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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 Counsel
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
REF-066902, PROCEDURES TO REQUEST BARRIER REMOVAL FOR PROGRAM ACCESSIBILITY FOR STUDENTS AND OTHER INDIVIDUALS WITH DISABILITIES, March 11, 2019
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AED Daily/Monthly Readiness Status Checklist
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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
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Asthma Forms
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Asthma Program Resources
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
National Association of School Nurses (NASN) Asthma Resources Information Page
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Audiologic Resource Unit (ARU)
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ARU Referral Form (Fillable)
ARU Module in Welligent
ARU Portal Helpful Tips
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Authorization to Receive/Release of Medical Information
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Authorization to Receive/Release Medical Information
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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 below
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
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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:
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Condom Availability Program
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Confidential Health Information for a Student
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Dental Observation Form
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Report of Dental Observation
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Diabetes
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See Protocol section
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Ear, Nose, and Throat Observation
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Report of Ear, Nose, and Throat Observation
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First Aid
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Notice of First Aid
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Food Borne Illness Reporting
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Food Borne Illness Reporting
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Food Handler Certificate
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Food Handler Certificate
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Head Injury
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Cautions Regarding Head Injury Forms
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Health Office Referral
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Health Office Referral to Physical Education Teacher
Pupil Health Exclusion, August 2016
School Readmittance
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Health Office Sign-In
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Health Office Sign-In Sheet
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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
Hospital Medical Referral
Psychiatric Referral for Home Instruction
Non-Medical Referral for Home Instruction
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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:
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Immunizations Forms
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Policy:
BUL-6718.0 - Educational Rights and Guidelines for Youth in Foster Care, Experiencing Homelessness and/or ..
Forms:
Immunization Medical Exemptions
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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:
Request for Medical Exemption
Request for Medical Exclusion
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Medical Waste: Transport Checklist, Tracking Document and Generator Certificate
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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.
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Medication Forms
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Policy:
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
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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***
MHET Preliminary Information Form
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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
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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
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Pediculosis (Head Lice)
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Permanent Health History
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Permanent Health History
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Preschool Forms
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Home Instruction Referral Forms
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Principal - Credentialed Nurse Conference
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Principal - Nurse Conference Form
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School Attendance Review Board (SARB) and Site School Nurses
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Seizure
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See Protocols section: Seizure Care for more information/forms
Seizure Record
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Special Diet Request Form
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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:
Athletics Clearance 2021/2022
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
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
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Stull
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Initial Planning Template
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Substitute Folder Forms
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Elementary - Information for Sub School Nurses
Secondary - Information for Sub School Nurses
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Time Reporting and Mileage Forms
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Time Card and Differential Form
Differential Form
School Nurse (Certificated)
LVN (Classified)
Mileage
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)
Z-Time
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Training Log
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Transfer Form
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School Nurse (RN) Employee Initiated Transfer Form, 2/2018
Licensed Vocational Nurse (LVN) (Employee Initiated)Transfer Form
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Vision Screening
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Resources
Vision Screening Presentations and Training:
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Visually Impaired (VI) Program
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District Reference Guide:
REF-5527.0 - Visually Impaired Program: Referral, Assessment, and Scope of Service
Form:
VI Referral Form
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