All Health Forms
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Different health forms are utilized within Amesbury Public Schools. The completion of these forms is essential to ensure that students receive the necessary care, services and accommodations throughout the school day. Parents, guardians, and clinicians may fill out the following forms to be submitted to the student's designated school nurse. Click the links below to find out more information.
Copies of these forms are readily available at the health office of your designated school nurse.
Care Plans for...
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Medication(s)
A Medication Authorization Plan (MAP) is required for any medication that is to be administered at school or during school hours. To ensure the safety of all students, no child is permitted to bring their medication to school. Medications MUST be delivered to the school by an authorized adult in its original pharmacy container with its pharmaceutical label.
Exceptions to the policy regarding students carrying their medications are considered on an individual basis and currently apply to students with asthma, diabetes or life-threatening allergies.
All necessary forms must be completed and signed by a parent/guardian AND a medical provider, unless otherwise specified.
It is important to note that students may self-administer certain prescribed medications (anaphylaxis medications, enzymes, inhalers and insulin) provided that specific criteria has been met. According to 105 CMR 210.000, “self administration” means that the student is capable of consuming or applying prescription medication in the manner directed by the licensed prescriber, without needing additional help or guidance and as long as the designated school nurse deems it appropriate.
You may print these documents or contact your designated school nurse for paper copies.
A parent/guardian needs to complete a Medication Administration Plan (MAP) with each medication that may be administered during school hours:
Medication Administration Plan
*It is also very helpful to provide a recent photo of your child to be placed on their MAP.
View our APS policy on Procedure for the Administration of Medication here:
https://z2policy.ctspublish.com/masc/browse/amesburyset/amesbury/JLCD-R
Have questions? Please contact your designated school nurse.
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Asthma / Inhaler use
If your child needs to use a rescue inhaler while at school, it is essential that this Asthma Action Plan is filled out by the student's healthcare provider and submitted to your designated school nurse.
The student's healthcare provider must complete:
The provider for the student may utilize this Asthma Action Plan or a plan from their own practice. Upon completion, it should be submitted to the school nurse or sent via fax. To obtain contact details for your school nurse, please visit HERE.
A Medication Administration Plan must also be completed, as any inhalers are classified as medications. This form is accessible under the section labeled "Medication Forms."
Please provide to the nurse:
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a completed Asthma Action Plan by their healthcare provider,
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a completed Medication Administration Plan by parent/guardian,
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and a recent photo of your child to be placed on the student's action plan.
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Diabetes
Diabetic Medical Management Plan (DMMP) is a plan of care for a student with diabetes. It is based on an individualized, prescribed plan from both the student's personal health care team and parent/guardian with the specific needs of an individual student in mind. It should detail all the elements of care and assistance for that student.
The student's healthcare provider must complete and submit before the start of school:
Diabetic Medical Management Plan (DMMP)
The provider for the student may utilize this DMMP or a plan from their own practice. Upon completion, it should be submitted to the school nurse or sent via fax. To obtain contact details for your school nurse, please click HERE.
A Medication Administration Plan must also be completed, as insulin is classified as a medication. This form is accessible under the section labeled "Medication Forms."
The Diabetic Questionnaire must be filled out at the start of each school year to ensure that school nurses have a comprehensive understanding of your child's requirements during the school day, thereby facilitating optimal conditions for both your child and the school staff so that your child can achieve a positive and successful academic year.
This should be completed by the student's parent/guardian:
Please provide to the nurse:
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a completed Diabetic Medical Management Plan by their healthcare provider,
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a completed Medication Administration Plan by parent/guardian,
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a recent photo of your child to be placed on the student's action plan and emergency medication (s),
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diabetic supplies,
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and schedule an appointment prior to the start of the academic year or upon your child's enrollment with your designated school nurse.
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It is essential to schedule an appointment with your designated school nurse before the start of each academic school year. Additionally, if your child was enrolled in APS during the previous year, it is advisable to contact your school nurse PRIOR to completing any paperwork to prevent unnecessary duplications.
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Seizure / Epilepsy
A Seizure Action Plan (SAP) is a tool that organizes and communicates the student's health care needs. The SAP helps ensure a safe environment for the student and outlines basic first aid to be shared with necessary staff as well as appropriate emergency responses to ensure the child's safety in the event of an acute seizure emergency.
To be completed by the student's healthcare provider:
The provider for the student may utilize this Seizure Action Plan or a plan from their own practice. Upon completion, it should be submitted to the school nurse or sent via fax. To obtain contact details for your school nurse, please click HERE.
A Medication Administration Plan must also be completed if your child has been prescribed emergency life-saving medication such as Diastat, Midazolam, Valtoco or other rescue prescription, as these are all classified as medications. This form is accessible under the section labeled "Medication Forms."
The Seizure Questionnaire must be filled out at the start of each school year to ensure that school nurses have a comprehensive understanding of your child's requirements during the school day, thereby facilitating optimal conditions for both your child and the school staff so that your child can achieve a positive and successful academic year.
This should be completed by the student's parent/guardian:
Please provide to the nurse:
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a completed Seizure Action Plan by their healthcare provider,
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a completed Medication Administration Plan by parent/guardian,
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a recent photo of your child to be placed on the student's action plan and any emergency medication(s),
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a completed seizure questionnaire,
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and schedule an appointment prior to the start of the academic year or upon your child's enrollment with your designated school nurse.
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It is essential to schedule an appointment with your designated school nurse before the start of each academic school year. Additionally, if your child was enrolled in APS during the previous year, it is advisable to contact your school nurse PRIOR to completing any paperwork to prevent unnecessary duplications.
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Severe Allergies
An Allergy Action Plan is used to accommodate a child’s needs throughout the school including in the classroom, cafeteria, during school-sponsored activities, and on the school bus.
The student's healthcare provider must complete and submit before the start of school:
The provider for the student may utilize this Allergy Action Plan or a plan from their own practice. Upon completion, it should be submitted to the school nurse or sent via fax. To obtain contact details for your school nurse, please click HERE.
A Medication Administration Plan must also be completed, as epinephrine is classified as a medication. This form is accessible under the section labeled "Medication Forms."
*No longer have allergies?? It is possible for individuals to outgrow allergies, or perhaps your child has undergone specialized follow-up and it has been determined that your child no longer has a life-threatening allergy. This is exciting news!
However, we ask that you provide written medical confirmation from your healthcare provider, addressed to the school nurse, indicating that these allergies have genuinely been resolved. This will be added to your child's school health chart and will confirm that no further accommodations are required.
Please provide to the nurse:
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a completed Allergy Action Plan by their healthcare provider,
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a completed Medication Administration Plan by parent/guardian,
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a recent photo of your child to be placed on the student's action plan and any emergency medication(s),
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(optional) schedule an appointment prior to the start of the academic year or upon your child's enrollment with your designated school nurse.
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It is OPTIONAL to schedule an appointment with your designated school nurse before the start of each academic school year but your school nurse would appreciate it.
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Other Health Forms & Guidelines...
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Student Emergency Health Form
The Student Emergency Health Information form or Emergency Form, is generally filled out at the beginning of the academic year or when a student transfers to our schools. Its purpose is to inform the school nurse of the student's essential health requirements, including consent or refusal of specific over-the-counter medications as determined by our school physician, as well as potassium iodide (KI) in the case of a nuclear emergency. Additionally, the form includes emergency contact details for use during a health crisis. The reverse side of this form outlines the rationale for administering KI, along with its potential risks and benefits.
Student Emergency Health Information Form
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Student Health History Form
A Student Health History Form must be submitted upon enrollment in Amesbury Public Schools or periodically, as necessary, with health or environmental changes. The purpose of this form is to provide your school nurse with a comprehensive health profile of your child, facilitating an evaluation of any potential accommodations that may be needed within the school setting, as well as determining the necessity for an Individualized Health Care Plan (IHCP) or other specialized care plan.
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Student Health Guidelines
Student Health Guidelines are revised annually by the nurses of Amesbury Public Schools and distributed to parents and guardians at the beginning of each academic year, serving as a valuable resource for nursing information. This document contains essential information that has been summarized into a concise flyer for your convenience. We encourage you to review it and display it on your fridge or home communication board for quick and easy access!
Student Health Guidelines 2024-2025 SY
Student Health Guidelines 2025-2026 SY
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Revised: 1/6/2025
