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Home/Hospital School

Referral Forms: Home Medical Referral

                            Hospital Medical Referral

                            Psychiatric Referral

                            Non-Medical Referral for Home Instruction


Request for Medication to be Taken During School Hours, Form 33.199 (Feb 2023)

Asthma Action Plan English/Spanish Jan 2024

Request for Self-Admin of Medication, From 33.205 (March 2023)

Request to Self-Carry Emergency Medication (English)

Request to Self-Carry Emergency Medication (Spanish)

Permanent Health History

English -  Spanish

English - Armenian

English - Chinese

English - Farsi

English - Korean

English - Russian

English - Tagalog

Release of Medical Information

Authorization to Receive/Release Medical Information  

Special Diet

Medical Statement to Request for Special Diet


 Shots for School


In-Home COVID Vaccine for Homebound LA County Residents  

Please contact 211 for assistance with basic needs and other resources at https://211la.org/search-resources

Health Brochures

My Child Has A Health Problem

My Child Has A Health Problem



My Child Needs Medication/s in School

My Child Needs Medication
in School




My Child Has Medical Treatment/s

My Child Needs Medical Treatments During
the School Day




My Child Has Severe Allergies

My Child Has Severe Allergies


My Child Has Asthma

My Child Has Asthma


My Child Has Diabetes

My Child Has Diabetes






My Child Has Seizures

My Child Has Seizures





SPHCS Guidelines

Authorization Form

Adrenal Insufficiency Care

Solu-Cortef Protocol Guidelines  

Authorization Form for Emergency Medication for Adrenal Insufficiency and Student Emergency Care Plan



Anaphylaxis English-Spanish
Autonomic Dysreflexia English-Spanish
Catheterization, Clean English-Spanish
Catheterization, Sterile English-Spanish
Clean Self Catheterization with Assistance English-Spanish
Clean Self-Catheterization English-Spanish

Diabetes Care

Blood Glucose Testing




Hyperglycemia Treatment

Gastrostomy - Bolus Method Feeding English-Spanish
Gastrostomy - Slow Drip Method or Pump English-Spanish
 Gastrostomy  - Replacement English-Spanish
Jejunostomy - Slow Drip or Pump English-Spanish
Oral - Nasal Suctioning
Oropharyngeal and Nasopharyngeal Suctioning English-Spanish
Ostomy Care English-Spanish
Oxygen Therapy English-Spanish

Seizure Care - Action Plan

Seizure Care- Parent Questionnaire English-Spanish

Seizure Care - Nasal Benzodiazepines (Nayzilam & Valtoco)


Seizure Care - Diastat Administration


Seizure Care - Vagus Nerve Stimulation

Tracheostomy - Suctioning English-Spanish

Tracheostomy -Tube Replacement

(Emergency Procedure Only)
































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    Contact Info

    121 N. Beaudry Ave.,
    Los Angeles, CA 90012 
    P: (213) 202-7580
    F: (213) 580-6557
    E: DistrictNursing@lausd.net

    Sosse Bedrossian, MSN, MA, RN, FNP-C


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