SMH homepage
District Nursing ServicesHuman Relations, Diversity & EquityPupil ServicesRestorative JusticeSchool Mental Health School Enrollment, Placement & Assessment CenterStudent Medical Services & Medi-Cal ProgramsStudent Support ProgramsWellness Programs

  • Protocols

    Each Specialized Physical Healthcare Service (SPHCS) now has the specific authorization form posted under the protocol guideline. This form requires the signature of the licensed healthcare provider and parent on one page.  The parent section is available in four languages.

     
 
A. Specialized Health Care Services: Form - 2018/2019 (5/2018) | Guidelines: Guidelines, (Rev. 4/2017) 
C. Authorization for Protocol (Generic) - See the each individual protocol to download the protocol-specific authorization form
G.  Protocol and Medication Checklist Form- Medication/Protocol Checklist for Licensed and Unlicensed
        Assistive Personnel
H. Review for Support Services Due to Health Needs -Complete for Student with Protocol Before the IEP
       Meeting
 
  
  
 
Protocols Guidelines: 
 
For Immunization Clinics' Use -  Anaphylactic Reaction to Immunizing Agent (Emergency Care Protocol), (11/2017) 
 
 
For Identified Students in Schools - Anaphylaxis Protocol Emergency Treatment of Anaphylaxis (05/2016)
 
Authorization Forms: (5/2017):
 
Epinephrine for Schools: REF - 6632.1 Administration of Epinephrine Auto-Injectors, March 2016
 
 
Authorization Forms: (5/2017)
 
 
 
a. Clean Catheterization Guidelines (Rev. 1/18)
   Authorization Forms for Clean Catheterization (5/2017)
 
 
    Authorization Forms for Clean Self-Catheterization with Assistance (5/2017)
 
 
c. Clean Self-Catheterization Guidelines (Rev. 1/16)
   Authorization Forms for Clean Self-Catherization (5/2017)
 
 
d. Sterile Catheterization Guidelines (Rev. 05/2016)
   Authorization Forms for Sterile Catheterization (5/2017)
 
 
1. Blood Glucose Testing (6/2017)
2. Hypoglycemic Reaction (6/2017)
3. Glucagon Injection (Severe Hypoglycemia) (6/2017)
 
 
Authorization Forms 
 
Other Related Forms and Information

For LAUSD Food Services Web Page for Menu click here; for carbohydrate count click here.

 

Gastrostomy
 
    Authorization Forms for Gastrostomy Feeding: Bolus Method (5/2017) 
 
    Authorization Forms for Gastrostomy Feeding: Slow Drip Method or Pump (5/2017) 
 
    Authorization Forms for Gastrostomy Tube Replacement (5/2017) 
 
  
Jejunostomy
 
 Authorization Forms for Jejunostomy Tube Feeding: Slow Drip Method or Pump (5/2017) 
 
 
 
 
Authorization Forms with the Parent Section in Different Languages (5/2017) 
 
 
 
Mechanical Ventilation Guidelines (Rev. 5/2016)
 Authorization Forms for Mechanical Ventilation (5/2017) 
 
Other Related Forms/Information 
 
 

 

Ostomy Care (Rev. 4/2017)

Authorization Forms with the Parent Section in Different Languages (5/2017) 
 
 
 
Oxygen Therapy - Guidelines (Rev. 12/15)
 
Authorization Forms for Oxygen Therapy (5/2017)
 
 
 
Protocols:
1.  Diastat - Diastat Guidelines  (11/15)
Authorization Forms for Diastat (5/2017)
 
2.   Vagus Nerve Stimulation (VNS) - VNS Guidelines (2/15)
Authorization Forms for VNS (5/2017)
Related Forms and Information
      c. Seizure Action Plan: English/Spanish
      d. Seizure Record
      e. Parent Questionnaire for Students with Seizures
          (1) English/Spanish (2)  English/Armenian (3) English/Chinese (4) English/Korean
Protocols 
   1. Oral Nasal Suctioning (Rev. 6/15)
       Authorization Forms for Oral/Nasal Suctioning (5/2017)
 
      Authorization Forms for Oropharyngeal and Nasopharyngeal Suctioning (5/2017)
 
   3. Tracheostomy Suctioning (Rev. 6/15)
      Authorization Forms for Tracheostomy Suctioning (5/2017)
   4. Tracheostomy Tube Replacement (Rev. 6/15)
      Authorization Forms for Tracheostomy Tube Replacement (5/2017)
 
Related Forms:
 
 

What's New

Forms

Protocols

References

District Policies Regarding Critical Issues

Immunizations Guidelines and School Based Clinics

Tdap Toolkit & Clinic Packet

Pertussis

Health Brochures

Measles

 

 

Types of Services and Supervisor Contact Information

 

 

Infant and Preschool Special Education

Special Education Resource Nurse

Pre-school Transition School Nurse

Visually Impaired Program

Carlson Home Hospital

Specialized Physical Healthcare Services

 

Audiometric Testing Program

CPR/Automated External Defibrillators

Communicable Disease

Condom Availability

Nurse Family Partnership

Oral Health Programs

Queens Care

  • Announcements

    Immunization Program and SMS School-based Clinics Schedule

     CPR Class Schedule    LAUSD American Heart Association