Health Forms

  • School Related Health Forms   

    Several health forms are used in the Amesbury Public Schools. Using these forms helps assure that children get the care, services, and accommodations they need during the school day.
    The following forms can be completed by parent/guardian and physician/health care provider, and submitted to the child's school nurse. (Forms must be printed and completed by hand, not on-line.)

     

    CLICK ON THE LINK AT THE BOTTOM OF THE PAGE FOR THE FORM YOU NEED 

    MEDICATION ADMINISTRATION FORM

    A Medication Authorization form is necessary for any medications that are to be taken at school or during the school day.  For the safety of all children, no child is allowed to transport his/her medication to school. Medications MUST be brought to school by a designated adult in an original pharmacy container.

    Exclusions to students carrying their medications are on a case by case basis and are currently applicable to individuals with Asthma, Life Threatening Allergies and Diabetes.
    Forms must be downloaded, completed and signed by parent/guardian AND medical provider.

     

    STUDENT HEALTH INFORMATION FORM

    Typically completed at the start of a school year or upon transfer into our schools, this is a health questionnaire to let your child's school nurse be aware of his/her health needs. The form also provides emergency contact numbers in event of a health emergency.  On the reverse of this form are the reasons for taking KI and it's associated benefits and risks. (KI Form)

     

    MASSACHUSETTS SCHOOL PHYSICAL FORM

    Amesbury Public Schools encourages families to utilize their own medical care provider for the performance of the physical examinations, whenever possible. A record of that exam should be provided to the school nurse:

    1.      Within one year prior to entrance to school or within 30 days after school entry and at intervals of either three or four years thereafter. (grades K, 4, 7 & 10).

    2.      Students under 16 and over 14 years of age requesting employment certificates,

    3.      Prior to a student’s participation in competitive athletics, on an annual basis.

     

    Note: Parent/Guardians are always welcomed and encouraged to keep the school nurse up to date with annual physicals/immunizations as they change.

     

    DIABETIC MEDICAL MANAGEMENT PLAN

    The DMMP is a plan of care for the 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.

     

    SEIZURE ACTION PLAN

    A tool that organizes and communicates the student's health care needs. A seizure action plan helps ensure a safe environment for the student, and outlines basic first aid as well as appropriate emergency responses to ensure the child's safety in the event of an acute seizure emergency.

     

    STUDENT SELF-ADMINISTRATION OF PRESCRIPTION MEDICATIONS

    Students may self administer certain prescription medications (Anaphylaxis medications, enzymes, inhalers, insulin) provided that specific conditions are met. For the purposes of 105 CMR 210.000, “self administration” shall mean that the student is able to consume or apply prescription medication in the manner directed by the licensed prescriber, without additional assistance or direction.

     

    ALLERGY ACTION PLAN

    A plan that accommodates the child’s needs throughout the school including in the classroom, in the cafeteria, in after-care programs, during school-sponsored activities, and on the school bus.

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