Catholic Schools Catholic Schools Catholic Schools Catholic Schools Catholic Schools Catholic Schools Catholic Schools Catholic Schools Catholic Schools

 

 

III. HEALTH GUIDELINES APPENDICES
A. Diocesan Individualized Health Care Plan A - 1

B. Emergency Information and Immunization Record Card B - 1

C. Student Health Record Folder
Health Record C - 1a Second Page C - 1b
Student Health Progress Notes C -1c
Active Problems, Medications -- Medical History C - 1d

D. Health Record Release Form D - 1

E. KidsCare Information Sheet E - 1

F. Student Health History and Physical Examination Forms
1. Elementary F - 1
2. High School:
Annual Preparticipation Physical Examination F - 2a
Annual Preparticipation Physical Evaluation F - 2b

G. Sample Immunization Forms  
1. School Immunizations Required for Under Age 7 G - 1
2. School Immunizations Required for Age 7-10 Years G - 2
3. School Immunizations Required for Age 11 and Older G - 3
4. Arizona School Immunization Record (ASIR) G - 4
5. U.S. Vaccine Trade Names G - 5
6. Request for Exemption to Immunization -- Schools G - 6
7. Referral Notice of Inadequate Immunization -- School/Child Care/Head Start G - 7
8. ADHS School Kindergarten Immunization Data Report G - 8
9. ADHS School 7th & 10th Grade Immunization Data Report G - 9
10. ASIIS Application Form G-10
11. Proof of Immunization or Immunity to Measles, Mumps, and Rubella for School Staff G -11
 
H. County Health Departments H - 1

I. Fluoride Mouth Rinse Permission Form I - 1

J. Screening Forms
1. Grid of Required and Recommended Screenings J - 1
2. Annual Hearing Screening Report  J - 2
3. BMI Growth Charts:
Boys J - 3a
Girls J - 3b
4. Blood Pressure Referral Levels J - 4  
5. Scoliosis Screening Permission Form J - 5
6. Spinal Screening Form J - 6

K. Sample Referral Letters to Parents   
1. Hearing Referral K - 1
2. Vision Referral K - 2
3. Overweight Risk Referral K - 3
4. Blood Pressure Referral K - 4
5. Scoliosis Referral K - 5
6. Lice Letter to Parents:
Parental Notification of Head Lice K - 6a
10 Steps to Keep Head Lice and Their Eggs Out of Your Child's Hair K - 6b
7. General Health Referral K - 7

L. Injury/Illness Handouts for Parents (Adapted from Sunnyside USD, Tucson)
1. Asthma and Outdoor Air Pollution L - 1
2. Backpack Strategies L - 2
3. Cold/Flu Symptoms L - 3
4. Dental Problem L - 4
5. Head Injury L - 5
6. Head Lice L - 6
7. Impetigo L - 7
8. Mouth Sores L - 8
9. Pinkeye L - 9
10. Sore Throat L-10
11. Stomach Ache L-11
12. Strain/Sprain L-12
13. Sty L-13
14. UTI L-14
15. Wound L-15

M. Injury/Impairment Assessment Tools for Nurses
1. Eye Injury M - 1
2. Fractures, Dislocations, Strains, Sprains, Contusions M - 2
3. Head Injury M - 3
4. Shock M - 4
5. Substance Abuse Checklist:
Suspected Substance Abuse - Physical Assessment Checklist M - 5a
Substance Abuse Indicators M - 5b

N. Diocesan Accident Forms    
1. Diocesan Accident Report N - 1
2. Diocesan Insurance Claim Form N - 2

O. Forms for Chronic Health Problems    
1. Diabetes Management Plan O - 1
2. Asthma Action Plan O - 2
3. Allergy Action Plan O - 3
4. Seizure Action Plan O - 4

P. Communicable Disease Report Form P - 1

Q. Medication Forms
1. Medication Permission and Administration
Parent's Consent for Giving Medication at School Q - 1a
Medication Record Q -1b
2. Student Permission to Carry an Inhaler Q - 2
3. Student Permission to Carry an EpiPen Q - 3
4. Medication Administration Training and Persons Designated to Administer Medications:
Training Record for Persons Designated to Administer Medications to Students Q - 4a
Persons Designated to Administer Medications Q - 4b
5. Medication Incident Report Q - 5
6. ADEQ Medication Disposal Brochure Q - 6

R. Child Abuse and/or Neglect Report Forms:
Child Abuse Report R - 1a
Documentation Sheet for Possible Abuse/Neglect R - 1b

S. Health Education/Promotion Resource List S - 1