District Nursing Services / Forms

Forms

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

BUL-4692.8, SECTION 504 OF THE REHABILITATION ACT OF 1973, February 28, 2021, Office of General Counsel

Educational Equity Compliance Office: SECTION 504 AND INDIVIDUALS WITH DISABILITIES web page

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

Sample Templates - Requires Updates

Sample Accommodations and Modifications

AED Daily/Monthly Readiness Status Checklist

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

Asthma Forms

ACT Under 12: (1) English (2) Spanish

ACT Over 12 : (1) English (2) Spanish

Asthma Action Plan (English) | Asthma Action Plan (Spanish)

Asthma Care Provider Information 33.06

Authorization to Release/Receive Medical Information

Confidential Health Information for Asthma

Inhalers Informational Flyer

Request for Medication During School Hours (English/Spanish)

Request for Self Administration of Medication to be taken During School Hours: English | Spanish

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:

Website: http://www.labreathmobile.com/

Video- LAUSD Nurse and Teacher Information

Breathmobile Flyer

Breathmobile Referral Form

LAC-USC Breathmobile Fact Sheet

National Association of School Nurses (NASN) Asthma Resources Information Page

Website:

http://www.nasn.org/ToolsResources/Asthma

Audiologic Resource Unit (ARU)

ARU Referral Form (Fillable)

ARU Module in Welligent

ARU Portal Helpful Tips

Authorization to Receive/Release of Medical Information

Authorization to Receive/Release Medical Information

CD Notifications (Chicken Pox, Fifth Disease, Hand, Foot & Mouth Disease, Headlice, Scabies)

Sign-in to MyLAUSD first before clicking the links below

Notification Forms

Chicken Pox: (1) For Student Parent/Guardian (2) For Employees

Fifth Disease

Hand, Foot and Mouth 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

Child Health and Disability Prevention Program (CHDP) Forms

District Bulletin:

BUL-2514.2 Child Health and Disability Prevention (CHDP) Program and Blood Lead Testing

Forms:

CHDP Consent for Health Assessment, Eligibility Determination

CHDP Eligibility Table - 2008

C HDP Report of Health Examination for School Entry (PM 171A)

CHDP Waiver of Health Examination for School Entry (PM 171 B)

CHDP Letter for 1st Grade Physical Exam

Condom Availability Program

Condom Distribution- Order Form

Reference Guide 5010.2 - Condom Availability Program

Confidential Health Information for a Student

With Severe Allergies

Dental Observation Form

Report of Dental Observation

Diabetes

See Protocol section

Ear, Nose, and Throat Observation

Report of Ear, Nose, and Throat Observation

First Aid

Notice of First Aid

Food Borne Illness Reporting

Food Borne Illness Reporting

Food Handler Certificate

Food Handler Certificate

Head Injury

Cautions Regarding Head Injury Forms

English and Spanish

English/Korean

Health Office Referral

Health Office Referral to Physical Education Teacher

Pupil Health Exclusion, August 2016

Readmit of Pupils with Medical/Amb Assisted Devices

School Readmittance

Health Office Sign-In

Health Office Sign-In Sheet

Home/Hospital Instructions Referral Forms

Bulletin 1229.3, 7/2/2018 - Carlson Home, Hospital & Home Online Academy Instructional Services

Referral Forms: Home Medical Referral

Hospital Medical Referral

Psychiatric Referral

Non-Medical Referral for Home Instruction

IEP Forms

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:

IEP/IFSP School Nurse Health Assessment

Review for Support Services Due to Health Needs

Immunizations Forms

Policy:

BUL-1660.9 Immunization Guidelines

REF-6629.0 Compliance with California Immunization Law - Removal of Personal Exemption

REF-6300.2 Tdap Requirements

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

Forms:

Notification of Immunizations Due (English/Spanish)Notification of Immunizations Due (English/Spanish)

Immunization Medical Exemptions

Exemptions 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)

Related Resources:

Handbook, Records, & Guides

California Immunization Handbook, 11th Edition, January 2021

Toolkit for Schools

Medical Exemptions and Exclusions (Not for Immunizations)

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

Medical Waste: Transport Checklist, Tracking Document and Generator Certificate

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.

Medication Forms

Policy:

BUL-3878.3- Assisting Students with Prescribed Medications at School

A ttachment A Request for Medication to be Taken During School Hours Eng |Span

For Download: Fillable version of Attachment A

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: Asthma Action Plan (English) | Spanish

Attachment H Medical Waste Transport Preparation Checklist

Mental Health Evaluation Team (MHET) Preliminary Information Request Form

***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

Naloxone: Administration of Naloxone Spray

BUL-133120 ADMINISTRATION OF NALOXONE NASAL SPRAY

IOC: NALOXONE (NARCAN) NASAL SPRAY

LAUSD DNS NALOXONE TRAINING FOR SCHOOL NURSES: NURSE SUPPLEMENTAL

DNS NALOXONE TRAINING TOOLKIT

INSTRUCTIONS FOR ADMINISTRATION OF NALOXONE

NALOXONE EMERGENCY RESPONSE SITE PLAN

NALOXONE NASAL SPRAY MONTHLY CHECKLIST

NALOXONE TRAINING LOG

REPORT OF NALOXONE ADMINISTRATION FORM (BLANK)

NALOXONE SKILLS AND PROCEDURES

NALOXONE SKILLS SHEET

SAMPLE LETTER: NALOXONE REQUEST FOR VOLUNTEERS

SAMPLE LETTER: NALOXONE VOLUNTEER NOTIFICATION

Nurse-Family Partnership Referral Form

Nurse-Family Partnership Referral Form

Related District Publication:

B UL-3276.1 Compliance on Services for Pregnant Minors and Parenting Minors, August 15, 2007

Oral Health Assessment Form

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)

District Bulletin:

BUL-1937.3 Reporting Communicable Diseases

Forms:

Exclusion, June 2016

Fact Sheet (English & Spanish), June 2016

General Notification Letter, June 2016

Permanent Health History

Permanent Health History

Preschool Forms

Medical Exclusion OR Clearance to Attend School for Preschool-Aged Childre n

Return to School Interview Checklist

Home Instruction Referral Forms

Referral Form

Protocols

Principal - Credentialed Nurse Conference

Principal - Nurse Conference Form

School Attendance Review Board (SARB) and Site School Nurses

School Attendance Review Board and Site School Nurses

Seizure

See Protocols section: Seizure Care for more information/forms

Seizure Record

Special Diet Request Form

Special Diet Request Form

Sports/Athletics Forms

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

Stull

Initial Planning Template

Substitute Folder Forms

Elementary - Information for Sub School Nurses

Secondary - Information for Sub School Nurses

Time Reporting and Mileage Forms

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

Pre-Approval to Work Additional Time (Z-Time), rev. 6/2022

Additional Time Reporting_2022-2023 , rev. 6/2022 (fund column completed by the Supervisor)

Absence

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

Training Log

Student Specific Training Log

Training Log

Transfer Form

School Nurse (RN) Employee Initiated Transfer Form, 2/2018

Licensed Vocational Nurse (LVN) (Employee Initiated)Transfer Form

Vision Screening

Report of Vision Screening English/Spanish

Report of Color Vision Test

Resources

Guide for Vision Screening

Vision Screening Summary Table

Vision Screening Presentations and Training:

Vision Screening Guidelines_1-25-22

Spot Vision Screener Product Overview Training_1-25-22

Visually Impaired (VI) Program

District Reference Guide:

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

Form:

VI Referral Form

School-site Crisis Team Training Recorded Webinar Series 2021

ALL 14 WEBINARS ARE NOW AVAILABLE FOR VIEWING ON MyPLN

Search Keyword: RECORDED WEBINARS 2021

School-site Crisis Team Training Recorded Webinar Series 2021 FLYER

COVID-19 Employee Resources

Link to the Division of District Operations > Emergency Services

COVID-19 Employee Resources

Nursing E-Library

Forms

Protocols

References

District Policies Regarding Critical Issues

Immunizations and Enrollment

Immunizations Guidelines and School Based Clinics

Immunization Toolkit for Schools

Important Health Information

Measles

Pertussis

Health Brochures

Local District Nursing Services

Types of Services and Supervisor Contact Information

Special Education Services

Infant and Preschool Special Education

Special Education Resource Nurse

Pre-school Transition School Nurse

Visually Impaired Program

Specialized Physical Healthcare Services

Specialized Nursing Programs

Audiometric Testing Program

Carlson Home Hospital

CPR/Automated External Defibrillators

Communicable Disease

Condom Availability

Nurse Family Partnership

Oral Health Programs

Queens Care

DNS Parent Resources Page

https://achieve.lausd.net/parent-resources

DNS Retirement Slide Show

...for general access or to download the file, click here.

Contact

Director:
Sosse Bedrossian, MSN, MA, RN, FNP-C

Address:
121 N. Beaudry Ave.,
Los Angeles, CA 90012
P: (213) 202-7580

F: (213) 580-6557

Email District Nursing Services

Visitor Parking Information