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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)

Permanent Health History

Permanent Health History Form  

Release of Medical Information


Special Diet

Medical Statement to Request for Special Diet


 Shots for School

Corona Virus Response and Recovery

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

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
Diabetic Care - Blood Glucose Testing English
Diabetic Care - Hypoglycemia English
Diabetic Care - Glucagon English
Diabetic Care - Baqsimi  
Diabetic  Care - Hyperglycemia Treatment English
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 English-Spanish

Oropharyngeal and Nasopharyngeal Suctioning

Ostomy Care English-Spanish

Oxygen Therapy


Seizure Care - Action Plan


Seizure Care- Parent Questionnaire


 Seizure Care - Nasal Benzodiazepines (Nayzilam & Valtoco)


Seizure Care - Diastat Administration

Seizure Care - Vagus Nerve Stimulation English-Spanish

Tracheostomy - Suctioning


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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