• Forms

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


District Bulletin 

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



School Year 2017/2018



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

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

BUL-1937.3 Reporting Communicable Diseases

District Bulletin:

BUL-2514.1 Child Health and Disability Prevention (CHDP) Program and Blood Lead Testing



School Nurse Health Office Daily Log 




Report of Dental Observation




Diabetes Management Information for Trained Personnel


Related District Publication:

MEM-5221.0 - Diabetes Type 2 Information Factsheet for Parents of 7th Grade Students


See Protocol section


Report of Ear, Nose, and Throat Observation


 Notice of First Aid



Food Borne Illness Reporting

Food Handler Certificate


Guidelines for Student Expulsion Support Services and School Site Nurses 

Cautions Regarding Head Injury Forms


Health Office Referral to Physical Education Teacher


Pupil Health Exclusion, August 2016


School Readmittance


Bulletin 1229.2 - Home, Hospital & Tele-Teaching Instructional Services (Carlson Home Hospital School)

Referral Forms:  Home Medical Referral

                           Hospital Medical Referral

                           Psychiatric Referral for Home Instruction

                           Non-Medical Referral for Home Instruction



District Bulletin:

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



REF-6300.2 Tdap Requirements
BUL-6718.0 -  Educational Rights and Guidelines for Youth in Foster Care, Experiencing Homelessness and/or ..


Medical Waste Tracking Document and Generator Certificate - For Transporting Expired Medications and Sharps Container



BUL-3878.2 - Assisting Student with Prescribed Medications at School


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 





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

Return to School Interview Checklist


 Authorization to Receive/Release Medical Information



Reports Due Dates 2017-2018



 Seizure Record



Special Diet Request Form




Disrict Bulletin:

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

BUL-6429.3 Athletic Rules and Regulations



Athletic Injury Tracking Form

Concussion Injury Report

Flowchart on Concussion Injury Documentation

Medical Clearance Form - to start Stage III of RTP Protocol




 Initial Planning Template



Elementary - Information for Sub School Nurses

Secondary - Information for Sub School Nurses




Time Card and Multi-funded Form

NEW - Multi-Funded Time Reporting Form for School Nurses - use starting February 2018
District Policy: BUL-2673.8, Documentation for Employees Paid from Federal and State Categorical Programs

Pre-Approval for Additional Work Time (Z-Time) 
Worked Hours Reporting - Z-Time Form (fund column will be completed by the Immediate Supervisor)

Procedures for School Nurses (RN) Reporting Absence in District Nursing  - click here to download
Certicate of Absence and Other Payroll Forms (linked to the Payroll Administration website)


Employee Initiated Transfer Form, 3/2018



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