Health Forms

MEDICATION FORMS

For Asthma medications: (example: Albuterol)

For Epinephrine medications: (examples: EpiPen, Auvi-Q, Adrenaclick)

 

The "Emergency Treatment for Anaphylaxis: Epinephrine Auto Injector" form and The Self Administration Medication Form (if the Pen is to be possibly self-injected) is signed by the Healthcare Provider and Parent. #1-7 is completely filled out.

For Self-Administration (self-carry) Medications: *If you use an inhaler for Asthma, use the Asthma

 

Action Plan form above.

 

This medication form authorizes the Student to self-carry and self-administer medication during school hours, during field trips, and athletic events. For Controlled Substances, please use form in next section below - "Request for Medication to be Taken During School Hours".

ADMINISTRATIVE GUIDE 2312-6: Children wearing braces, casts or using crutches, wheel chairs, and the like, shall be permitted to attend school only on written permission of the physician in charge of the case.

Please email the School Nurse (sidebar link on "Health Office" page) for a helpful form that the Healthcare Provider (HCP) can fill out. Or Alternatively, an acceptable medical note from your HCP will have the following:

• Student’s Name, Birthdate.
• Medical reason for the accommodation/limitation.
• Description of the accommodation/limitation.
• Duration of this accommodation/limitation.
• HCP’s Signature & Legible Name, Credentials, and Sign Date.

(Please note that all medical notes are valid for 1 calendar from HCP’s sign date and will need to be renewed.)

 

 

The Sports Evaluation requires annual renewal and is valid one calendar year from the date of the licensed health care provider’s signature.

Written authorizations must be:

• signed by the licensed health care provider
• signed by the parent/guardian and
• have a clinic ink stamp
• explain ALL “Yes” answers to help process your form. Please use black or blue ink, not pencil, to fill out the form.
• have passing eye vision results (20/30 or better in each eye). Bring your corrective lenses for the physical.

Dear LAUSD athletes and their parents/guardians:

COVID-19 and its wide range of complications may present challenges to everyday activities. One of the complications affecting sports participation is damage to the heart. The greater the severity of COVID-19, the greater the risk is for heart disease. Please speak to your health care provider regarding sports participation after a positive test for COVID-19 within the last 3-6 months or if at any time you have symptoms consistent with COVID-19 (fever/chills, cough, shortness of breath or difficulty breathing, muscle or body aches, headache, new lost sense of taste or smell, sore throat, nasal congestion, nausea, vomiting, and/or diarrhea). Your health care provider should include screening questions for cardiac symptoms such as palpitations, irregular pulse, chest pain, difficulty breathing, fainting, and fatigue, and complete the medical clearance form, “COVID-19 Return to School and Clearance to Begin COVID Graduated Return to Play (GRTP).” See Form next section.

 

 

Concussion Medical Clearance Form is Needed to start Stage III of RTP Protocol (signed by MD/DO):

For more information & additional forms, click on the LAUSD Nursing’s Parent Resources Link or Google “LAUSD Parent Resources  Nursing”: https://achieve.lausd.net/parent-resources