Student Information
Name: Date of Birth:
School/Teacher: Grade:
Parent/Guardian: Address:
Home Phone:
Work Phone:
Other Emergency Contact: Phone:
Physician: Phone:
Medical Diagnosis: Preferred Hospital:
Date Requested Date Received
1. Referral received from:
2. Parent contact
3. Authorization for release of information signed by parent/guardian
4. Medical/nursing/educational records
5. Nursing assesssment: Home visit, school site observation
6. Individualized Health Care Plan complete
7. Emergency Action Plan developed
8. Request for written orders to physician
9. Parent Request for Special Care on file
10. Review of procedure with parent/guardian
11. Staffing/placement meeting
12. Staff/In-service training
13. Transportation plan completed
14. Equipment and supplies checklist


School Nurse Signature Date