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New York State Center for School Health

Supporting Student Success Through Health and Education

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The forms and notifications are provided as guidance based on current best practice. 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

Contains documentation forms for daily visit, illness and injury notifications and letters and NYSDOH communicable diseases fact sheets.

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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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FERPA Disclosure Log | Authorization

Forms necessary to comply with FERPA

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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 Promotions | Safety

Contains letters to parents regarding animals in the school setting, 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, and letter and notifications to parents/ guardians.

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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 & 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 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 8, 2019

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