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Forms
The forms are grouped with other related information i.e. District publications.
- 504 Forms and Publications
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Section 504 - Equity Compliance Website
BUL-4692.8, SECTION 504 OF THE REHABILITATION ACT OF 1973, February 28, 2021, Office of General CounselEducational Equity Compliance Office: SECTION 504 AND INDIVIDUALS WITH DISABILITIES web pageREF-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 OfficeREF-066902, PROCEDURES TO REQUEST BARRIER REMOVAL FOR PROGRAM ACCESSIBILITY FOR STUDENTS AND OTHER INDIVIDUALS WITH DISABILITIES, March 11, 2019Sample Templates - Requires Updates - Asthma Forms
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Request for Medication During School Hours (English/Spanish)REF-1526, Self Administration of Inhalers and Epinephrine Auto-InjectorOther Resources:LAC-USC Breathmobile Program:Website: http://www.labreathmobile.com/Video- LAUSD Nurse and Teacher InformationNational Association of School Nurses (NASN) Asthma Resources Information Page
- Audiologic Resource Unit (ARU)
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- Authorization to Receive/Release of Medical Information
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Authorization to Receive/Release Medical Information
- Automated External Defibrillator
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District Bulletin
BUL 4480.2, Policy and Procedure for the Acquisition and Use of Automated External Defibrillators (AEDs) -
- CD Notifications (Chicken Pox, Fifth Disease, Hand, Foot & Mouth Disease, Headlice, Scabies)
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Sign-in to MyLAUSD first before clicking the links belowNotification FormsChicken Pox: (1) For Student Parent/Guardian (2) For EmployeesHeadlice: (1) General Notification (2) Student Exclusion (3) Fact SheetDistrict 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 - Child Health and Disability Prevention Program (CHDP) Forms
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District Bulletin:
BUL-2514.2 Child Health and Disability Prevention (CHDP) Program and Blood Lead Testing
Forms: - Condom Availability Program
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Condom Distribution- Order FormReference Guide 5010.2 - Condom Availability Program
- Confidential Health Information for a Student
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- Dental Observation Form
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- Diabetes
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- Ear, Nose, and Throat Observation
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Report of Ear, Nose, and Throat Observation
- Exclusion
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- First Aid
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- Food Borne Illness Reporting
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- Food Handler Certificate
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- Head Injury
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Cautions Regarding Head Injury Forms
- Head Lice
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District Bulletin:BUL-1937.3 Reporting Communicable DiseasesForms:Fact Sheet (English/Spanish), March 2023
- Health Office Referral
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Health Office Referral to Physical Education Teacher
Pupil Health Exclusion, August 2016
- Health Office Sign-In
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- Home/Hospital Instructions Referral Forms
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Bulletin 1229.3, 7/2/2018 - Carlson Home, Hospital & Home Online Academy Instructional Services
Referral Forms: Home Medical Referral
Non-Medical Referral for Home Instruction
- IEP Forms
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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
Forms: - Immunizations Forms
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Policy:BUL-1660.9 Immunization GuidelinesREF-6300.2 Tdap RequirementsBUL-6718.0 - Educational Rights and Guidelines for Youth in Foster Care, Experiencing Homelessness and/or ..Forms:Immunization Medical ExemptionsExemptions FAQs (updated 3/9/2021)Pre-2020 Medical Exemptions by Disciplined Physicians (updated 4/14/2021)School and Child Care Webinar Presentation (4/14/2021)
- Medical Exemptions and Exclusions (Not for Immunizations)
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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
Forms:
- Medical Waste: Transport Checklist, Tracking Document and Generator Certificate
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For Transporting Expired Medications and/or Sharps Container
Medical Waste Tracking Doc and Generator Certificate 2023-2024
***A separate Tracking Document MUST be completed for Medication and Sharps Container. To download another copy of the Tracking Document, click here.
***EXPIRED Hand Sanitizer Disposal Information
- Medication Forms
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Attachment B Renewal of Request for Medication to Be Taken During School Hours
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: Asthma Action Plan (English) | Spanish
Attachment H Medical Waste Transport Preparation Checklist
- Mental Health Evaluation Team (MHET) Preliminary Information Request Form
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***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***
- Naloxone: Administration of Naloxone Spray
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BUL-133120 ADMINISTRATION OF NALOXONE NASAL SPRAY
IOC: NALOXONE (NARCAN) NASAL SPRAY
LAUSD DNS NALOXONE TRAINING FOR SCHOOL NURSES: NURSE SUPPLEMENTAL
INSTRUCTIONS FOR ADMINISTRATION OF NALOXONE
NALOXONE EMERGENCY RESPONSE SITE PLAN
NALOXONE NASAL SPRAY MONTHLY CHECKLIST
REPORT OF NALOXONE ADMINISTRATION FORM (BLANK)
NALOXONE SKILLS AND PROCEDURES
SAMPLE LETTER: NALOXONE REQUEST FOR VOLUNTEERS
- Nurse-Family Partnership Referral Form
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Nurse-Family Partnership Referral Form
Related District Publication:
BUL-3276.1 Compliance on Services for Pregnant Minors and Parenting Minors, August 15, 2007
- Oral Health Assessment Form
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District Bulletin:
BUL-3585.6, Oral Health Assessment for Kindergarten or First Grade Entry, August 1, 2016
Form:
Oral Health Assessment/Waiver Request Form
- Permanent Health History
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- Preschool Forms
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Home Instruction Referral Forms
- Principal - Credentialed Nurse Conference
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- Readmission
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- School Attendance Review Board (SARB) and Site School Nurses
- Seizure
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See Protocols section: Seizure Care for more information/forms
- Special Diet Request Form
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- Sports/Athletics Forms
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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
Memo:
Guidance for Screening Pre Participation of Examination (PPE) Forms (COVID)
IOC Student Athlete Returning from a Positive COVID-19 Test
Forms:
PPE with Parent's Section in English
PPE with Parent's Section in Spanish
Medical Conditions and Sports Participation
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
- Substitute Folder Forms
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Elementary - Information for Sub School Nurses
Secondary - Information for Sub School Nurses
- Time Reporting and Mileage Forms
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Absence
Certificate of Absence and Other Payroll Forms (linked to the Payroll Administration website)MileageZ-TimePRE-APPROVAL FOR ADDITIONAL WORK TIME rev. 6/202222-23 REQUEST FOR PAYMENT OF ADDITIONAL TIME rev. 6/2022 (fund column completed by the Supervisor) - Training Log
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- Transfer Form
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Credentialed School Nurse Transfer Form 3/2023
Licensed Vocational Nurse (LVN) (Employee Initiated)Transfer Form
- Vision Screening
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Report of Vision Screening English/Spanish
Report of Color Vision Test
Resources
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
- Visually Impaired (VI) Program
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District Reference Guide:
REF-5527.0 - Visually Impaired Program: Referral, Assessment, and Scope of Service
Form:
- School-site Crisis Team Training Recorded Webinar Series 2021
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ALL 14 WEBINARS ARE NOW AVAILABLE FOR VIEWING ON MyPLN
- Search Keyword: RECORDED WEBINARS 2021
School-site Crisis Team Training Recorded Webinar Series 2021 FLYER
- COVID-19 Employee Resources
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Link to the Division of District Operations > Emergency Services
- Nursing E-Library
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District Policies Regarding Critical Issues
- Immunizations and Enrollment
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Immunizations Guidelines and School Based Clinics
Immunization Toolkit for Schools
- Important Health Information
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- Local District Nursing Services
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Types of Services and Supervisor Contact Information
- Special Education Services
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Infant and Preschool Special Education
Special Education Resource Nurse
Pre-school Transition School Nurse
Specialized Physical Healthcare Services
- Specialized Nursing Programs
- DNS Parent Resources Page
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DNS Retirement Slide Show
...for general access or to download the file, click here.
Contact
Director:
Sosse Bedrossian, MSN, MA, RN, FNP-CAddress:
121 N. Beaudry Ave.,
Los Angeles, CA 90012
P: (213) 202-7580F: (213) 580-6557