Health Forms & Medications
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
Medication Forms
A parent/guardian needs to complete a Medication Administration Plan with each medication that may be administered during school hours:
Medication Administration Plan (MAP)
What is a MAP?
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.
Can my child self-administer their medication?
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.
Checklist for medication administration in school:
- Medication Administration Plan (MAP) (needs to be completed by parent/guardian),
- unexpired medication in its original container with a prescription label on it. This must be brought in by an adult, not the student.
- Updated photo of your child.
You may print these documents or contact your designated school nurse for paper copies.
View our APS policy here: APS Policies and Procedures for the Administration of Medication
Have questions? Please contact your designated school nurse.
Asthma Forms
What is an Asthma Action Plan?
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 the designated school nurse. An Asthma Action Plan is a medication order for an inhaler that specifies when a child may need to take their medication and what triggers they have.
The student's healthcare provider must complete:
Where do I submit an Asthma Action Plan?
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 click HERE.
A Medication Administration Plan must also be completed, as any inhalers are classified as medications.
Checklist for inhalers in school:
-
a completed Asthma Action Plan by their healthcare provider,
-
a completed Medication Administration Plan completed by a parent/guardian,
-
a recent photo of your child to be placed on the student's action plan.
Diabetes Forms
What is a Diabetic Medical Management Plan?
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 a DMMP before the start of school:
Diabetic Medical Management Plan (DMMP)
Where do I submit a completed 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.
What other forms do I need to submit?
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:
Checklist for diabetic forms and supplies in school:
-
a completed Diabetic Medical Management Plan by their healthcare provider,
-
a Diabetes Questionnaire (to be completed by parent/guardian),
-
a completed Medication Administration Plan by parent/guardian,
-
if prescribed: unexpired insulin and emergency medication in its original container with a clear prescription label on it,
-
a recent photo of your child to be placed on the student's action plan and emergency medication (s),
-
diabetic supplies,
- snack bags for the student to be stored in each of their classes,
-
schedule an appointment prior to the start of the academic year or upon your child's enrollment with your designated school nurse.
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.
Seizure / Epilepsy Forms
What is a Seizure Action Plan?
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:
Where do I submit a completed Seizure Action Plan?
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.
What other forms do I need to submit?
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:
Checklist for student's with seizures:
-
a completed Seizure Action Plan by their healthcare provider,
- a completed Seizure Questionnaire by parent/guardian,
-
a completed Medication Administration Plan by parent/guardian,
-
if prescribed: unexpired emergency medication in its original container with a prescription label on it. This must be brought in by an adult, not the student.
-
a recent photo of your child to be placed on the student's action plan and any emergency medication(s),
-
schedule an appointment prior to the start of the academic year or upon your child's enrollment with your designated school nurse.
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.
Severe Allergy Forms
What is an Allergy Action Plan?
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 for those that have a life-threatening allergy or anaphylaxis. An Allergy Action Plan is completed by a physician that includes all allergens a child may have and the signs and symptoms of their possible reaction to these allergens along with a prescription for any life-saving medication such as epinephrine and an antihistamine.
The student's healthcare provider must complete and submit an Allergy Action Plan before the start of school:
Where do I submit a completed Allergy Action Plan?
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.
What other forms do I submit with an Allergy Action Plan?
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."
What if it's been determined my child no longer has allergies?
It is possible for individuals to outgrow their 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. If so, 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 resolved. This will be added to your child's school health chart and we can confirm that no further accommodations are required and your child's health record be updated.
Checklist for a student with a severe allergy:
-
a completed Allergy Action Plan by their healthcare provider,
-
a completed Medication Administration Plan by parent/guardian,
-
Unexpired Epinephrine Autoinjector in its original container/box with a prescription label on it,
-
a recent photo of your child to be placed on the student's action plan and any emergency medication(s),
-
(optional) schedule an appointment prior to the start of the academic year or upon your child's enrollment with your designated school nurse.
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.
Other Health Forms & Guidelines
Student Emergency Card
The Student Health Information card or Emergency Card, 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 for 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.
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.
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!