• Forms

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


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 2021/2022:

 AED Brand: FRx | CR2





Asthma Program Resources 
ACT Under 12: (1) English  (2) Spanish
ACT Over 12  : (1) English  (2) Spanish
District FORMS and Other Publications:
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 


School Nurse Health Office Daily Log 




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


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, 2021-2022


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



BUL-3878.2 - Assisting Student with Prescribed Medications at School
Medication Record/Log: SY 2021 - 2022

Request for Medication to be Taken During School Hours - English Spanish

 | Spanish


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

Distance Learning Guidelines for the Credentialed School Nurse

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)



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)

Worked Hours Reporting - Z-Time Form, rev. 6/2021 (fund column will be completed by the Immediate Supervisor)

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


Employee Initiated Transfer Form, 2/2018



Report of Vision Screening English/Spanish



District Reference Guide:

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



VI Referral Form



  • Announcements

    Immunization Program and SMS School-based Clinics Schedule

     CPR Class Schedule    LAUSD American Heart Association