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Forms
The forms are grouped with forms and other information i.e. related 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)
Checklist:
- Asthma Forms
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Asthma Program ResourcesDistrict FORMS and Other Publications:REF-1526, Self Administration of Inhalers and Epinephrine Auto-InjectorOther Resources:Los Angeles County Breathmobile Program:Website: http://www.labreathmobile.com/National Association of School Nurses (NASN) Asthma Resources Information Page
- Authorization to Receive/Release of Medical Information
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Authorization to Receive/Release Medical Information
- CD Notifications (Chicken Pox, Hand, Fifth Disease, Foot & Mouth Disease, Headlice, Scabies)
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District Bulletin:
BUL-1645.2 Infection Control Guidelines for Preventing the Spread of Communicable Diseases
BUL-1937.3 Reporting Communicable Diseases
- 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 Form
- 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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- Guidelines for School Expulsion Support Services
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Guidelines for Student Expulsion Support Services and School Site Nurses
- Head Injury
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Cautions Regarding Head Injury Forms
- 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 1229.2 - Home, Hospital & Tele-Teaching Instructional Services (Carlson Home Hospital School)
Referral Forms: Home Medical Referral
Psychiatric Referral for Home Instruction
Non-Medical Referral for Home Instruction
- IEP Forms
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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
Forms: - Immunizations Forms
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Policy:BUL-1660.8 Immunization GuidelinesREF-6300.2 Tdap RequirementsBUL-6718.0 - Educational Rights and Guidelines for Youth in Foster Care, Experiencing Homelessness and/or ..Forms:Medical Exemptions
- Medical Exemptions and Exclusions
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Please make sure to sign in to MyLAUSD before clicking the links below.
Policy: BUL-3219.2, Student Medical Exemption and Exclusion Policy and Procedures
Forms:
- Medical Waste Tracking Document and Generator Certificate
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Medical Waste Tracking Document and Generator Certificate - For Transporting Expired Medications and Sharps Container
- Medication Forms
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Policy:BUL-3878.2 - Assisting Student with Prescribed Medications at SchoolForms:Medication Records - School Year: 2018-2019
- 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
- Pediatric TB Risk Assessment Questionnaire
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English | Chinese | Spanish | Tagalog | Vietnamese
- 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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Return to School Interview Checklist
- Reports Timeline
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- School Attendance Review Board (SARB) and Site School Nurses
- Scoliosis Screening
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Scoliosis Screening Program-WaiverScoliosis Screening Follow Up Notice (English)Scoliosis Screening Follow Up Notice (Spanish)
- Seizure Record 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-6429.2 Athletic Rules and Regulations
Clearance Policy for Student - Athletes with Impaired Vision
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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- 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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Time Card and Multi-funded FormDistrict Policy: BUL-2673.8, Documentation for Employees Paid from Federal and State Categorical ProgramsMulti-Funded Time Reporting Form for School NursesMileageZ-TimePre-Approval for Additional Work Time (Z-Time)Worked Hours Reporting - Z-Time Form (fund column will be completed by the Immediate Supervisor)Absence
Procedures for School Nurses (RN) Reporting Absence in District Nursing - click here to downloadCertificate 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, 3/2018
- 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
- Immunizations and Enrollment
- 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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