Forms

School Health Service Forms

Immunization

• DHS School Immunization

• Sample Letter to Notify Families of Full Implementation of DHS 144

• Template for 2025-2026 School Year Immunization Requirements

Head Injuries/Concussions

• Concussion and Head Injury Statute 118.293 Resources and Forms

Sudden Cardiac Arrest

• Sudden Cardiac Arrest Statute 118.2935 Resources and Forms

Tuberculosis/Staff Physical Exam

• F-02314A (10/2019) - School Employee Risk Assessment Questionnaire
• F-02284 (08/2025) - Record of School Employee Examination

Student Examination/Health History/Injury

• School Nurse Chronic Health Assessment Tool
• School-Age Parent Medical Statement
• Students with Special Dietary Needs
• Student Accident Report
• Kindergarten Eye Health Examination Report
  • (English version)
  • (Spanish version)

• School District Health Record Information (English/Spanish)

Medical Advisor and Private Care Nursing

• Template of Agreements
• Sample Agreement between District and Private Duty Nurse Provided by Parents
• Sample Memorandum of Understanding for Private Duty Nurse

Sample Health Plans

• Nursing and Related Services
• Sample - IHP
• Fillable Sample IHP form
• Sample - Emergency Action Plan

• Parent Authorization for Specialized Health Care

• Parent Authorization for Attendant Care Services

• Sample - Student Health Plan

School Nurse Job Description and Evaluation Samples

• School Nurse Job Description District-Hired
• School Nurse Memorandum of Understanding (contracted services)
• School Nurse Performance Evaluation

Sample Consents

• AAP and NASN Sample Combined FERPA/HIPAA Consent Form

Hearing Screening

• Hearing Screening Results - Parent Notification
• Hearing Screening Sheet Sample
• Sample Hearing Screening Referral/Medical Evaluation
• Sample Parent Letter Hearing Referral