Table of Contents School Health Nursing Services Goal of School Health Services Quality Assurance in the School Health Program

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2 Table of Contents School Health Nursing Services Goal of School Health Services 1 Quality Assurance in the School Health Program 2 Management of Students with Chronic Medical Conditions 3,4 Request to Parent regarding Students with Chronic Conditions or Meds (English) 5 Chronic Condition Form (English) 6 Request to Parent regarding Students with Chronic Conditions or Meds (Spanish) 7 Chronic Condition Form (Spanish) 8 UCPS Authorization for Exchange of Health and Education Information (English) 9 UCPS Authorization for Exchange of Health and Education Information (Spanish) 10 Individual Health Plan Policy and Procedure 11,12 Request for Medical Documentation to write IHP (English) 13 Request for Medical Documentation to write IHP (Spanish) 14 Parent Cover Letter for Initial IHP (English) 15 Parent Cover Letter for Initial IHP (Spanish) 16 Students with Special Health Care Procedures and Needs Parent Authorization for Specialized Health Care (English) 20 Parent Authorization for Specialized Health Care (Spanish) 21 UCPS Plan of Treatment 22 Vagal Nerve Stimulator Order from MD 23 Protocols Protocols for School Nurses 24 Protocol for Fever 25 Protocol for Vomiting 26 Protocol for Diarrhea 27 Protocol for PPD Skin Testing in the Schools 28,29 Protocol for Stock Albuterol Use in the Schools 30 Protocol for Treatment of Anaphylaxis with Epinephrine 31,32 Protocol for Treatment of Status Asthmaticus with Epinephrine 33,34 Protocol for Human Bites 35,36 Protocol for Blood Glucose Testing of Students 37 Protocol for Pulse Oximetry 38 Protocol for Treatment of Allergic Reactions/Prevent Sting Reactions/Benadryl 39,40 Health-Related Classes offered by School Health 41 Medications Administration of Medication- UCPS policy Guidelines for Administration of Medications at School UCPS Medication Consent Form (English) 50 UCPS Medication Consent Form (Spanish- for information only) 51 Authorization for Self-Medication for Emergency Meds (English) 52 Authorization for Self-Medication for Emergency Meds (Spanish for information) 53 Responsibility of Trained Medication Administrator 54 Attendance Roster for Administration of Medications in the School Setting 55 Medication Administration Test and Key 56,57 Reference Guidelines for Administration of Medicine by Staff 58 Medication Incident Report- Explanation 59 Medication Incident Report Form 60 Field Trip Medication Log 61 End of the Year Medication Information (English) 62 End of the Year Medication Information (Spanish) 63

3 Immunizations Immunizations School and Nurse Responsibilities 64 UCPS North Carolina Immunization Law Information to be signed by parent (English) 65 UCPS North Carolina Immunization Law Information to be signed by parent (Spanish) 66 Notification of Needed Immunizations (English) 67 Notification of Needed Immunization (Spanish) 68 Necessary Proof of Immunization Compliance (English) 69 Necessary Proof of Immunization Compliance (Spanish) 70 Rising 6 th Graders Tdap Notification (English) 71 Rising 6 th Graders Tdap Notification (Spanish) 72 Kindergarten Health Assessment Kindergarten Health Assessment School and Nurse Responsibilities 73 Notification of Needed Immunizations & Physical Exam Pre-K (English) 74 Notification of Needed Immunizations & Physical Exam Pre-K (Spanish) 75 Notification of Needed Immunizations & Physical Exam Kindergarten (English) 76 Notification of Needed Immunizations & Physical Exam Kindergarten (Spanish) 77 Suspension Notice of Delinquent Kindergarten Health Assessment (English) 78 Suspension Notice of Delinquent Kindergarten Health Assessment (Spanish) 79 Emergency Medical Response in the Schools Emergency Medical Response in the Schools School and Nurse Responsibilities 80 Treatment of Anaphylaxis with Epinephrine 81 Heart Attacks 82 Head Injury Notification (English) 83 Head Injury Notification (Spanish) 84 Emergency Assessment Form 85 Emergency Evaluation Request Form 86 Emergency Response Bag List 87 Health Room First Aid in the Classroom Health Room Basic First Aid Needs 99 School Health Documentation Audit Tool 100 Health Room Visit Form 101 Health Room Volunteer Guidelines 102,103 ESL Referral Form 104 Vision Screenings Vision Screenings- School and Nurse Responsibilities 105 Vision Screening Log 106 Vision Referral Letter (English) 107 Vision Referral Letter (Spanish) 108 Follow Up Letter for Vision Referral (English) 109 Follow Up Letter for Vision Referral (Spanish) 110 Color Vision Referral (English) 111 Color Vision Referral (Spanish) 112 Functional Vision Test Form 113 Functional Vision Test Instructions Communicable Disease Control Communicable Disease Control 120 Reportable Diseases School, Nurse, & Health Department Responsibilities 121 Reportable Diseases in North Carolina 122 Measles 123,124 Mumps 125 Rubella 126 Tuberculosis 127 Pertussis 128,129

4 Meningitis 130,131 Non-Reportable Communicable Diseases and Conditions 132 MRSA MRSA Protocol Confirmed MRSA Report Form 136 MRSA letter to inform parent of confirmed case (English) 137 MRSA letter to inform parent of confirmed case (Spanish) 138 MRSA in Schools (English) 139 MRSA in Schools (Spanish) 140 MRSA FAQS 141,142 MRSA FAQS (Spanish) 143,144 Chickenpox 146,147 Individual Letter for Chickenpox (English) 148 Individual Letter for Chickenpox (Spanish) 149 Classroom Letter for Chickenpox (English) 150 Classroom Letter for Chickenpox (Spanish) 151 Shingles 152,153 Classroom Letter for Shingles (English) 154 Classroom Letter for Shingles (Spanish) 155 Fifth Disease 156,157 Individual Letter for Fifth Disease (English) 158 Individual Letter for Fifth Disease (Spanish) 159 Classroom Letter for Fifth Disease (English) 160 Classroom Letter for Fifth Disease (Spanish) 161 Conjunctivitis 162,163 Individual Letter for Conjunctivitis (English) 164 Individual Letter for Conjunctivitis (Spanish) 165 Classroom Letter for Conjunctivitis (English) 166 Classroom Letter for Conjunctivitis (Spanish) 167 Differential Nursing Diagnosis Letter for Conjunctivitis (English) 168 Differential Nursing Diagnosis Letter for Conjunctivitis (Spanish) 169 Head Lice 170 UCPS policy regarding Lice and Nits 171,172 Tips on Getting Rid of Head Lice (English) Tips on Getting Rid of Head Lice (Spanish) Individual Letter for Head Lice (English) 180,181 Individual Letter for Head Lice (Spanish) 182,183 Classroom Letter for Head Lice (English) 184 Classroom Letter for Head Lice (Spanish) 185 Ringworm 186,187 Individual Letter for Ringworm (English) 188 Individual Letter for Ringworm (Spanish) 189 Classroom Letter for Ringworm (English) 190 Classroom Letter for Ringworm (Spanish) 191 Impetigo 192,193 Individual Letter for Impetigo (English) 194 Individual Letter for Impetigo (Spanish) 195 Classroom Letter for Impetigo (English) 196 Classroom Letter for Impetigo (Spanish) 197 Scabies 198 Individual Letter for Scabies (English) 199 Individual Letter for Scabies (Spanish) 200 Classroom Letter for Scabies (English) 201

5 Classroom Letter for Scabies (Spanish) 202 Strept Throat and Scarlet Fever 203,204 Individual Letter for Strept Throat (English) 205 Individual Letter for Strept Throat (Spanish) 206 Classroom Letter for Strept Throat (English) 207 Classroom Letter for Strept Throat (Spanish) 208 School Wide Letter for Strept Throat (English) 209 School Wide Letter for Strept Throat (Spanish) 210 Influenza 211 Classroom Letter for Influenza (English) 212 Classroom Letter for Influenza (Spanish) 213 Mononucleosis 214 Classroom Letter for Mono (English) 215 Classroom Letter for Mono (Spanish) 216 Poison Ivy/Oak 217 Hepatitis A 218,219 Molluscum Contagiosum 220 E. Coli Diarrhea 221 Common Skin Warts 222 Ear Infections 223,224 Tick Borne Illnesses 225,226 Tick Removal Letter (English) 227 Tick Removal Letter (Spanish) 228 Bloodborne Diseases Hepatitis B 229,230 Hepatitis C 231,232 HIV/AIDS 233,234 Exposure Control Plan BBP Exposure Plan Administrative Guidelines Exposure to Bloodborne Pathogens Appendix A1 Employee Exposure Determination Questionnaire 252,253 Appendix A2 Job classification Categories 254 Appendix B Risk Assessment PPE by Job Classification 255 Appendix C1 Immunization Administration/Declination Form 256 Appendix C2 Hepatitis B Vaccine Standing Orders for At-Risk Staff 257 Appendix D1 Injury with Exposure Report Section Appendix D2 Injury with Exposure Report Section Appendix D3 Injury with Exposure Report Section Appendix E1 Bloodborne Pathogens Training Attendance Record 261 Appendix E2 BBP At-Risk Employee Post-Test 262 BBP At-Risk Employee Test- Answer Key & Teaching Points Appendix E3 BBP Class Information UCPS Specific Information 266,267 Appendix F Annual Update Log 268 Appendix G OSHA Log for At-Risk Staff Members 269 Appendix H OSHA Bloodborne Pathogen Standards BBP Letter 1 Referral to Physician 307 BBP Letter 2 Follow Up for Possible BBP Exposure 308 BBP Letter 3 Bloodborne Pathogens Exposure Contact Information 309 BBP Letter 4 Authorization for Exchange of Confidential Health Information 310

6 Goal of School Health Nursing Services The school nurses in Union County are employed and governed by the Union County Public Schools. The goal of School Health Services is to strengthen and facilitate the educational process through identification, intervention and correction of health related barriers of learning in students. The program is designed to assure a safe, healthy environment conducive to learning, and to provide professional care for those who become ill or injured in order to maximize the quality of in-class time by reducing the incidence of health related absenteeism. Cooperation between school nurses and school personnel is essential in providing comprehensive and effective school health services. The role of the school nurse is to (1) help families and school personnel prepare a safe and appropriate response to medical emergencies that a student might experience during school, (2) assure that all health related procedures and treatments are performed safely and accurately by trained school personnel, (3) implement Individual Health Care Plans and Plans of Treatment as needed for students with chronic medical conditions, (4) assist to maximize the quality of the student s educational experience by reducing the incidence of health related absenteeism, (5) assure that medications administered during school are done so correctly and according to school policy, and (6) serve as a health advisor to school faculty and staff. The role of the schools in providing school health services is to (1) identify and refer students in need of health services to the school nurse, (2) administer medications to students according to school policy, and (3) establish an emergency response team for medical emergencies. The school nurse works collaboratively with students, parents, educators, staff members and other community resources to deliver health services within the schools. The principal serves a key role, in that he/she works closely with the school nurse in the delivery of health services in each school. The above stated goals of the school nurse and schools can best be accomplished through joint planning and evaluation by the school system, the health department, and the school nurses. Evaluation of the quality of nursing care by review of the clinical practice is one way to ensure excellence in practice. Peer review, quality assurance, and continuing education contribute towards this aim. 1 jsl

7 Quality Assurance in the School Health Program Quality Assurance, QA, is the ongoing process of monitoring, evaluating, changing, and redefining activities to assure that services provided meet the defined goals as well as the needs of the population served. The goals of the UCPS School Health Program include strengthening and facilitating the educational process through identification, intervention and correction of health related barriers to learning in students. The program is designed to assure a safe, healthy environment conducive to learning, and to provide professional care for those who become ill or injured in order to maximize the quality of classroom time by reducing the incidence of health related absenteeism. Monitoring of the school health program is done by the collection of data by the school nurse at each school and this statistical information is entered into the computer and compiled at the end of the school year for analysis and evaluation. The analysis of the data allows the school nurses to identify areas of needed improvement in order to provide quality health care that meets or exceeds expectations. The collection of daily, weekly, and monthly activity data by is generated by the school nurses. A quality assurance tool is used to monitor and analyze the nursing documentation pieces for consistency of charting and practice. This tool is used as a audit tool by the school nurse supervisors on an annual basis (see page 100 for example of the Audit Tool). Quality of services rendered will also be measured by the review of principal concerns and satisfaction surveys. The satisfaction survey is given to principals to measure opinions about the service provided by the school nurses. These opinions will be kept confidential and will be used to identify trends/needs for improvement. From these identified trends/needs, administrative decisions can be made to address persistent or particularly problematic areas. A School Health Advisory Council (SHAC) has been established to address all of the issues involved with the School Health program. This council is comprised of a core group of parents, youth, educators and other community members. The goals of the SHAC include giving advice and support to issues that involve school health, and to assist in promoting healthy behaviors and a healthy environment in the Union County Public Schools. QA is a continuous process that involves the school nurses in planning and implementing a continuous stream of improvements in order to provide quality services. The school nurse supervisor represents the school health program to discuss and address the quality issues of school nursing. This ongoing and ever changing process requires the input of a medical advisor, and a chain of supervisors and directors that goes all the way to the superintendent of public schools. 2 jsl

8 Management of Students with Chronic Health Conditions Students identified with a written, diagnosed health condition such as asthma, severe allergies, seizure disorders, diabetes, sickle cell or any condition that puts them at risk for having a medical emergency that could require emergency intervention by school staff during the school day will have an Individual Health Care Plan (IHP). The IHP will be developed by the school nurse in collaboration with the parent/guardian and the student s physician. A standard letter to each parent will be used to solicit medical information as well as request a written diagnosis from the Health Care Provider. Classroom teachers, whose class association with each student may make them aware of a condition not identified by the parent/guardian, should also refer at risk students to the nurse for the possible development of the Individual Health Care Plan. Objective: To identify any student with a health care condition that could require emergency intervention by school staff during the school day. To develop and implement an Individual Health Care Plan (IHP) giving specific instructions on how to handle an emergency for a particular student. Method: School Responsibility 1. Schools will send a letter home with each student within the first week of school and with any new or transfer student upon enrollment soliciting medical information about the student, including a written diagnosis by the health care provider. IHPs will only be written for students with an identified diagnosed condition, as evident by a signature from a health care provider. This information may be obtained by any number of documents, including but not limited to a kindergarten health assessment or physical, a diet order, a written letter from the health care provider, or a related medication consent form. IHPs cannot be generated based solely on the verbal history of the parent/guardian or a previous IHP without supporting documentation. 2. Teachers/staff will meet with the school nurse as needed to implement IHPs and receive directions for students in their care. 3. Teachers/staff will make referrals to the school nurse anytime during the school year when there is a status change in a student with an existing IHP or a student with a newly diagnosed medical condition. 3

9 Nurse Responsibility 1. Review returned parent/guardian letters and diagnoses relative to students who have conditions that could require emergency intervention by school personnel, compile a listing of students that will need IHPs completed/updated for the current school year. 2. Determine if the referral is a new request or if the student has had an IHP completed previously for the same condition. If no referral has been made the IHP will be an initial work up; if an IHP was completed during the previous year, an update of that information will be done. 3. Distribute copies of the completed/updated IHP to parent/guardian, school health room, classroom teacher(s), itinerant personnel and other school staff having contact with the student (ie. UCPS afterschool program, bus coordinator, cafeteria if IHP is related to a food allergen or condition). Copies will also be made available in an Individualized Health Care Folder for each student and added to the nurses file cabinet, as well as a copy placed into the student s cumulative record. 4. Conference with primary teacher and any other personnel, upon request, to explain/clarify information provided and assure understanding. 5. Make copies for all 2 nd semester teachers in Middle/High Schools as classes for that student change. 4 jsl

10 Dr. Mary Ellis Superintendent School Health Office 400 North Church Street Monroe, NC Phone Fax Dear Parent/Guardian, I am sending this letter to gather information about students who have health needs. Please fill out the reverse side of this form, Request for Health Information, whether or not your student has medical needs that could affect learning or might require emergency care during the school day. Chronic Health Conditions Please complete the reverse side of this form annually If your child has a life-threatening condition/allergy, please notify the school nurse and any other staff members who will be in contact with your child (including the cafeteria/bus driver/coach/extracurricular activities). Contact the school nurse if you need to schedule a conference to discuss details regarding the development of a health care plan for your child. Provide necessary changes that occur during the school year, either with contact numbers or your child s health condition. Medication Administration Medication must be sent in the original container if it is an over-the-counter medicine or a prescription bottle if it is a prescription medicine. Please check expiration dates. School personnel are not allowed to give expired medications. The school does not provide any medications, including ointments, creams, pain relievers, eye drops, etc. Any medication given at school must be provided by the parent/guardian. A medication consent form is required for any medication given at school. Signatures from a parent/guardian AND the student s health care provider are required for ANY medication to be given at school. This includes prescription as well as over the counter medications. Faxed consents from parents and/or doctors are acceptable. The entire UCPS medication policy may be viewed online at If you have questions or concerns, please contact the school. I would be happy to speak with you. Sincerely, School Nurse Globalization. Innovation. Graduation. 5 jsl In compliance with federal law, UCPS administers all educational programs, employment activities and admissions without discrimination against any person on the basis of gender, race, color, religion, national origin, age or disability.

11 Request for Health Information Must be completed annually School Date Student s Name Date of Birth Teacher Grade Parent/Guardian (names) Home Phone Mom s work Mom s cell Dad s work Dad s cell Emergency Contact Person Daytime Phone Drug Allergy(s) None Known Yes (list) Treating Physician Office Phone MY CHILD DOES NOT HAVE ANY KNOWN MEDICAL CONDITIONS. (You may stop here if there are no known medical conditions. Please sign at the bottom and return.) Asthma Triggers: environmental seasonal exercise induced Inhaler at school- upper respiratory infection others MD order required. Inhaler location: Carried by student (requires self carry form) Classroom Health Room Diabetes Type I Type II Diagnosis Date: Insulin by: Pump Injections Desire Diabetes Care Plan: yes no, independent with all care Please call for Nurse Conference - Notify your school nurse and principal immediately if newly diagnosed Food Allergy** Peanuts Tree Nuts Milk other/s Date/Type of Last Reaction Student Needs for Class/School Diet Order signed by MD required (diet form may be obtained in the front office) Severe Sting Allergy** Date and Type/Description of Last Reaction **Notify your school nurse and principal immediately if anaphylaxis may occur** Epilepsy Type(s) of Seizure(s): controlled with medication on medication, continues to have seizures Diastat needed at school no medication needed at school Date and Type/description of last seizure Other conditions/or specify pertinent data to help us better serve your child: Does your child take routine medication(s) yes no List Meds: Does your child need medication(s) at school? yes no List Meds: If your child needs medication at school, a medication consent form is required to be signed by the health care provider and the parent/guardian. *Medication cannot be given at the school until appropriate consents have been received. * **UCPS does not provide medications for students.** I give permission to the School Staff/School Nurse to share information regarding my child s medical condition(s) with my physician or emergency personnel: Date: Parent/Guardian Signature A health care provider s written diagnosis is required in order for an Individualized Healthcare Plan to be developed by the school nurse. Also, please let your school nurse know if your child participates in extracurricular school activities. 6 jsl

12 Dr. Mary Ellis Superintendent Board of Education School Health Office 400 North Church Street Monroe, NC Phone Fax Estimados Padres/Tutores, Les estoy enviando esta carta para recopilar información sobre los estudiantes que tienen necesidades médicas. Por favor llene el reverso de esta forma, Solicitud de Información de Salud, ya sea que su estudiante tenga o no necesidades médicas que puedan afectar su aprendizaje o que pueda requerir de cuidado de emergencia durante el día de clases. Condiciones de Salud Crónicas Por favor complete el reverso de esta forma anualmente Si su hijo/hija tiene alguna condición o alergia que atenta contra su vida, por favor notifíqueselo a la enfermera de la escuela y a cualquier otro miembro del personal docente que esté en contacto con su hijo/hija (incluyendo al personal de la cafetería/chofer del autobús/entrenador deportivo/personal de actividades extracurriculares. Llame a la enfermera de la escuela en caso de que necesite programar una conferencia para discutir los detalles relacionados con el desarrollo del plan de cuidado medico para su hijo/hija. Proporcione todos los cambios necesarios que ocurran durante el año escolar, ya sean los números de teléfono de contacto o la condición medica de su hijo/hija. Administración de Medicamentos Los medicamentos deben ser enviados a la escuela en su envase original en caso de que sea un medicamento comprado sin receta médica o en el envase de la receta en caso de ser un medicamento con receta médica. Por favor marque todas las fechas de vencimiento. Al personal de la escuela no le está permitido administrar medicamentos vencidos. La escuela no provee ningún medicamento, incluyendo ungüento, lociones, analgésicos, gotas para los ojos, etc. Cualquier medicamento administrado en la escuela debe ser suministrado por los padres o el tutor. Cualquier forma de consentimiento para medicamento es requerida para cualquier medicamento que vaya a ser administrado en la escuela. Las firmas de los padres o el tutor Y del medico del estudiante son requeridas para CUALQUIER medicamento administrado en la escuela. Esto incluye medicamentos recetados y sin receta medica. Se aceptan consentimientos de los padres y/o del medico enviados a través del Fax. Puede revisar el reglamento completo de las Escuelas Públicas del Condado Unión sobre los medicamentos en nuestro sitio en el Internet en la siguiente dirección: Si usted tiene alguna pregunta o preocupaciones, por favor llame a la escuela. Estaré encantada de poder hablar con usted. Sinceramente, La Enfermera de la Escuela Globalization. Innovation. Graduation. 7 jsl In compliance with federal law, UCPS administers all educational programs, employment activities and admissions without discrimination against any person on the basis of gender, race, color, religion, national origin, age or disability.

13 Petición de Información Médica Debe ser completada anualmente Escuela Fecha Nombre del Estudiante Fecha de Nacimiento Maestro Grado Padres/Representante Legal (nombres) Teléfono de la Casa Teléfono Trabajo de la Madre Celular de la Madre Teléfono del Trabajo del Padre Celular del Padre Persona Contacto de Emergencia Teléfono en el Día Medicamentos al cual es alérgico a saber ninguno Sí (anote) Médico que lo atiende Teléfono MI HIJO NO TIENE NINGUNA CONDICIÓN MEDICA CONOCIDA. (Usted puede parar aquí si no existe ninguna condición médica. Por favor firme la parte de debajo y devuélvala) Asma Causada por: el ambiente cambio de estación después del ejercicio físico Inhaladores en la escuela por infecciones respiratorias otros Requieren orden médica. Lugar donde se mantiene el inhalador: Llevado por el estudiante (requiere forma de auto administración) En el Salón de Clases En la Enfermería Diabetes Tipo I Tipo II Fecha del Diagnostico: Insulina por: Bombeo Inyecciones Plan Deseado para Cuidar la Diabetes: sí no, cuidado independiente **Llame para Conferencia** **Notifique a la enfermera y al director de la escuela si es un diagnostico reciente** Alergias a los Alimentos** Maní Avellanas Leche Otro(s) Fecha y/tipo de la Última Reacción Necesidades del Estudiante en la Clase/Escuela Requiere orden dietética firmada por el médico (puede obtener la forma en la oficina de la escuela) Picada de Insectos Severa** Fecha y/describa la Última Reacción **Notifique a la enfermera y el director de la escuela inmediatamente si ocurre un ataque alérgico ** Tipo de Epilepsia(s) de Convulsión(es): Controladas con medicamento Está en medicamento, y continua teniendo convulsiones Necesita Diastat en la escuela no necesita medicamento en la escuela Fecha y Tipo/describa la última convulsión Otras condiciones/o especifique los datos pertinentes que nos ayuden a servir mejor a su hijo/hija: Toma su hijo/hija medicamento regularmente? Sí No Anote Cual: Necesita su hijo medicamento en la escuela? Sí No Anote Cual: Si su hijo necesita tomar algún medicamento en la escuela, se requiere una forma de consentimiento para el medicamento firmada por el medico y por los padres o tutor. *Ningún medicamento puede ser administrado en la escuela hasta que no se hayan recibido los consentimientos apropiados. * **UCPS no provee medicamento para estudiantes. ** Doy mi permiso al Personal/Enfermera de la Escuela para compartir la información relacionada con la condición o condiciones médicas de mi hijo/hija con mí médico o personal de emergencia: Fecha: Firma del Padre/Madre/o Representante Legal Se requiere de una diagnosis escrita por un medico para que un Plan de Cuidado de Salud Individualizado sea desarrollado por la enfermera de la escuela. También, por favor comuníquele a la enfermera de la escuela si su hijo/hija participa en actividades extracurriculares. 8 js

14 Union County Public Schools Authorization for exchange of Health and Education Information Patient/Student Name: Date of Birth: I hereby authorize [insert health care providers name & title] and [insert name & title of school official] to exchange health and education/records for the purposes listed below. [insert address & phone of school] [insert address & phone of HCProvider] Description: The health information to be disclosed consists of: The education information to be disclosed consists of: Purpose: This information will be used for the following purpose(s): 1. Educational evaluation and program planning 2. Health assessment and planning for health care services and treatment in school. 3. Medical evaluation and treatment. 4. Other: Authorization This authorization is valid for one calendar year. It will expire on [insert date]. I understand that I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent. I recognize that health records, once received by the school district, may not be protected by the HIPAA Privacy Rule, but will become education records protected by the Family Educational Rights and Privacy Act. I also understand that if I refuse to sign, such refusal will not interfere with my child s ability to obtain health care. Parent/Guardian Signature Date Student s Signature* Date *If a minor student is authorized to consent to health care without parental consent under federal or state law, only the student shall sign this authorization form. In North Carolina, a competent minor, depending on age, can consent to outpatient mental health care, alcohol and drug abuse treatment, testing for HIV/AIDS, and reproductive health care services. Copies: Parent or student* Physician or other health care provider releasing the protected health information School official requesting/receiving the protected health information. jsl

15 Union County Public Schools Autorización para Intercambiar Información de Salud y Educación Nombre del Paciente/Estudiante: Fecha de Nac.: Por este medio autorizo a [anote nombre y titulo del proveedor medico] y [anote nombre y titulo del funcionario escolar] para intercambiar archivos de salud y educativos para los propósitos anotados abajo. [anote la dirección y teléfono de la escuela] [anote la dirección y teléfono del medico] Descripción: La información médica a ser revelada consiste de: La información escolar a ser revelada consiste de: Propósito: Esta información será usada con el siguiente(s) propósito(s): 1. Evaluación educativa y planeamiento del programa 2. La evaluación médica y el planeamiento para los servicios de cuidado de salud y tratamiento en la escuela. 3. Evaluación médica y tratamiento. 4. Otro: Autorización Esta autorización es valida por un año completo. [anote la fecha]. Yo entiendo que puedo revocar esta autorización en cualquier momento por medio de una nota por escrito declarando el retiro de mi consentimiento. Reconozco que los archivos médicos, una vez recibidos por el distrito escolar, no pueden ser protegidos por el Reglamento de Privacidad HIPAA, pero vendrán a ser archivos educativos protegidos por los Derechos de Educación Familiar y la Ley de Privacidad. También comprendo que si yo rehúso firmar, tal rechazo no va a interferir con la habilidad de mi hijo en obtener cuidados médicos. Firma del Padre/Tutor Fecha Firma del Estudiante* Fecha *Si un estudiante menor de edad es autorizado para recibir cuidado medico sin el consentimiento de los padres bajo la ley federal o ley estatal, solamente el estudiante debe firmar esta forma de autorización. En Carolina del Norte, un menor competente, dependiendo de la edad, puede dar consentimiento para recibir cuidado como paciente ambulante para salud mental, tratamiento para el abuso de alcohol y drogas, prueba de VIH/SIDA, y los servicios de cuidados de salud reproductiva. Copies: Parent or student* Physician or other health care provider releasing the protected health information School official requesting/receiving the protected health information. jsl

16 Individual Health Plan (IHP) Administrative Procedure 1. Teacher/front office will receive a completed copy of the Request for Health Care for Acute and Chronic Medical Conditions form from the student s parent/guardian. This completed form will be forwarded to the school nurse. The school nurse will review the form and send home appropriate notification that a written medical diagnosis is needed by a health care provider in order to consider the writing of an Individual Healthcare Plan (IHP). 2. A confidential Chronic Condition List will be developed by the school nurse for staff to receive on an as needed basis only. It will include pertinent information regarding the student s health condition. The list should be developed and given to staff/principal within the first 2-4 weeks of school and updated as needed. 3. The school nurse will determine if the filled out form is a new request or if the child has had an IHP completed previously for the same condition. If an IHP was completed during the previous year, the copy of that plan will be secured from the school health files and an update of that plan will be done. The nurse will prioritize the urgency of updating the IHP. 4. The school nurse will obtain current information from the parent/guardian and/or student related to the treatment/handling of the specific health condition as needed in order to update any existing IHPs. 5. If specific medical information is needed from a health care provider, a signed consent to share information may be needed from the parent/guardian. 6. The school nurse will write an Individualized Healthcare Plan on students with diagnosed medical issues that require staff to be trained on the care of that student while at school in the event of an emergency. 7. The school nurse distributes copies as follows: a) Parent- upon request b) Schools- Health Room/Main Office, primary classroom teacher, all teachers that have that child during the day (including but not limited to PE, Art, Music, Media, Afterschool, Cafeteria manager for food allergies) any staff that may regularly interact with the student or give care to the student during the school day, all members of the Emergency Care Team (ECT), staff in charge of transportation for students who ride the bus. The staff should keep their copy of the IHP for future reference. 11 jsl

17 c) Cum folder 8. The original copies of the IHP s will be filed into the student s Individual School Health Record as they are updated. 12 jsl

18 Dr. Mary Ellis Superintendent 400 North Church Street Monroe, NC Phone Fax Student: Date: Grade: Medical Condition(s): Dear Parent, It has come to my attention that your child has a chronic medical condition for which you would like the staff at school to be notified. According to new federal laws, students with chronic medical conditions requiring an Individualized Healthcare Plan must be considered for a 504 accommodation plan. In order to write this Individualized Healthcare Plan, written documentation of the medical condition is now required from the student s physician or health care provider. Therefore, in order to write/update a Healthcare Plan for your child, I will need written documentation of the medical condition signed by his/her licensed physician or health care provider. Please return this to my attention at school as soon as possible. Please call me at if you have questions or concerns. I would be happy to speak with you regarding this request. Sincerely, School Nurse Globalization. Innovation. Graduation. 13 jsl In compliance with federal law, UCPS administers all educational programs, employment activities and admissions without discrimination against any person on the basis of gender, race, color, religion, national origin, age or disability.

19 Dr. Mary Ellis Superintendent 400 North Church Street Monroe, NC Phone Fax Estudiante: Fecha: Grado: Condición(es) Médica(s): Estimados Padres, Ha llegado a mi conocimiento que su hijo sufre de una enfermedad crónica para la cual usted desearía que el personal de la escuela sea notificado. De acuerdo con las nuevas leyes federales, los estudiantes con condiciones médicas crónicas que requieren de un Plan de Salud Individual deben ser considerados para un plan de adaptación 504. Para poder redactar este Plan de Salud Individual, ahora se requiere la documentación escrita sobre la condición médica del estudiante por parte del médico o proveedor de atención médica del estudiante. Por lo tanto, con el fin de redactor o actualizar un Plan de Salud para su hijo/hija, necesitaré la documentación de la condición médica firmada por su médico certificado o del proveedor de atención médica. Por favor devuelva esta forma dirigida a mi persona a la escuela lo más pronto posible. Por favor llámeme al teléfono si usted tiene preguntas o preocupaciones. Estaré encantada de platicar con usted en relación a esta petición. Sinceramente, La Enfermera de la Escuela IHP Diagnosis Request Globalización. Innovación. Graduación. 14 jsl De acuerdo con la ley federal, UCPS administra todos los programas educativos, actividades de empleo y admisiones sin discriminación contra cualquier persona por razón de sexo, raza, color, religión, origen nacional, edad o discapacidad

20 Dr. Mary Ellis Superintendent School Health Office 400 North Church Street Monroe, NC Phone Fax Date Student Dear Parents, Enclosed, you will find an Individualized Health Care Plan for your child. I have used the information you gave me in order to develop this plan. Please review the plan for accuracy. If you need to make changes, please do so directly on the plan. Then sign at the bottom and return the plan to my attention. When I have received the plan back from you, I will make copies for each of your child s teachers (as well as the bus administrator, afterschool and cafeteria manager if applicable). This plan will be available to school personnel in the event that your child has a medical emergency at school. Please call me at if you have questions or concerns regarding this plan or your child s health condition. I would be happy to speak with you. Sincerely, School Nurse 15 Globalization. Innovation. Graduation. jsl In compliance with federal law, UCPS administers all educational programs, employment activities and admissions without discrimination against any person on the basis of gender, race, color, religion, national origin, age or disability.

21 Dr. Mary Ellis Superintendent School Health Office 400 North Church Street Monroe, NC Phone Fax Fecha Estudiante Estimados Padres, Incluido, encontrará el Plan Individualizado de Cuidados Médicos para su hijo/hija. He utilizado la información que usted nos proporcionó para desarrollar este plan. Por favor revise el plan para ver si concuerda. Si usted necesita hacer cambios, por favor hágalo directamente en el plan. Después firme en la parte de abajo y devuelva el plan directamente a mí. Cuando yo haya recibido el plan de regreso a mí, le haré copias para cada uno de los maestros de su hijo/hija (Enfermería, el Autobús si es aplicable, la Cafetería si es aplicable). Este plan estará disponible para todo el personal de la escuela en el caso de que su hijo/hija necesite cuidados médicos de emergencia en la escuela. Por favor me llama al si usted tiene alguna pregunta o preocupaciones en relación a este plan o la condición de salud de su hijo/hija. Estaré feliz de hablar con usted. Sinceramente, La Enfermera de la Escuela IHP Cover Letter 16 Globalization. Innovation. Graduation. jsl In compliance with federal law, UCPS administers all educational programs, employment activities and admissions without discrimination against any person on the basis of gender, race, color, religion, national origin, age or disability.

22 Students with Special Health Care Procedures and Needs Objective: To identify and plan for the management of students with special health needs, medical procedures and treatment needs that may impede learning. Method: Communication School Responsibility 1. Students that are identified with special health care needs will be referred to the school nurse immediately to initiate a plan of care. Nurse Responsibility 1. Upon receiving notification from the school of a student with special health care needs (preferably prior to entering school), the school nurse will contact the parent/guardian, school personnel, and student s physician to obtain information pertinent to the student s needs during the school day. 2. The parent/guardian must authorize the administration of the specialized health care procedure per the form entitled UCPS Parent Authorization for Specialized Health Care. 3. The student s physician must sign and return the Plan of Treatment form which outlines specific nursing procedures to the school, authorizing the administration of the specialized health care procedure(s). When indicated, an Individual Health Care Plan will be developed and a Medication Consent Form must also be signed by a physician and parent/guardian and returned to school. 4. Information concerning any special procedures or medical plans will be kept current and updated at the beginning of every school year by the school nurse and maintained in a designated place in each school. This includes the following: a. The Parent Authorization for Specialized Health Care form, completed and signed. b. A Plan of Treatment form, signed by the physician, authorizing the health care procedure to be administered. Nursing procedures for each treatment will be attached to the medical plan of treatment. c. An Individual Health Care Plan describing the steps to be taken in the event of an emergency. d. A Medication Consent form may also be included, as indicated. 5. The nurse will review all pertinent health care plans/procedures/treatments with the school personnel who will be in contact with the student and provide copies of the information to the appropriate school personnel. 17 jsl

23 Training and Supervision School Responsibility 1. School personnel will be designated to perform long term procedures (ie. catherizations, suction and tracheostomy care, ostomy care, tube feeding, etc.). The school nurse and the principal will work closely together to identify the staff member most appropriate to perform the procedure. 2. The admission of a medically fragile student to school will not be permitted until the Plan of Treatment, Parent Authorization for Specialized Health Care, student-specific nursing procedures, and Individual Health Care Plan are in place and staff is adequately trained. Nurse Responsibility 1. The designated school staff will be trained by the school nurse in the performance of all specialized procedures so that they are qualified to perform the procedures. 2. The nurse will supervise the designated school staff in the performance of the specialized procedures until proficiency is demonstrated and as often as the nurse feels it is needed after that. A skills checklist will be used to show evidence of mastery of the required procedure(s). The checklist will be filed in the student s Individualized Health Care Folder. 3. Specialized health care procedures which may be performed by trained school staff include but are not limited to: a. gastrostomy tube feeding b. care and cleaning ostomies c. tracheostomy suctioning d. care and cleaning of tracheostomy and stoma e. clean intermittent catherization f. care of an external catherization g. postural drainage and percussion therapy h. administration of tube or rectal medications i. intermittent temperature or blood pressure monitoring j. other Parent Responsibility 1. To inform school of changes in the student s Treatment Plan and/or medications as they occur so that information can be updated and implemented. 18

24 2. Specialized health care procedures that are the responsibility of the parent and will not be done by school personnel or the school nurse include but are not limited to: a. Replacing gastrostomy tube feeding sites b. Changing malfunctioning insulin pump sites 19

25 UNION COUNTY PUBLIC SCHOOLS PARENT AUTHORIZATION FOR SPECIALIZED HEALTH CARE As the parents/guardians of, (Student s Name) (Birthday) we request that the following healthcare service(s) be administered to our child. We understand that a trained designated person(s) will be performing the health care service. It is our understanding that in performing this service, the designated person(s) will be using a standardized procedure which has been approved by our physician. Physician s Name Address Phone Health care service(s) requested: We will notify the school immediately if the health status of changes, we change physicians, or there is a change or cancellation of the procedure. We understand that the above procedure should be scheduled before or after school hours whenever possible. We have read and fully understand the Plan of Treatment as it is written and have had the opportunity to ask questions regarding the Plan. We authorize the treatments and medications to be given as ordered. Parent/Guardian Parent/Guardian Address City/State Home Phone Work Phone Home Phone Work Phone Date: 20 jsl

26 UNION COUNTY PUBLIC SCHOOLS AUTORIZACIÓN DE LOS PADRES PARA CUIDADOS MEDICOS ESPECIALIZADOS Como padres/tutor legal de, (Nombre del Estudiante) (Fecha de Nacimiento) Solicitamos que los siguientes servicios médicos sean administrados a mi hijo/hija. Comprendemos que una persona(s) calificada designada llevara a cabo los servicios de cuidado medico. Comprendemos que al llevar a cabo estos servicios, la persona(s) designada estará utilizando un procedimiento estandarizado el cual ha sido aprobado por nuestro medico. Nombre del Medico Dirección Teléfono Servicios médicos solicitados: Le notificaremos a la escuela inmediatamente si el estado de salud de cambia, si cambiamos de medico o si hay algún cambio o cancelación del procedimiento.. Comprendemos que el procedimiento descrito arriba debe ser programado antes o después de las horas de clases cuando sea posible. Hemos leído y comprendemos en su totalidad el Plan de Tratamiento como está escrito y hemos tenido la oportunidad de hacer preguntas relacionas con el Plan. Autorizamos que los tratamientos y medicamentos sean administrados como se ordene. Padre/Madre/Tutor Padre/Madre/Tutor Dirección Ciudad/Estado Teléfono del Hogar Teléfono del Trabajo Teléfono del Hogar Teléfono del Trabajo Fecha: 21 jsl

27 UNION COUNTY PUBLIC SCHOOLS PLAN OF TREATMENT Student s Name & Address School Name & Address: Parent/Guardian: Phone: FAX: Phone: FAX: Teacher s Name: DOB: Sex: Medications: Dose/Frequency/Route Pertinent Diagnoses: Date of onset: Allergies: Mental/Emotional Status Surgical Procedures Related to Care Date: Able to be responsible for self care Needs assistance with care Unable to participate in care Functional Limitation/Requirements Goals: no restrictions dyspnea partial wt. bearing bowel/bladder hearing wheelchair (incontinence) speech walker contractures vision crutches paralysis/paresis exercises other prescribed Physician s Orders For Procedures/Treatments/Observations Physician s Name & Address Nurse s Signature Date: I certify that the above services are required and are authorized by me with a written plan of treatment which will be periodically reviewed by me. This patient is under my care and is in need of these services. I authorize school staff to administer treatments and medications during school hours as appropriate. Phone Number: Physician s Signature: Date: FAX Number: 22

28 Union County Public Schools School Health Office Order for Vagal Nerve Stimulator in Schools Student s Name: DOB: Student s Address: Student s Phone #: Mother s Name: Phone: Work: Cell: Father s Name: Phone: Work: Cell: Preferred Hospital: School: Teacher/Homeroom: Grade: Please have the student s Health Care Provider complete the following information: Student s Diagnosis: 1. Observe seizure activity and time of seizure. 2. If seizure is longer then minutes, swipe the magnet from midline of the chest in a right downward motion. 3. Wait seconds and repeat swipe. 4. Repeat times waiting seconds in between and observe students for further seizure activity. 5. If student continues to have a seizure longer than minutes, CALL Call Parent/ guardian. 7. Document on seizure flow sheet. 8. Activity restrictions if any: 9. Other: Health Care Provider (print): Phone #: Fax # : Address: Health Care Provider s signature: Date: I have reviewed this order and give my permission for the School Health Nurse to train school personnel to follow this order. Parent/Guardian Signature: Date: I have provided training and instruction regarding this order to: School Health Nurse Signature: Date: Duration of the order: School Year: 23 jsl

29 Protocols for School Nurses Protocols, also known as standing orders, are written for procedures in which a nurse must have a doctor s order to perform. They are based upon standard courses of care and best practice and require a medical doctor s signature. The following pages outline each protocol to give the nurse specific direction for each incidence. The protocols for fever, vomiting, and diarrhea may be helpful to school staff as well in deciding when to send a child home from school due to illness. Our medical consultant for Union County Public Schools is Dr. Nancy Bizzell. She has reviewed and signed the following protocols. Dr. Bizzell is also the doctor at Carolina OccMed. 24 jsl