Health Guide


	School Health Services \| Confidentiality of PPS

DoDEA Health Services Guide

The following sections are available as Word 2000 files for personalization by a particular school or school nurse. DDESS should use appropriate state forms not available on DoDEA's Web site or CD.

Section H - Forms

Section I - Information Papers

The following Section H forms listed below are in Adobe Acrobat portable document format (PDF). These files are not customizable, but can be filled out electronically and printed.

[Adobe Acrobat Reader is available from the Adobe web site. DoDEA does not support or endorse Adobe Systems Incorporated or its products.]

Section H: Forms

Table of Contents

H.1 Student Health History

H.2 Immunization Forms

H.3 Medication Forms

H.4 Medical Referral Forms

H.5 Memorandums for Teachers

H.6 Notices to Parents/Sponsors

H.7 Accident/Injury Reports

H.8 Asthma Documentation and Forms

H.9 ADHD Documentation and Forms

H.10 History/Informational Forms

H.11 Health Services Information Sheets

H.12 Miscellaneous Forms

Section H: Contents

H.1 Student Health History

H.2 Immunization Forms

H.2.1 Certificate of Immunization, Last Date Only

H.2.2 Certificate of Immunization, All Dates, Under 5 Years Version

H.2.3 Certificate of Immunization, All Dates, Age 5 and older

H.2.4 Incomplete Immunizations, Registration

H.2.5 Delinquent Immunizations, Notice of

H.2.6 Disenrollment, Incomplete Immunizations

Back to Table of Contents

H.3 Medication Forms

H.3.1 Medication During School Day, Memorandum for Parents

H.3.2 Medication During School Hours, Physician/Parent Signatures

H.3.3 Medication "Hold Harmless" Permission Form

H.3.4 Medication Log, Study Trip Administration

H.3.5 Medication Incident Report

H.3.6 Student Allergic Reaction Information

H.3.7 Anaphylactic Emergency Information

H.3.8 Standing Order

H.3.9 Student Retention of Medications, Permission for

H.3.10 Medication Inservice

Back to Table of Contents

H.4 Medical Referral Forms

H.4.1 Vision Screening Referral

H.4.2 Hearing Screening Referral

H.4.3 Scoliosis Screening Referral

H.4.4 Dental Screening Report

H.4.5 Health Screening Record, Student

H.4.6 Student Health Referral

H.4.7 Medical Referral

H.4.8 Adaptive Recommendations

H.4.9 Request for Specialized Health Care Procedures, Parents and Physician

H.4.10 Patient Assessment Checklist

H.4.11 Head Injury

H.4.12 Head Injury Flow Sheet

H.4.13 Eye Injury Flow Sheet

H.4.14 Shock Flow Sheet

H.4.15 Fractures, Dislocations, Sprains/Strains, Contusions

Back to Table of Contents

H.5 Memorandums for Teachers

H.5.1 Confidential Health Problems

H.5.2 Confidential Health Condition, Student

H.5.3 Behavioral Checklist for Suspected Chemical Abuse

Back to Table of Contents

H.6 Notices to Parents/Sponsors

H.6.1 Parent Notice of Scoliosis Screening

H.6.2 Parent Notice of Pediculosis

H.6.3 Additional Medical Information, Request for

Back to Table of Contents

H.7 Accident/Injury Reports (copy of most current
needs to be added)

Back to Table of Contents

H.8 Asthma Documentation and Forms

H.8.1 Parent Letter, Peak Flow Monitoring

H.8.2 Referral to Physician

H.8.3 Asthma Management Plan

H.8.4 Asthma Information, Request for

Back to Table of Contents

H.9 ADHD Documentation and Forms

H.9.1 Referral, Teacher to Nurse

H.9.2 Health Assessment, Individualized, ADD/ADHD Referral

H.9.3 Physician Report to Nurse

H.9.4 ADD/ADHD Monitoring Scale, DoDEA

H.9.5 ADD/ADHD Monitoring Scale, Interpretation

Back to Table of Contents

H.10 History/Informational Forms

H.10.1 Health Assessment

H.10.2 Preschool Functional Screening

H.10.3 Social/Family/Medical History: Grades 6-12

H.10.4 Social/Family/Medical History: Middle School

H.10.5 Social/Family/Medical History: Preschool-Grade 5

H.10.6 Social/Family/Medical History: Three-Year Review

Back to Table of Contents

H.11 Health Services Information Sheets

H.11.1 Weekly Log of Nursing Activities

H.11.2 Conference Log

H.11.3 School Health Services Summary

H.11.4 End-of-Year Checkout, School Nurse

Back to Table of Contents

H.12 Miscellaneous Forms

H.12.1 Medical Power of Attorney

H.12.2 Authorization for Medical Care of Dependent

H.12.3 Sports Physical

H.12.4 Physical for Sports, Scouts, and Activities

Last Revised: November 1, 2007

Contact Information
DoDEA P.P.S. Coordinator 4040 North Fairfax Drive Arlington, VA 22203 (703) 696-4479 x1916