Samples and Forms / Health Services Forms and Notifications

New Forms Related to COVID-19
Are Under Communicable Disease | Illness | Injury Notifications |Consents

The forms and notifications are provided as guidance based on current best practices. They do not constitute a mandate nor imply liability should the school choose other options. These sample resources may be modified for your use consistent with NYSED, local district policy, and school medical director guidance.
Click here for Guidelines related to the topic contents below are located on the Laws|Guidelines|Memos page.

Athletics Forms | Letters | Notifications

Physical Examinations, Re-certification form and other forms necessary for Interscholastic Sports.

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Communicable Disease | Illness | Injury Notifications | Consents | Non-Patient Specific Orders (Includes COVID-19 Samples)

Contains sample forms for when to keep students home from school, NYSDOH communicable diseases fact sheets, and checklists for notifying parents and guardians of student illness and injury which occurs in school. COVID resources include sample consent for testing and sample non-patient specific orders for BinaxNow™ COVID-19 Test.

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Disease Specific ECP | IHP | 504 |Diabetes Addendum | Flow Sheets

Sample Care Plans, Emergency Plans, Action Plans for anaphylaxis, asthma, diabetes, seizures and other emergency conditions requiring immediate response, emergency flow sheets for both school nurses, unlicensed staff.

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Health Examination & Dental Forms | Parent Letters | Notifications

Contains Sample NYSED health examination form, dental certificate info, NYSED sample interval form, sample notifications to parents/guardians and provider.

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Health Office Daily Visit Logs and Cumulative|Summary Records

Contains sample student health office visit record, cumulative health record template, daily student visit form.

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Health Promotions | Safety

Contains letters regarding animals in the school, classroom treats, summer newsletters, What you say in here stays in here poster, etc

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Immunizations Forms | Notifications

Contains NYSDOH Immunization requirements, documentation and tracking forms, sample exemption letters, exclusion letter and immunization requirement notifications to parents/ guardians, sample exclusion letter for Principals.

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Medicaid Resources

Sample Documentation Forms for Medicaid Reimbursable Services includes spaces for NPI and ICD numbers.

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Medication Forms | Letters | Notifications (Includes Medication on Field Trips)

Contains administration and authorization forms, diabetes tracking & field trip forms, training student & staff form, and parent notification forms.

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Post Restraint Resources

Contains sample form which maybe customized for your district's use in documenting student health status post restraint use.

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Screening Charts | Forms | Letters | Notifications

Contains resources recording health exams and screening for hearing, scoliosis, and vision screening.

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School Health Office Data Collection and Responsibilities

Beginning/ending nursing checklist, screening records, monthly/weekly/annual nursing tasks/activities worksheets

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Staff Health and Contact Forms

Contain staff emergency contact form, emergency care flow sheet, and physical examination report.

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Last Modified on April 7, 2021

New York State Center for School Health