Forms

School Health Service Forms

Tuberculosis/Staff Physical Exam

• F-02314A (10/2019) - School Employee Risk Assessment Questionnaire
• F-02284 (02/2018) - Record of School Employee Examination

Student Examination/Health History/Injury

• School-Age Parent Medical Statement
• Students with Special Dietary Needs
• Student Accident Report
• Kindergarten Eye Health Examination Report
  • (English version)
  • (Spanish version)

• School District Health Record Information

Immunization

• DHS School Immunization

• Meningococcal Disease Resources

  • Parent Sample Letter - English
  • Parent Sample Letter - Spanish

Medical Advisor and Private Care Nursing

• Template of Agreements
• Sample Agreement between District and Private Duty Nurse Provided by Parents
• Sample Memorandum of Understanding for Private Duty Nurse

Sample Health Plans

• Nursing and Related Services
• Sample - IHP
• Sample - Emergency Action Plan

School Nurse Job Description and Evaluation Samples

• School Nurse Job Description District-Hired
• School Nurse Memorandum of Understanding (contracted services)
• School Nurse Performance Evaluation