Medical / Health Services Forms

PLEASE NOTE:

Each form is listed twice. The first is in PDF format. The second is an RTF file which is required for compliance with the Americans with Disabilities Act.

Medication Forms

5330 F1 Request for Administration of Prescription & Nonprescription Medication by School Personnel

5330 F2 Request for Student to Carry and Administer Own Prescription Medication by Inhaler

5330 F2 Request for Student to Carry and Administer Own Prescription Medication by Inhaler (.rtf)

5330 F4 (HS/MS) Request for Student to Self-Administer Nonprescription Medication w/o Supervision

5330 F4 (HS/MS) Request for Student to Self-Administer Nonprescription Medication w/o Supervision (.

5330A F1 Consent for Diabetic Management

5330A F1 Consent for Diabetic Management (.rtf)

5330A E F1 Allergy and Anaphylaxis Emergency Orders and Care Plan

5330A E F1 Allergy and Anaphylaxis Emergency Orders and Care Plan (.rtf)

Asthma / Allergy Forms

5330 F1 Request for Administration of Prescription & Nonprescription Medication by School Personnel

5330 F2 Request for Student to Carry and Administer Own Prescription Medication by Inhaler

5330 F2 Request for Student to Carry and Administer Own Prescription Medication by Inhaler (.rtf)

5330A E F1 Allergy and Anaphylaxis Emergency Orders and Care Plan

5330A E F1 Allergy and Anaphylaxis Emergency Orders and Care Plan (.rtf)

5335 F1 / 5340 F4 Parent/Guardian Information on Child's Life-Threatening Allergy

5335 F1 / 5340 F4 Parent/Guardian Information on Child's Life-Threatening Allergy (.rtf)

5340 F6 Parent-Guardian Information on Child's Asthma

5340 F6 Parent-Guardian Information on Child's Asthma (.rtf)

Assisted Feeding Forms

5330 F1 Request for Administration of Prescription & Nonprescription Medication by School Personnel

5311 F2 Health Care Provider Authorization and Recommendations for Assisted Oral Feedings

5311 F2 Health Care Provider Authorization and Recommendations for Assisted Oral Feedings (.rtf)

5311 F3 Health Care Provider Authorization and Recommendations for Assisted Tube Feedings

5311 F3 Health Care Provider Authorization and Recommendations for Assisted Tube Feedings (.rtf)

5311 F4 Emergency Procedures for Gastrostomy (G) or Gastrojejunostomy (GJ) Tubes

5311 F4 Emergency Procedures for Gastrostomy (G) or Gastrojejunostomy (GJ) Tubes (.rtf)

5311 F10 Parent Agreement for Mic-Key Gastrostomy (G) Tube Re-insertion

5311 F10 Parent Agreement for Mic-Key Gastrostomy (G) Tube Re-insertion (.rtf)

Catheter Forms

5330 C F1 Request for Clean Intermittent Catheterization by School Personnel

5330 C F1 Request for Clean Intermittent Catheterization by School Personnel (.rtf)

Immunization Forms

5320 F2 Immunization Exemption

5320 F2 Immunization Exemption (.rtf)

Private Provider Forms

3120.091 F1 Private Provider Plan

3120.091 F1 Private Provider Plan (.rtf)

3120.091 F2 Liability Release for Parent/Guardian of Student Receiving Private Provider Services or

3120.091 F3 Liability Release for Private Providers

3120.091 F3 Liability Release for Private Providers (.rtf)

Seizure Care Forms

5330 F1 Request for Administration of Prescription & Nonprescription Medication by School Personnel

5340 F5 Parent-Guardian Information on Child's Seizure Disorder

5340 F5 Parent-Guardian Information on Child's Seizure Disorder (.rtf)

TB Forms

5320 F3 District Tuberculosis Testing Form

5320 F3 District Tuberculosis Testing Form (.rtf)

Other Medical / Health Services Forms

2340C F1 District-Sponsored Overnight Trips Medical Permission Form

2340C F1 District-Sponsored Overnight Trips Medical Permission Form (.rtf)

2340C F1a 6th Grade Outdoor Education District-Sponsored Overnight Trips Medical Permission Form

2340C F1a 6th Grade Outdoor Education District-Sponsored Overnight Trips Medical Permission Form (.r

2412 F2 Home Instruction Physician Referral

2412 F2 Home Instruction Physician Referral (.rtf)

5112 F2 Preschool Health Assessment Record

5112 F2 Preschool Health Assessment Record (.rtf)

5310 F1 Student Health History Form

5310 F1 Student Health History Form (.rtf)

5320 F4 Parent Varicella (Chicken Pox) Report Form

5320 F4 Parent Varicella (Chicken Pox) Report Form (.rtf)

5320 F5 Medical Provider Review and Determination of Parent Reported Varicella

5320 F5 Medical Provider Review and Determination of Parent Reported Varicella (.rtf)

8330 F4a Parent Consent for Record Release Form

8330 F4a Parent Consent for Record Release Form (.rtf)

8431 F2 Advisory of Pesticide Application in Classroom Buildings

8431 F2 Advisory of Pesticide Application in Classroom Buildings (.rtf)

Dublin City Schools

The Dublin Difference

PLEASE NOTE:

Medication Forms

Asthma / Allergy Forms

Assisted Feeding Forms

Catheter Forms

Immunization Forms

Private Provider Forms

Seizure Care Forms

TB Forms

Other Medical / Health Services Forms