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The Health Services forms and documents included below are samples only and are not endorsed or mandated by Ñî¹óåú´«Ã½. Any sample contained in these guidelines should be approved by each individual school district¡¯s administration and/or board of directors as applicable.

Anaphylaxis Sample Forms

• Bee or Insect Allergy Assessment Form
• Food Allergy Assessment Form
• Post Evaluation Anaphylaxis Training
• Pre-Assessment or Anaphylaxis Training
• Sample RN Checklist for Students with Life Threatening Allergies
• Sample School Letter to all Parents
• Sample Substitute Teacher Letter
• Student Food Allergy Assessment Form
• 3665 Life Threatening Allergy Emergency Care Plan Individual Health Plan sample
• Sample Anaphylaxis Training Assessment

Medication Guidelines Forms

• Administering Medication per Gastrostomy Button Bolus Method
• Authorization for Administration of Oxygen
• Discontinuation of Medication Administration at School
• Field Trip Medication Administration Skills Checklist
• Field Trip Medication Record
• Medical Authorization for Asthma Management at School
• Medication Administration Delegation
• Prescription for School Supplied Stock Epinephrine Auto-Injectors for School Use Pursuant to RCW 8A.210.383
• Sample Medication Administration Early Administration (English and Spanish)
• Sample Medication Administration Incident Report
• Sample Medication Administration Record
• Sample Medication Administration Record with Receipt and Count Logs
• Sample Medication Inventory Record
• Sample Parent Letter Leftover Medication
• Sample Permission to Administer Medication at School
• Sample Receipt for Medication
• Sample Student Skills Checklist for Self-Administration of Emergency Medication
• Sample Authorization to Administer Medication at School
• Severe Allergy Reaction 504 Plan & Medication Orders
• Standing Order for the Administration of School Supplied Stock Epinephrine Auto Injectors
• Student Agreement to Self-Carry Self Administer Medication
• Topical Ointment Past Salve Cream Skills Checklist
• Transdermal Patch Skills Checklist
• Skills checklist for Intranasal Midazolam Administration
• Sample Spanish/English Discontinuing of Medication Administration
• Sample Emergency Medication Administration Record
• Rescinding Delegation RN
• Sample Oral (Solid) Medication Administration Skill Checklist
• Sample Oral (liquid) Medication Administration Skill Checklist
• Sample Nasal Spray Skills Checklist
• Sample Metered Dose Inhalers (MDI) Skills Checklist
• Sample Medication Supervision Documentation
• Sample Medication by Nebulizer Skills Checklist
• Medication Received Return Sign In Out Sample Sheet
• Medical Authorization for Asthma Management at School
• General Medication Administration Skills Checklist
• Eye Drops or Ointment Skills Checklist (Sample)
• EpiPen Skills Checklist Procedure
• Ear Drops Skills Checklist (Sample)
• Confidentiality of Student Health Information

Procedure & Policy Forms

• Sample Medication Policies and Procedures WSSDA 3416
• Procedure Medication at School Policy 3416P WSSDA
• Sample Policy for Medication

Diabetes Sample Forms

• Model Designation of a Parent- Designated Adult
• Model Voluntary Parent-Designated Adult Notice of Intent
• Diabetes planning-new student tool-kit
• ADA Model-504-Plan-CURRENT
• Letter for supplies SPS
• High Blood Glucose (Hyperglycemia) Emergency Care Plan-for a student who uses INSULIN INJECTIONS
• High Blood Glucose (Hyperglycemia) Emergency Care Plan-for a student who uses INSULIN PUMP
• Employee Verification of Health Information Training
• Skills Check for PDAs for Additional Care Authorized by Parent version updates
• PDA Skills Check
• Low Blood Glucose (Hypoglycemia) Emergency Care Plan WITH & WITHOUT INSULIN PUMP
• EPIC school orders 2022 to 2023
• ADA DMMP-updated-11-11-22
• 3415F1- Designation of a Parent {3425F1}
• ADA DMMP-Spanish-3-21-23
• Meal Service for Students with Diabetes

Vision and Hearing Screening Sample Forms

• Vision Screening Sample Form | Spanish