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School Nurse Screening and Emergency Contact
Health screening and observation of students in K-12 are responsibilities charged to teachers and school nurses. Please complete the following information regarding your student.
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* Indicates required question
Student Last Name
*
Your answer
Student First Name
*
Your answer
Student ID Number (Lunch Number)
*
Your answer
Bus Number
*
Your answer
Student Date of Birth
*
MM
/
DD
/
YYYY
Grade Level in 2020-2021
*
9th Grade
10th Grade
11th Grade
12th Grade
Parent/Guardian First and Last Name
*
Your answer
Parent/Guardian Telephone Number
*
Your answer
Parent/Guardian Alternate Telephone Number
Your answer
Parent/Guardian Email Address
*
Your answer
It is important that the school is aware of any special health problems your child has. Please check all conditions below:
*
Allergies
Asthma/Carry an Inhaler?
Diabetes
Hearing problem-Hearing Aid
Bleeding Disorder
Gastrointestinal
Special Diet Order
Heart Problem
Kidney Problem
Migrane Headaches
Orthopedic (Bone) Problem
Seizures
Sickle Cell Disease or Trait
Vision Problem
Learning Disorder
My child does not have any of the listed health conditions
Other:
Required
Please explain any health conditions you selected in the question above.
Your answer
Does your child require medication during school hours?
*
Yes- Documentation from a physician will be required.
No
If your child needs medication during school hours please list it below
Your answer
If your student will require an emergency action plan for any condition selected above, please describe below.
Your answer
If your child has asthma, will they be carrying an inhaler during school:
Yes
No
Clear selection
If your child has diabetes, will they be carrying an insulin pen, insulin pump, glucagon, or none of these:
Insulin Pen
Insulin Pump
Glucagon
None
Clear selection
If your child has seizures, what was the date of the last one? Will they be carrying Diastat or any other anti-seizure medication?
Your answer
If your child has an allergy, will they be carrying an EpiPen during school:
Yes
No
Clear selection
Has your child had a head injury / concussion in the last year? If so, please list the date and details below:
Your answer
Are there any other health conditions or medications from home we should be aware of?
Your answer
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