HEALTH FORMS
Health Information Form
- Provides information about your child's current health, medical concerns and insurance information applicable to the student during the school year.
- Must be completed by the parent/guardian with each new school year
- A key communication tool for the school nurse in caring for your child while at school and in the case of an emergency situation.
- Must be on file in the school clinic every school year in order for a student to attend field trips off of school grounds
| health_information_form.pdf |
Medication Permission Form
This form must be completed and signed by the parent/guardian before medication can be given while at school. One form per medication. This form is only valid for one school year. Medication will be stored in the clinic, in the original container that is labeled appropriately and within the expiration date. Please read the back of the form for the MCPS medication policy.
This form must be completed and signed by the parent/guardian before medication can be given while at school. One form per medication. This form is only valid for one school year. Medication will be stored in the clinic, in the original container that is labeled appropriately and within the expiration date. Please read the back of the form for the MCPS medication policy.
- Over -the Counter Medications: must be completed and signed by parent/guardian.
- Prescription Medications: must be completed and signed by parent/guardian and physician.
Students may carry inhaler and/or EpiPen on their person with proper documentation.
| mcps_med_permission_form.docx |
Allergy Forms
- Emergency Action Plan: Required by the school for students who have been diagnosed with a severe allergy which may involve use of an epinephrine injection for an anaphylaxis reaction The form provides a guide to caring for your child in the event of exposure to a known allergen or allergic reaction while at school.
- Form for Students with Special Dietary Needs: Provides communication to our school cafeteria, teachers and nurse about specific dietary restrictions or requirements related to health conditions diagnosed by a physician.
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Asthma Action Plan
All students with asthma should have a written Asthma Action Plan that details personal information about the child's asthma symptoms, medications, and any specific instructions about what to do if an asthma episode does not improve with prescribed medication. This form should be signed by both the parent/guardian and physician.
All students with asthma should have a written Asthma Action Plan that details personal information about the child's asthma symptoms, medications, and any specific instructions about what to do if an asthma episode does not improve with prescribed medication. This form should be signed by both the parent/guardian and physician.
| Asthma Action Plan |
Concussion Care Plan
Acute Concussion Evaluation (ACE) Care Plan: Personal plan based on specific concussion symptoms and is designed to help speed recovery from a concussion. Facilitates communication from parents and physician to the school personnel, which includes specific instruction and supports that should be implemented as a student returns to normal daily activities of school, when recovering from a concussion.
Acute Concussion Evaluation (ACE) Care Plan: Personal plan based on specific concussion symptoms and is designed to help speed recovery from a concussion. Facilitates communication from parents and physician to the school personnel, which includes specific instruction and supports that should be implemented as a student returns to normal daily activities of school, when recovering from a concussion.
| Concussion Care Plan |
Diabetes Forms
Diabetes Medical Management Plan: Required for those students who have been diagnosed with diabetes by their doctor. The DMMP is developed by the physician and paretn/guardian with the specific needs of an individual student in mind. It should detail all the elements of care and assistance for that student during the school day. These forms must be updated every school year and as changes occur.
Part 1 - School nurse distributes this form to the parent/guardian to determine permission or denial of permission for insulin and/or glucagon administration by trained unlicensed personnel.Part 2 - Physician distributes these forms to parents to sign and bring to their child's school to authorize communication between the school and physician on diabetes care.
Part 3 - If the child wears an insulin pump, then this form needs to be completed by the physician and the parent/guardian to provide child's proficiency of pump operation and where they will require assistance/supervision.
Part 4- If the child is going to carry or self administer insulin and/or perform blood glucose checks in the classroom, this form is recommended to be completed by the physician, school nurse and parent/guardian to inform everyone of expectations and responsibilities.
Supply List for Diabetic student: Medications, supplies and snacks that must be provided by the parents and kept in the clinic and also carried by the student throughout the school year.
Diabetes Medical Management Plan: Required for those students who have been diagnosed with diabetes by their doctor. The DMMP is developed by the physician and paretn/guardian with the specific needs of an individual student in mind. It should detail all the elements of care and assistance for that student during the school day. These forms must be updated every school year and as changes occur.
Part 1 - School nurse distributes this form to the parent/guardian to determine permission or denial of permission for insulin and/or glucagon administration by trained unlicensed personnel.Part 2 - Physician distributes these forms to parents to sign and bring to their child's school to authorize communication between the school and physician on diabetes care.
Part 3 - If the child wears an insulin pump, then this form needs to be completed by the physician and the parent/guardian to provide child's proficiency of pump operation and where they will require assistance/supervision.
Part 4- If the child is going to carry or self administer insulin and/or perform blood glucose checks in the classroom, this form is recommended to be completed by the physician, school nurse and parent/guardian to inform everyone of expectations and responsibilities.
Supply List for Diabetic student: Medications, supplies and snacks that must be provided by the parents and kept in the clinic and also carried by the student throughout the school year.
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Seizure Action Plan
This form is required for those students who have been diagnosed with a seizure disorder by their doctor. This form is designed to provide basic information about a student's seizure(s), and medication, as well as what school personnel should do for the student during a seizure. The form should be must be updated every school year and when a change in health status occurs.
This form is required for those students who have been diagnosed with a seizure disorder by their doctor. This form is designed to provide basic information about a student's seizure(s), and medication, as well as what school personnel should do for the student during a seizure. The form should be must be updated every school year and when a change in health status occurs.
| Seizure Action Plan |
General Care Plan
This form pertains to any non-specific medical condition that has been diagnosed by a physician that may required specific interventions by the school nurse throughout the school year. Information in this form provides specific instructions for the nurse and other school personnel to provide medical care and assistance to the student as prescribed by a doctor. The form must be signed by a doctor, parent/guardian and must be updated every school year and when changes occur.
This form pertains to any non-specific medical condition that has been diagnosed by a physician that may required specific interventions by the school nurse throughout the school year. Information in this form provides specific instructions for the nurse and other school personnel to provide medical care and assistance to the student as prescribed by a doctor. The form must be signed by a doctor, parent/guardian and must be updated every school year and when changes occur.
| individualized_healthcare_plan.docx |