Health Services Sample Forms

The Health Services forms and documents included below are samples only and are not endorsed or mandated by OSPI. 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 (Liquid) Medication Administration Skills 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