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Forms
The forms are grouped with other related information i.e. District publications.
- 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) -
Form:
AED Daily/Monthly Readiness Status Checklist Form - 2020/2021
- Asthma Forms
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Asthma Program ResourcesDistrict FORMS and Other Publications: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
- 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-2514.1 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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- Daily Log
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School Nurse Health Office Daily Log
- 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
- 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
- Health History
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- Health Office Referral
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Health Office Referral to Physical Education Teacher
Pupil Health Exclusion, August 2016
- 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
Psychiatric Referral for Home Instruction
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: Checklist, Tracking Document, and Generator Certificate
***A separate Tracking Document MUST be completed for Medication and Sharps Container. To download another copy of the Tracking Document, click here.
- Medication Forms
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Policy:BUL-3878.2 - Assisting Student with Prescribed Medications at SchoolForms:Medication Record/Log: 2020 - 2021
Request for Medication to be Taken During School Hours - English | Spanish
Request for Self-Administration of Medication During School Hours - English
| Spanish - 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
- Pediculosis (Head Lice)
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District Bulletin:BUL-1937.3 Reporting Communicable DiseasesForms:Exclusion, June 2016Fact Sheet (English & Spanish), June 2016
- Preschool Forms
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Home Instruction Referral Forms
- Principal - Credentialed Nurse Conference
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Principal - Nurse Conference Form
Distance Learning Guidelines for the Credentialed School Nurse
- 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: Athletics Clearance 2020/2021
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
- Stull
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- Time Reporting and Mileage Forms
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Time Card and Differential Form
Time card, 33.65 form
Differential Form
School Nurse (Certificated)
MileageDaily 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-TimeWorked Hours Reporting - Z-Time Form (fund column will be completed by the Immediate Supervisor)Absence
Certificate of Absence and Other Payroll Forms (linked to the Payroll Administration website) - Training Log
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- Transfer Form
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Employee Initiated Transfer Form, 2/2018
- Vision Screening
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Report of Vision Screening English/Spanish
Report of Color Vision Test - Visually Impaired (VI) Program
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District Reference Guide:
REF-5527.0 - Visually Impaired Program: Referral, Assessment, and Scope of Service
Form:
- What's New
- Nursing E-Library
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District Policies Regarding Critical Issues
- Parent Resources
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- 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
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Contact
Director:
Sosse Bedrossian, MSN, MA, RN, FNP-CAddress:
121 N. Beaudry Ave.,
Los Angeles, CA 90012
P: (213) 202-7580F: (213) 580-6557
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Announcements
