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  • Forms

    The forms are grouped with other related information i.e. District publications.

Section 504 - Equity Compliance Website

BUL-4692.8, SECTION 504 OF THE REHABILITATION ACT OF 1973, February 28, 2021, Office of General Counsel
Educational Equity Compliance Office: SECTION 504 AND INDIVIDUALS WITH DISABILITIES web page
REF-6241.4, MANDATORY USE OF THE WELLIGENT SECTION 504 PROGRAM MODULE TO CONDUCT ALL SECTION 504 ACTIVITIES, February 2, 2020, Office of General Counsel & Educational Equity Compliance Office
Sample Templates - Requires Updates



District Bulletin 

BUL-4480.1, Policy and Procedure for the Acquisition and Use of Automated External Defibrillators (AEDs) - 

AED Daily/Monthly Readiness Status Checklist Form: SY 2022/2023







Asthma Program Resources 
ACT Under 12: (1) English  (2) Spanish
ACT Over 12  : (1) English  (2) Spanish
District FORMS and Other Publications:
Attachment E Request for Self Administration of Medication to be taken During School Hours
Attachment F Student Contract for Self-Administration/Self-Carry of Medication During School Hour
REF-1526, Self Administration of Inhalers and Epinephrine Auto-Injector
Other Resources:
LAC-USC Breathmobile Program:
                  Video- LAUSD Nurse and Teacher Information  
                  Breathmobile Flyer
                  Breathmobile Referral Form 
National Association of School Nurses (NASN) Asthma Resources Information Page


ARU Referral Form (Fillable)

ARU Module in Welligent

ARU Portal Helpful Tips




Authorization to Receive/Release Medical Information



to MyLAUSD first before clicking the links below 
Notification Forms
      Chicken Pox: (1) For Student Parent/Guardian  (2) For Employees
      Fifth Disease
      Headlice: (1) General Notification (2) Student Exclusion (3)Fact Sheet
District Bulletin (Policy):

BUL-1645.2 Infection Control Guidelines for Preventing the Spread of Communicable Diseases

BUL-1937.3 Reporting Communicable Diseases


Communicable Disease: Handbook - Nov. 2015
District Bulletin:

BUL-2514.2 Child Health and Disability Prevention (CHDP) Program and Blood Lead Testing

Reference Guide 5010.2 - Condom Availability Program 


Report of Dental Observation




See Protocol section


Report of Ear, Nose, and Throat Observation



 Notice of First Aid



Food Borne Illness Reporting


Food Handler Certificate


Cautions Regarding Head Injury Forms


Health Office Referral to Physical Education Teacher


Pupil Health Exclusion, August 2016


School Readmittance



Health Office Sign-In Sheet


Bulletin 1229.3, 7/2/2018 - Carlson Home, Hospital & Home Online Academy Instructional Services 

Referral Forms:  Home Medical Referral

                           Hospital Medical Referral

                           Psychiatric Referral for Home Instruction

                           Non-Medical Referral for Home Instruction



District Bulletin and Reference Guide

BUL-2030.1, Guidelines for an Individualized Health Assessment and the Participation of the Credentialed School Nurse in the Individualized Education Plan (IEP) Process

BUL-6639.0, Three-Year Review IEP Psycho-Educational Re-Assessment. Page 6 of 6 states that both health and academic assessment plans are required for all triennials.

REF-2481.4, Support for Students with Assessed Health Needs in Special Education Programs

REF-6300.2 Tdap Requirements
BUL-6718.0 -  Educational Rights and Guidelines for Youth in Foster Care, Experiencing Homelessness and/or ..
Immunization Medical Exemptions
Exemptions FAQs (updated 3/9/2021)
Related Resources:
California Immunization Handbook, 11th Edition, January 2021 
Toolkit for Schools 
Please make sure to sign in to MyLAUSD before clicking the links below.
This section is not about Medical Exemptions to required immunizations. For information on the medical exemption to required immunizations, click here.

Policy: BUL-3219.2, Student Medical Exemption and Exclusion Policy and Procedures


Request for Medical Exemption

Request for Medical Exclusion





For Transporting Expired Medications and/or Sharps Container

Medical Waste: Checklist, Tracking Document, and Generator Certificate, 2022-2023


***A separate Tracking Document MUST be completed for Medication and Sharps Container. To download another copy of the Tracking Document, click here.



BUL-3878.3- Assisting Students with Prescribed Medications at School

Attachment B Renewal of Request for Medication To Be Taken During School Hours 

Attachment C Training Log

Attachment D Medication Log

For Download: Fillable version of Attachment D School Year 2022/2023 

Attachment E Request for Self Administration of Medication to be taken During School Hours

Attachment F Student Contract for Self-Administration/Self-Carry of Medication During School Hours

Attachment GAsthma Action Plan. Downloadable version: English | Spanish

Attachment H Medical Waste Transport Preparation Checklist



***When requesting service/support from LASPD Dispatch (213.625.6631) for a student/employee identified as high risk for suicide/threat (per BUL-2637.4, BUL-5799.1, BUL-5798.0), the following Preliminary Information should be provided as indicated in the Mental Health Evaluation Team (MHET) PRELIMINARY INFORMATION Request Form***

MHET Preliminary Information Form


Nurse-Family Partnership Referral Form


Related District Publication:

BUL-3276.1 Compliance on Services for Pregnant Minors and Parenting Minors, August 15, 2007





District Bulletin:

BUL-3585.6, Oral Health Assessment for Kindergarten or First Grade Entry, August 1, 2016



Oral Health Assessment/Waiver Request Form


District Bulletin:
BUL-1937.3 Reporting Communicable Diseases
Exclusion,  June 2016 
Fact Sheet (English & Spanish), June 2016 


Permanent Health History

Home Instruction Referral Forms


Principal - Nurse Conference Form

See Protocols section: Seizure Care for more information/forms


 Seizure Record



Special Diet Request Form



Sign in the MyLAUSD first before clicking the links below


Disrict Bulletin:

BUL-4948.2 Medical Clearance and Return to Play Guidelines for Students Participating in Interscholastic 

BUL-6429.3 Athletic Rules and Regulations

Clearance Policy for Student-Athletes with Impaired Vision



Athletics Clearance 2021/2022

Guidance for Screening Pre Participation of Examination (PPE) Forms (COVID)

IOC Student Athlete Returning from a Positive COVID-19 Test 



PPE with Parent's Section in English

PPE with Parent's Section in Spanish

Medical Conditions and Sports Participation

Athletic Injury Tracking Form

Concussion Injury Report

Flowchart on Concussion Injury Documentation

Medical Clearance Form - to start Stage III of RTP Protocol

Hx of COVID-19 - Sports Participation Parent Letter

Post COVID-19 Return to School and Graduated Return to Play



 Initial Planning Template



Elementary - Information for Sub School Nurses

Secondary - Information for Sub School Nurses




Time Card and Differential Form



Differential Form

School Nurse (Certificated)

LVN  (Classified)




Daily Mileage Statement - this form MUST be downloaded and saved to your computer folder in order for the PDF features to work (fillable fields, total mileage etc)

Additional Time Reporting_2022-2023, rev. 6/2022 (fund column completed by the Supervisor)

Certificate of Absence and Other Payroll Forms (linked to the Payroll Administration website)


School Nurse (RN) Employee Initiated Transfer Form, 2/2018


Licensed Vocational Nurse (LVN) (Employee Initiated)Transfer Form


Report of Vision Screening English/Spanish

Report of Color Vision Test



Guide for Vision Screening


Vision Screening Summary Table


Vision Screening Presentations and Training:

Vision Screening Guidelines_1-25-22


Spot Vision Screener Product Overview Training_1-25-22


District Reference Guide:

REF-5527.0 - Visually Impaired Program: Referral, Assessment, and Scope of Service



VI Referral Form



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