Sample Health Services Forms and Notifications
Note: Sample 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.
Athletics Forms | Letters | Notifications
Student-Athletes with Medical Conditions - Confidential List
Sample Athletes Health Issues Form (fillable doc) which may be used by school nurses to share student medical needs with athletic directors/coaches (NYSCSH 7/21)
Sample clearance to participate in sports flowchart. (NYSCSH 4/18)
School Health Examination Guidelines 2018
Provides information on student health examination requirements and guidance for administrators and school health personnel in establishing the mandated health program. (Updated May 2018)
- Required NYS School Health Examination Form
The form may be printed and completed by hand. (NYSED 2020).
- Required NYS School Health Examination Form (Fillable PDF 2020)
This form may be completed electronically by saving it to your computer, entering the information into the fillable fields, and saving a copy for each student (NYSED 2020)
Sample Recommended NYSED Interval Health History for Athletics
Sample Recommended NYSED Interval Health History for Athletics (Fillable PDF) Includes questions related to COVID-19 (Updated 12/2020)
Sample Recommended NYSED Interval Health History for Athletics (Word) (Updated 12/2020)
Sample Recommended Medical Certificate of Limitations Form May be used to document private provider recommendations for accommodation for PE (5/2018).
Sample Athlete with Special Needs Supplemental History Form May be used to obtain additional health information from athletes with special needs. (AAP-Bright Futures, 3/2018)
The links below redirect to the NYS Education Department Athletics and Coaching Page for the most current information on this topic.
- Attachment C: Physical Maturity Form (page 17) - form to be filled out by both Director of PE/Athletics AND Medical Director
- Attachment H: Physical Maturity Chart (page 25) - Physical Maturity Chart - Recommended Tanner Scores APP
Page reviewed 12/1/21
- Required NYS School Health Examination Form
Communicable Disease | Illness | Injury Notifications | Consents | Non-Patient Specific Orders (Includes COVID-19 Samples)
Communicable Disease | COVID-19
The sample communications below should be reviewed and approved by your school medical director and school administrator. It is essential to maintain the confidentiality of affected students when sending notifications. If the local health department, in collaboration with the NYS Department of Health (NYSDOH), determines that there is an outbreak of a reportable communicable disease, they will provide response guidance to schools' medical directors and BOE's.
Communicable disease prevention, surveillance, notification, and reporting are important roles provided by the school health team. In addition to documenting the care of ill or injured students according to district procedures, it is important to share your observations and recommendations for following up with the student's parent or guardian. Information may include:
- A description of the illness which includes the date, time, and details of the complaint.
- Recommendations for follow up.
- School health services contact information.
General Information on Illness and School Attendance
When to Keep a Child - Home Instructions to Parents/Guardians Sample letter to share district guidelines. This letter should be reviewed and approved by the School Medical Director prior to use. (NYSCSH 12/2019)
Sample Your Child Was Seen In The Health Office With Symptoms of COVID-19
Your Child Was Seen In The Health Office With Symptoms of COVID-19 Sample letter to send home with students who present with COVID-19 symptoms. This letter should be reviewed and approved by the School Medical Director prior to use. (NYSCSH 11/2021)
Sample Non-Patient Specific Order for BinaxNow™ COVID-19 Testing
Sample Non-Patient Specific Order for BinaxNow™ COVID-19 TestingThis sample order can be used for schools implementing BinaxNow™ COVID-19 testing of students. It contains the required elements of an NYS non-patient-specific order. It should be reviewed and approved by the school medical director prior to use. (NYSCSH 12/20/20)
Sample School COVID-19 Testing Consent Form and Instructions
Sample School COVID Testing Consent Form (PDF)This sample consent form was created to assist schools with the requirement to have parent/guardian permission on file prior to testing a child, this form also informs the parent/guardian of their child’s test results and other information which may be disclosed as permitted by law. (NYSCSH 10/22/21)
Sample Spanish School COVID Testing Consent Form (PDF) (NYSCSH 11/22/21)
Sample School COVID Testing Consent Form Instructions This instruction sheet was created to assist schools in using the Sample COVID Testing Consent Form as a PDF. (NYSCSH 12/3/20)
Sample Health Office Visit for Illness|Injury Notifications and NYSDOH Information Fact Sheets
Sample Illness Notification This letter may be customized to alert parents/guardians to communicable illnesses. (NYSCSH12/1/19).
NYSDOH and CDC Information Fact Sheets (this list is not all-inclusive)
- Chicken Pox NYSDOH Fact Sheet
- Conjunctivitis - Letter to Parents/Guardians (NYSCSH, 11/2019)
- Conjunctivitis (Pink Eye) Fact Sheet Pink Eye
- Fifth Disease NYSDOH Fact Sheet
- Flu NYSDOH Fact Sheet Parents: Fight Flu at Home and School English, Spanish, Bengali, Chinese, Haitian Creole, Korean, and Russian
- Hand Food Mouth Disease (Coxsackie Virus) NYSDOH Fact Sheet
- Head Lice Alert Letter For Parents/Guardians Emphasizing Prevention (NYSCSH, 3/2019)
- Pediculosis (Lice) NYSDOH Fact Sheet
- Lice Treatment Guidelines (CDC)
- Impetigo NYSDOH Fact Sheet
- Measles Resources for Parents and Childcare Provider Measles Webpage (CDC)
- Measles NYSDOH Fact Sheet Measles notification is determined in consultation with NYSDOH|LHD
- Pinworm Infection NYSDOH Fact Sheet
- Mycoplasma Infection (walking pneumonia, atypical pneumonia) Disease NYSDOH Fact Sheet
- Ringworm NYSDOH Fact Sheet
- Scabies NYSDOH Fact Sheets
- Shingles NYSDOH Fact Sheet
- Skin Infections in Athletes NYSDOH Fact Sheet
- Streptococcal Infections NYSDOH Fact Sheet
The following sample form may be customized and used by districts based on your school Medical Director's Guidance and BOE policies.
Notification to Parent/Guardian of Student Health Office Visit Provides a checklist that may be used by the school nurse to document student visits, first aid provided, and the method by which the parent/guardian was notified. It includes information on injuries related to abrasions, cuts, or puncture wounds, which may require follow-up. Symptoms of potential infection and recommendations for monitoring are provided. Your school medical director should approve this form.Additional Resources on these topics are available in the A-Z Resources
Communicable Disease - "C" page of the A-Z Resources
Injury Prevention - "I" page of the A-Z ResourcesPage updated 11/17/21
Disease Specific ECP | IHP | 504 |Diabetes Addendum | Flow Sheets
Sample Resources Below should be reviewed and approved by the School Medical Director and/or BOE prior to use.
Allergy|Anaphylaxis Care Plans
Asthma Care Plans and Action Plans (AAP)
Asthma Action Plan-NYSDOH (5/2017)
Sample Emergency Care Plan for Unlicensed School Personnel: ASTHMA (11/2021) Provides easy-to-understand information for unlicensed school staff to assist and respond to an asthma emergency.
Sample Letter to Families about Metered Dose Inhalers, Spacers and Nebulizers Provides information on why an MDI and Spacer is preferable over a nebulizer during the COVID Pandemic (NYSCSH 9/2/20).
Sample Provider and Parent Guardian Permission for the use of School Provided Spacer/Valved Holding Chamber Provides schools the opportunity to provide a back-up spacer in the event that the student's is not available. (7/7/20)
Diabetes Medical Management Plans (DMMPs)|Addendum to Allow HCP Provide Criteria for Parents Input on Insulin Dose
Effective tools for successful diabetes medical management
Here you will find a sample Diabetes Medical Management Plan, a sample template for an Individualized Health Care Plan, and sample Emergency Care Plans for Hypoglycemia and Hyperglycemia.
The National Institute of Diabetes and Digestive and Kidney Diseases.
Additional FAQs, as to who can carry out a Diabetic Emergency plan within a school system, how long do they last, etc.
DMMP Addendum: Role of Parents/Guardians in Adjustment of Insulin Dose
Allows the HCP to provide criteria by which the parent may be consulted in adjusting insulin doses administered by a nurse during school hours and at school-sponsored events, to the extent reasonably practicable. 5/2017 Note: HCP orders only allow the parent to provide proposed adjustments or dosages and require the health care professional to make the ultimate decision after exercising his/her professional judgment.
Math Calculation Checker Worksheet for Insulin Deviation
This worksheet may be used to verify that math calculations performed by the RN are correct. (9/2017)
Diabetes Hypoglycemia|Hyperglycemia Plans
Glucagon Training Documentation Form for School Personnel Documents understanding and skills attainment for staff voluntarily administering glucagon for students with patient-specific orders. This form is also available with the PPT training program on the NYSCSH Glucagon page.
Diabetes Sample 504 Plans
Generic Sample Care Plans and Other Emergency Documentation for Students and Staff
Sample Generic Emergency Care Plan for Unlicensed School Personnel (5/16) Information for unlicensed school staff to assist with emergency health issues.
Special Health Care Needs Record May be used to document student health concerns, provider|parent permissions, medications, and ECP (9/12)
Seizure Sample Care Plans | 504 Plans | Interview Questionnaire for Seizure History
Seizure ECP - Customizable template for the HCP to document type of seizure and treatment plan. Separate medication order would be needed. (NYSCSH, 6/2012)
Seizure ECP with Medication Information - Customizable template for HCP to document response plan for seizures. Includes area for medication and Vagal Nerve Stimulator orders. (NYSCSH, 9/2012)
Parent Interview Questionnaire for Seizure History - Documents seizure history, medications, and current understanding of the condition (NYSCSH, 6/2012)
Page updated 9/16/21
FERPA Disclosure Log | Authorization
Sample Permission to Share Protected Health Information (HIPAA) - Allows the parent to designate health care providers who may share information with designated school staff (8/12)
Page Reviewed 11/17/21
Health Examination Forms, Parent Letters and Notifications
Health examinations are required for new entrants and in grades Pre-K or K, 1, 3, 5, 7, 9, and 11.
(Section 136.3 Health Examinations and Screenings. Effective 7/1/18)
School Health Examination Form and Instructions for an EHR Compatible Form
Required NYS School Health Examination Form
This form may be printed and completed by hand. (NYSED 2020)
Required NYS School Health Examination Form (Fillable PDF)
This form may be completed electronically by saving it to your computer, entering the information into the fillable fields, and saving a copy for each student (NYSED 2020).
Instructions for Completion of the New York State School Health Examination EHR Compatible Form
Provides direction to health care providers on the required components and the required presentation order of those components for an electronic health record form to be an equivalent form. (NYSED 2020) Posted 1/28/21
School Health Examination Form Sample Resources
Instructions for School Nurses and School Medical Directors Related to Completion of the Required Health Examination Form Effective 1/31/2021. Contains instructions for school nurses and school medical directors and customizable, sample notifications for parents/guardians and community health care providers reminding them of the need to use the required form. (NYSCSH 1/28/21)
Required NYS School Health Examination Form FAQ's Provides answers to questions the Center has received regarding use and completion of the form. (NYSCSH 1/28/21)
Interval Health History Forms may be modified by local school districts. If modified, it should be reviewed and approved by the School Medical Director and Administration prior to use.
Sample Recommended NYSED Interval Health History for Athletics (Fillable PDF) Completed by parent/guardian no earlier than 30 days prior to the start of the sport. This form now includes questions related to COVID-19 (Updated, 12/2020)
Sample Recommended NYSED Interval Health History for Athletics (Word) Completed by parent/guardian no earlier than 30 days prior to the start of the sport. This form now includes questions related to COVID-19 (Updated 12/2020)
Spanish Sample Recommended NYSED Interval Health History for Athletics (Word) (Updated 1/2021)
Medical Certificate of Limitations Form
Sample Recommended Form-Medical Certificate of Limitations Used to document private provider recommendations for accommodation for PE. (Updated 05/2018)
Sample Athlete with Disabilities Form-This resource from the American Academy of Pediatrics may be helpful in collecting additional health information from athletes with disabilities. (AAP-Bright Futures, 2019)
Sample Athlete with Special Needs Supplemental Form American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine.PDF (2010)
Sample Medical History Update Form Optional form that may be used to obtain current health information from the parent/guardian in non-mandated health examination yeas or to provide student history prior to a school-provided physical exam (2/2018)
Health Exam and Screening Requirements Charts|Determination for Ungraded Students
Dental Certificate|Dental Providers|Letter to Parents/Guardians Regarding Dental Exams
Sample Dental Certificate-NYSED This form aligns with health exam grade levels. NYS law (Chapter 281) permits schools to request an oral health assessment when requesting a health exam. It may be completed by a registered dentist or NYS registered dental hygienist.
Letter to Parents Regarding Health and Dental Examination Requirements Informs parents/guardians of the mandated requirements for health appraisal within 30 days of school entry (5/12/21).
School Medical Director Delegation StatementSchool Medical Director Delegation Statement Written delegation is required for review of health examinations, interval health history for athletic, and screening students for vision, hearing, & scoliosis per Education Law, Article 19, section 905,(1). This sample may be customized by the district to comply with that requirement (6/2018).Page updated 7/14/21
Health Office Daily Visit Logs and Cumulative | Summary Records
Page Reviewed 11/18/21
Health Promotion | Safety
These letters 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.
Animals in the School Building
Food in the School Building
Classroom Treats - This is a general letter that should be altered to align with your district’s policies on classroom treats (some districts only allow pre-packaged snacks, some allow home-baked goods). This is a template only and does not reflect any state guidance or recommendations.
What You Say In Here Stays In Here - This 8.5 X 11-inch printable poster can be printed and displayed to make students aware of school staff members' responsibility to share information that could result in harm of self of others according to school policies (NYSCSH 10/2017).
Page Reviewed 11/18/21
Immunizations Forms | Notifications
2021-2022 NYSDOH Immunization Requirements for School Attendance Chart (6/2/21)
Sample Letter to Parents/Guardians for 2021-2022 immunizations for students
Chronological Age/Grade Chart (6/2/21)
Sample Letter for Administrators/Principals to Inform Parents/Guardians of Exclusion
Sample Exclusion Letter for Principal to Send to Parents - This sample letter for principals can be customized to send letters to parents/guardians whose children have not received the required immunizations for school attendance. The first page includes information for the administrator and should be deleted prior to sending it to parents and guardians. This resource includes a memo from the NYSDOH stating that immunizations are required whether learning is provided in-person, remotely or hybrid is also included. (NYSCSH, 9/19/20)
Sample 2020-2021 Exclusion Notification of Missing Immunizations (Shot) During COVID-19 with December 11, 2020 Deadline Provides a sample that principals can customize to send letters to parents/guardians whose children have not received the required immunizations for school attendance (NYSCSH, 11/17/20).
Sample Medical Exemption Letters/Forms From the NYSDOH and NYSCSH
Immunization Requirements for School Attendance/Medical Exemption Statement for Children 0-18 years of Age Form. This form must be completed annually (NYSDOH).
Sample Medical Exemption Approval Letter with Notification of Exclusion During Communicable Disease Outbreak This sample letter may be customized to inform parents/guardians that their child has that in the case of an outbreak, their child would be excluded for the length of contagion. Ideally, this information should be communicated when the exemption is granted. (NYSCSH, 9/2019)
Page Reviewed 11/22/21
Medication Forms, Letters, Notifications
Administration/Use Tracking Forms
Daily Medication Record School Year (Excel format) - Calendar view of medication charting for an individual student modifiable for your school district. (6/2018)
Dose Counting Daily Medication Record (Excel format) - Calendar view record of medication administration which provides a continuous count of medication given and medication remaining. (7/2018)
Dose Counting Daily Medication Record School Year (PDF format) - Calendar view record of medication administration which provides a continuous count of medication given and medication remaining. (7/2018)
Daily Medication Sheet For Summer School - July and August calendar view of medication charting. (7/2018)
Monthly Medication Administration Record (Medicaid Compliant) - Records date, times, doses, exception codes, reactions, Medicaid compliant signature boxes, and NPI number. (7/2017)
Administration Authorization / Permission Forms
Administration of Medication at School-Parent/Guardian & Health Care Provider Permission to Administer Medication - Documents provider order & parent permission for medication use at school. It does not indicate allow permission for the student to carry and use the medication independently. Additional permission from the provider and parent for Independent Medication Carry and Use must also be completed for that to occur (3/2019)
- Attestation Sample Form - This form may be used as an addendum along with provider order and parent/guardian permission for students to carry and use medications that require rapid administration. (9/2017)
- Attestation: Sample Letter to Parents/Guardians - Informs parents and guardians about the attestation requirements (9/2017)
Sample Provider and Parent Guardian Permission for the use of School Provided Spacer/Valved Holding Chamber - Provides schools the opportunity to provide a backup spacer in the event that the student's spacer is not available. (7/7/20)
Sample Sunscreen Parent Permission for students who can independently apply or with adult assistance to help apply their own or school-provided sunscreen.
Determining Who Can Administer Medication and Students Capability
Levels of Assistance in Administering Medications Guide- Provides guidance in determining how may and may not administer medications in school and how to determine who may do so. (Updated 9/2019)
Diabetes Medication Forms
Blood Glucose / Insulin Log for Individual Students (NYSDOH Guide-Page 94)
Diabetes Medical Management Plan Addendum: Role of Parents/Guardians in Adjustment of Insulin Dose Documents provider permission to allow parents/guardians to adjust the insulin dose. (5/2017)
Field Trip Forms
Parent/Guardian Permission for Field Trip Attendance and Medication Delivery - Documents field trip information and parent/guardian permission for the administration of medications. Provider attestation must be included for independent medication use.
School Checklist for Medications on Field Trips - Checklist of responsibilities regarding medication administration on field trips for the School Board/Administration, School Nurse/District Personnel, Parent/Student. Includes options for the provision of medication to students who require medication on field trips. (12/2016- Currently being updated)
Parent/Guardian Medication Communications & Notification
Sample Medication Delivery Information for Parents- Provides information for Parents/Guardians on what is needed to administer medications at school, including recommendations for a spacer for MDI use vs. nebulizer. (7/7/20)
Sample End of Year Pick Up - Medication pick-up information for end of year
Parent/Guardian Designation to Authorize Another Adult to Administer Medication - Document parent/guardian permission to authorize another adult to administer medication to their child for a specific event (Updated 1/2018)
Receipt Forms for Medications / Expiration of Medication Form / Documentation of Medication Errors
Receipt of Medication Delivered to School - Documents receipt of initial and subsequent medication delivery from parents.
Receipt of Medication Returned to Parent/Guardian - Documents the return of medication from the Health Office to the parent/guardian.
Expiration of Medication Recording Form - Documents student name, teacher/grade, medication name, and expiration date.
Medication Incident Report Form - Documents medication error, notifications made, and outcome.
Sample Sunscreen Parent Permission for students who can independently apply or with adult assistance to help apply their own or school-provided sunscreen.
Training & Self Determination Forms and Checklists
Checklist Training Unlicensed Personnel to Assist Supervised Students in Taking Their Own Medications - Checklist of training criteria for unlicensed assistive personnel to assist supervised (self-directed) students in taking their own medications (10/2015)
Nursing Assessment for Determination of Supervised (formerly Self-Directed) Student - This is a customizable version of the above document. This lists the steps to go through in the determination of supervised student (10/2015)
Page Updated 11/22/21
Post Restraint Resources
POST RESTRAINT FORM
Page Reviewed 11/24/21
School Health Office Data Collection and Responsibilities
Emergency Care Data Collection (NYSCSH)
The following data collection is being done on a voluntary basis. This is not mandated, but data collection is important to demonstrate the response of the school nurse in a medical emergency, to help advocate for staffing needs, create policy and programs, and create a healthy and safe environment. Please complete the following forms if the emergency medication or treatment listed is used:
- AED Administration Sample Reporting Tool
- Concussion Injury Sample Reporting Tool (11/2021)
- Diastat Administration Sample Reporting Tool (11/2021)
- Epinephrine Administration Sample Reporting Tool
- Glucagon Administration Sample Reporting Tool (11/2021)
- Opioid Overdose Prevention Sample Reporting Tool
*Note: All naloxone use should be reported in accordance with district policy utilizing the NYSDOH Reporting Form located on the NYSDOH website. Click here for the form
Health Data Documentation and Tracking Forms:
Beginning of School Checklist for the Professional School Nurse (11/2021) - List of tasks for the beginning of the school year.
End of School Checklist for the Professional School Nurse (11/2021) - List of tasks for the end of the school year.
Students Healthcare Needs Tracking Form - Customizable chart to list health concerns, orders, medications, ECP status, and notes. (NYSCSH, 2/2021)
Health Office Visit Data Collection Tool
Sample School Health Office Data Collection Tool - Customizable, easy-to-use documentation tool to collect data on school health care staffing, student health data, vision & hearing deficits, and student outcomes. (5/5/21)
School Nurse Responsibilities | Checklists | Overview of Tasks:
Nursing Annual Responsibilities (11/2021)
Nursing Monthly Responsibilities (11/2021)
Page Updated 11/23/21
Screening Charts | Forms | Letters | Notifications
SCREENING FORMS, CHARTS
New NYS & NYC Screening & Health Examination Requirements Chart- Dental certificate requests should align with the new health exam grade levels (7/2018)
Vision Screening Parent/Guardian Notification Results and Referral Form (10/2018)
Note: Parents must be notified of both passing and failing vision results. If a student passes it is sufficient to just indicated passed. However, if they fail you should provide the findings so the follow-up provider has a frame of reference. This form allows you to provide that information.Sample DelegationSample School Medical Director Delegation Statement - Written delegation is required for review of health examinations, interval health history for athletic, and screening students for vision, hearing, & scoliosis per Education Law, Article 19, section 905,(1). This sample may be customized by the district to comply with that requirement.
Page Reviewed 11/24/21
Staff Health and Contact Forms
Page Reviewed 6/29/21