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Student-Athletes with Medical Conditions - Confidential List

Athletes Health Issues Sample Fillable Form (NYSCSH 7/21)
May be used by school nurses to share student medical needs with athletic directors/coaches.

Sample Flow Chart for Sports Clearance (NYSCSH 4/18)- Update pending

Health Examination Resources for Schools

School Health Examination Guidelines (NYSED 2022)
Requirements and guidance for administrators and school health personnel on mandated student health examinations and establishing a health program.

Sample Recommended NYSED Interval Health History for Athletics

To be completed by the parent/guardian no earlier than 30 days before the start of the sport. May be modified by local school districts. If modified, it should be reviewed and approved by the School Medical Director and Administration prior to use.

NYSED Dominic Murray Sudden Cardiac Arrest Prevention Act Memo is found here: Laws | Guidelines | Memos - Athletics 

Sample Recommended NYSED Interval Health History for Athletics (Fillable PDF NYSED)
This form includes questions related to the Dominic Murray Sudden Cardiac Arrest Act and COVID-19.

Sample Recommended NYSED Interval Health History for Athletics (Fillable Word NYSED)
This form includes questions related to the Dominic Murray Sudden Cardiac Arrest Act and COVID-19.

Spanish Sample Recommended NYSED Interval Health History for Athletics (NYSED 6/22)

(NYSED 6/22)
Both the memo and the parent/guardian letter contain the required information regarding signs or symptoms of pending or increased risk of sudden cardiac arrest that is to be included on the parent/guardian consent for interscholastic athletics.  

Dominic Murray Sudden Cardiac Arrest Chart (NYSCSH 11/2024)

Sample Recommended Medical Certificate of Limitations Form (NYSED 2022)
May be used to document private provider recommendations for PE accommodation.

(AAP 2019))
May be used to obtain additional health information from athletes with special needs. From the American Academy of Pediatrics.

Page Updated 12/12/24

Communicable Disease

The sample communications below should be reviewed and approved by your school medical director and school administrator. It is essential to maintain the confidentiality of affected students when sending notifications. If the local health department, in collaboration with the NYS Department of Health (NYSDOH), determines that there is an outbreak of a reportable communicable disease, they will provide response guidance to schools' medical directors and the Board of Education (BOE).

Communicable disease prevention, surveillance, notification, and reporting are important roles provided by the school health team. In addition to documenting the care of ill or injured students according to district procedures, it is essential to share your observations and recommendations for following up with the student's parents/ guardians. Information may include:

1. A description of the illness, including the complaint's date, time, and details.
2. Recommendations for follow-up.
3. School health services contact information.

General Information on Illness and School Attendance

When to Keep a Child Home - Instructions to Parents/Guardians (NYSCSH 12/19)
Sample letter to share district guidelines. This letter should be reviewed and approved by the School Medical Director prior to use.  

Sample Health Office Visit for Illness | Injury Notification

Sample Injury Notification (NYSCSH 9/22)
This letter may be customized to alert parents/guardians to an injury.

Sample Illness Notification (NYSCSH 9/22)
This letter may be customized to alert parents/guardians about the reason their child was seen in the health office, the care provided, recommendations, and notification of an attempt to contact them.

• • Conjunctivitis - Letter to Parents/Guardians (NYSCSH 11/19)
  • Head Lice Alert Letter For Parents/Guardians (NYSCSH 3/19)

Sample Nursing Process (NYSCSH 9/22)

Communicable Disease Information & Factsheets

A-Z directory of information

A-Z directory of fact sheets

Page Updated 8/23/24

Sample School Recommendations Following Concussion (NYSCSH 12/19)
A customizable checklist which can be provided to the health care provider to allow them to indicate what Return To Learn (RTL) and Return To Play (RTP) accommodations they recommend for the student. Adapted from the AAP with permission.

Sample TBI Return Monitoring (NYSCSH 11/17)
Sample tracking tool schools may use to track students' symptoms for RTL and RTP.

Sample Acute Concussion Care Plan and Parent Information Sheet (NYSCSH 12/19)
This template can be customized for your needs. It includes a care plan and information sheet for parents and students.

This form is part of the "Heads Up: Brain Injury in Your Practice" toolkit developed by the CDC. It provides a referral plan by the private provider containing information on current symptoms and recommendations for RTL and RTP.   

Page Updated 11/15/22

Sample resources below should be reviewed and approved by the School Medical Director and/or BOE prior to use.

Allergy and Anaphylaxis Care Plans

Available in English and Spanish

Available in English and Spanish

Asthma Care Plans | Asthma Action Plans (AAP) | Sample Letters

Sample Emergency Care Plan for Unlicensed School Personnel: ASTHMA (NYSCSH 11/2021)
Provides easy-to-understand information for unlicensed school staff to assist and respond to an asthma emergency.

Sample Letter to Families about Metered Dose Inhalers, Spacers, and Nebulizers (NYSCSH 3/2024)
Provides information on discussing with their child's healthcare provider on nebulizer usage in comparison to MDI with spacer.

Sample Provider and Parent Guardian Permission for the use of School Provided Spacer/Valved Holding Chamber (NYSCSH 3/2024)
This allows schools to provide a backup spacer in the event that the student's inhaler is not available.

Diabetes Medical Management Plans (DMMPs) | DMMP Addendum

NYSDOH Sample DMMP
This document is from the pages 82-86.

Sample Diabetes Medical Management Plan, a sample template for an Individualized Health Care Plan, and sample Emergency Care Plans for Hypoglycemia and Hyperglycemia.

  
Sample DMMP, IHP, and ECPs under Health Care and Education Plans.

DMMP Addendum: Role of Parents/Guardians in Adjustment of Insulin Dose
Allows the HCP to provide criteria by which the parent may be consulted in adjusting insulin doses administered by a nurse during school hours and at school-sponsored events to the extent reasonably practicable. Note: HCP orders only allow the parent to provide proposed adjustments or dosages and require the health care professional to make the ultimate decision after exercising his/her professional judgment. 

Math Calculation Checker Worksheet for Insulin Deviation
This worksheet may be used to verify math calculations performed by the RN.

Diabetes Hypoglycemia | Hyperglycemia Plans

Hypo and Hyperglycemia Chart for School Staff
Excerpted from NYSDOH Diabetes in Children with the permission of the NYSDOH.

Hypoglycemia Sample Emergency Care Plan (NYSCSH 10/17)

Hyperglycemia Sample Emergency Care Plan (NYSCSH 10/17)

Glucagon Training Documentation Form for School Personnel
Documents understanding and skills attainment for staff voluntarily administering glucagon for students with patient-specific orders. Full training found here: NYSCSH e-Learning & Learning Management System (LMS) 

Diabetes Sample 504 Plans

Generic Sample Care Plans and Other Emergency Documentation for Students and Staff

Sample Generic Emergency Care Plan for Unlicensed School Personnel (NYSCSH 12/16)
Information for unlicensed school staff to assist with emergency health issues. 

Sample Students With Special Health Care Needs Record (NYSCH 2/21)
May be used by the school nurse to record students' health care concerns, medication, and emergency care plan status.

Sample Emergency Care Flow Sheet (NYSCSH 12/16)

Sample Emergency Care Flow Sheet for Staff (NYSCSH 9/17)

Sample Individual Health Care Plan (NYSCSH 8/18)

Seizure Sample Care Plans | Interview Questionnaire for Seizure History

Please note: To best support children with seizures, the child's provider should indicate any activity restrictions based on the student's seizure history.
The school may reach out to the provider to clarify or to gather more information on the restrictions indicated.

Seizure Emergency Care Plan - Updated Version Coming Soon
Provides information for emergency management in both English and Spanish.

Seizure ECP (NYSCSH 6/12) - Updated Version Coming Soon
Customizable template for the HCP to document the type of seizure and treatment plan. Separate medication orders would be needed. 

Parent Interview Questionnaire for Seizure History (NYSCSH 6/12) - Updated Version Coming Soon
Documents seizure history, medications, and current understanding of the condition 

Can be used to record seizures. Includes calendars, diaries, and logs. Links to the Epilepsy Foundation Seizure Forms page.

Page Updated 7/15/24

The following sample resources were created in MS Word and may be customized in consultation with district administration and counsel. The school district medical Director oversees the school health program and should be informed of any EAI programs implemented.

• • AED-EAI Maintenance Checklist - EAI-AED Maintenance Checklist (NYSCSH 08/24)
    The checklist may be used to document the security of both the AED and the EAI
  • District EAI Notification to Parents/Guardians (NYSCSH 08/24)
    Provides information regarding the implementation of the program within the school district and contact resources for more information and date of administration.
  • Epinephrine Log- Epinephrine Placement/Use Log (NYSCSH 08/24) 
    This sample log includes areas for the date, location, brand/dose, lot #, expiration date, and date of administration.
  • Epinephrine District Staff Training Summary (NYSCSH 08/24) 
    This sample form is adapted to be used for either patient-specific or non-patient-specific EAI administration by trained staff. Training must be completed annually. The required training must be used for non-patient-specific epinephrine administration. 

Page created 8/2024

FERPA Disclosure Log (NYSCSH 8/12)
Documents student health records viewed by non-health office staff.

School Districts should work with their legal counsel when creating a FERPA form if one is needed.

Health examinations are required for new entrants and in grades Pre-K or K, 1, 3, 5, 7, 9, and 11 (Section 136.3 Health Examinations and Screenings. Effective 7/1/18).

The cardiac history only needs to be completed for students to participate in athletic activities.  

The regulation defines athletic activities as:
Participation in sessions for instruction and practice in skills, attitudes, and knowledge through participation in individual, group and team activities organized on an intramural, extramural, interschool athletic, or inclusive athletic basis to supplement regular physical education class instruction, otherwise known as extraclass periods in physical education or extraclass activities.

School Health Examination Form and Instructions for an EHR Compatible Form

Required NYS School Health Examination Form (PDF) (NYSED 2023) 
This form may be printed and completed by hand. 

Required NYS School Health Examination Form (Fillable PDF) (NYSED 2023) 
This form may be completed electronically by saving it to your computer, entering the information into the fillable fields, and saving a copy for each student.

(NYSED 2020) 
Provides directions for health care providers on the required components and presentation order of those components for an electronic health record form to be an equivalent form.

School Health Examination Form Sample Resources

Instructions for School Nurses and Medical Directors Related to Completion of the Required Health Examination Form (NYSCSH 10/23) 

Sample Parent/Guardian Notification Regarding the Completion of the Required NYS School Health Examination Form (NYSCSH 10/23) 

Sample Healthcare Provider Notification Regarding Completion of the Required NYS School Health Examination Form (NYSCSH 10/23) 

Sample Parent Notification/Request for Mandated Health Appraisal (NYSCSH 1/20)

Health Examination FAQs
Provides answers to questions the Center has received regarding the use and completion of the form.

Medical Certificate of Limitations Form

Sample Recommended Form - Medical Certificate of Limitations (NYSED 2022)
Used to document private provider recommendations for accommodation for PE.

Sample Medical History Update Form (NYSCSH 2/18) 
An optional form that may be used to obtain current health information from the parent/guardian in non-mandated health examination years or to provide student history prior to a school-provided physical exam.

Screening & Health Exam Requirements Charts | Determination for Ungraded Students

NYS & NYC Screening & Health Examination Requirements Chart (NYSCSH 7/18)

Chronological Age/Grade Chart (NYSCSH 4/24)

Dental Certificate | Letter to Parents/Guardians Regarding Dental Exams

Sample Dental Certificate (NYSED 3/18)
This form aligns with health exam grade levels. NYS law (Chapter 281) permits schools to request an oral health assessment when requesting a health exam. It may be completed by a registered dentist or NYS-registered dental hygienist.

Letter to Parents Regarding Health and Dental Examination Requirements (NYSCSH 5/21)
Informs parents/guardians of the mandated requirements for health appraisal within 30 days of school entry.

School Medical Director Delegation Statement 

Sample Individual Student Health Office Visit Record (NYSCSH 8/24)

Sample Student Cumulative Health Record (NYSCSH 8/19)

Sample Students With Special Health Care Needs Record (NYSCSH 2/21)
May be used to record students' health care concerns, medication, and emergency care plan status.

Emergency Go Bag Sample Supply List (NYSCSH 12/23)

Page Updated 8/12/24

These letters are provided as guidance based on current best practices. They do not constitute a mandate nor imply liability should the school choose other options. These sample resources may be modified for your use consistent with NYSED, local district policy, and school medical director guidance.

Animals in the School Building

Sample Parent Letter - Animals in the Classroom (NYSCSH 3/17)

Sample Permission Form - Animals in the Classroom (NYSCSH 3/17)

Food in the School Building

Classroom Treats (NYSCSH 3/17)
A general letter that should be altered to align with your district’s policies on classroom treats (some districts only allow pre-packaged snacks, some allow home-baked goods). This is a template only and does not reflect any state guidance or recommendations.

Safety Posters

What You Say In Here Stays in Here (NYSCSH 10/17)
8.5 x 11-inch printable poster. This poster can be printed and displayed to make students aware of school staff members' responsibility to share information that could result in self-harm or harm to others, according to school policies. 

Cold Weather Precautions

 Sample Letter to Parents About Cold Weather Precautions  (NYSCSH 2/18)

Page Updated 8/12/24

Children entering or attending school in New York State, including summer school and distance learning, must comply with immunization requirements.

Immunization Sample Letter & Forms for the 2024-2025 School Year

Immunization Request Letter to Parents/Guardians of Students in PreK-12 (NYSCSH 4/24)
This sample letter may be used with the Immunization Requirements for School Entrance/Attendance Chart to notify parents/guardians of students in grades Pre K - 12 about immunization requirements for school entrance/attendance. This sample notification letter encompasses multiple ages and grade levels of students.

Chronological Age/Grade Chart (NYSCSH 4/24)

Note: Any or all of the forms above may be shared with parents/guardians and providers to help keep students on track with immunization requirements.

Sample Letter for Administrators/Principals to Inform Parents/Guardians of Exclusion & 310 Appeals Information

Sample Exclusion Letter for Principals to Send to Parent/Guardian (NYSCSH 9/22)
This sample may be customized to send to parents/ guardians whose children have not received the required immunizations for school attendance. 

NYS Education Law 310 provides that persons considering themselves aggrieved by an action taken at a school district meeting or by school authorities may appeal to the Commissioner of Education for a review of such action. Includes instructions and sample forms for filing an appeal. 

Medical Exemption Forms and Sample Letters

Sample Approval Letter for Medical Exemption to Vaccines (NYSCSH 12/18/24)

Sample Denial and Exclusion Letter for Medical Exemption to Vaccines (NYSCSH 12/18/24)

This NYSDOH form must be completed and resubmitted annually.

(NYSDOH 3/2022)

(NYSDOH 6/2019)

Page Updated 12/19/24

Sample Administration / Use Tracking Forms

Daily Medication Record School Year (Excel - NYSCSH 12/2021)
Calendar view of medication charting for an individual student modifiable for your school district.

Dose Counting Medication Record  (Excel - NYSCSH 7/2018)
Calendar view record of medication administration which provides a continuous count of medication given and medication remaining.

Dose Counting Medication Record (PDF - NYSCSH 7/2018)
Calendar view record of medication administration which provides a continuous count of medication given and medication remaining.

Daily Medication Sheet - Summer School (NYSCSH 11/2021)
July and August calendar view of medication charting.

Monthly Medication Administration Record (Medicaid Compliant)(NYSCSH 2/2017)
Records date, times, doses, exception codes, reactions, Medicaid-compliant signature boxes, and NPI number.

Sample Administration Authorization / Permission Forms

Provider & Parent Permission to Administer Medication at School/School Sponsored Events (NYSCSH 3/2019)
Documents provider order & parent permission for medication use at school. It does not indicate permission for the student to carry and use the medication independently. Additional permission from the provider and parent for Independent Medication Carry and Use must also be completed for that to occur.

• • Attestation: Sample Provider Form (NYSCSH 9/2017)
    This form may be used as an addendum along with a provider order and parent/guardian permission for students to carry and use medications that require rapid administration.
  • Attestation: Sample Letter to Parents/Guardians (NYSCSH 9/2017)
    Informs parents and guardians about the attestation requirements

Provider & Parent/Guardian Permission for the Use of School-Provided Spacer/Valved Holding Chamber (NYSCSH 7/2020)
Provides schools the opportunity to provide a backup spacer if the student's spacer is not available.

Sample Sunscreen Parent Permission (NYSCSH 8/2018)
Can be used for students who can independently apply or apply with adult assistance their own or school-provided sunscreen.

Using Insect Repellents Safely and Effectively (NYSCSH 7/2021)
Provides information to reduce the risk of insect bites/stings at school and minimize the need for personal insect repellents.

Sample Insect Repellent Use Parent Permission Form (NYSCSH 5/2021)
Insect repellent use at school by a student requires parent/guardian permission but does not require a medication order since it is not considered a medication.

Determining Who Can Administer Medication and Student's Capability

Guide to Determining Levels of Assistance in Medication Delivery (NYSCSH 7/2023)
This guide assists in determining who may and may not administer medication in school.

Diabetes Medication Forms

(NYSDOH Guide-Page 94)

Diabetes Medical Management Plan Addendum (NYSCSH 5/2017)
Role of Parents/Guardians in Adjustment of Insulin Dose Documents provider permission to allow parents/guardians to adjust the insulin dose.

Field Trip Forms

Sample Field Trip Medication Record for Unlicensed Professionals Assisting Supervised Students (NYSCSH 2/2024)

Sample Field Trip Medication Record for Licensed Professionals Administering Medications (NYSCSH 2/2024)

Sample Field Trip Notification with Information for Parents on Insect Repellents (NYSCSH 6/2018)

Parent/Guardian Medication Communications & Notification

Sample Medication Delivery Information for Parents (NYSCSH 7/2020)
Provides information for Parents/Guardians on what is needed to administer medications at school, including recommendations for a spacer for MDI use vs. a nebulizer.

Sample End-of-Year Medication Pick-Up (NYSCSH 3/2017) 
Medication pick-up information for end of year

Parent/Guardian Designation to Authorize Another Adult to Administer Medication (NYSCSH 8/2024)
Parent/guardian permission document to authorize another adult to administer medication to their student for a specific event.

(2009)

Receipt Forms for Medications / Expiration of Medication Form / Documentation of Medication Errors

Receipt of Medication Delivered to School (NYSCSH 8/2012)
Documents receipt of initial and subsequent medication delivery from parents.

Receipt of Medication Returned to Parent/Guardian (NYSCSH 6/2012)
Documents the return of medication from the Health Office to the parent/guardian.

Medication Expiration Tracking Tool (Word - NYSCSH 8/2022)
Documents student initials, DOB, medication name, expiration date, and date of parent communication.

Medication Expiration Tracking Tool (Fillable PDF - NYSCSH 8/2022)
Documents student initials, DOB, medication name, expiration date, and date of parent communication.

Medication Incident Report Form (NYSCSH 3/2023)
Sample document for medication errors, notifications made, and outcomes. For more detailed information, see page 41 in . 

Training & Self-Determination Forms and Checklists

Checklist Training Unlicensed Personnel to Assist Supervised Students in Taking Their Own Medications (NYSCSH 11/2021)
Checklist of training criteria for unlicensed personnel to assist supervised (formerly self-directed) students in taking their own medications.

Nursing Assessment for Determination of Supervised Student (NYSCSH 11/2021)
This is a customizable version. This lists the steps to go through in the determination of supervised students.

Page Updated 9/4/24

*Note: All naloxone use should be reported in accordance with district policy.

In addition:
Option # 1 Registered NYSDOH Opioid Overdose Prevention Programs report administration to both the clinical director and program director.
Option # 3 Registered NYSDOH Opioid Overdose Prevention Programs report administration to their program partner. 

Opioid Overdose Prevention Naloxone Inventory Log (NYSCSH 2/2019)

Monthly AED/EAI/Naloxone Maintenance Check Sheet (NYSCSH 2/2019)

Opioid Overdose Prevention Training Log Summary (NYSCSH 2/2019)

See Also:

Opioid Overdose Prevention Webpage

Page Updated 4/24/24

Sample Post-Restraint Assessment Form (NYSCSH 8/17) 
This sample form may be customized for your district's use in documenting student health status post-restraint use. 

Page Updated 11/15/22

School Nurse Responsibilities | Checklists | Overview of Tasks

Nursing Annual Responsibilities (NYSCSH 11/21)

Nursing Monthly Responsibilities (NYSCSH 11/21)

Nursing Quarterly/Semiannual Responsibilities (NYSCSH 11/21)

School Nurse Beginning of School Checklist (NYSCSH 11/21) - List of tasks for the beginning of the school year.

School Nurse End of School Checklist (NYSCSH 11/21) - List of tasks for the end of the school year. 

End of School Year Packet

End of School Year Parent Letter (NYSCSH 4/24)
Can be sent home with the NYS Required Health Examination Form and the NYS Immunization Requirements for School Entrance/Attendance to complete the End of School Year Packet.

Page Updated 04/29/24

Emergency Care Data Collection

School districts may voluntarily utilize, maintain, and monitor the following data collection tools. Though not mandated, data collection is essential to demonstrate the school nurse's response to a medical emergency, help advocate for staffing needs, create and update district policies and programs, and create a healthy and safe environment.

The following sample forms may be utilized for data collection if the emergency medication or treatment listed is used:

• • AED Administration Sample Data Collection Tool (NYSCSH 5/23)
  • Concussion Injury Sample Data Collection Tool  (NYSCSH 5/23)
  • Emergency Seizure Medication Sample Data Collection Tool (NYSCSH 5/23)
  • Epinephrine Administration Sample Data Collection Tool (NYSCSH 5/23)
  • Glucagon Administration Sample Data Collection Tool (NYSCSH 5/23)

Health Office Visit Data Collection Tool

Sample School Health Office Data Collection Tool (NYSCSH 8/24)
Customizable, easy-to-use documentation tool to collect data on school health care staffing, student health data, vision & hearing deficits, and student outcomes.

Health Data Documentation & Tracking Forms

School Nurse Weekly Excel Worksheet (NYSCSH 3/22)

School Nurse Monthly Activities Recording Form (NYSCSH 5/20)

Page Updated 8/12/24

Screening Forms | Charts

NYS & NYC Screening & Health Examination Requirements Chart (NYSCSH 7/18) 

Sample Letter to Parent/Guardian Regarding Required Screenings (NYSCSH 12/18)

Hearing

Hearing Screening Parent/Guardian Notification Results and Referral Form (NYSCSH 5/18)

Sample Classroom Teacher Observations- Hearing (NYSCSH 5/18)

Scoliosis

Scoliosis Screening Parent/Guardian Notification Results and Referral Form (NYSCSH 5/18)

Vision

Vision Screening Parent/Guardian Notification Results and Referral Form (NYSCSH 10/18)  
Note: Parents must be notified of both passing and failing vision results. If a student passes, it is sufficient to just indicated passed. However, if they fail, you should provide the findings, so the follow-up provider has a frame of reference. This form allows you to provide that information.

Sample Classroom Teacher Observation - Vision (NYSCSH 5/18)

Sample Delegation

Page Updated 8/23/24

Sample Emergency Care Flow Sheet for Staff (NYSCSH 10/17) 
School Nurse documentation form

Page Updated 11/21/23