation 
to school attendance shall be issued, upon request, by a 
town clerk, and no fee shall be charged therefor by a town 
clerk or other official. 
The superintendent of schools or a person authorized by 
him in writing may revoke the employment certificate or 
home permit of any child failing to attend a continuation 
school or course of instruction when so required by sections 
twenty-two and twenty-five of chapter seventy-one. When- 
ever such a certificate authorizing employment of a child 
elsewhere than in his place of residence is held by him the 
77 superintendent of schools of the town of his employment 
shall forthwith notify the superintendent of schools issuing 
the certificates of the child’s failure to comply with said 
section twenty-two. 
Section 88. The school record required by section eighty- 
seven shall be filled out and signed by the principal or 
teacher in charge of the school which the child last attended, 
and shall be furnished only to a child who, after due exami- 
nation and investigation, is found to be entitled thereto. 
Said school record shall state the grade last completed by 
such child and the studies pursued in completion thereof. 
It shall state the number of days during which such child 
has attended school during the twelve months next pre- 
ceding the time of application for said school record. It 
shall also give the name, date of birth, and the residence of 
the child as shown on the records of the school and the name 
of the parent, guardian or custodian. If the school record 
is not obtainable from the principal or teacher in charge of 
the school which such child last attended, the requirement 
of a school record may be waived. 
No such school record shall be issued or accepted and 
no employment permit granted unless the child possesses 
the educational qualifications described in section one of 
chapter seventy-six; provided, that a child over fourteen 
who does not possess such qualifications may be granted a 
limited employment permit good only during hours when 
school is not in session. 
No such school record shall be issued or accepted unless 
the child has regularly attended the public or other lawfully 
approved schools for not less than one hundred and thirty 
days after becoming thirteen; provided, that the school 
record may be accepted in the case of a person who has been 
an attendant at a public day or other lawfully approved 
school for a period of not less than seven years, if in the 
opinion of the superintendent of schools such person is 
mentally incapable of acquiring the educational qualifica- 
tions herein prescribed; and provided, further, that the 
78 superintendent may suspend this requirement in any case 
when in his opinion the interests of the child will best be 
served thereby. 
Section 89. The employment permit required under this 
chapter shall state the name, sex, date and place of birth, 
and the place of residence of the child, and describe the 
color of his hair and eyes and any distinguishing facial 
marks. It shall certify that the child named in such permit 
has personally appeared before the person issuing the permit 
and has been examined, and, except in the case of a limited 
permit, found to possess the educational qualifications de- 
scribed in section one of chapter seventy-six, and that all 
the papers required by section eighty-seven have been duly 
examined, approved and filed and that all the conditions 
and requirements for issuing an employment permit have 
been fulfilled. It shall state the grade last completed by 
said child. Every such permit shall be signed in the pres- 
ence of the person issuing the same by the child in whose 
name it is issued. It shall state the name of the employer 
for whom, and the nature of the employment in which, the 
permit authorizes the child to be employed. It shall bear 
a number, show the date of its issue and be signed by the 
person issuing it. No fee shall be exacted by a town clerk 
or other official for an employment permit or for any paper 
required by sections eighty-seven to ninety-five, inclusive. 
No duplicate employment permit shall be issued until it 
shall appear to the satisfaction of the person authorized to 
issue permits that the original has been lost. A record 
giving all the facts contained on every employment permit 
issued shall be filed in the office issuing the same, together 
with the papers required by section eighty-seven. A record 
shall also be kept of the names and addresses of all children 
to whom permits have been refused, together with the names 
of the schools which said children should attend and the 
reasons for refusal. All the aforesaid records and papers 
shall be preserved until such children, if living, have become 
sixteen. Such records and statistics concerning the issuance 
79 of employment permits as may be prescribed by the depart- 
ment of education shall be kept, and shall be open to the 
inspection of said department, its officers or agents. The 
permits and other papers required in connection with the 
issuing of employment permits and educational certificates 
under this chapter shall be furnished to the local school 
committees by the department of labor and industries, by 
which they shall be prepared after conference with the de- 
partment of education and the approval of the forms thereof 
by the attorney-general. Said permits, certificates, and 
papers may bear explanatory matter necessary to facilitate 
the enforcement of this chapter or to comply with future 
legislative requirements. 
Section 90. Whoever employs a child under sixteen, or 
whoever procures, or, having under his control a child under 
sixteen, permits him to be employed in violation of section 
eighty-six, shall be punished by a fine of not less than ten 
nor more than fifty dollars or by imprisonment for not more 
than one month; and whoever continues to employ a child 
under sixteen in violation of said section, after being notified 
thereof by a supervisor of attendance or by an inspector, 
shall for every day thereafter while such employment con- 
tinues be punished by a fine of not less than fifty nor more 
than two hundred dollars or by imprisonment for not more 
than two months; and whoever forges, or procures to be 
forged, or assists in forging a certificate of birth or other 
evidence of the age of such child, and whoever presents or 
assists in presenting a forged certificate or evidence of birth 
to the superintendent of schools or to a person authorized 
by law to issue permits, for the purpose of fraudulently 
obtaining the employment permit required by section 
eighty-six, shall be punished by a fine of not less than ten 
nor more than five hundred dollars or by imprisonment for 
not more than one year, or both. Whoever, being author- 
ized to sign an employment permit, knowingly certifies to 
any materially false statement therein shall be punished by 
a fine of not less than ten or more than two hundred dollars. 
80 Whoever, without authority, alters an employment permit 
after the same is issued shall be punished by a fine of ten 
dollars. 
Children’s Health Camps 
Chap. Ill, Sec. 62A. (Added by Chapter 248, Acts of 
1924). In each city and town which accepts this and the 
six following sections, in a city by vote of its city council 
subject to the provisions of its charter, or in a town by vote 
of its inhabitants, there shall, except as provided by section 
sixty-two F, be established, without unreasonable delay, 
one or more children’s health camps for the care and treat- 
ment of children of school age in said city or town who upon 
examination are found to be in need of such care and treat- 
ment, but no child shall be given care or medical treatment 
whose parents or guardian objects thereto. 
Sec. 62B. In each such city and town there shall be an 
unpaid commission, called the commission on children’s 
health camps, to consist of the mayor or chairman of the 
board of selectmen, who shall have no vote, the superin- 
tendent of schools, the members of the board of health, all 
to serve ex officiis, and also seven residents of such city or 
town to be appointed by the mayor or the chairman of the 
board of selectmen. One member of said board shall be 
designated as chairman by the mayor or the chairman of 
the board of selectmen. Of the seven persons first appointed 
after such acceptance, two shall be appointed for terms of 
one year each, two for terms of two years each, and three 
for terms of three years each, and thereafter as the term of 
each member expires his successor shall be appointed for 
the term of three years. Each appointment made to fill a 
vacancy in said commission shall be for the balance of the 
unexpired term. 
Sec. 62C. Said commission shall establish, maintain and 
have control of all children’s health camps for the purposes 
named in section sixty-two A, and in addition, shall have 
81 the management of all sums appropriated by the city or 
town for the maintenance of such children’s health camps. 
Said commission may receive in trust for the aforesaid pur- 
poses any gift or bequest of money or securities and shall 
forthwith transfer any money or securities so received to the 
city or town treasurer, who shall administer the same as 
provided by the following section. 
Sec. 62D. The city or town treasurer shall invest, re- 
invest and hold in the name of said commission any money 
or securities, or the proceeds thereof, received from said 
commission under the preceding section, and shall disburse 
the income or principal thereof on its order; provided, that 
no disposition of either income or principal shall be made 
which is inconsistent with the terms of the trust on which 
the property is held. The treasurer shall furnish a bond 
satisfactory to the commission for the faithful performance 
of his duties relative to such property. 
Sec. 62E. The commission shall keep a record of its 
doings and at the close of each financial year shall make a 
report to the city or town, showing the total amount of such 
funds and other receipts together with investments, receipts 
and disbursements on account of the same, setting forth in 
detail the sources of the receipts and the purposes of the 
expenditures. 
Sec. 62F. Any two or more such cities or towns may 
vote to form, for such period of time not exceeding five years 
as such cities or towns may from time to time determine, a 
union children’s health camp district for the purpose of 
establishing therein one or more union children’s health 
camps. The management of such union children’s health 
camps in such district shall be vested in an unpaid commis- 
sion, called the commission on union children’s health 
camps, to consist of the following persons from each of the 
cities or towns constituting such union, namely, the mayor or 
chairman of the board of selectmen, who shall have no vote, 
the superintendent of schools, the members of the board of 
82 health, all to serve, ex officiis, and also not exceeding ten 
members, residents of the cities and towns, comprising the 
district, to be elected by the ex officiis members of the com- 
mission for terms commensurate with the duration of the 
agreement forming or continuing the union. The term of 
each person elected to fill a vacancy among the members 
not serving ex officiis shall be for the balance of the unex- 
pired term. The treasurer of said commission shall be the 
treasurer for the time being of such city or town within the 
district as is determined by the members of the commission. 
The provisions of sections sixty-two C to sixty-two E, in- 
clusive, so far as applicable, shall apply to such commission. 
Sec. 62G. No children’s health camp shall be established 
under section sixty-two C or sixty-two F unless the location 
and construction plans of such camp have been approved by 
the department, which may inspect any camp at any time. 
Sec. 62H. (Added by chapter 17, Acts of 1925, section 2.) 
A contract for the care and treatment of children coming 
within the provisions of section sixty-two A, entered into 
by the commission on children’s health camps of a city or 
town which accepts or has accepted sections sixty-two A to 
sixty-two G, inclusive, or by a commission on union chil- 
dren’s health camps established or to be established under 
section sixty-two F, with the persons having control of any 
institution approved by the department in or near said city 
or town, shall, while such contract remains in force and effec- 
tive, be deemed satisfactory compliance on the part of such 
city or town or union with the provisions of said sections 
sixty-two A to sixty-two G, inclusive, relative to the estab- 
lishment and maintenance of children’s health camps. No 
such contract shall become effective until it has been ap- 
proved by the department. 
Publication or this Document Approved bt George J. Cronin, State Purchasing Agent 
5m-8-49-26780 
83 (FRONT) 
Massachusetts Department of Public Health 
Dental Certificate 
This Is To Certify That 
Has Had All Dental Work Done That Is Necessary At This Time. 
Dentist 
date -19 
THIS CERTIFICATE EXPIRES IN SIX MONTHS 
AN EXAMINATION IS NECESSARY BEFORE THIS CERTIFICATE CAN BE AWARDED 
PROTECT YOUR CHILDREN'S TEETH 
BY A VISIT TO THE DENTIST EACH SIX MONTHS 
50m 4-49—26085 
(REVERSE) 
WHAT A DENTAL CERTIFICATE SHOULD MEAN 
1. The final judgment concerning any mouth condition rests with the 
family dentist. 
2. The following suggestions are offered concerning the standard for what 
the Dental Certificate should mean: 
a. The mouth should be as clean as possible with special attention 
to food and tartar. 
b. All cavities should be adequately treated. 
c. Special attention should be given to all pits and fissures in decidu- 
ous and permanent teeth. 
d. All abscessed teeth should be extracted. 
Endorsed Jjy 
The Dental Advisory Committee 
of the 
Massachusetts Department of Public Health 
84 Dental Examination Request 
Pupil’s Name. 
Town School 
Date Teacher 
Has your child had a dental examination by your family dentist within 
the last six months? If not, will you arrange for such an examination as 
soon as possible? In either case, please have the dentist fill in and sign 
below, then return this sheet to the teacher. 
This is to certify that I have examined and found the condition checked below 
□ No dental defects. 
□ Dental defects which were present have been completely cared for. 
□ Treatment has been started. 
□ Treatment is needed but no provision is made for it. 
Date 
Signature of Dentist 
It is not possible to take my child to the family dentist for an examination. 
Parent or Guardian 
THIS CARD IS TO BE FILED IN SCHOOL WITH 
PHYSICAL RECORD CARD 
Massachusetts Department of Public Health 
50m-7-’48—24066. 
85 2.a.i.total 
~ 1.a.total 
X100 = % entering 
children 
examined 
2.a,i,total parents 
present 
f 2.a.i.total 
XI00 a- % examined 
with parent 
present 
2.a.iii. 
- 2.a.ii 
X100 - % receiving 
care. 
2.Health supervision; 
a. Entering children: 
i. Number of children entering school for first time having had medical examination* 
during the school year (or calendar year); 
Public schools Parochial schools Total 
Examined by: Parent present Parent present Parent present 
Yes [No Total Yes [No Total Yes [No Total 
- 
NOTE: examined in the spring and summer preceding school opening may be included, 
ii, Humber of entering children needing medical care 
iii. Number of these children for whom such care was known to bo provided 
iv. How is care financed for children whose parents cannot provide such care? 
v. How is eligibility for such care determined and by whom? 
Public Parochial Other Total 
I. Enrollments 
Number of children in health .jurisdiction enrolled in schools: 
I. SCHOOL HEALTH 
a. Number entering school for the first time 
b. Total in elementary grades (kindergarten to 
grade inclusive)..,,, 
c. Number in secondary grades (grades 
to inclusive) 
NOTE: Indicate if no parochial schools. 
Private physicians. 
Health department.. 
Board of education. 
Other agency 
Total. 
86 " 2,b.iii(b) 
- 2.b.iii(a53T„™ 
X100 « % teachers 
keeping 
2.Health supervision - continued 
a. Entering children - continued 
vi. Average number of children examined per hour (check): 
Public schools: 5 10 15 20 More than 20 
Parochial schools: 5 10 15 20 More than 20 
vii. Are the findings of the above examinations made known to the classroom teacher? 
If so, describe method 
b. Children in elementary grades: 
i. Is there a medical record primarily for the use of physician and nurse, and a 
separate pupil health record primarily for the use of the classroom teacher? 
Public schools: Medical record Parochial schools: Medical record 
Pupil health record Pupil health record 
ii. Are teacher-nurse conferences held in each elementary school classroom at least 
once annually in which all children in the classroom are discussed and individual 
children selected and referred for medical examinations? 
Public schools Parochial schools_ 
iii. Is the pupil health record used as a basis for referring children of the elementary 
grades to the physician (or indirectly through the nurse) for medical examinations? 
Public schools, Parochial schools 
(a) Number of elementary teachers in health jurisdiction 
(b) Number of elementary teachers keeping records, 
iv. Are elementary school teachers given systematic instruction on signs or symptoms as 
a basis for referring children for medical examinations? 
Public schools_ Parochial schools 
Who gives this instruction? 
NOTE: This does not mean that all the findings of the examination need be given the 
teacher, but rather that she or he have knowledge of such of the findings as will aid the 
school system in understanding the child and in contributing to his health and well being. 
87 2.b.v - - 
— l.b.total 
XI00 = % elem. 
children referred 
to physician 
S.b.vi 
.-r 2.b,v 
X100 =. % referred 
children seen by 
physician 
2.b,vii 
■f 2.b.vi 
XI00 - % seen by 
physician with 
.parent present 
5.b. 
■f l.b,total 
'XIOO = % elem. 
children with 
dental work 
complete 
S.c. 
f l,c.total_ 
X100 = % secondary 
pupils with dental 
work complete 
2.Health supervision - continued: 
b. Children in elementary grades - continued: 
v. Number of children referred by teachers in accordance with ii. and ill. above: 
Public schools Parochial schools Total 
▼i. Number of referred children seen by physician for examination or advice: 
Public schools Parochial schools Total_ 
vii. Number of referred children seen by physicians with parent present: 
Public schools Parochial schools Total 
vlli. Number of nurse conferences with parents in schools and at heme (not including 
nurse conferences while nurse is present at medical 
o. Children in secondary grades: 
i. What groups of students were examined by the school medical advisor during the 
school year?. 
Number of students examined 
ii* Number of pupils examined by school medical advisor who were specially referred 
by the school staff 
Hi* Are secondary school teachers given systematic instruction on signs and symptoms as 
a basis for referring pupils to the physician? 
Who gives this instruction?. 
iv. Are individual records from elementary grades continued in use for secondary 
school pupils: Medical record Pupil health record. 
3. Dental supervision: 
a. Is there a planned educational and follow-up program to direct children to a dentist 
for care and to note when such care has been received? 
b. Number of elementary school children not needing dental care or having had dental work 
completed during the school year (or calendar year): 
Public schools Parochial schools Total 
c. Number of secondary school pupils not needing dental care or having had dental work 
completed during the school year (or calendar year). 
88 5.b. 
t 2.b7ill(a) 
X100 » % teachers 
trained 
5. Teacher training: 
a. Has special inservice training in health education been carried on this year? 
Public schools Parochial schools 
If so, 
b. Number of teachers in elementary grades participating 
6, Cooperative planning in health instruction: 
a. Is there a trained supervisor of health education (in addition to physical education 
supervisor) within the public school system?_ 
b. Is there a trained supervisor of health education in: the health department 
voluntary agencies 
3. Dental supervision - continued: 
d. Are treatment services for children provided in: Centralized clinics 
Mobile Private dentists' offices_ 
e. If facilities are not adequate to meet the total needs of children, what age groups 
are given preference, or what other limitations are set? 
b. What progress has been made during the year in meeting these problems? 
4. Problem analysis: 
a. List the most important local school child health problems 
89 7. Urban 
b. 
- a.ill 
X100 «. % pupils 
with approved water 
c. iii 
t a.ill 
X100 « % pupils 
with approved exc. 
disposal 
7. Rural 
b. 
4- a.lv 
X100 « % pupils 
with approved water 
supply 
c. 
- a.iy 
X100 =3 pupils 
with approved exc, 
disposal 
8. a.iii 
h 7.a.iii_ 
X100 - % urban 
pupils with 
meals. 
8.a.iy 
4- 7.a.iv 
X100 - % rural 
pupils with 
meals t 
6. Cooperative planning in health instruction - continued; 
c. If there is no supervisor of health education in the public school system, is the 
trained supervisor of the health department or voluntary agencies utilized to aid in: 
Curriculum construction Instruction of classroom teachers, 
d. Is there a written program for school health instruction which has been cooperatively 
developed with the health department? 
e. What provisions are made to develop an integrated program of health 
f. During which of the school terms of the secondary school was health taught as a special 
subject? 
Number of schools Enrollment 
Urban Rttral Urban Rural Total 
i. ii. ill. iy. v. 
c. Nutritional program: 
1. Number of schools pith planned nutritional program coordinated with lunches 
ii. Number of pupils reached 
iii. Describe program 
7 Water supply and excreta disposal 
facilities: 
a. Total 
b. Water supply approved,... 
c. Excreta disposal facilities 
approved 
8. School lunch: 
a. Complete noon meal served......• 
b. Milk or supplementary lunch 
served 
90 9.Health supervision of school staff; 
a. Is chest x-ray required of new employees; Professional 
Clerical Foodhandlers 
Custodial Bus drivers_ 
b. Is chest x-ray required at intervals of all staff of above classifications? 
How frequently?, 
8. School lunch - continued; 
d. Pupils participate in following lunchroom services; Menu planning 
Waiting on table or counter 
Food Cleaning 
e. What agencies participate in school lunch program, and how? 
91