• 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)

 

Checklist:

School Year 2017/2018

School Year 2018/2019

 

  

 

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

 Authorization to Receive/Release Medical Information

 

 
District Bulletin:

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

BUL-1937.3 Reporting Communicable Diseases

 
Notification Forms for Chicken Pox: (1) For Parent/Guardian  (2) For Employees 
 
 
 
 
 
 
District Bulletin:

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

 
Forms:
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 

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

 

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

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

Request for Medical Exemption

Request for Medical Exclusion

 

 

 

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

 

 

 
Policy:
 
BUL-3878.2 - Assisting Student with Prescribed Medications at School
 
 
Forms:
 
Medication Records - School Year: 2018-2019
 
 
 
 

 

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

 

Form:

Oral Health Assessment/Waiver Request Form 

 

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

Return to School Interview Checklist

 

 

Reports Due Dates 2017-2018

 

 
 
 
 

 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-6429.2 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

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

 
District Policy: BUL-2673.8, Documentation for Employees Paid from Federal and State Categorical Programs 
 
Time Card: 2017-2018 | 2018-2019
 
 
 
  
 
Mileage 
 
Z-Time 

 
Pre-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 download
 
Certificate 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

 

Form:

VI Referral Form

 

 

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