- Monthly Priorities - School Nursing Activities Calendar
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- 504 Forms and Publications
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Section 504 - Equity Compliance Website
BUL-4692.10, SECTION 504 OF THE REHABILITATION ACT OF 1973, August 26, 2024, Office of General CounselEducational Equity Compliance Office: SECTION 504 AND INDIVIDUALS WITH DISABILITIES web pageREF-6241.4, MANDATORY USE OF THE WELLIGENT SECTION 504 PROGRAM MODULE TO CONDUCT ALL SECTION 504 ACTIVITIES, February 2, 2020, Office of General Counsel & Educational Equity Compliance OfficeREF-066902, PROCEDURES TO REQUEST BARRIER REMOVAL FOR PROGRAM ACCESSIBILITY FOR STUDENTS AND OTHER INDIVIDUALS WITH DISABILITIES, March 11, 2019TEMPLATES:
U.S. DEPARTMENT OF EDUCATION SECTION 504 INFORMATION SHEETS:
- Asthma Forms
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REF-1526, Self Administration of Inhalers and Epinephrine Auto-InjectorWebsite: Allergy & Asthma NetworkVideo- LAUSD Nurse and Teacher InformationNational Association of School Nurses (NASN) Asthma Resources Information Page
- Audiology: Audiologic Resource Unit (ARU)
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ARU Referral Form (Fillable), September 2024
- Audiometry
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Audiometry Follow-Up Form (for use by School Nurses with audio certificate)
- Authorization to Receive/Release of Medical Information
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Authorization to Receive/Release Medical Information
- Automated External Defibrillator
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District Bulletin
BUL 4480.2, Policy and Procedure for the Acquisition and Use of Automated External Defibrillators (AED)
- CD Notifications (Chicken Pox, Fifth Disease, Hand, Foot & Mouth Disease, Headlice, Scabies)
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Sign-in to MyLAUSD first before clicking the links belowNotification FormsChicken Pox: (1) For Student Parent/Guardian (2) For EmployeesHeadlice: (1) General Notification Letter(2) Student Exclusion (3) Fact SheetDistrict Bulletin (Policy):
BUL-1645.2 Infection Control Guidelines for Preventing the Spread of Communicable Diseases
BUL-1937.3 Reporting Communicable Diseases
Communicable Disease: Handbook - Nov. 2015 - Child Health and Disability Prevention Program (CHDP) Forms
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The CHDP program has been discontinued by the state. However, based on the memo from Department of Health Care Services, a physical examination is recommended as an optional step for ensuring children's health and readiness. Please reach out to a LAUSD School-Based Clinics near the student's residence for more information.Forms:
- Condom Availability Program
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Condom Distribution- Order FormReference Guide 5010.2 - Condom Availability Program
- Confidential Health Information for a Student
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- Dental Observation Form
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Oral Health Assessment Mandate
District Bulletin: BUL 3585.7, Oral Health Assessment for Kindergarten or First Grade Entry, December 2, 2024
Forms:
Oral Health Program Notification Letter:English | Spanish
Oral Health Assessment Form: English | Spanish
Oral Health Assessment Waiver Request Form: English | Spanish
List of Dental Clinics:By Area: - Diabetes
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- Ear, Nose, and Throat Observation
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Report of Ear, Nose, and Throat Observation
- Exclusion
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- Field Trip
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Field Trip Personal Health History Form
Medication Form for OVERNIGHT Field Trips
For Medication name/s NOT LISTED on the form for Overnight Field Trips, use the form below:
- First Aid
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- Food Borne Illness Reporting
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- Food Handler Certificate
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- Head Injury
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Cautions Regarding Head Injury Forms
- Head Lice
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District Bulletin:BUL-1937.3 Reporting Communicable DiseasesForms:Fact Sheet (English/Spanish), March 2023
- Health Office Referral
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Health Office Referral to Physical Education Teacher
Pupil Health Exclusion, August 2016
School Readmittance, January 2025
- Health Office Sign-In
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- Home/Hospital Instructions Referral Forms
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Bulletin 1229.3, 7/2/2018 - Carlson Home, Hospital & Home Online Academy Instructional Services
Referral Forms: Home Medical Referral
Non-Medical Referral for Home Instruction
- IEP Forms
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District Bulletin and Reference Guide
BUL-2030.1, Guidelines for an Individualized Health Assessment and the Participation of the Credentialed School Nurse in the Individualized Education Plan (IEP) Process
BUL-6639.0, Three-Year Review IEP Psycho-Educational Re-Assessment. Page 6 of 6 states that both health and academic assessment plans are required for all triennials.
REF-2481.4, Support for Students with Assessed Health Needs in Special Education Programs
Forms: - Immunizations Forms
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Policy:BUL 1660.10: Immunization GuidelinesAttachment A: Office Guide for ImmunizationsAttachment B: Immunization Status and School Admission Quick Reference GuideAttachment C: English Required Immunizations for School EntryAttachment C1: Spanish Required Immunization for School EntryAttachment D: English Immunization Follow-Up LetterAttachment D1: Spanish Immunization Follow-Up LetterAttachment F: English HPV Letter (for 6th Graders)Attachment F1: Spanish HPV Letter (for 6th Graders)REF-6300.2 Tdap RequirementsBUL-6718.0 - Educational Rights and Guidelines for Youth in Foster Care, Experiencing Homelessness and/or ..Forms:Attachment D: English Immunization Follow-Up LetterAttachment D1: Spanish Immunization Follow-Up LetterImmunization Medical ExemptionsExemptions FAQs (updated 3/9/2021)Pre-2020 Medical Exemptions by Disciplined Physicians (updated 4/14/2021)
- Medical Exemptions and Exclusions (Not for Immunizations)
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Please make sure to sign in to MyLAUSD before clicking the links below.This section is not about Medical Exemptions to required immunizations. For information on the medical exemption to required immunizations, click here.
Policy: BUL-3219.2, Student Medical Exemption and Exclusion Policy and Procedures
Forms:
- Medical Waste: Transport Checklist, Tracking Document and Generator Certificate
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For Transporting Expired Medications and/or Sharps Container
Medical Waste Tracking Doc and Generator Certificate 2024-2025
***A separate Tracking Document MUST be completed for Medication and Sharps Container. To download another copy of the Tracking Document, click here.
***EXPIRED Hand Sanitizer Disposal Information
- Medication Forms
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Attachment B Renewal of Request for Medication to Be Taken During School Hours
Attachment D Medication Log. For download, click here for 2024/2025
Attachment E Request for Self-Administration of Medication to be Taken During School Hours
Attachment E-1 & E-2 ENGLISH- Request for Self-Carry of Emergency Medication to be Taken During School Hours with Student Contract
Attachments E-1 & E-2 SPANISH - Request for Self-Carry of Emergency Medication to be Taken During School Hours with Student Contract.
Attachment F Student Contract for Self-Administration/Self-Carry of Medication During School Hours
Attachment GAsthma Action Plan. Downloadable version: Asthma Action Plan English/Spanish, 1/2024
Attachment H Medical Waste Transport Preparation Checklist
- Mental Health Evaluation Team (MHET) Preliminary Information Request Form
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***When requesting service/support from LASPD Dispatch (213.625.6631) for a student/employee identified as high risk for suicide/threat (per BUL-2637.4, BUL-5799.1, BUL-5798.0), the following Preliminary Information should be provided as indicated in the Mental Health Evaluation Team (MHET) PRELIMINARY INFORMATION Request Form***
- Naloxone: Administration of Naloxone Spray
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BUL-133120 ADMINISTRATION OF NALOXONE NASAL SPRAY
IOC: NALOXONE (NARCAN) NASAL SPRAY
LAUSD DNS NALOXONE TRAINING FOR SCHOOL NURSES: NURSE SUPPLEMENTAL
DNS PD: NALOXONE TRAINING TOOLKIT 12/13/22
INSTRUCTIONS FOR ADMINISTRATION OF NALOXONE
NALOXONE EMERGENCY RESPONSE SITE PLAN
NALOXONE NASAL SPRAY MONTHLY CHECKLIST
REPORT OF NALOXONE ADMINISTRATION FORM (BLANK)
NALOXONE SKILLS AND PROCEDURES
SAMPLE LETTER: NALOXONE REQUEST FOR VOLUNTEERS
SAMPLE LETTER: NALOXONE VOLUNTEER NOTIFICATION
- Nurse-Family Partnership Referral Form
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Nurse-Family Partnership Referral Form
Related District Publication:
BUL-3276.1 Compliance on Services for Pregnant Minors and Parenting Minors, August 15, 2007
- Oral Health Assessment Form
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District Bulletin: BUL 3585.7, Oral Health Assessment for Kindergarten or First Grade Entry, December 2, 2024
Form:
Oral Health Program Notification Letter:English | Spanish
Oral Health Assessment Form: English | Spanish
Oral Health Assessment Waiver Request Form: English | Spanish
List of Dental Clinics:By Area: - Permanent Health History
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Permanent Health History
- Preschool Forms
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Home Instruction Referral Forms
- Principal - Credentialed Nurse Conference
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- Readmission
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- School Attendance Review Board (SARB) and Site School Nurses
- Seizure
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See Protocols section: Seizure Care for more information/forms
- Special Diet Request Form
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- Sports/Athletics Forms
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Sign in the MyLAUSD first before clicking the links below
Disrict Bulletin:
BUL-4948.2 Medical Clearance and Return to Play Guidelines for Students Participating in Interscholastic
BUL-6429.4 Athletic Rules and Regulations
Clearance Policy for Student-Athletes with Impaired Vision
Memo:
Guidance for Screening Pre Participation of Examination (PPE) Forms (COVID)
IOC Student Athlete Returning from a Positive COVID-19 Test
Forms:
PPE with Parent's Section in English
PPE with Parent's Section in Spanish
Medical Conditions and Sports Participation
Concussion Injury and Return to Play Forms
Flowchart: Documentation of Suspected Concussion Injury
Medical Clearance Form - to start Stage III of RTP Protocol
Hx of COVID-19 - Sports Participation Parent Letter
Post COVID-19 Return to School and Graduated Return to Play
- Substitute Folder Forms
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Elementary - Information for Sub School Nurses, January 2025
Secondary - Information for Sub School Nurses, January 2025
- Time Reporting and Mileage Forms
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FMLA Forms DownloadAbsence
Certificate of Absence and Other Payroll Forms (linked to the Payroll Administration website)MileageMileage Form - this form MUST be downloaded and saved to your computer folder in order for the PDF features to work (fillable fields, total mileage etc)Z-TimePre-Approval For Additional Work Time rev. 8/16/20242024/2025 Request for Payment of Additional Time (fund column completed by the Supervisor) - Training Logs
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Information | Training Logs Access: DNS
- DNS Training Logs are submitted at: Submit Training Logs
- All submitted training logs (Student Specific, General, and Supervisor Checklist) are housed on SharePoint: Access Submitted Training Logs
JOB AID: Downloading Training Records from SharePoint
Contact your Nursing Coordinator if:
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You can’t access the Training Log SharePoint Link
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A training log needs to be marked as an error (provide explanation)
- Transfer Form
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Credentialed School Nurse Transfer Form 3/2023
Licensed Vocational Nurse (LVN) (Employee Initiated)Transfer Form
- Vision Screening
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Report of Vision Screening English/Spanish
Report of Color Vision Test
Resources
Guide for Vision Screening
Vision Screening Summary Table
Vision Screening Presentations and Training:
Vision Screening Guidelines_1-25-22
Spot Vision Screener Product Overview Training_1-25-22
- Visually Impaired (VI) Program
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District Reference Guide:
REF-5527.0 - Visually Impaired Program: Referral, Assessment, and Scope of Service
Form:
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Quick Links
