Health Forms (Nurse)

Form Name
Crisis Response Forms
Suicide Intervention Report
MSBSD Crisis Response Manual

Form Name	Form Number
Asthma Action Plan	101A & 101B
Allergy/Anaphylaxis Action Plan	102A & 102B
Severe Allergic Reactions Parent Letter	103
Diabetes Care Plan HCP form for injection (Use Page 5 of the Diabetes Care Plan)	104A
Diabetes Care Plan	104 105 full set of forms
Diabetes Agreement for Independently Managing	104-105D
Continuous Glucose Monitor CGM) IHP Addendum	104-105E
Diabetes Care for Out-of-School-hours activities	104-105 F
Diabetes Care Plan HCP form for pumps	105A
Medication Authorization	106
Medication Authorization Long Term	111
Short Term/Field Trip Medications	107
Reminder of Medication Shortage	109
Over-The-Counter Medication Authorization Form for Field Trips	110
Medication Administration Record Log Sheet	111
Medication Error Report	112
Field Trip Health information form	113
List of of Unlicensed School Staff (Training Record)	114
Parental Delegation for Training UAP with Authorization and Delegation	115
MEDICATIONS – RECEIVED OR RETURNED	118
Herbal and non-herbal supplement authorization	120

Form Name	Form Number
Immunization Required Letter	301
Immunization Exclusion Policy	303
Refrigerator Temp Log	305
Consent to Receive Hepatitis B Vaccine	306
Declination to Receive Hepatitis B Vaccine	307
Religious Exemption Form	308
Medical Exemption Form	309
Immunization waiver statement for McKinney-Vento and military students	312
Vaccination Review Consent Form	313

Form Name	Form Number
Scabies Exclusion Policy and Facts	401
Strep Throat Exclusion Policy and Facts	402
Impetigo Exclusion Policy and Facts	403
Conjunctivitis Exclusion Policy and Facts	404
Head Lice Policy	405
Head Lice Parent Letter of Awareness	406
Head Lice Found on Student Parent Letter	407
Head Lice Control Data Log	408
CDC Treatment Guidelines for Head Lice	409
Temporary Exclusion Policy	410
Bed bug Letter/Parent Resource	414
HLT 415 Pertussis Guidance for Schools	415

Form Name	Form Number
Dental Screening Referral	501
Hearing Referral	502
Vision Screening Referral	504
Vision Referral Follow-Up	505
Scoliosis Screening	507
Mass Health Screening Forms	509
IEP/RTI Referral Health Screening Report	510
Body Mass Index Referral Letter	511

Form Name	Form Number
Individualized Health Care Plan	605A
Specialized Health Care Procedures Authorization	605B
Parent Delegation/Training Authorization	605C
Emergency Care Plan	606
Parent Questionnaire of Student with Seizures/Seizure Action Plan	607A/B & 608
Seizure Observation Record	609
School Nurses Care information	610
Return to school/PE/Activity form	612

Form Name	Form Number
Head Injury Information Sheet	701
Student Incident/Injury Report (Synergy directions) Student Incident/Injury Report (Public Forms)	702A & 702B
Physical Restraint Report	702C
Nurse Physical Restraint Assessment	702D
Child Abuse Reports (OCS)	703
State of Alaska OCS Interview Request	704
Unusual Behavior Assessment	705A & 705B
Animal Control Statement	706
Report of Epinephrine Administration	707A & 707B

Form Name	Form Number
Daily Log	801
Nurse-Parent Referral	802
Referral to Health Care Provider	803
Annual Training Staff Acknowledgement Worksheet	804
Authorization to Release Information (ROI)	805A
FERPA Release of Information Guide for School Nurses
Medical Statement to Request Special Meals or Accommodations	808
Concussion Return to Play Guidelines	809
Concussion Signs & Symptoms Checklist	810
MSBSD Accula or Cue Test Result

Form Name	Form Number
Medic First Aid CPR Certification Course Preparation Guide	HLT 811
Medic First Aid Rate My Program	HLT811b
Excel Spreadsheet Class Upload Roster Form	HLT 811a
Pediatric First Aid -CPR AED Roster	HLT 811c
Generic Incident Report	RM01