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The
School Health Form Advisory Board was established by
Act 685 (R.S.40:5.12) in the 2004 Regular
Legislative Session to develop standardized school
health forms. The goal of the forms is to eliminate
the duplication of information submitted to schools
and school nurses relative to health information and
screenings, allergies, illnesses, sports physicals,
medication administration, and prescribed
procedures.
The
Department of Education, in collaboration with the
Department of Health and Hospitals, jointly
promulgated rules and regulations for the use and
distribution of the standardized school health
forms. (See Bulletin 741, the Louisiana Handbook for
School Administrators, also known as Title 28 of the
Louisiana Administrative Code.) Effective August
2007, R.S. 40:5.12. requires all local educational
agencies to implement the use of the standardized
school health forms.
Seven forms have been developed. The most current
versions of the school health forms (below) replace
all other forms used to obtain health information,
including previously piloted versions of these
forms. These forms shall not be changed or altered
in any manner.
1.
School Entrance & General Health Exam Form/Sports
Physical Form
– This form can be used for sports physicals* and/or
other health evaluations provided to school nurses
and school systems. This form includes detailed
instructions for the medical provider, including a
list of suggested screens to be done if medically
indicated based on history or clinical findings.
This form can also be used to meet the requirements
of the KIDMED periodic and interperiodic assessments
if the required reproductive health information is
included.
2.
Physician’s Authorization for Special Health Care
– For any procedure orders, i.e., blood
glucose monitoring, catheterization, etc.,
prescribed by a licensed provider that a student
must receive during the school day.
3.
Medication Order For Louisiana Public Schools – For medication orders prescribed by a licensed provider
that a student must receive during the school day.
4.
Medication
and Treatment Administration Plan
The
physician has a section to complete and the form
must be presented with the Medication Order before
the nurse can accept the medication at school.
5.
Request for
Administering Medication at School and Release from
Liability
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The parent/guardian must
meet with the school nurse and present this form
along with the Medication Order and Medication and
Treatment Administration Plan before medications can
be administered at school.
6.
Health Information Form
– For pertinent health and emergency contact
information provided by parents/legal guardians to
the school district.
7.
Authorization for Release of Confidential
Information
– Required to be signed by parent/legal guardian
before health information can be shared between the
school system and health care providers, i.e.,
hospital, physician, service agency, school RN,
and/or other health provider.
Questions or comments may be directed to Maureen
Daly, MD, MPH, Office of Public Health,
mdaly@dhh.la.gov.
To download copies of the school health forms please
click on the desired form above.
*This form or the Louisiana High
School Athletic Association (LHSAA) form is
acceptable by the LHSAA for sports physicals.
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