Short Term Medication Form 

Inventory Log     

Field Trip Permission Form 

Short term medications forms are to be used for medications to be given for 10 days or less.  All forms can be filled out by the parent/guardian.  After 10 days the medication can no longer be given by staff.  If the medication is going to be needed for more than 10 days the Long term medication forms will need to be completed.

Long Term Med Form 

Inventory Log 

Field Trip Permission Form 

Long term medication forms are to be used when medication will be given for more than 10 days.  The long term form has to be filled out by the MD and signed by both MD and parent/guardian to be accepted.  The ULP, inventory log and field trip forms can be filled out and signed by the parent/guardian. 

For a safe and healthy school experience we require an Asthma Action Plan and other needed forms listed below for every student that has been diagnosed with asthma.  These forms should be updated by a healthcare provider each school year.

All students using an inhaler/nebulizer must follow district guidelines for medication use in school.

Students may carry their inhaler when the proper school district forms are completed and with parent, provider, and registered school nurse authorization.

All asthma related medications, equipment, and supplies must be provided by the parent/guardian.

Asthma action plan, self admin section and supplementary treatment orders  forms have to be filled out by the MD and signed by both MD and parent/guardian to be accepted.  ULP section, inventory log and field trip forms can be filled out and signed only by parent/guardian.  

 

 

Inventory Log 

Field Trip Permission Form 

Asthma Action Plan 

Specialized Nursing Services (nebulizers) 

 

Allergy Action Plan Form

Inventory Log 

Field Trip Permission Form 

Food Accommodation Form 

 

Long term medication form, allergy action plan, food accommodation form and the  self admin forms  have to be filled out by the MD and signed by both MD and parent/guardian to be accepted.  ULP, inventory log and field trip forms can be filled out and signed only by parent/guardian.

For a safe and healthy school experience we require an Allergy Action Plan for every student that has been diagnosed with a severe allergy that may require treatment while at school, including emergency medication administration for a life-threatening allergies.  This form is completed by a healthcare provider and must be updated each school year.  All forms needed for the school year are listed above.

Students may carry their epi pen when proper school district forms are completed and with parent, provider, and registered school nurse authorization.

For additional information related to the management of allergies in school you can refer to the Allergy Handbook.  This handbook was adopted by the School Board to provide guidance for parents and staff on how to respond to allergies in schools.  

Long Term Med Form 

Unlicensed Personnel Administration Form 

Inventory Log 

Field Trip Permission Form 

Seizure Action Plan 

Long term medication form, seizure action plan and self admin form  forms have to be filled out by the MD and signed by both MD and parent/guardian to be accepted.  ULP, inventory log and field trip forms can be filled out and signed only by parent/guardian.

An Individualized Healthcare Plan is a professional tool used by School Nurses, to provide a framework that ensures safe and effective diabetes management in the school setting.  This plan is developed by the Registered School Nurse and includes the Health Care Provider's medical orders for administration of insulin. All care plans must be updated at the beginning of each school year.  All needed forms for the school year are listed below.  ULP form, Field trip form

 

Unlicensed Personal Form 

Field Trip Form 

Blood Sugar Algorithm 

Specialized Nursing Services  

Continuous Glucose Monitoring Form 

Healthcare Plan for School and Parent 

Healthcare Plan DM with Injections and Provider Orders 

Healthcare Plan with Pump 

Agreement for Students Independently Managing DM 

 

 

 

Please review all forms.  Some information will have to be filled out by either the MD, parent/guardian or student or by all for us to accept them.  

Over-The-Counter-Medication- Administration Form