1. Cindy Harrah ARNP, MSN Nicklaus Children’s Hospital
Required forms
Cindy Harrah ARNP, MSN
Nicklaus Children’s Hospital

2. Websites to locate forms
Florida Department of Health Miami Dade
and-nutrition-services/school-health/additional-resources.html
Miami Dade County Public Schools
The Children’s Trust
teams

3. Medication Administration Forms
Authorization for Medication (MDCPS FM-2702E)
Required annually and for changes in dose or frequency
Separate form for each medication
Not required for Diabetic medications and supplies
Completed by PCP
Must indicate training and self-administration
Parent Signature Required

4. Medication Administration Forms
Student Medication Log (MDCPS FM- 7115)
Form must be completed
Medication must be brought by parent/guardian
Medications need to be counted with parent/guardian and documented on medication log for initial and subsequent medication refills
Returned medication must be documented on medication log
Parents and nurse initial verified count (received/returned)
Required to have separate medication log for each medication

5. Medication Error Report (MDCPS FM-7495)
Completed for all medication errors
Notify School Administration
Notify parent
Notify Poison Control for wrong dose or medication
Notify Comprehensive Health Services
Notify DOH

6. Diabetic Management Plan (MDCPS FM-7596)
New form required annually and changes to orders
Does not require Medication Authorization Form
No additional orders required for Glucagon, glucose tablets or gel, blood sugar monitoring, or ketones
Requires PCP, parent and nurse signatures
PCP must indicate student training, supervision, and authorization to carry supplies

8. Daily Diabetic Log (MDCPS FM- 7597)
Completed for all students
File in medication binder

9. INDIVIDUAL HEALTH CARE PLAN Medical History and consent
Requires parent signature
Parental permission to disclose condition, must circle “I do“
Ensure form is complete

10. INDIVIDUAL HEALTH CARE PLAN Emergency care plan
Roles and Responsibilities
Individualize to student
Requires parent/guardian, principal and RN signature
Ensure form is complete

11. Individual Health Care Plan
Develop with parent/guardian
Periodic evaluation
Completed by RN

12. Individual health care plan cont.

13. Individual health care plan cont.

14. Diabetes Delegation of care
RN/ARNP completes nursing assessment
Determine appropriateness of delegation
Develop Individual Health Care Plan
Provide Educational training
Level I General awareness
Level II Child Specific with teacher
Level III UAP Skills Checklist
Form required for each student

15. Uap SKILLS CHECKLIST Level III training completed annually
Quarterly monitoring of skills

18. Assessment of Student for Self management
PCP indicates student is trained and authorized to carry diabetic supplies
RN/ARNP determines student ability to self- manage Diabetes
Skills assessment completed annually with periodic monitoring
Parent, student, and RN signature required

19. Severe Allergy Action plan (DOH form)
Completed annually and for changes
Requires Medication Authorization Form
Requires PCP and parent signatures
Verify appropriate dose ordered
JR 0.15 mg pounds
0.30 mg > 66 pounds

20. Severe Allergy Action Plan
Select appropriate form
Epi-pen most common
Adrenaclick and Auvi-Q
Trained staff required to sign
RN and parent signature required

22. Severe allergy delegation of care
RN/ARNP completes nursing assessment
Determine appropriateness of delegation
Develop Individual Health Care Plan
Provide Educational training
Level I General awareness
Level II Child Specific with teacher
Level III UAP Skills Checklist
Form required for each student

23. UAP skills checklist Level III training completed annually
Quarterly monitoring of skills
UAP required to sign

24. Assessment of Student for Self management
PCP indicates student is trained and authorized to carry Epinephrine
RN/ARNP determines student ability to self- manage Severe Allergic Reactions
Skills assessment completed annually with periodic monitoring
Parent, student, and RN signature required

25. Diet prescription for meals at school (MDCPS FM-5425)
Utilized for food allergies and special diets
PCP and parent signature required
Original form given to cafeteria manager
Copy of form for student record
Form updated 07/17

26. Asthma Action Plan
Form required annually and for changes in dose and frequency
MD signature required
Medication authorization form required

27. Asthma delegation of care
RN/ARNP completes nursing assessment
Determine appropriateness of delegation
Develop Individual Health Care Plan
Provide Educational training
Level I General awareness
Level II Child Specific with teacher
Level III UAP Skills Checklist
Form required for each student

28. UAP skills Checklist Level III training completed annually
Quarterly monitoring of skills

30. Assessment of Student for Self management
PCP indicates student is trained and authorized to carry inhaler
RN/ARNP determines student ability to self-manage Asthma
Skills assessment completed annually with periodic monitoring
Parent, student, and RN signature required

31. Seizure action plan
Form required annually and for changes in dose and frequency
MD and parent signature required
Medication authorization form required

32. Delegation of care- seizures
RN/ARNP completes nursing assessment
Determine appropriateness of delegation
Diastat request 504
Develop Individual Health Care Plan
Provide Educational training
Level I General awareness
Level II Child Specific with teacher
Level III UAP Skills Checklist
Form required for each student

33. Uap skills checklist Level III training completed annually
Quarterly monitoring of skills
UAP required to sign
Emphasize monitoring and recording:
Type of seizure
Duration
LOC
Environment
Post-seizure respiratory pattern

34. Physician referral for in-school nursing services (MDCPS FM-4560)
MDCPS School Board
Refer to SST(School Support Team)
SST determines appropriateness for referral for possible 504
Student with physical/health needs referred to SST
Rehabilitation Act of 1973
Section 504 requires school districts to conduct evaluation for special needs/accommodations
Considerations for 504
Frequency of required IHP services
Intensity of required IHP services
The complexity of the required IHP services
The health and safety risk
Need for additional services or accommodations

35. Request for in-school nursing services
Form completed annually by PCP
Eligibility determined on a case by case basis

36. PHYSICIAN STATEMENT (mdCPS fm-1920)
Required form for SST and 504 plans
Completed by MD

37. Consent for mutual exchange (mdCPS fm-2185e)
Required for SST and 504
Completed by parent

38. Vision screening m-team report (MDCPS FM-2125)
Required for SST evaluation
Document screening results and referral

39. Bmi non-referral screening letter (DOH)
BMI screenings
Mandated screenings grades 1, 3, 6
Grade 9
Optional per statutes
Program objective TCT
Letter sent to all students screened
Nutrition education handout provided

40. Bmi Referral letter (doh)
Referral letter required for
Underweight students
Overweight students at discretion of RN
Obese students
Exception athletic build
PCP to evaluate nutritional status and complete form
Nutrition education handout provided

41. Vision screening referral letter (Mdcps fm-6898)
Mandated screenings
K, 1, 3, and 6
Replaces “E” letter
Revision 4/16
Letter sent to students who do not pass screening
Heiken consent

42. cumulative school health record (DOH 3041)
Maintained in students cumulative record
Contains health information only
Initiated upon entry into MDCPS
Form may be obtained from MDCPS Comprehensive Health Services
Document dates of screenings and record review under corresponding grade
Do not place results on page 1

43. cumulative school health record (DOH 3041)
Document all chronic illnesses, hospitalizations, injuries, and allergies on page 2
Document staff trainings and care plans

44. cumulative school health record (DOH 3041)
Stamp/write additional health record exist
Name of agency
Signature and credentials
Document screening results, referrals, and outcomes
May use screening form

46. School health entry exam DOH 3040 (part 1)
Required upon school entry
Within 12 month of initial start
Completed by parents
Signature required
Review for chronic illnesses
Work with registrar to ensure completion

47. School health entry exam DOH 3040 (part 2)
Required upon school entry
Must be within 12 months of initial start
Completed by MD, ARNP, PA
TB risk assessment required
Review for chronic illnesses
Stored in Cumulative Health Record DOH 3041
Work with registrar to ensure form complete prior to school registration

48. Florida certificate of immunization DH-680
Required for school entry
Updated for vaccine compliance
Stored in cumulative Health Record DH 3041
Follow MDCPS/CDC requirements
TME cannot be future for 7th grade Tdap
Permanent medical exemptions should indicate vaccine and condition

49. Religious exemption DOH 681
Completed by DOH only
Indicate religious exemption on health jacket (3041)
Special consideration for unvaccinated students during outbreaks

50. School Health room review
Manuals present, accessible, and up to date
Medication Policy and Procedure
Medication Manual present and accessible
Medication administration training
UAP Skills checklist
Delegation of care
Medication Error report
Clinic log present
Clinic Physical Facilities
Space adequate
Restrooms
1 elementary
2 secondary
Beds/cots
1 elementary
2 secondary (separated)
Clean, disposable covering
Visible

51. School Health room review
Emergency supplies available
2016 Emergency Guidelines
CPR and First Aid certification
Posted list of staff certified
AED
Medication administration
Medication authorization
Medication counted, not expired
Medication labeled including OTC medications
Adequate storage
Medication Log

52. Student Health Record review
Cumulative Health Record
Immunization Record
TME not expired/extended
Correct spacing
Physical Examination
TB risk assessment
Allergies/Chronic Illness
Medication Authorization/Action Plans
Screenings
Grade specific
Dates, results, follow up, outcome
Student Data Card

53. Student Health Record review
Individual Health Care Plans
Individualized, student specific
Ongoing evaluation
Emergency Care Plan/Emergency Action Plan