Substance Abuse Referral - Vital Signs Record (FOR PPS NURSES ONLY!)
This form should be used for any student referred for a medical examination/drug test for being in possession or suspicion of drug or alcohol use. Another staff member has submitted the request for intervention separately.  This sheet is only for documenting the vital signs which used to be completed on the paper forms, which are no longer in use.
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Below is an image of our original paper forms.  Note the nurse's section circled in red.  Please use this form and fill out the questions below.
Today's Date: *
MM
/
DD
/
YYYY
Your Name: *
Your School: *
Student initials and ID#: *
Student BP: *
Pulse: *
Resp: *
Was 911 contacted for this student? *
Any additional comments or observations? *
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Paterson Public Schools. Report Abuse
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