Health Services

School Services

School Counseling Services

School Health Services

School Psychological Services

DoDEA
Student Health and Wellness ISS
4800 Mark Center Drive
Alexandria, VA 22350-1400
(571) 372-6011

DoDEA Student Services: School Health Services Forms

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.

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Section H: Contents

H.1 Student Health History
(Updated 2/7/2012)

H.1.1 Returning Student Health History
(Updated 2/7/2012)

H.2 Immunization Form
(Updated 2/7/2012)

H.2.1 Request for Exemptions From Immunizations
(Updated 2/7/2012)

H.2.4 Incomplete Immunizations, Registration
(Updated 8/2012)

H.2.5 Delinquent Immunizations, Notice of
(Updated 2/7/2012)

H.2.6 Disenrollment, Incomplete Immunizations
(Updated 2/7/2012)

H3: Medication Forms

H.3.1 Medication During School Day, Memorandum for Parents

H.3.10 Medication Inservice

H.3.11 Individual Medication Log

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

H4: Medication Referral Forms

H.4.1 Vision Screening Referral

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

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

H5: 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

H6: 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

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

H8: 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

H9: 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

H9.5 ADD/ADHD Monitoring Scale, Interpretation

H10: 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

H11: 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

H12: 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