PASADENA UNIFIED SCHOOL DISTRICT
HEALTH PROGRAMS PROCEDURE GUIDE
2010 - 2011
Board of Education
Bob Harrison President Renatta Cooper Vice-President Tom Selinske Member Scott Phelps Member Ed Honowitz Member Ramon Miramontes Member Elizabeth Pomeroy Member
Edwin Diaz. Superintendent of Schools and Edwin Diaz Secretary to the Board of Education
Ann Rector Coordinator of Health Programs ACKNOWLEDGMENTS
A number of people contributed significantly to this Procedure Guide. We are deeply grateful to the Pomona Unified School District for their Guide which was used as a model for the development of this Procedure Guide; to Louise Singleton, School Nurse Practitioner and Consultant, who dedicated many hours to reviewing, correcting, and revising each procedure; and to the Pasadena Unified School District Nurses and Nurse Practitioners who also provided many hours reviewing the procedures and assisting with revisions and additions. A special thank you also to the Los Angeles County Office of Education, Educational Support Services Division for providing sample procedures and reviewing the Guide, and to the State of California Department of Education for Education Code Regulations, legal support, and new laws.
This book addresses just some of the current challenges facing the nurse in the school setting. Without the help of the above mentioned agencies and individuals, this valuable resource would not have been possible.
Rev. 07/01/08 Table of Contents Section I - General Information
I. General Information A. Program Outline...... 1 B. Credentialed School Nurse 1. Job Description...... 2 2. Job Description Credential School Nurse/Nurse Practitioner...... 4 3. Specific Services Provided by the Certificated School Nurse...... 6 4. Mandated Services...... 8 5. Health Office Monthly Activities - Suggested Guidelines...... 9 6. Orientation Checklist...... 15 7. Evaluation a. Guidelines...... 19 b. Forms...... 20 c. Goals Worksheet...... 24 C. Health Clerk 1. Job Description/Responsibilities...... 25 2. Health Clerk Guidelines Manual...... 27 3. Evaluation Forms...... 32 4. Memo Student Immunizations and Medical Conditions...... 36 5. Medical Code List...... 37 D. Responsibilities of Office Personnel...... 39 E. Report Forms 1. Daily Health Office Log...... 40 2. Monthly Reports………………………………………….……..41, 42, 43 3. Monthly Reports First & Second Semester……………..…..44, 45, 46, 47 F. Lists 1. Casts/Crutches/Wheelchair...... 48 Rev. 07/01/08 Table of Contents (cont’d) 2. Communicable Diseases...... 49 3. Medications...... 50 4. Special Health Concerns (Old Liability List)...... 51 G. Referral List 1. Counseling...... 52 2. Hearing...... 53 3. Medical Care...... 54 4. SST Meetings...... 55 5. Vision...... 56 6. Young & Healthy...... 57 H. Follow Up 1. Referral for Health Care...... 58 2. Request for Follow-up...... 60 3. Health Update …………………………………………………………..62 I. Specific Diseases Letters/Forms 1. Asthma a. Guidelines...... 64 b. Standard School Emergency Response...... 65 c. Asthma Information Log...... 66 d. Parent Letter...... 67 e. Parent Guidelines for School Attendance...... 69 f. Asthma Survey Consent...... 71 g. Asthma Survey...... 73 h. Administration of Medication ...... 75 i. Nebulizer Consent Letter...... 77 j. Asthma Episodic Log...... 79
Rev. 07/01/08 Table of Contents (cont’d)
k. Asthma Algorithm...... 83 l. Emergency Care Plan...... 84 2. Diabetes a. Letter to Parent...... 85 b. Blood Glucose Graph...... 87 c. Type 2 Diabetes Information letter……………………...... 88,89, 90-96 J. Health Office Information 1. Sample of Student Health Record...... 97 2. Pupil Health Office Visit Card...... 99 3. Health Office Student Pass...... 100 4. Emergency Card Information...... 101 5. Sample of Emergency Card...... 102 6. Flagging of Health Records...... 103 7. Health Office Supplies a. Ordering...... 104 b. List...... 105 c. Warehouse Order Form...... 107 d. Outside Order Form...... 108
Rev. 07/01/08 Program Outline The Pasadena Unified School District through its Board of Education has maintained a long history of support for a comprehensive school health program. The program is designed to protect and promote the health and well being of all students and staff. This procedure guide for the health service staff is only one part of a comprehensive school health system that includes health education, physical education services, psychological counseling services, a safe and healthy school environment, and health promotion for staff, parent, and community involvement. A school based health program provides for early identification of health problems and expertise and leadership from the school nurse in triage and treatment for injury and illness including Red Cross First Aid and CPR Instruction for students (when appropriate) and staff. The following activities are the responsibility of each school nurse: Assessing school community Health Programs and educational needs. Providing mandated vision, hearing, and scoliosis screening, referral and follow-up as necessary. Ensuring adequate immunization status of students. Assisting in ensuring that special education pupils with extended learning and/or physical disabilities will be placed in appropriate classes or classroom settings. Providing nursing expertise to students, families, and staff as appropriate. Providing support and leadership regarding child abuse, case finding, reporting, and follow-up. Conducting health appraisals, screening, and follow-up. Providing teachers with resource materials and background for health-related education classes. Providing personal health counseling to students, parents, and staff as appropriate. Assisting families in need to obtain medical and social services. Implementing innovative programs which build upon student strengths and ensure optimal learning. Acting as liaison between the school and community resources. Providing health-related input and expertise to related district programs. Assessing the acutely ill and injured, and providing treatment and referral through the district clinic and other resources. Case Management
The primary goal is to strengthen and facilitate the educational process by improving and protecting the health status of students and staff.
Primary Health Care Clinic 351 S. Hudson, Room 130 The Pasadena Unified School District Primary Health Care Clinic, staffed by Nurse Practitioners, provides medical services for uninsured children, preschool through high school. Children receive complete physical examinations, CHDP exams, sports and camp physicals, and medical care for illness and injury. Other services include immunizations, tuberculosis screening tests, counseling, and health education. Referrals and appointments are made through school nurses and health clerks. This Clinic has a Title I outreach worker to assist families with accessing MediCal, Healthy Families, California Kids, and other health care plans for medical homes for children.
Drug Prevention As part of a Comprehensive Health Education program, students receive instruction in drug prevention at all grade levels. The programs help students build self-esteem, improve peer relationships and learn to make healthy, drug-free choices.
Rev. 07/01/08 I - 1 POSITION TITLE : CREDENTIALED SCHOOL NURSE JOB DESCRIPTION
RESPONSIBLE TO: Coordinator of Health Programs
QUALIFICATIONS:
1. California licensure as a Registered Nurse
2. Baccalaureate Degree
3. Health Services Credential. (Possession of a Preliminary Credential may be acceptable.)
ROLE: Strengthens the educational process through a comprehensive health program which focuses on improvement and protection of the health of pupils and school personnel in accordance with state law and district policy and procedures.
POSITION RESPONSIBILITIES:
1. Identifies student health problems through case findings, and screening procedures.
2. Counsels students, parents and school personnel about illness, physical defects, social, and potential health problems.
3. Refers students needing medical or dental care. Assists families to solve financial, transportation and other barriers to health care.
4. Completes health assessment of Special Education candidates including social and emotional components of the family setting. Is a member of the I.E.P. team.
5. Conducts a communicable disease program directed toward the control of communicable disease in the school, including immunization assessment and compliance.
6. Maintains health records of students and documents care provided.
7. Informs teachers of health problems of students and suggests ways of preventing complications and enhancing a student’s achievement potential.
8. Provides emergency care for seriously ill and injured students.
9. Counsels parents, pupils and school staff regarding health related attendance problems. Assists with Home Teaching referrals.
10. Supervises the administration of medications according to district policy. Rev. 07/01/08 I - 2 11. Confers and communicates with physicians and other health professionals.
12. Assists site staff in the referral process for suspected child abuse.
13. Serves as a liaison to community agencies.
14. Supports professional health career programs.
15. Reports health problems of students and school environment to administrators. Assists in the identification of safety and health hazards.
16. Maintains first aid supplies including kits for classroom.
17. Supervises work of clerical personnel and student helpers in health office.
18. May participate in teaching school personnel First Aid and CPR to meet immediate needs of students and staff.
19. Serves as a resource and consultant in health education. Teaches health education topics in the classroom.
20. Maintains professional competence through participation in inservice education activities.
Rev. 07/01/08 I - 3 POSITION TITLE : CREDENTIALED SCHOOL NURSE/NURSE PRACTITIONER JOB DESCRIPTION
RESPONSIBLE TO: Coordinator of Health Programs
MINIMUM REQUIREMENTS: 1. Master's degree with a major in nursing from an appropriately accredited institution of higher learning and completion of an accredited nurse practitioner program.
2. Must hold a valid California Registered Nurse license and a valid California Nurse Practitioner license.
3. California Health Services Credential.
DESIRABLE QUALIFICATIONS: 1. Two years experience as a nurse practitioner.
2. Two years experience as a school nurse and/or public health nurse.
3. Holds national professional certification.
4. Knowledge of bilingual, bicultural healthcare and health practices.
5. Experience working with an urban, multiethnic population.
6. Knowledge of state and federal regulations regarding funding sources for provision of medical care.
7. The ability to communicate effectively in both written and oral forms.
8. The ability to work effectively and cooperatively with professionals, paraprofessionals and community groups.
9. Availability of private transportation.
RESPONSIBILITIES: Under direction of the Director of Health Programs and supervising physicians per protocols, provides health services. The nurse practitioners performs assessments, makes a diagnosis, develops and implements a treatment plan including student and family education, provides follow-up and evaluation of client status and interacts with professional colleagues to provide comprehensive care. The nurse practitioner is qualified to perform all duties described under the school nurse job description in addition to the above responsibilities according to assignment. The major focus of school nursing is prevention of disabilities through early detection and correction of health problems and provision of a comprehensive service/education program for staff, parents and students. In addition the nurse practitioner is responsible for maintaining school based clinic including supervising staff, clinic operations, quality assurance, managing funding, and grant writing. Rev. 07/01/08 I - 4 EXAMPLES OF DUTIES: 1. Performs direct primary care such as complete physical examinations, including head to toe exam, ordering indicated lab work and studies, immunizations, and anticipatory guidance on all children.
2. Employs strong focus on adolescent health care and prevention through identification of at risk behaviors utilizing the Guidelines for Adolescent Practice.
3. Conducts preventive screening procedures based on age and history.
4. Performs evaluation, diagnosis, treatment and follow-up for common acute and routine chronic illness.
5. Furnishes pharmacological agents and non-pharmacological therapies per protocol.
6. Identifies needs of the individual, family and/or community as a result of the evaluation of the collected data, and facilitates appropriate utilization of the healthcare system.
7. Updates and records changes in health status.
8. Maintains communication with parents, school staff, and involved community practitioners or agencies to promote needed treatment and secures reports of findings pertinent to educational planning.
9. Administers immunizations and TB tests for all students, employees and volunteers within the district.
10. Provides employee pre-employment physical examinations.
11. Consults and serves as a resource person to teachers, staff, and administrators involved in the school programs.
12. Provides in-classroom health education.
13. Participates in quality assurance review on a periodic basis including regular chart review
14. Nurse practitioners combine the roles of provider, educator, manager and consultant. They act as a preceptor with numerous educational institutions i.e.: UCLA, USC, CSULA, and Azusa Pacific.
15. Performs other duties, as assigned.
Rev. 07/01/08 I - 5 SPECIFIC SERVICES PROVIDED BY THE CERTIFICATED SCHOOL NURSE
1. Hearing Assessment.
2. Vision assessment.
3. General health assessment of children.
4. Counseling students with physical, social and emotional problems.
5. Counseling parents regarding health problems affecting the student’s achievement.
6. Assisting parents with appropriate referrals for further diagnosis and treatment of their child’s health problems.
7. Assisting families with financial barriers to treatment.
8. Consulting with teachers regarding student’s health problems and their adjustment in the classroom.
9. Continuous monitoring of community resources to meet student’s needs.
10. Managing communicable disease outbreaks in conjunction with the Pasadena Health Department or the County Health Department.
11. Assisting school personnel in the recognition of signs and symptoms of communicable disease.
12. Consulting with teachers on up-to-date and scientific health information.
13. Assisting teachers with resources for health education.
14. Giving lessons in health education in the classroom.
15. Staff inservices on a variety of health topics.
16. Providing Mantoux skin tests for students and employees at the district clinic.
17. Assessment, referral and administration of required immunizations for students at the district clinic.
18. Providing American Red Cross First Aid and CPR Training for students and staff.
19. Certifying student illness for admission to home teaching.
20. Certifying student illness in special attendance problems, and counseling student and parents.
Rev. 07/01/08 I - 6 SERVICES PROVIDED BY THE CERTIFICATED SCHOOL NURSE (CONTINUED)
21. Screening of students referred to Student Study Team to identify or rule out problems that may interfere with achievement in the classroom.
22. Health assessment, including neuromaturational development, of students referred for evaluation by Guidance Team.
23. Referral for complete physical examination (excluding X-ray and special tests requiring laboratory work) to the district clinic for the student who qualifies financially under CHDP and Medi-Cal requirements.
24. Specialized physical health care services to qualifying student (e.g., catheterization, tracheostomy care, gavage feeding).
25. Crisis intervention.
26. Bereavement counseling of students dealing with death or other serious loss.
27. Assisting school staff in preparing for earthquakes and other disasters.
28. IEP assessment, screening and written report.
Services may be obtained by referral from a teacher, psychologist, speech therapist or any other staff person, student self-referral, physician or other private practitioner referral, community agency referral, or parent request.
Rev. 07/01/08 I - 7 MANDATED SCHOOL NURSING ACTIVITIES ON DISTRICT TIME
School nursing activities are mandated in the California Education Code (CEC) Title 5 or Health and Safety Code (H & SC). Health Education is also mandated and the school nurse initiates, facilitates, and serves as a resource to the classroom teacher. Mandates include special education assessment which is under the direction of that department.
PRIORITIES OF THE DAY
CEC 49400 a. Crisis intervention: Child abuse, rape, serious traumas, serious illness, pregnancy, suicide attempts, drug ingestion, and other emotional crisis as well as needed screening.
H & SC 3380 b. Immunizations and reporting of immunizations (students need immunization to be 3389 admitted to school).
PROGRAM PRIORITIES
CEC 49452 1. Vision (including color) and hearing screening, referral and follow-up.
455, 456
2. Identification of other health problems, referral and follow-up.
3. Communicable disease control (i.e., pediculosis, scabies, shigella and childhood diseases).
C E C 4. Scoliosis screening, referral and follow-up. 49452.5
C E C 5. Dental disease identification, referral and follow-up. 49400
6. Attendance counseling of students and parents regarding health related absences (home visits on request from principal).
7. Follow-up on all identified problems including those identified in the CHDP examinations.
8. Annual and other special reports, maintenance of student records including special education records and other reports.
9. Life process and other health education activities.
10. Dental education at appropriate elementary grade levels.
A definition of diligent care (CEC 49400) has come from the State Department of Education:
“A public education agency does have the responsibility of ensuring that all pupils receive “diligent care” related to their health needs and physical development (see Education Code Section 49400 et. Seq.). This means that public education agencies must be involved in screening, consultation and referral activities which will assist parents in obtaining proper medical treatment for their child.”
Rev. 07/01/08 I - 8 HEALTH OFFICE MONTHLY ACTIVITIES SUGGESTED GUIDELINES
SEPTEMBER
1. Before school begins or as soon as possible, discuss current mandatory immunization guidelines with office staff. Confirm need for written verification of Immunization status. Clarify procedure for referral to Health Programs Immunization Clinic. See current flyer.
2. Compile a list of students with waivers of immunizations. This must be current if exclusions become necessary.
3. Check supply of forms, first aid supplies and arrange health room cupboards.
4. Prepare/distribute first aid kits and latex gloves to the classroom and noon-duty personnel. In secondary schools, distribute to home economic, shops, labs, etc. Gloves distributed to all staff per OSHA guidelines.
5. Begin preparing a list of students with significant health problems - Health Concerns list. Distribute to appropriate staff, maintaining confidentiality rights of students. Serious health problems should have treatment strategies outlined. Copy to be sent to Health Programs Coordinator.
6. Make a list of students with parental waivers excluding first aid/medical treatment. Post a list of those names on the inner door of the first aid cabinet.
7. Visit each classroom, introduce yourself and explain your function and procedures.
8. If possible, attend the first staff meeting to become acquainted with new teachers. This meeting often occurs before school begins.
9. Request office staff to inform you of any new student who reports a physical problem at the time of enrollment. Review enrollment forms.
10. Notify all office personnel of daily schedule for nurse, health clerk, and procedures to follow when emergencies occur. Obtain current school nurse on call list.
11. Set up file or notebook to expedite follow-up activities on students.
12. Review special education class lists for needed assessments and required designated instructional services. Determine timeline.
13. Plan conferences with teachers to inform them of individual student health needs.
Rev. 07/01/08 I - 9 HEALTH OFFICE MONTHLY ACTIVITIES (CONTINUED)
SEPTEMBER (CONTINUED)
14. Send CHDP letters home to all 1st graders who do not have CHDP certificates. Check CHDP worksheet from previous year. Check procedures for CHDP program. May send letter informing parents of CHDP availability and qualifying requirements for students in grade 2-12.
15. Begin Kindergarten immunization audit report. Forms will come from the Health Department. Instructions for completing should be followed closely. Submit to coordinator for district compilation.
16. Become familiar with the cumulative health records of each student so you may understand individual health status and develop intervention strategies. Prepare health folders for students new-to-district.
17. Prepare a list of parent volunteers to assist during screening and other activities.
18. List all students requiring medication in school. Train staff who will be responsible in the absence of nurse and Health Programs assistant. Complete sign-off sheet.
19. List all students requiring assistance with specialized health procedures. Train staff who will assist student and complete sign-off sheet.
20. Schedule with principal time to present certificated and classified staff inservices on mandated subjects (e.g., blood borne pathogens & child abuse identification and reporting).
21. Monthly report due.
OCTOBER
1. Continue nurse-teacher conferences so the teacher is current with health needs of students.
2. Attend staff meetings if relevant to health programs.
3. Schedule and conduct hearing and vision testing. Make appropriate referrals. Record results of testing programs on health folder as soon as possible and develop format for keeping yearly totals up-to-date. (Annual reports due June 1st.)
4. Meet with parent groups. Discuss health education articles for their newsletters. Offer assistance such as participation in health education programs for meetings, as time permits.
Rev. 07/01/08 I - 10 HEALTH OFFICE MONTHLY ACTIVITIES (CONTINUED)
OCTOBER (CONTINUED)
5. Continue follow-up on previously referred students including special education.
6. Initiate vision and hearing on all new enrollees. Report results to teachers. Discuss with teachers their observations before contacting parents to report deviations.
7. Continue immunization program monitoring.
8. Attend parent night presentations for 5th, 6th, 7th, & 9th grade Human Growth Lessons.
9. Schedule 5th grade Human Growth lessons.
10. Provide Coordinator of Health with updated copy of Health Concerns list.
11. Monthly reports due.
12. As soon as possible, schedule vision and hearing screening date. Grades K, 2nd, 5th, 8th, and 10th, and Special Education students.
NOVEMBER
1. Test vision and hearing of all new enrollees if it hasn’t been done within the last two years.
2. Continue to follow-up on all referrals.
3. Continue follow-up on CHDP letters of first graders and others, as appropriate.
4. Continue immunization program monitoring.
5. Continue vision and hearing screening.
6. Schedule scoliosis screening at middle schools. 7th grade girls and 8th grade boys are mandated and will be done by the Screening Team in January or February.
7. Attend annual CPR recertification class.
8. Monthly report due.
9. Schedule Kindergarten hand washing class.
Rev. 07/01/08 I - 11 HEALTH OFFICE MONTHLY ACTIVITIES (CONTINUED)
DECEMBER
1. Continue testing, referral and follow-up on new and referred students. Record those receiving care.
2. Restock first aid boxes whenever needed.
3. Continue immunization program monitoring.
4. Continue follow-up on CHDP program. Secure waivers where appropriate.
5. Gather data for CHDP report (due to state January 15th). 100% compliance is mandated.
6. Prepare for the dental education/inspection program in February. Gather materials, confirm with dentist. Organize parent volunteers.
7. Continue vision and hearing screening.
8. Monthly report due.
JANUARY AND FEBRUARY 1. Schedule dental education class for 1st graders
2. Conduct dental inspections with volunteer dentist. Refer for care.
3. Be alert for early signs of communicable disease. Staff and parent education is an important part of communicable disease control (appropriate for all year, but winter months are frequently flu months.)
4. Evaluate progress in testing program. Continue testing, referrals and follow-up.
5. Continue immunization program monitoring.
6. Continue immunization follow-up on referrals including special education.
7. Send CHDP letter to kindergarten students and assist in scheduling at clinic.
8. Continue all types of health education.
9. Schedule color vision on K or 1st grade males. Complete and record.
10. Conduct mandated scoliosis screening. Refer and record.
11. Monthly report due.
Rev. 07/01/08 I - 12 HEALTH OFFICE MONTHLY ACTIVITIES (CONTINUED)
MARCH AND APRIL
1. Schedule 6th grade human growth lessons.
2. Continue to arrange time with teachers for teacher-nurse conferences.
3. Continue immunization program monitoring.
4. Continue testing and referral for vision, hearing and scoliosis on new and referred students.
5. Continue follow-up on all referrals including special education.
6. Continue Health Education.
7. Monthly report due.
MAY
1. Complete all follow-up on referrals for any assessment or screening.
2. Monthly report due.
JUNE
1. Enlist teacher cooperation in encouraging parents and children to follow up with identified health problems during summer vacation.
2. Forward copies of students with health problems who are being promoted to middle school/high school to nurses at these schools.
3. Request that teachers and other personnel return first aid kits issued in September. Clean and store kits.
4. Store equipment left at site in a locked cabinet or area.
5. Return audiometers to health office for calibration. Return any equipment needing repair.
Rev. 07/01/08 I - 13 HEALTH OFFICE MONTHLY ACTIVITIES (CONTINUED)
JUNE (CONTINUED)
6. Submit the following reports to Health Programs:
- Health Concerns list of promoted students (also send to receiving site) - Immunization Concerns List of promoted students (also send to receiving site) - Annual Vision Report - Annual Hearing Report - Scoliosis and Orthopedic Screening Report - Monthly Report
7. Obtain list of special education students attending summer school, and forward to summer school nurses (Health Concerns).
Rev. 07/01/08 I - 14 ORIENTATION CHECKLIST SCHOOL NURSE
A GUIDELINE CHECKLIST TO ASSIST SCHOOL NURSES IN COMPLETING THEIR ORIENTATION RESPONSIBILITIES.
I. IMMUNIZATIONS Contact - Immunization Clinic Facilitator/Health Programs Coordinator Procedure for referrals to Area Clinics Completion of Kindergarten Immunization Audit Mantoux Audit Students with immunizations waivers Immunization recording on student files Familiarization with immunization clinic (Inservice training in immunization and mantoux procedures) Forms and additional information in the Health Programs Procedure Guide.
II. VISION AND HEARING SCREENING Contact - Health Resource Specialist/Screening Team Facilitator Inservice on Snellen and Kindergarten screenings Inservice on Audiometers Scheduling and organizing classroom time Referrals Recording results Color vision on K or 1st grade males Forms and additional information in the Health Programs Procedure Guide.
III. HEALTH EDUCATION TO STUDENTS (Examples) Contact - Unit Leaders A. Kindergarten Handwashing Lessons (Communicable disease prevention) Scheduling classroom presentations Availability of prepared lesson plans, i.e., Scrubby Bear Acquirement of Health Education materials Observation of other nurses
B. First Grade - Dental Health Scheduling classroom presentations Availability of prepared lesson plans Acquisition of Health Education materials Observation of other nurses Scheduling screening with assigned dentist Referrals Organizing parent volunteers for dentist screening Familiarization with resource Manual
Rev. 07/01/08 I - 15 C. Fifth Grade Family - Growth and Development Information to parents/staff via letter Scheduling classroom presentations Acquisition of Health Education materials Availability of prepared lesson plans and videos Observation of other nurses
D. Sixth Grade - Human Reproductive System Information on HIV to parents/staff via letter Scheduling classroom presentations Acquisition of Health education materials Availability of prepared lesson plans and videos
E. Seventh Grade - Contraception Information to parents (letter) Scheduling of classroom presentations Acquisition of Health education materials (may have Planned Parenthood speakers) Availability of prepared lesson plans and video (7th grade health curriculum) Observation of nurses to other speakers
F. Ninth Grade - CPR instruction CPR instructor certification from American Heart Association or American Red Cross. Scheduling of classes with health teacher Maintenance of mannequins
IV. SPECIAL EDUCATION A. School Nurse Role in Special Education Health assessment done by school nurse Medical referrals and follow up Writing of Goals/Objectives for I.E.P. (Individualized Education Program) as related to medical/health needs Visitation to facilities/classroom Referral and screening process Completion of Monthly Report and State School Register D.I.S. book
B. Programs available (Upon completion of Special Ed. Assessment) Special Day Class (SDC) Resource Specialist Program (RSP) Adaptive Physical Education Pre-K and Preschool Program California Children’s Services (CCS) (Roosevelt School)
Rev. 07/01/08 I - 16 V. CHILD HEALTH AND DISABILITY PREVENTION PROGRAM (CHDPP) Contact - CHDP Clinic Lead Nurse Practitioner Parent permission release for physical exam CHDP eligibility Scheduling at health clinic Review procedures for CHDP Program School nurse follow-up on medical/health referral as needed Familiarizing self to clinic CHDP Annual Report due December for 1st Graders Forms and additional information in the Health Programs Procedure Guide.
VI. REFERRAL SERVICES WITHIN THE COMMUNITY Assisting parents with appropriate referrals Assisting families with financial barriers to treatment Monitoring of community resources Referrals and follow-up
VII. YOUNG AND HEALTHY Contact - Staff at Young and Healthy Eligibility Familiarization with forms and referral procedures
VIII. SUSPECTED CHILD ABUSE Contact - Health Programs Coordinator Understanding how child abuse is handled in PUSD State and Federal Law Assisting site staff in recognition and referral process for suspected child abuse cases Forms and additional information in Health Programs Procedure Guide.
IX. MEDICATIONS Contact - Health Programs Coordinator Listing of all students at your site requiring medication while at school Daily Log/Sign-off sheet Orientation of appropriate school personnel on absence of school nurse Proper administration and storage of prescribed medications
X. EMERGENCY PROTOCOL/FIRST AID Contact - Health Programs Coordinator Providing emergency care/when to call 911 Inservice to site staff on emergency first aid What to do when parent cannot be contacted Emergency Card/Letter to parents Accident Report Classroom first aid box Forms and additional information in Health Programs Procedure Guide.
Rev. 07/01/08 I - 17 XI. UNDERSTANDING CHAIN OF COMMAND Faculty Administrators
XII. SUPERVISION OF CLERICAL PERSONNEL Contact - Health Programs Coordinator Orienting health clerk Supervising and coordinating work of health clerk Familiarization with health clerk duties
XIII. HOME TEACHING SERVICES Contact - Home and Hospital School Health Programs Assistant/Clerk Certifying students illness Admission to home teaching/monitoring of services Completion Reports Forms and additional information in Health Programs Procedure Guide.
XIV. COMMUNICABLE DISEASE Contact - Coordinator Inter-communication with county or city health department Education of site staff on signs and symptoms of communicable disease Notification to parents Forms and additional information in Health Programs Procedure Guide.
XV. LEA Medi-Cal Billing Contact - Health Programs Medi-Cal Program Assistant Provider I.D. number Purposes and procedures for completing forms Eligible services System/partnership with Health Clerk Form completion and follow through responsibilities Forms and additional information in Health Programs Procedure Guide and LEA Provider Resource Book.
XVI. GENERAL INFORMATION Contact - Health Programs Secretary Evaluations Mileage/travel reimbursement Ordering supplies Daily Log/monthly tally Forms and additional information in Health Programs Procedure Guide.
Rev. 07/01/08 I - 18 Pasadena Unified School District Evaluation/Supervision - Non Instructional Certificated Employees
The Superintendent or designee shall ensure that certificated employees have access to written regulations related to the evaluation of their performance in their assigned duties. (Education Code 35171)
(cf. 4116 - Probationary/Permanent Status) (cf. 4315.1 - Competence in Evaluation of Teachers)
Non instructional certificated employees shall be evaluated on their performance in fulfilling their defined job responsibilities. (Education Code 44662)
Evaluations shall include recommendations, if necessary, as to areas of improvement in the employee’s performance. If an employee is not performing satisfactorily according to standards approved by the Board, the Superintendent or designee shall so notify the employee in writing, describing the unsatisfactory performance. The Superintendent or designee shall also confer with the employee, make specific recommendations as to areas of improvement, and provide assistance to the employee. (Education Code 44664)
Non-instructional certificated staff members employed on a 12-month basis shall receive a copy of their evaluation no later than June 30 of the year in which the evaluation is made. Before July 30 of the year in which the evaluation takes place, the employee and the evaluator shall meet to discuss the evaluation. (Education Code 44663)
Rev. 07/01/08 I - 19 PASADENA UNIFIED SCHOOL DISTRICT Pasadena, California Self- and Summative Evaluation for Non-Teaching Certificated Personnel
NA Not Applicable Name of Evaluatee Name of Evaluator Date 1. Does not meet 2. Needs improvement 3. Meets 4. Exceeds Location
I. DEVELOPING STAFF PERSONNEL
A. Maintains good staff morale. N/A 1 2 3 4
B. Is approachable. N/A 1 2 3 4
C. Emphasizes the importance of team work. N/A 1 2 3 4
D. Maintains effective communication. N/A 1 2 3 4
E. Shows sensitivity as evidences by understanding of others, N/A 1 2 3 4 empathy, and acceptance of others point of view.
Evaluator Comments: Evaluatee Comments:
II. JOB PERFORMANCE
A. Performs those duties as established for the N/A 1 2 3 4 respective positions.
B. Communicates effectively in oral and written form. N/A 1 2 3 4
C. Exhibits creativity by innovation, flexibility and initiative. N/A 1 2 3 4
D. Demonstrates knowledge of current research findings N/A 1 2 3 4 and trends.
E. Assists staff to achieve goals which improve the program N/A 1 2 3 4 in area served.
F. Provides a good working environment as evidenced by N/A 1 2 3 4 attention to staff needs and suggestions.
G. Supports learning opportunities for students and/or N/A 1 2 3 4 provides services for students.
Evaluator Comments: Evaluatee Comments:
FM 651 WSN0553 Rev 12/94 Rev. 07/01/08 I - 20 III. PROFESSIONAL RESPONSIBILITY
A. Assumes responsibility for records, materials, and equipment. N/A 1 2 3 4
B. Seeks appropriate help when needed; accepts supervision in a N/A 1 2 3 4 positive manner.
C. Works constructively with staff and students. N/A 1 2 3 4
D. Conducts workshops, demonstrations, and inservice trainings. N/A 1 2 3 4
E. Effectively assists in the development and implementation of N/A 1 2 3 4 behavior management.
F. Displays knowledge of community resources and utilizes and N/A 1 2 3 4 refers when appropriate.
G. Works and communicates effectively with parents and the N/A 1 2 3 4 community.
H. Participates in professional growth activities. N/A 1 2 3 4
Evaluator Comments: Evaluatee Comments:
IV. IMPLEMENTING SCHOOL POLICIES
A. Carries out instructions properly. N/A 1 2 3 4
B. Is consistent in the administration of policies and rules. N/A 1 2 3 4
C. Adheres to Board policies as well as appropriate state N/A 1 2 3 4 regulations and laws.
Evaluator Comments: Evaluatee Comments:
Assistance Recommended:
Evaluator’s Signature Evaluatee’s Signature FM 651 WSN0553 Rev 12/94
DISTRIBUTION: Original to Personnel Department, first copy for employee, second copy for school or office.
SIGNATURES: This report has been discussed with me and signing this report does not necessarily mean that I agree with all the ratings. Both the evaluator and the evaluatee shall date and sign the report. In case the evaluatee refuses to sign the report, the evaluator shall request a witness to sign as evidence that the conference has been held. SUMMARY STATEMENT (DATE) Current employment status (check one)
Permanent Probationary Temporary
Evaluator’s Recommendation
I. Recommended for continued employment III. Performance is unsatisfactory – recommended for Assistance and evaluation as outlined for the II. Recommended for continued employment with school year. assistance and evaluation as outlined for the school year. Assistance recommended (use additional sheets if necessary) Assistance recommended (use additional sheets if necessary)
FM 651 WSN0553 Rev 12/94
IV. Performance is unsatisfactory
(Evalator’s Signature) (Evaluatee’s Signature) DISTRIBUTION: Original to personnel deprtment, first copy for employee, second copy for school or office.
SIGNATURES: This report has been discussed with me and signing this report does not necessarily mean that I agree with all the ratings. Both the evaluator and the evaluatee shall date and sign the report. In case the evaluatee refuses to sign the report, the evaluator shall Request a witness to sign as evidence that the conference has been held. PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
TO: FROM: Ann Rector, Coordinator of Health Programs SUBJECT: Nurse Evaluation Input
EMPLOYEE: DATE: SCHOOL:
Please indicate below your assessment of this employee.
Excels Above Satis- Needs Unsatis- Average factory Improve- factory ment 1. Responds with warmth and communicates effectively with children
2. Works cooperatively with and communicates effectively with our staff.
3. Works cooperatively with and communicates effectively with parents.
4. Provides effective consultive services.
5. Supports District/school policies.
6. Keeps scheduled time commitments.
COMMENTS:
Principal
Rev. 07/01/08 I - 23 Page PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
NAME YEAR
SCHOOL POSITION
GOALS/MAJOR ACTIVITIES Beginning Completion Status Date Date *
* STATUS: In planning; Operational; Completed
Rev. 07/01/08 I - 24 POSITION TITLE: HEALTH CLERK
JOB DESCRIPTION: Under the direction of the Health Programs Coordinator and the supervision of the school nurse, assists in the daily operation of the School Health Office; administers first aid to ill and injured students, and performs a variety of clerical duties relating to the school health program.
QUALIFICATIONS:
KNOWLEDGE OF:
1. CPR and First Aid principles and techniques (certification required) 2. Child Abuse reporting requirements and procedure 3. Confidentiality of medical information 4. General clerical and record keeping procedures 5. Correct English grammar, spelling and usage
ABILITY TO:
1. Effectively use required knowledge to carry out job duties in accordance with state laws and district regulations
2. Work cooperatively and effectively with children and adults 3. Analyze situations accurately and adopt an effective course of action 4. Meet schedules and time lines 5. Follow confidentiality requirements 6. Perform work independently with minimal direction 7. Operate office equipment, i.e. computer, typewriter and copier 8. Type 30 wpm
GENERAL RESPONSIBILITIES:
1. Admits and supervises ill and injured students in the Health Office. Performs routine first aid and screens ill students. Notifies parents of injuries and students too ill to remain in school. Maintains a daily log with adequate documentation.
2. Communicates significant illnesses or injuries to school nurse and/or building administrator. Administers CPR immediately when necessary. Fills out accident reports.
Rev. 07/01/08 I - 25 3. Screens student records for adequate immunizations. Communicates needs to parents and excludes students for non-compliance according to policy. Prepares kindergarten immunization audit and TB report under supervision of school nurse. Maintains an accurate list of students exempted from immunization requirement.
4. Reviews records for CHDP documentation. Follows up with parents and CHDP clinic to schedule appointments and complete paperwork. Maintains a worksheet of all K and 1st grade students who have not provided proof of the required physical examination.
5. Administers medication supplied by parent with written orders from doctor and signed consent from parent under direction of the school nurse.
6. Prepares, distributes and maintains First Aid and Disaster First Aid Kits as directed by the school nurse.
7. Maintains adequate health office supplies. Prepares requisitions for the school nurse to approve. Replenishes daily supplies - ongoing.
8. Measures heights and weights as directed by the school nurse.
9. Makes health record for all kindergarten students and students new to the district.
10. Maintains health records and files. Duplicates materials as needed. Maintains emergency cards. Updates information.
11. Assists with the health screening programs performed by the school nurse. Records screening results on student record. Flags health records of students according to procedure.
12. Conducts classroom inspections for communicable disease under the direction of the school nurse.
13. Assists the nurse to maintain an accurate updated list of enrolled students with health problems. (Special Health Concerns List)
14. Follows California State law regarding Child Abuse reporting responsibilities.
15. Performs general clerical duties such as typing, distributing notices, etc.
16. Maintains the Health Office in a clean orderly manner.
17. Performs other duties as directed by the school nurse and/or school administrators.
18. Attends in-service training for specialized procedures and works under the supervision of the school.
Rev. 07/01/08 I - 26 HEALTH CLERK GUIDELINES MANUAL
Beginning of School Year Procedures
1. Student programs: File alphabetically, divided by grade levels.
2. Filing: Set up manila folders for CHDP File Health, General Information Immunizations & TB Registration Information (RIs) - mark with current school year, - Hold & File RIs - New, Type
3. Registration forms (Rls): Divide RIs and attached forms into Transfer students (coming from a PUSD school) New students (coming from a school outside PUSD) Emergency cards Then alphabetize & place in manila folders.
4. Emergency cards (Procedure Guide [PG] I-61): File in alphabetical order and discard old cards after checking with Nurse.
5. Transfer Students: Check with Office Manager/Registrar re incoming transfer students, pull Health Records when ready and file. (see1 2.2.).
6. Class List: Middle & High: Check with Data Control Clerk and request one class list each (two copies if Nurse would like one also), sorted alphabetically by last name to be delivered to Health Office once a month. You may also contact Rosemarie Riley at I.T.S. directly at 795-6981 ext. 339 for printouts. Elementary: request copy of class list from Office Manager and update at least weekly.
7. Health Records: In September check all Health Records against class list and pull any that are not listed on it - double check with Office Manager/Registrar. While checking Health Records, check also for immunizations and waivers. Flag records as needed and add name and information to Immunization Worksheet (PG VI-16), (see 2.4.). Update any Health Records that haven't been updated (new grade level & school year) and file in proper drawer.
1 “see…” refers to this document
Rev. 07/01/08 I - 27 8. Pupil Health Office Visit Card: Check all cards against current class list, discard old cards after checking with your Nurse!
Ongoing Procedures
1. Regular Office Traffic: For any student who comes to the Health Office keep a Pupil Health Office Visit Card (PG I-58) and record all information re procedures, phone calls, etc., on it. Also sign student in and out on Daily Health Office Log (PG I-30). In case of an injury, always fill out an Injury Report [PG II-30]) and make every effort to contact parent/guardian. In case of a fight have student fill out an Incident Report and Injury Report as needed and refer him/her to the Dean/Principal after contacting parent/guardian.
2. Transfer Students: Update information on Health Record (school name & year, grade level in pencil) File RI inside Pull Pupil Health Office Visit card if inside (usually only 7th or 8th graders) Check immunizations - flag if necessary (PG IV, A-G) (see 2.4.) Check for positive TB test follow-up (PG IV, I) (see 2.4.) Check for CSIR card (PG IV, G-17) and fill one out if needed (see 2.3.) File in filing cabinet
3. New Students: Check all newly registering students for immunizations and TB test. If they do not meet the requirements do not register until they do, unless they have homeless status (NCLB)! If they are up to date but need further immunizations later, flag record and write their name and info on the immunization worksheet (see 2.4.). Check for TB test: go by current information. Type new Health Record (PG I, J-57). Type new blue CSIR (California School Immunization Record) cards and record immunizations, sign and date it. On Health Record: use black pen to record immunization and family information as needed (Repro pen preferable, order from Warehouse). A. Pencil in address, school info, telephone number, immunization due dates if additional ones are needed. B. Flag as indicated (PG I-62) C. If health problem present, add name to Liability list (PG I-37). D. Fold all forms & CSIR card and place inside Health Record. E. Check with Nurse whether she wants call slips made up right away or later for Vision & Hearing test. F. Place on Nurse's desk for reviewing re liabilities etc. G. File when completed.
Rev. 07/01/08 I - 28 4. Immunizations and TB follow-up: Worksheets: write month/year in red on top left corner: use 1 or more for each month of the school year. File in chronological order in Immunization & TB file folder. Write name of student, grade level, immunizations or TB follow-up needed on appropriate worksheet under the month they are due. If immunization/s needed, mail out Inadequate Immunization Notice (PG VI-11) to parent/guardian or send home with student. After 2 weeks, follow up with phone call. Try to get parents to comply before sending out Immunization Exclusion Notice (PG VI-13). Exclude student if necessary and stay in touch with parent/guardian. Upon completion, make copy of new immunizations and place in record; update Health Record, CSIR card and on computer enter into student database. Enter student immunization including updates, TB and medical information into student database on computer throughout the year (Reminder Memo with computer printout will go out to you at the beginning of the 2nd semester). TB follow-up: if student tested positive, refer for chest X-ray and request note from MD re results and possible preventive medicine (INH), note on record and file. Check immunization worksheets each week and work on them as needed.
5. CHDP: Work on CHDPs for 1st graders continuously from September-December! Exclude students no later than 90 days after entering school if out of compliance. In spring, work on CHDPs for Kindergartners. Follow guidelines set out in Procedure Guide, Section V.
6. In October: request address labels for all grades sorted by last name from your Data Control Clerk. or I.T.S. directly (see 1.6.). Label Pupil Health Office Visit cards for new students and continuing students as they come to the Health Office (Middle & High).
7. In Fall and in Spring: check all Health Records against class list. Pull out any extra Health Records and check with Registrar/Records re status. Make a list of students without Health Records, check whether you have RIs. If no RI, check with Registrar re no-shows. Check Rls every other month against class list and Health Records, discard no-shows. If student here, but no Health Record in Cume try to get information from Records at 795-6981 ext. 283. If not found, check with Nurse re contacting parents for missing medical and immunization information and type a new Health Record complete with CSIR card (type Duplicate Record in upper left corner of Health Record). Type a CSIR card for any Health Records lacking one. Height & weight screening (Elementary): measure in fall and spring and record on Health Record as directed by Nurse.
8. Withdrawing students: Sign withdrawal form and sign student out in Health Office Manual, file Pupil Health Office Visit card inside Health Record and pass on to Registrar/Records.
Rev. 07/01/08 I - 29 9. When making any copies from old or new forms always save one copy and file in a manila folder labeled "Masters" to use for future copying. If you need a new form send a draft to Health Programs; all forms must be approved by the Director!
10. File incoming papers and records daily.
11. Vision and hearing screening results & scoliosis test: transcribe from class list per Nurse's request as directed by Nurse.
13. Ordering Supplies: Check inventory (PG I-63) and place orders 2-4 times per year or as needed. Order start-up supplies for the following school year in April of current school year and use up remaining budget. To find out budget status, check with Nurse/Office Manager or call Ed. Center and request information from Accounting Department (current budget info is sent to Principal/Office Manager every 2 weeks).
End of School Year Procedures
1. Make copies of updated Liability list and send to all Middle/High Schools in District.
2. In June: update all Health Records with next school year and grade level information and file in next year's grade level if the transferring student’s Health Records have been passed on to the Office Manager/Registrar. If not, do this at the start of the new school year.
3. File Medication Authorization forms inside Health Records and file any other relevant papers.
4. Pull all Pupil Health Office Visit cards from students transferring to secondary schools and file inside Health Records.
5. Check with Office Manager/Registrar and pull all transferring students’ Health Records when ready.
6. Make copies of all forms and registration packets as needed to start new school year.
Annual Reports
Immunization Assessment of Kindergarten Students (PG V-8): due around October 9th Mandatory TB Report (PG VI-26): due around November 15th CHDP Report (PG V-8): due around December 21st
Rev. 07/01/08 I - 30 General Guidelines
Read the Procedure Guide, any First Aid Guidelines Manual and Workbooks Check with Nurse and other Health Clerks and get a “Buddy” Health Clerk if you are new Amend and update this manual as needed for your site Learn as you go along!
Notes :
Rev. 07/01/08 I - 31 Report of Performance for Probationary Classified Employees available at:
http://www.pasadena.k12.ca.us/forms/Evaluations/Classified.pdf
Rev. 07/01/08 I - 32 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
TO: FROM: Ann Rector, Coordinator of Health Programs SUBJECT: Health Clerk Evaluation Input
EMPLOYEE: DATE: SCHOOL:
Please indicate below your assessment of this employee.
Excels Above Satis- Needs Unsatis- Average factory Improve- factory ment 1. Relates well to students.
2. Communicates easily with parents.
3. Demonstrates integrity and loyalty to nurse, health programs, and school.
4. Keeps scheduled time commitments and demonstrates conscientious attitude.
5. Knows and stays within limitations of her role.
COMMENTS:
Principal
Rev. 07/09/08 I - 35 SAMPLE ONLY – UPDATED ANNUALLY
PASADENA UNIFIED SCHOOL DISTRICT Health Programs
MEMORANDUM
TO: All Health Clerks DATE: September, 2008
FROM: Ann Rector
SUBJECT: Student Immunizations & Medical Conditions
Enclosed is a current printout for your school of all PK, Kindergarten and new students in grades 1- 12 whose immunizations and medical conditions are not yet on the computer. Also enclosed is an updated copy of the “ICD-9 Medical Codes for Students” list dated 3/15/2000.
The project of entering student’s immunizations and any known health conditions into the computer is ongoing and needs to be completed before the end of the current school year. Please remember to update the student database any time you receive proof of additional immunizations/booster shots given.
If you have any questions about using or accessing Aeries, please contact the ITS Help Desk at (626) 396-3600 Ext. 88830. For general questions, please call (626) 396 – 3600 extension 88900.
Thank you!
Rev. 07/01/08. I - 36 SAMPLE ONLY – UPDATED ANNUALLY
Health Concern ICD 9 CM Code Acne (pustular)(vulgaris) 706.10 Allergy, unspecified 995.30 Allergy to food (any) (ingested) 693.10 Alopecia 704.00 Anaphylactic shock/reaction to eggs 995.68 Anaphylactic shock/reaction to food 995.60 Anaphylactic shock/reaction to milk products 995.67 Anaphylactic shock/reaction to peanuts 995.61 Anemia unspecified 285.90 Arthritis, juvenile 714.30 Asthma, unspecified 493.90 Autism, infantile 299.0 Bee Sting Allergy 989.50 Bell’s Palsy, paralysis 351.00 Bladder Disorder, unspecified 596.90 Blood Disorder/Blood Forming Organs Disorder 289.90 Cerebral Palsy, infantile, unspecified 343.90 Color Blindness 368.50 Colostomy status V443 Conjunctivitis, unspecified 372.00 Conjunctivitis chronic 372.10 Cystic Fibrosis 277.00 Deficiency Vitamin D with rickets 2680 Dental Caries 521.00 Depression 311.00 Developmental Delay 783.40 Diabetes Melitus 250.00 Disorder, bipolar (unspecified) 296.70 Disorder, conduct 312.82 Disorder, depressive 311.00 Disorder, eating unspecified 307.50 Disorder, gastrointestinal 536.90 Disorder, menstrual 626.40 Disorder, oppositional, childhood & adolescence 313.81 Down’s syndrome 758.00 Eczema 691.80 Epilepsy, unspecified 345.90 Examination, eye V 720 Gastritis 535.40 Graves’disease (other Specified disorders of thyroid) 246.80 Headache, migraine 346.00 Headache, tension 307.81 Hearing Loss, conductive 389.00 Heart Disease/Defect, congenital 746.00 Hernia, diaphragmatic 553.3 Hydrocephalus, obstructive 331.40 Hydrocephalus, congenital 742.30 Hyperactive/A.D.D. 314.01 Hypoglycemia, diabetic 250.8 Impetigo 684.00 Infection Wound, post-operative 998.50 Murmur (cardiac)(Heart) 785.20 Muscular Dystrophy (congenital, hereditary) 359.10 Myalgia 729.10 Nervous Disorder/Anxiety 300.0 Neurological Disease, unspecified 349.90 Nosebleeds 784.70
Rev. 07/01/08. I - 37 SAMPLE ONLY – UPDATED ANNUALLY
Health Concern ICD 9 CM Code Obesity 278.00 Orthodontics V 58.5 Osgood-Schlatter 732.40 Otitis Media 382.9 Pain, stomach (dyspepsia, indigestion) 536.80 Paralysis 344.00 Reaction to Aspirin 995.20 Reaction to Penicillin 995.30 Redness, eye 379.93 Refusal of treatment, because of, due to patient’s decision Refusal of treatment, because of, due to reason of conscience or religion Rheumatic Fever 390.00 Rhinitis allergic 477.90 Scarlet Fever 034.10 Scoliosis 737.30 Seizure Disorder 780.39 Seizures, febrile 780.31 Severe Menstrual Cramps 625.20 Short stature, constitutional 783.40 Sickle Cell Anemia 282.60 Sinus Allergy, sinusitis 477.90 Sinusitis 473.00 Skin Allergy, skin reaction 692.90 Slipped epiphysis (uspecified osteochondropathy) 732.90 Speech Defect (Developmental speech or language disorder) 315.30 Spina Bifida 741.00 Sty, stye 373.11 Tinea capitis 111.00 Tinea corporis 110.50 Tiredness 780.70 Transplant bone marrow V 042.81 Vision Problem 368.90
Rev. 07/01/08. I - 38 SAMPLE ONLY – UPDATED ANNUALLY
GENERAL PROCEDURES FOR SCHOOL PERSONNEL
Secretarial Responsibility to Health Office
1. Notify health clerk or nurse of parent-reported illness that may be communicable. For example: • Chicken pox • Conjunctivitis • Fifth Disease • Hepatitis • Impetigo, Ringworm or Scabies • Measles or Mumps • Strep infections or Scarlet Fever • Tuberculosis
2. Notify nurse of any health problem causing a child to miss more than a week of school or chronic absences caused by any illness.
3. Pediculosis - If Health Office is not available, call parent and exclude child. Leave a note for the health office to follow up.
4. If Health Office staff is not available, the office staff can consult with the school nurse on call or the Ed Center Health Clinic.
Maintain Communicable Disease Log Book
1. Date contacted/reported (this is what Public Health wants) 2. Student 3. Disease 4. Date Resolved 5. Physician Clearance
Rev. 07/01/08. I - 39 Health Office Daily Log for (month/day/year) at School
PLEASE PRINT
DATE NAME TIME GRD TEACHER REASON FOR VISIT TEMP DISPOSITION TIME INIT IN OUT 1
2
3
4
5
6
7
8
924
10
11
12
13
14
15
16
17
18
19
20
Rev. 07/01/04 I - 40 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS MONTHLY REPORT I. GENERAL a.Students seen in Health Office: This should reflect the students logged into office daily log. b.Students with Medications in Health Office: The number of students with medications at school.
II. SCREENING a.Vision: Include all students you screen for vision. b. Hearing: Include all students you screen for hearing. c. Scoliosis: Include all students you screen for scoliosis. d. Color Vision: Include all students you screen for color vision. e. Dental: Include all students you screen for dental. f.Lice: Include all students you screen for head lice. Count positive cases under communicable disease. g.Other: Include any other screening you do (substance abuse screening, immunization screening as part of registration, TB screening as a result of a positive case at your school site).
III. CHILD SAFETY a. Emergency/Crisis Situations: Include any 911 calls, psychiatric hotline calls, etc. b. Injury Reports Filed: Number of injury reports completed. c. Child Abuse Reports Filed: Number of cases filed by health office.
IV. SPECIAL EDUCATION a. IEP Evaluations: Number of students evaluated as part of an IEP (initial, triennial, annual, and addendum). b. IEP Meetings: Number of meetings the nurse attended. c. SST Evaluations: Number of students evaluated for SST. d. SST Meetings: Number of SST meetings attended by nurse.
V. COMMUNICABLE DISEASE CONTROL: a. Chickenpox Cases: Diagnosed cases. If suspected put under screened. b. Conjunctivitis Cases: Diagnosed cases. If suspected put under screened. c. Head Lice Cases: Diagnosed cases. Log students you screen under Section II. Screening. d. Positive PPD Cases: Diagnosed cases. e. Ringworm Cases: Diagnosed cases. f. Other: g. Other: ______h.Exclusions for communicable disease: Number of students excluded by health office due to suspected communicable disease.
VI. HEALTH EDUCATION a. Parent Conference/Education, Phone: Log in number of phone calls made/received to parents. b. Parent Conference/Education, In person: Log encounters with parents in person. c. Teacher Conference: Log any instances where you discussed health-related concerns with a
Rev. 03/15/10 I - 41 teacher regarding his/her student. d. Classroom Presentations: Any educational presentations you deliver to students. For example, hand-washing class, family life education, etc. e. Staff In-service: Any educational in-services you have given to staff. Do not include staff meetings you attend but do not present any information.
VII. HEALTH REFERRALS a. Young & Healthy Referrals: Number of students referred to Y&H. b. Vision Referrals: Number of students referred for vision f/u. c. Hearing Referrals: Number of students referred for hearing f/u. d. Dental Referrals: Number of students referred to a dentist for f/u. e. Impact Referrals: Number of students referred to Impact. f. Mental Health Referrals: Number of students referred for mental health (whether it is at school site or off-site). g. Referral for Medical Care: Number of students you refer to follow-up medical care.
VIII. HEALTH CARE DELIVERED a. Asthma Care: Actual number of times students came in for asthma management (whether it was an assessment of peak flow, PO2 reading, administering MDI or administering nebulizer). b. Diabetes Care: Actual number of times students came in for diabetes management (blood glucose checks, insulin administration, pump care, etc.). c. Seizure Care: Actual number of times health office assisted with seizure care (timing, recording seizures, administering medications such as Diastat, etc.). d. Medications Administered: Actual number of times medications were administered for reasons other than asthma, diabetes, seizures, in health office. For example, ADHD meds, headache meds, creams, etc.). e. TB Tests Administered: Number of TB tests given to parent volunteers. f. Immunizations Administered: Include flu vaccines as well as other immunizations you give. g. Gastrostomy Tube Feeding: Performed or observed by nurse. h. I&O Catheterization: Performed or observed by nurse. i. Tracheotomy Care: Performed or observed by nurse. j. Health Care to Staff: Count all encounters where you deliver health care to staff members (e.g. Blood pressure checks, first aid, etc.). k. CHDP Physicals (Nurse Practitioners Only): Count all CHDP physicals performed by nurse practitioner. l. Other: Any other health care delivered to student not captured above.
Rev. 03/15/10 I - 42 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
FIRST SEMESTER MONTHLY REPORT Year ______Nurse ______School ______SEP OCT NOV DEC JAN I. GENERAL c.Students seen in Health Office: d.Students with Medications in Health Office: II. SCREENING h.Vision: i. Hearing: j. Scoliosis: k. Color Vision: l. Dental: m.Lice: n.Other: ______III. CHILD SAFETY d. Emergency/Crisis Situations: e. Injury Reports Filed: f. Child Abuse Reports Filed: IV. SPECIAL EDUCATION e. IEP Evaluations: f. IEP Meetings: g. SST Evaluations: h. SST Meetings: V. COMMUNICABLE DISEASE CONTROL: Rev. 03/15/10 I - 43 SEP OCT NOV DEC JAN i. Chickenpox Cases: j. Conjunctivitis Cases: k. Head Lice Cases: l. Positive PPD Cases: m. Ringworm Cases: n. Other: o. Other: ______p.Exclusions for communicable disease: VI. HEALTH EDUCATION f. Parent Conference/Education, Phone: g. Parent Conference/Education, In person: h. Teacher Conference: i. Classroom Presentations: a. Grade Level: b. Topic: j. Staff In-service: VII. HEALTH REFERRALS h. Young & Healthy Referrals: i. Vision Referrals: j. Hearing Referrals: k. Dental Referrals: l. Impact Referrals: m. Mental Health Referrals: n. Referral for Medical Care: VIII. HEALTH CARE DELIVERED m. Asthma Care: n. Diabetes Care: o. Seizure Care: p. Medications Administered: q. TB Tests Administered: r. Immunizations Administered: s. Gastrostomy Tube Feeding: t. I&O Catheterization: u. Tracheotomy Care: v. Health Care to Staff: w. CHDP Physicals (Nurse Practitioners Only): x. Other:
Rev. 03/15/10 I - 44 PASADENA UNIFIED SCHOOL DISTRICT SECOND HEALTH PROGRAMS MONTHLY REPORTS
Year ______Nurse ______School ______FEB MAR APR MAY JUN I. GENERAL e.Students seen in Health Office: f. Students with Medications in Health Office: II. SCREENING o.Vision: p. Hearing: q. Scoliosis: r. Color Vision: s. Dental: t.Lice: u.Other: ______III. CHILD SAFETY g. Emergency/Crisis Situations: h. Injury Reports Filed: i. Child Abuse Reports Filed: IV. SPECIAL EDUCATION i. IEP Evaluations: j. IEP Meetings: k. SST Evaluations: l. SST Meetings: V. COMMUNICABLE DISEASE CONTROL: q. Chickenpox Cases: r. Conjunctivitis Cases: s. Head Lice Cases: t. Positive PPD Cases: u. Ringworm Cases: v. Other: w. Other: ______x.Exclusions for communicable disease:
VI. HEALTH EDUCATION k. Parent Conference/Education, Phone: l. Parent Conference/Education, In person: m. Teacher Conference: n. Classroom Presentations: a. Grade Level: b. Topic: o. Staff In-service: VII. HEALTH REFERRALS o. Young & Healthy Referrals: p. Vision Referrals: q. Hearing Referrals: r. Dental Referrals: s. Impact Referrals: t. Mental Health Referrals:
Rev. 03/15/10 I - 45 FEB MAR APR MAY JUN u. Referral for Medical Care: VIII. HEALTH CARE DELIVERED y. Asthma Care: z. Diabetes Care: aa. Seizure Care: bb. Medications Administered: cc. TB Tests Administered: dd. Immunizations Administered: ee. Gastrostomy Tube Feeding: ff. I&O Catheterization: gg. Tracheotomy Care: hh. Health Care to Staff: ii. CHDP Physicals (Nurse Practitioners Only): jj. Other:
Rev. 03/15/10 I - 46 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
STUDENTS ON CAST/CRUTCHES/ WHEELCHAIR SCHOOL YEAR
DR.’S NAME GRADE FROM (DATE) TO (DATE) TYPE NOTE
Rev. 03/15/10 I - 47 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
STUDENTS WITH COMMUNICABLE DISEASE SCHOOL YEAR
DATE NAME GRADE DISEASE HEALT ONSET CLEARANCE H DEPT. DATE DATE
Rev. 03/15/10 I - 48 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
STUDENTS ON MEDICATION SCHOOL YEAR
NAME GRADE MEDICATION TIME TO BE GIVEN
Rev. 03/15/10 I - 49 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS STUDENTS WITH SPECIAL HEALTH CONCERNS SCHOOL YEAR School Nurse
STUDENT Last Name First Name I.D. Number Birthdate Special Health Problems Grade Teacher
Rev. 07/01/08 I - 50 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
STUDENTS REFERRED FOR COUNSELING SCHOOL YEAR
NAME GRADE DATE AGENCY/IN OFFICE
Rev. 07/01/08 I - 51 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
STUDENTS REFERRED FOR HEARING SCHOOL YEAR
NAME DATE I.D.# GRADE RESULTS RETEST REFER FOLLOW-UP
Rev. 07/01/08 I - 52 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
STUDENTS REFERRED FOR MEDICAL CARE SCHOOL YEAR
NAME GRADE DATE PROBLEM FOLLOW-UP
Rev. 07/01/08 I - 53 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
STUDENTS REFERRED FOR SST MEETING SCHOOL YEAR
NAME GRADE DATE ASSESSMENT DONE SST MTG. DATE
Rev. 07/01/08 I - 54 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
STUDENTS REFERRED FOR VISION SCHOOL YEAR
NAME DATE I.D.# GRADE RESULTS REFERRAL FOLLOW-UP SENT WITH STU/MAILED
Rev. 07/01/08 I - 55 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
STUDENTS REFERRED TO YOUNG AND HEALTHY SCHOOL YEAR
NAME DATE GRADE PROBLEM REFERRED TO APPT. FORM GIVEN
Rev. 07/01/08 I - 56 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
REFERRAL FOR HEALTH CARE
Child’s Name: DOB: Grade: Date: Dear Parents: Your child needs follow-up care for
1. Your child may return on , ONLY IF WELL FOR 24 HOURS. 2. Your child must be cleared by the school nurse/health assistant before returning. 3. Please have your doctor/dentist complete the lower portion of this form. 4. Please sign below so the doctor/dentist can supply needed information.
Parent Signature: Date:
TO BE COMPLETED BY HEALTH CARE PROVIDER/DENTIST
Date examined by Provider/Dentist:
Provider/Dentist Signature: Phone:
Diagnosis and/or special instructions:
Treatment plan:
PLEASE RETURN School Nurse: FORM TO: School:
Address:
Telephone:
Rev. 07/01/08 I - 57 DISTRITO ESCOLAR UNIFICADO DE PASADENA PROGRAMAS DE SALUD
RECOMENDACIÓN PARA CUIDADO DE SALUD
Nombre del Niño: FDN:. Grado: Fecha:
Estimados Padres:
Su niño necesita continuar atendiéndose el/la
1. Su niño puede regresar el estad, SÓLO SI NO HA ESTADO ENFERMO POR 24 HORAS. 2. La enfermera de la escuela/asistente de salud debe ver a su niño antes de que regrese a la escuela. 3. Por favor pídale a su médico/dentista que complete la porción de abajo de esta forma. 4. Por favor firme abajo para que el médico/dentista pueda dar la información que se necesita.
Firma del Padre/Tutor: Fecha
PARA QUE LA COMPLETE EL PROVEEDOR DE SERVICIOS MÉDICOS/DENTALES
Fecha en que fue examinado por el Proveedor/Dentista: Firma del Proveedor/Dentista: Teléfono Diagnósis y/o instrucciones especiales:
Plan del Tratamiento:
POR FAVOR REGRESE Enfermera de la Escuela: LA FORMA A: Escuela: Domicilio:
No. de Teléfono:
Rev. 07/01/08 I - 58 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
REQUEST FOR FOLLOW-UP
Student’s Name Date of Birth School Grade
Dear Parent/Guardian:
Please take this form to your health care provider and return his/her report to school as soon as possible.
Sincerely,
School Nurse Date
TO BE COMPLETED BY HEALTH CARE PROVIDER
Date Examined: Provider’s Name Provider’s Address Provider’s Signature Phone: Fax: Assessment:
Treatment Plan:
PLEASE RETURN Name: THIS FORM TO: School:
Address: ______
Rev. 07/01/08 I - 59 DISTRITO ESCOLAR UNIFICADO DE PASADENA PROGRAMAS DE SALUD
PETICICIÓN PARA CONTINUACIÓN DE LOS SERVICIOS
Nombre del Estudiante: Fecha de Nacimiento: Escuela: Estimados Padre/Tutor:
Por favor lleve esta forma a la persona que le da servicios de salud y regrese su reporte a la escuela tan pronto como le sea posible.
Respetuosamente,
Enfermera de la Escuela Fecha
PARA QUE LO COMPLETE LA PERSONA QUE PROVEA EL CUIDADO DE SALUD
Fecha del Examen: Nombre de la Persona que lo Hizo: Domicilio de la Persona que Provee el Cuidado de Salud: Firma de la Persona que Provee el Cuidado De Salud: Tel: Fax:
Evaluación:
Plan para Tratamiento:
POR FAVOR REGRESE Nombre: ESTA FORMA A: Escuela:
Domicilio:______
Rev. 07/01/08 I - 60 Rev. 07/01/08 I - 61 ASTHMA GUIDELINES
SEPTEMBER-JUNE
Contact an asthma educator through Health Programs with any questions or need for assistance regarding asthma management, (626) 396-3600 Ext. 88240.
1. Identify students with a diagnosis of asthma from the previous year’s “Health Concerns List”, and for new students, from their health history forms. List these students on the “Asthma Information Log”, creating a new log yearly. Enter newly diagnosed students in Aeries. Post the algorithm in a visible place in the Health office. Ensure that you and the Health Clerk understand it! YOU MUST INSERVICE THE OFFICE STAFF ON THE ADMINISTRATION OF ASTHMA MEDICATION, AS WELL AS ON EMERGENCY RESPONSE TO ASTHMA EPISODES. Give an inservice on asthma at a school staff meeting as early in the year as possible.
2. Give asthma packets to parents of students who need asthma medication at school, i.e. those who are symptomatic. Include in the packets: a. Parent Letter b. Parent Guidelines for School Attendance c. Asthma Consent (if it is being used during the current year) d. School Asthma Survey (if it is not being used for data collection, it is advisable to have the survey completed yearly to maintain current health information. This is especially important for students seen on a regular basis with asthma symptoms). e. Emergency Nebulizer Consent f. Asthma Medication Administration Form g. Pasadena Community Asthma Project Asthma class schedule Follow-up with parents, telephoning as needed.
3. Each time a student is seen in the health office for an asthma episode, record on the “Episodic Log”: The date and time the student enters and leaves The medication given The pulse oximetry reading, if a pulse oximeter is available at your site The peak flow reading before and after medication is given, if no pulse ox is available A parent contact, if symptoms persist and/or if the student is symptomatic more than twice weekly.
4. Parents supply their student’s equipment, but we maintain a supply of cardboard mouthpieces used with the universal peak-flow meter, an emergency supply of nebulizer kits (order through MacGill 1-800-323-2841, www.macgill.com) and albuterol solution (from the clinic).
Rev. 07/01/08 I - 62 PLEASE POST PLEASE POST PLEASE POST
STANDARD SCHOOL EMERGENCY RESPONSE PROCEDURE FOR SEVERE ASTHMA EPISODE
NEVER LEAVE A PUPIL WITH BREATHING PROBLEMS ALONE DO NOT SEND A PUPIL WITH BREATHING PROBLEM ANYWHERE
IF YOU SEE THIS:
1. Wheezing, continuous coughing, shortness of breath, or breathing becomes worse even after medication has been given.
2. Student has difficult breathing: Chest and neck are pulled in with breathing. Student is hunched over. Student is struggling to breathe.
3. Student has trouble talking or walking and cannot resume activity.
4. Lips or fingernails are blue or gray.
DO THIS:
1. STAY WITH STUDENT * CALL FOR HELP * CALL 911
2. KEEP STUDENT SITTING UPRIGHT
3. ASK STUDENT IF THEIR MEDICATION IS WITH THEM OR HAVE MEDICATION BROUGHT TO STUDENT AND ASSIST IN ADMINISTRATION.
4. WATCH BREATHING AND BE PREPARED TO ADMINISTER CPR UNTIL PARAMEDICS ARRIVE.
5. HAVE HELP NOTIFY SCHOOL NURSE AND PARENT
Rev. 07/01/08 I - 63 ASTHMA INFORMATION LOG School
Class Date Meds Survey Documented Health Info Parent at In Date Name In Concerns given contact School Computer List ed
Rev. 07/01/08 I - 64
P A S A D E N A U N I F I E D S C H O O L D I S T R I C T
E D U C A T I O N C E N T E R ● H E A L T H P R O G R A M S
ASTHMA
School Date
Dear Parent:
You have told us that your child has asthma. Please fill out the enclosed forms and return them to the Health Office as soon as possible. The information will be shared with appropriate personnel such as your child's classroom teacher(s) and physical education teacher. This will help them in working with your child to minimize restrictions, any feelings of being treated differently, and possible absenteeism.
To help your child, please advise us of any changes in your child's asthma or medication schedules promptly. Sincerely,
Ann Rector Coordinator of Health Programs School Nurse APPROVED:
Alice Petrossian Chief Academic Officer
351 South Hudson Avenue ∙ Pasadena, CA 91109 (626) 396-3600 Ext. 88240 ∙ Fax (626) 584-1540 www.pusd.us
Rev. 03/15/10
P A S A D E N A U N I F I E D S C H O O L D I S T R I C T
E D U C A T I O N C E N T E R ● H E A L T H P R O G R A M S
ASMA
Escuela Fecha
Estimado Padre/Tutor:
Ud. nos ha dicho que su niño/a padece de asma. Por favor llene los formularios adjuntos y regréselos a la Oficina de Salud tan pronto como sea posible. Compartiré la información con el personal apropiado, como la maestra del aula de su niño/a y la maestra de educación física. Esta información les ayudará a trabajar con su niño/a para minimizar las restricciones y posibles ausencias, así como para evitar que se sienta tratado/a de manera diferente.
Para ayudar a su niño/a, por favor avísenos de cambios en la condición asmática de su niño/a u horarios para el medicamento.
Atentamente,
Ann Rector Coordinadora de los Programas de Salud Enfermera de la Escuela
APROBADO:
Alice Petrossian Chief Academic Officer
351 South Hudson Avenue ∙ Pasadena, CA 91109 (626) 396-3600 Ext.88240 ∙ Fax (626) 584-1540 www.pusd.us Rev. 03/15/10 ASTHMA
Signs for Deciding to Go to School or Stay Home
------Signs for deciding to go to school
Stuffy nose, but not wheezing or coughing; or A little wheezing or coughing which goes away after taking medicine; or Able to do usual daily activities; or No extra effort needed to breathe; or Peak flow score in the green zone.
Signs for deciding to stay home
Respiratory infection such as a sore throat or swollen, painful neck glands; or Fever over 100F orally or 101F rectally; face hot and flushed; or Wheezing or coughing which continues or does not get better one hour after giving the medicine (or 5-10 minutes after using sprays); or Weakness or tiredness that makes it hard to take part in usual daily activities; or Breathing with difficulty; or Peak flow is below 80% of personal best and is not responding to treatment.
FIVE EMERGENCY SIGNS ------Five signs to call your doctor or get emergency medical care for asthma – Having any one of these signs means medical care is needed.
1. Wheeze, cough, or shortness of breath gets worse, even after the medicine has been given time to work. Most inhaled bronchodilator medications produce effect within 5 to 10 minutes. Discuss the time your medicines take to work with your doctor. 2. Child has a hard time breathing. Signs of this are: Chest and neck are pulled or sucked in with each breath. Hunching or lifting shoulders. Struggling to breathe. 3. Child has trouble walking or talking, stops playing and cannot start again. 4. Peak flow rate gets lower, or does not improve after treatment with bronchodilators, or drops to 50% or less of your personal best. Discuss this peak flow level with your doctor. 5. Lips or fingernails are grey or blue. If this happens, go to the doctor or emergency room right away !
Rev. 03/15/10 ASMA Síntomas para Decidir si Va a la Escuela O se Queda en Casa
Síntomas para decidir si va a la escuela
Nariz congestionada, pero no tiene resuello asmático o tiene tos; o Tiene poquito resuello asmático o tos, los cuales se quitan después de tomar la medicina; o Puede hacer las actividades diarias usuales; o No necesita esfuerzo extra para respirar; o El marcador para la fuerza de la respicarión marcó en la zona verde.
Síntomas
Infección respiratoria como dolor o inflamación de la garganta, dolor en las glándulas del cuello; o Más de 100F oral ó 101F rectal; la cara caliente y encendida; o Resuello asmático o tos continua o no se mejora en una hora después de darle la medicina (ó 5-10 minutos después de usar los atomizadores); o Debilidad o cansancio que hace que sea muy difícil tomar parte en actividades diarias usuales; o Respirando con dificuldad; o El marcador para la fuerza de la respiración está abajo del 80% de lo que es cuando puede respirar bien y no está respondiendo al tratamiento.
CINCO SÍNTOMAS DE EMERGENCIA
Cinco síntomas para llamar a su médico o para obtener cuidado médico de emergencia para el asma – Si tiene cualquiera de estos síntomas significa que necesita cuidado médico.
1. Resuello asmático, tos, o la dificultad para respirar se agrava, aún después que se le ha dado tiempo a la medicina para que haga efecto. La mayoría de medicinas de los atomizadores broncodilatadores hacen efecto de 5 a 10 minutos. Hable con su médico para saber el tiempo que duran las medicinas para hacer efecto. 2. El niño tiene dificultades para respirar. Los síntomas son: El pecho y el cuello se elevan o se sumen cada vez que respira. Los hombros se encorvan o elevan. Se esfuerza para respirar. 3. El niño tiene dificultades para caminar o hablar, deja de jugar y no puede comenzar de nuevo. 4. La fuerza de la respiración se debilita, o no se mejora después del tratamiento con los broncodilatadores, o baja a 50% ó menos de respiración regular. Hable con su médico acerca del nivel de esta fuerza de la respiración. 5. Los labios o uñas se ponen grises o azules. Si ésto sucede, ¡vaya al médico o emergencia inmediatamente!
Rev. 03/15/10 I - 68 PASADENA COMMUNITY ASTHMA PROJECT School Asthma Survey
PASADENA UNIFIED SCHOOL DISTRICT Health Programs
DEAR PARENT,
YOU HAVE INDICATED THAT YOUR CHILD HAS ASTHMA. ASTHMA IS ONE OF THE MOST COMMON CHILDHOOD ILLNESSES. IN AN EFFORT TO PREVENT ASTHMA EPISODES AT SCHOOL AND TO REDUCE SCHOOL ABSENTEEISM, THE SCHOOL DISTRICT IS PARTICIPATING IN THE PASADENA COMMUNITY ASTHMA PROJECT. THIS PROJECT IS A JOINT EFFORT BETWEEN HUNTINGTON MEMORIAL HOSPITAL, PASADENA HEALTH DEPARTMENT, YOUNG & HEALTHY, AND THE LOCAL SCHOOLS.
WE HAVE COLLECTED INFORMATION FROM THE SCHOOLS ABOUT YOUR CHILD’S ASTHMA AND WOULD LIKE TO SHARE THIS INFORMATION WITH YOUR HEALTHCARE PROVIDER.
THE ENCLOSED ASTHMA SURVEY WILL HELP THE SCHOOL NURSE PLAN FOR YOUR CHILD’S SPECIAL HEALTH NEEDS AT SCHOOL. PLEASE COMPLETE EACH SECTION CAREFULLY AND RETURN TO THE SCHOOL AS SOON AS POSSIBLE. IF YOU WOULD LIKE THE INFORMATION TO BE SHARED WITH MEMBERS OF THE PASADENA COMMUNITY ASTHMA PROJECT TO IMPROVE THE HEALTH CARE OF CHILDREN IN THE COMMUNITY AND YOUR HEALTHCARE PROVIDER, PLEASE SIGN BELOW.
I would like to participate in the Pasadena Community Asthma Project and agree to have the information in the Asthma Survey shared with members of the Pasadena Community Asthma Project and with my healthcare provider.
______Parent/Guardian Date
______Child’s Name Name of School
Telephone Consent - Consent obtained by: ______
Rev. 03/15/10 I - 69 PROYECTO DE ASMA DE LA COMUNIDAD DE PASADENA Encuesta de la Escuela acerca de Asma
DISTRITO ESCOLAR UNIFICADO DE PASADENA Programas de Salud
ESTIMADO PADRE,
USTED HA INDICADO QUE SU NIÑO TIENE ASMA. ASMA ES UNA DE LAS ENFERMEDADES MÁS COMUNES EN LA NIÑEZ. ESTAMOS HACIENDO UN ESFUEZO PARA PREVENIR LOS EPISODIOS DEL ASMA EN LA ESCUELA Y REDUCIR LAS AUSENCIAS ESCOLARES. EL DISTRITO ESCOLAR ESTÁ PARTICIPANDO EN EL PROYECTO DE ASMA DE LA COMUNIDAD DE PASADENA. ESTE PROYECTO ES UN ESFUERZO UNIDO ENTRE EL HOSPITAL HUNTINGTON MEMORIAL, EL DEPARTAMENTO DE SALUD DE PASADENA, JOVEN Y SALUDABLE Y LAS ESCUELAS LOCALES.
HEMOS RECOGIDO INFORMACIÓN DE LAS ESCUELAS ACERCA DEL ASMA DE SU NIÑO Y NOS GUSTARÍA COMPARTIR ESTA INFORMACIÓN CON SU MÉDICO.
LA ENCUESTA DEL ASMA QUE VA INCLUIDA LE AYUDARÁ A LA ENFERMERA DE LA ESCUELA A PLANEAR PARA LAS NECESIDADES ESPECIALES DE SALUD DE SU NIÑO EN LA ESCUELA. POR FAVOR COMPLETE CUIDADOSAMENTE CADA SECCIÓN Y REGRÉSELA A LA ESCUELA TAN PRONTO COMO LE SEA POSIBLE. SI DESEA QUE LA INFORMACIÓN SEA COMPARTIDA CON PERSONAS DEL PROYECTO DE ASMA DE LA COMUNIDAD DE PASADENA PARA MEJORAR EL CUIDADO DE SALUD DE LOS NIÑOS DE LA COMUNIDAD Y TAMBIÉN CON SU MÉDICO, POR FAVOR FIRME EN LA PARTE DE ABAJO.
Me gustaría participar en el Proyecto de Asma de la comunidad de Pasadena y estoy de acuerdo en que se comparta la información de la Encuesta del Asma con las personas del Proyecto de Asma de la Comunidad de Pasadena y con mi médico.
Padre o Tutor Fecha
Nombre del Niño Nombre de la Escuela
Consentimiento de Teléfono - Consentimiento obtenido por:
Rev. 03/15/10 I - 70 PASADENA COMMUNITY ASTHMA PROJECT Huntington Memorial Hospital
ASTHMA SURVEY (2001)
Location: ______Date: ______Completed by:
CLIENT INFORMATION CLIENT ID # ______
Client Name: ______Last Name First Name M.I. Age ______Date of Birth ______Grade ______Last Year’s School ______Parent/Guardian Name: ______Pager #: ( ) ) Address: ______(City, State, Zip)______
Home Phone: ( ) Work Phone: ( ) .
Physician/Healthcare Provider Name: ______Last Visit: 1 year 1 month 1 week Do you have to pay for your child’s asthma medicines? YES NO Consent obtained? YES NO
MEDICATION INFORMATION (Please check boxes for all medication taken) FREQUENCY ASTHMA Once Twice a Before As MEDICATIONS Daily Day Exercise Needed Proventil/Albuterol/Ventolin/Xopenex Azmacort/Vanceril/Pulmicort/Flovent/Aerobid Cromolyn/Tilade Singulair/Accolate Serevent/Advair
ASTHMA INFORMATION (Please check the one box that best describes your child.)
1. Does your child have asthma symptoms? Daily Less than 2 times/week More than 2 times/week
2. Does your child have asthma symptoms with exercise? Yes No
3. Does your child cough at night? Nightly Less than 2 times/month More than 2 times/month Greater than 1 time/week
4. Does your child miss physical education class due to asthma? Yes No Field trips? Yes No
5. Approximately how many days was your child absent from school during the previous school year due to asthma/bronchitis? ______days.
6. Has your child been hospitalized or in ER for asthma/bronchitis in the last 12 months? Hospitalized: # of times ______ER: # of times ______Intensive Care Unit: # of times ______
7. Does your child have a peak flow meter at home? Yes No If yes, how often is it used? Daily Occasionally as needed Personal peak flow best? ______
8. Does your child have a spacer? Yes No If yes, how often is it used? Daily Occasionally as needed
9. Have you been to an asthma class? Yes No
Rev. 03/15/10 I - 71 SAMPLE ONLY – UPDATED ANNUALLY
PROYECTO DE ASMA DE LA COMUNIDAD DE PASADENA Huntington Memorial Hospital (2001)
Lugar: ______Fecha: ______Completada por: ______
INFORMACIÓN DEL ESTUDIANTE: # DE LA I.D. DEL ESTUDIANTE: ______Nombre del Estudiante: ______Apellido Nombre Segundo Nombre (Inicial) Edad ______FDN ______Escuela a la que asistió el año pasado: ______Nombre del Padre/Tutor: ______# del Pager: ( ) Domicilio: ______(Ciudad, Estado, Zona Postal) ______Teléfono del Hogar: ( ) Teléfono del Trabajo: ( ) Nombre del Médico/Persona a Cargo de la Salud: ______
Last Visit: 1 year 1 month 1 week ¿Cubre su seguro de salud las medicinas para el asma? SI NO ¿Obtuvo consentimiento? SI NO INFORMACIÓN DE MEDICAMENTO (Por favor margque los cuadros para todas las medicinas que toma.) FRECUENCIA Una vez Dos veces Antes de hacer Solo si lo MÉTODO al dia al dia ejercicios necesita Proventil/Albuterol/Ventolin/Xopenex Azmacort/Vanceril/Pulmicort/Flovent/Aerobid Cromolyn/Tilade Singulair/Accolate Serevent/Advair
INFORMACIÓN DEL ASMA (Por favor marque uno de los cuadros que describa mejor a su niño.)
1. ¿Tiene su niño síntomas del asma? A Diario Más de 2 veces por semana Menos de 2 veces por semana
2. ¿Tiene su niño síntomas del asma cuando ejercita? Si No
3. ¿Tose su niño durante la noche? Todas las noches Menos de 2 veces al mes Más de 2 veces al mes Mucho más de 1 vez por semana
4. ¿No asiste su niño a la clase de educación física debido al asma? Si No ¿Viajes de excursión? Si No
5. ¿Aproximadamente cuántos dias estuvo ausente de la escuela su niño durante el año escolar pasado debido al asma o bronquitis? ______Dias.
6. ¿Ha estado hospitalizado su niño, o en ER por asma/bronquitis en los últimos 12 meses? Hospitalizado: # de veces ______ER: # de veces ______Unidad de Cuidado Intensivo: # de veces ______
Rev. 03/15/10 SAMPLE ONLY – UPDATED ANNUALLY
7. ¿Tiene en casa un aparato para medir la fuerza de la respiración de su niño? Si No Si la respuesta es positiva. ¿Qué tan seguido lo usa? A Diario Ocasionalmente, como sea necesario. ¿Cuándo puede respirar mejor? ______.
8. ¿Tiene su niño un espaciador? Si No Si la respuesta es positiva. ¿Qué tan seguido la usa? A Diario Ocasionalmente, como se mecesario.
9. ¿Ha estado en una clase de asma? Si No
Rev. 03/15/10 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
ADMINISTRATION OF MEDICATION DURING SCHOOL HOURS
Name of Student Birthdate Address Home Phone School ______Grade Teacher
THIS SECTION TO BE COMPLETED BY HEALTH CARE PROVIDER
TO THE HEALTH CARE PROVIDER: Please complete and sign the center section of this form when prescription or non-prescription medication must be given during school hours. This form is required by Section 11753.1, California Education Code, to authorize school personnel to assist the students with the administration of medication. Date:
Diagnosis or reason for medication: ASTHMA
Medication prescribed: (Please circle one or write in) Dose Frequency Albuterol, Ventolin, Proventil MDI ______Albuterol, Ventolin, Proventil Nebulizer ______Other ______Any special instruction, precautions, or possible side effects:
How long will this medication be necessary?
Signature of Health Care Provider ______Phone
Printed Name of Health Care Provider Fax Address
THIS SECTION TO BE COMPLTED BY PARENT/GUARDIAN
TO THE PARENT OR GUARDIAN : The medication must be delivered to the school in the original pharmacy container. Middle school and senior high school students may bring their medication to the health office. The parent or guardian must bring medication for grade-school aged students.
Rev. 03/15/10 PLEASE SIGN THE FOLLOWING STEMENT: I requested that the school assist my child, in taking the medication as directed above, and in accordance with the school policy. Signature of parent or guardian ______Date
DISTRITO ESCOLAR UNIFICADO DE PASADENA PROGRAMAS DE SALUD
ADMINISTRACIÓN DE MEDICAMENTO DURANTE LAS HORAS DE CLASES
Nombre del Alumno Fecha de nacimiento Domicilio No. de teléfono del hogar Escuela Grado Maestro/a
ESTA SECCIÓN ES PARA QUE LA COMPLETE EL PROVEEDOR DE CUIDADO DE SALUD
TO THE HEALTH CARE PROVIDER: Please complete and sign the center section of this form when prescription or non-prescription medication must be given during school hours. This form is required by Section 11753.1, California Education Code, to authorize school personnel to assist the students with the administration of medication. Date Diagnosis or reason for medication: ASTHMA Medication prescribed: (Please circle one or write in) Dose Frequency Albuterol, Ventolin, Proventil MDI Albuterol, Ventolin, Proventil Nebulizer Other ____ Any special instruction, precautions, or possible side effects:
How long will this medication be necessary?
Signature of Health Care Provider Phone Printed Name of Health Care Provider Fax Address
ESTA SECCIÓN ES PARA QUE LA COMPLETE EL PADRE O TUTOR
AL PADRE O TUTOR: El medicamento debe ser entregado a la escuela en el envase original de la botica. Los estudiantes de las escuelas intermedias y secundarias pueden traer su medicamento a la
Rev. 03/15/10 oficina de salud. El padre o tutor de los alumnos de la escuela elemental deben de llevar el medicamento a la escuela.P A S A D E N A U N I F I E D S C H O O L D I S T R I C T POR FAVOR FIRMEN LA SIGUIENTEE D U C A T IDECLARACIÓN O N C E N T E R : ● Pido H E que A L la T escuela H P R ayude O G R a A mi M S hijo/a que se tome la medicina como es indicado arriba y de acuerdo con las reglas de la escuela.
Firma del Padre o Tutor Fecha
Dear Parent/Guardian:
Children with asthma may have episodes of serious breathing difficulties at school and require paramedic transportation to the nearest hospital. The best way to avoid this situation is to provide albuterol solution for the nebulizer at the school. If you would like us to provide this service for your child, please complete the section below.
Student Name: ______
Emergency Dose of Albuterol by nebulizer: 1 unit dose (3 ml 0.083%) (Call your doctor to verify the dose if you are unsure of it.)
Parent’s Signature: ______Date: ______
Ann Rector Coordinator of Health Programs
Harold T. Wilson Jr., M.D. Physician Consultant
351 South Hudson Avenue ∙ Pasadena, CA 91109 (626) 396-3600 Ext. 88240 ∙ Fax (626) 584-1540 Rev. 03/15/10 www.pasadena.k12.ca.us ∙ www.pusd.us
P A S A D E N A U N I F I E D S C H O O L D I S T R I C T
E D U C A T I O N C E N T E R ● H E A L T H P R O G R A M S
Estimado Padre/Tutor:
Niños con asma pueden tener en la escuela episodios serios con dificultades para respirar y requieren transportación paramédica al hospital más cercano. La mejor forma para evitar esta situación es la de proveer la solución de albuterol para el nebulizador en la escuela. Si desean que nosotros proveamos este servicio para su niño, por favor complete la sección de abajo.
Nombre del Estudiante:
Dosis de Emergencia del Albuterol para el nebulizador: 1 unit dose (3 ml 0.083% (Llame a su médico para verificar la dosis si no está muy seguro de ella.)
Firma del Padre o Tutor:
Ann Rector Coordinadora de los Programas de Salud
Harold T. Wilson Jr., M.D. Doctor Consultante
351 South Hudson Avenue ∙ Pasadena, CA 91109 (626) 396-3600 Ext. 88240 ∙ Fax (626) 584-1540 Rev. 03/15/10 www.pasadena.k12.ca.us ∙ www.pusd.us PASADENA UNIFIED SCHOOL DISTRICT Nurse ______Int.______HEALTH PROGRAMS Health Clerk ______Int.______Asthma Episodic Log Other ______Int.______
Last Name ______First ______DOB ______School ______Grade______Teacher ______Emergency Information Parent/Guardian ______Home Phone (____)______Work Phone(____)______
**Personal Best Peak Flow/Date ______All Current Medications Medications at School Name Route/Dose Daily/PRN Name Route/Dose Daily/PRN 1. 1. 2. 2. 3. 3. 4. 4.
(If Peak flow is less than 60% after administration of medications CALL 911) Month/Day/Year Peak Flow Peak Flow Parent Time Total Initial Symptoms Before meds Action Taken After meds Action Taken Called out time in Time HO Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol)
Rev. 03/15/10 Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE PASADENA UNIFIED SCHOOL DISTRICT Nurse ______Int. ______HEALTH PROGRAMS Health Clerk ______Int. ______ASTHMA EPISODIC LOG Other ______Int. ______
Last Name ______First ______DOB ______
**Personal Best Peak Flow/Date ______(If Peak flow is less than 60% after administration of medications CALL 911)
Month/Day/Year Peak Flow Peak Flow Parent Time Total Initial Symptoms Before meds Action Taken After meds Action Taken Called out time in TIme HO Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol)
Rev. 03/15/10 Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE
PASADENA UNIFIED SCHOOL DISTRICT Nurse ______Int. ______HEALTH PROGRAMS Health Clerk ______Int. ______Asthma Episodic Log Other ______Int. ______
Last Name ______First ______DOB ______
**Personal Best Peak Flow/Date ______(If Peak flow is less than 60% after administration of medications CALL 911)
Month/Day/Year Peak Flow Peak Flow Parent Time Total Initial Symptoms Before meds Action Taken After meds Action Taken Called out time in TIme HO
Rev. 03/15/10 Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol)
Rev. 03/15/10 Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE PASADENA UNIFIED SCHOOL DISTRICT Nurse ______Int. ______HEALTH PROGRAMS Health Clerk ______Int. ______ASTHMA EPISODIC LOG Other ______Int. ______
Last Name ______First ______DOB ______
**Personal Best Peak Flow/Date ______(If Peak flow is less than 60% after administration of medications CALL 911)
Month/Day/Year Peak Flow Peak Flow Parent Time Total Initial Symptoms Before meds Action Taken After meds Action Taken Called out time in TIme HO Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol)
Rev. 03/15/10 Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, Pre PE paramedics) paramedics) Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE Short of Nebulizer Nebulizer breath (Albuterol) (Albuterol) Tight chest MDI MDI Chest pain Water Water Wheezing Other Other Coughing (ie, (ie, paramedics) paramedics) Pre PE
Rev. 03/15/10 PASADENA UNIFIED SCHOOL DISTRICT Health Programs
Management of Acute Asthma Exacerbation at School
Assess Symptoms / Peak Flow / Pulse Ox
If Pulse Ox ≤ 90% If Pulse Ox > 90% If Peak Flow < 50% of personal best If previous peak flow unknown or Or peak flow > 50% of personal best Cyanosis Trouble walking/talking Use of accessory muscles Give Albuterol Substernal retractions
After 30 minutes recheck peak flow and pulse ox
Give Albuterol inhalation Oxygen (if available) If pulse ox ≤ 90% If pulse ox > 90%, but < 95% If pulse ox ≥ 95% Call Paramedics If peak flow ≤ 50% If peak flow > 50%, but < 80% If peak flow > 80% and No wheezing No shortness of breath Give Aluterol No chest pain * If there is no parent consent call paramedics Call parents for pick up Harold T. Wilson Jr., M.D. May remain at school Return to school with Doctor’s Notify parents Rev. 03/15/10 note PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
STUDENTS WITH SPECIAL HEALTH CARE NEEDS EMERGENCY PLAN
ASTHMA
Student: Date:
Birthdate:
Parent’s name: Daytime phone #:
Preferred hospital in case of emergency:
Physician: Phone #:
STUDENT-SPECIFIC EMERGENCIES If You See This Do This 1. Wheezing, shortness of breath (may 1. Use peak flow meter cough), inability to talk, skin color 2. Give medications as ordered change. 3. Give tepid water 4. Notify Parents 5. If relief does not occur after these steps, CALL 9-1-1 2. Breathing appears to have stopped. CALL 911
IF AN EMERGENCY OCCURS:
1. If the emergency is life-threatening, immediately call 9-1-1. 2. Stay with student or designate another adult to do so. 3. Call or designate someone to call the principal and/or school nurse. A. State who you are. B. State where you are. C. State problem. 4. The following staff members are trained to deal with an emergency, and to initiate the appropriate procedures (i.e. Health Clerk, Office Staff, Teachers, Security). 1. 2. 3.
Rev. 07/01/08 I- 85 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
DIABETIC STUDENT INFORMATION REQUEST
Dear Parent/Guardian: Please provide the following information: Student’s name D.O.B. School Grade Room Parent/Guardian(s) name(s) Address zip Telephone (home) (work) Date of diagnosis Does he/she take insulin? If yes, Type(s) Dosage Time? Is blood sugar testing requested at school? When? When does your child need to take insulin at school? Are there restrictions on physical activity? When? Are extras snacks needed daily at school? When? What do you want your child to eat at school if he/she has an episode of low blood sugar?
(Please provide the nurse at your school with these items)
Parent Signature Date
Rev. 07/01/08 I- 86 DISTRITO ESCOLAR UNIFICADO DE PASADENA PROGRAMAS DE SALUD
PETICION DE INFORMACION DEL ALUMNO CON DIABETES
Estimado Padre/Tutor Por favor dé la información siguiente: Nombre del Alumno Fecha de Nacimiento Escuela Grado Aula Nombre del Padre/Tutor: Domicilio Zona Postal Teléfono (hogar) (trabajo) Fecha de la diagnosis ¿Toma el niño insulina? Si la respuesta es sí, ¿Qué clase? , Dosis , Hora ¿Se ha pedido que le hagan la prueba del azúcar en la escuela? ¿Cuándo? ¿Cuándo necesita su niño tomar insulina en la escuela? ¿Tiene restricciones en las actividades físicas? ¿Cuándo? ¿Necesita todos los días bocadillos extras en la escuela? ¿Cuándo? ¿Qué es lo que desea que su niño coma en la escuela si se le baja el azúcar en la sangre?
(Por favor entréguele a la enfermera de la escuela toda esta información)
Rev. 07/01/08 I- 87 Firma del Padre/Tutor Fecha
Rev. 07/01/08 I- 88 BLOOD GLUCOSE GRAPH Date and Time 600 550 500 450 400 375 350 325 300 275 250 225 200 175 150 125 100 80 70 60 50 40 30 20
Rev. 07/01/08 I- 89 P A S A D E N A U N I F I E D S C H O O L D I S T R I C T
E D U C A T I O N C E N T E R ● H E A L T H P R O G R A M S
September 01, 2010
Dear Parents / Guardians:
The below information is about Type 2 Diabetes. This information is required for all incoming 7th graders.
Type 2 Diabetes Information
Pursuant to California Education Code Section 49452.7, this type 2 diabetes information is for local educational agencies to provide to parents and guardians of incoming seventh grade students beginning July 1, 2010.
The California Department of Education developed this type 2 diabetes information in collaboration with the California Department of Public Health, American Diabetes Association, California School Nurses Organization, and Children’s Hospital of Orange County. This information will be available in multiple languages in Spring 2010. Description
Type 2 diabetes is the most common form of diabetes in adults.
← Until a few years ago, type 2 diabetes was rare in children, but it is becoming more common, especially for overweight teens.
← According to the U.S. Centers for Disease Control and Prevention (CDC), one in three American children born after 2000 will develop type 2 diabetes in his or her lifetime. Type 2 diabetes affects the way the body is able to use sugar (glucose) for energy.
← The body turns the carbohydrates in food into glucose, the basic fuel for the body’s cells.
← The pancreas makes insulin, a hormone that moves glucose from the blood to the cells.
← In type 2 diabetes, the body’s cells resist the effects of insulin, and blood glucose levels rise.
← Over time, glucose reaches dangerously high levels in the blood, which is called hyperglycemia. Rev. 07/01/08 I- 90 ← Hyperglycemia can lead to health problems like heart disease, blindness, and kidney failure.
← 351 South HudsonRisk Factors Avenue Associated ∙ Pasadena, with CA Type91109 2 Diabetes (626) 396-3600 Ext. 88240 ∙ Fax (626) 584-1540 It is recommendedwww.pasadena.k12.ca.us that students displaying ∙ www.pusd.us or possibly experiencing the risk factors and warning signs associated with type 2 diabetes be screened (tested) for the disease.
Risk Factors Researchers do not completely understand why some people develop type 2 diabetes and others do not; however, the following risk factors are associated with an increased risk of type 2 diabetes in children:
← Being overweight. The single greatest risk factor for type 2 diabetes in children is excess weight. In the U.S., almost one out of every five children is overweight. The chances are more than double that an overweight child will develop diabetes.
← Family history of diabetes. Many affected children and youth have at least one parent with diabetes or have a significant family history of the disease.
← Inactivity. Being inactive further reduces the body's ability to respond to insulin.
← Specific racial/ethnic groups. Native Americans, African Americans, Hispanics/Latinos, or Asian/Pacific Islanders are more prone than other ethnic groups to develop type 2 diabetes.
← Puberty. Young people in puberty are more likely to develop type 2 diabetes than younger children, probably because of normal rises in hormone levels that can cause insulin resistance during this stage of rapid growth and physical development.
← Warning Signs and Symptoms Associated with Type 2 Diabetes
Warning signs and symptoms of type 2 diabetes in children develop slowly, and initially there may be no symptoms. However, not everyone with insulin resistance or type 2 diabetes develops these warning signs, and not everyone who has these symptoms necessarily has type 2 diabetes.
← Increased hunger, even after eating
← Unexplained weight loss
← Increased thirst, dry mouth, and frequent urination
← Feeling very tired
← Blurred vision
← Slow healing of sores or cuts
Rev. 07/01/08 I- 91 ← Dark velvety or ridged patches of skin, especially on the back of the neck or under the arms
← Irregular periods, no periods, and/or excess facial and body hair growth in girls
← High blood pressure or abnormal blood fats levels Type 2 Diabetes Prevention Methods and Treatments
Healthy lifestyle choices can help prevent and treat type 2 diabetes. Even with a family history of diabetes, eating healthy foods in the correct amounts and exercising regularly can help children achieve or maintain a normal weight and normal blood glucose levels.
← Eat healthy foods. Make wise food choices. Eat foods low in fat and calories.
← Get more physical activity. Increase physical activity to at least 60 minutes every day.
← Take medication. If diet and exercise are not enough to control the disease, it may be necessary to treat type 2 diabetes with medication. The first step in treating type 2 diabetes is to visit a doctor. A doctor can determine if a child is overweight based on the child's age, weight, and height. A doctor can also request tests of a child's blood glucose to see if the child has diabetes or pre-diabetes (a condition which may lead to type 2 diabetes). Types of Diabetes Screening Tests That Are Available
← Glycated hemoglobin (A1C) test. A blood test measures the average blood sugar level over two to three months. An A1C level of 6.5 percent or higher on two separate tests indicates diabetes.
← Random (non-fasting) blood sugar test. A blood sample is taken at a random time. A random blood sugar level of 200 milligrams per deciliter (mg/dL) or higher suggests diabetes. This test must be confirmed with a fasting blood glucose test.
← Fasting blood sugar test. A blood sample is taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL is normal. A level of 100 to 125 mg/dL is considered pre-diabetes. A level of 126 mg/dL or higher on two separate tests indicates diabetes.
← Oral glucose tolerance test. A test measuring the fasting blood sugar level after an overnight fast with periodic testing for the next several hours after drinking a sugary liquid. A reading of more than 200 mg/dL after two hours indicates diabetes. Type 2 diabetes in children is a preventable/treatable disease and the guidance provided in this information sheet is intended to raise awareness about this disease. Contact your student's school nurse, school administrator, or health care provider if you have questions.
References
American Diabetes Association Clinical Journal (Outside Source)
Rev. 07/01/08 I- 92
Helping Children with Diabetes Succeed:P A SA A Guide D E N for A USchoolN I F Personnel I E D S C (PDF; H O O Outside L D I SSource) T R I C T
E D U C A T I O N C E N T E R ● H E A L T H P R O G R A M S KidsHealth (Outside Source) Mayo Clinic (Outside Source) National Library of Medicine (NLM) and National Institutes of Health’s (NIH) MedLine (Outside Source) US Centers for Disease Control and Prevention (Outside Source)
If you have additional questions, please phone the Health Office at 626-396-3600 – Extension 88240.
Thank you,
Ann Rector Coordinator Health Programs
Rev. 07/01/08 I- 93 351 South Hudson Avenue ∙ Pasadena, CA 91109 (626) 396-3600 Ext. 88240 ∙ Fax (626) 584-1540 www.pasadena.k12.ca.us ∙ www.pusd.us
1 de Septiembre de 2010
Estimados Padres / Tutores:
A todos los estudiantes que comienzan el séptimo grado, es requerido darles información sobre la Diabetes de Tipo 2.
INFORMACIÓN SOBRE LA DIABETES TIPO 2
Descripción:
La diabetes tipo 2 es la forma más común de diabetes en los adultos.
Algunos años atrás, la diabetes tipo 2 era poco frecuente en los niños, pero se está haciendo cada vez más común, especialmente en adolescentes con sobrepeso.
Según los Centros para el Control y la Prevención de Enfermedades de los EE. UU. (conocidos en inglés como CDC), uno de cada tres niños estadounidenses nacidos después del año 2000 desarrollará diabetes tipo 2 en algún momento de su vida.
La diabetes tipo 2 afecta la capacidad del cuerpo para usar el azúcar (glucosa) como fuente de energía.
El cuerpo convierte los carbohidratos de los alimentos en glucosa, que es el combustible básico de las células del cuerpo.
La insulina, una hormona que se produce en el páncreas, transporta la glucosa desde la sangre hacia las células.
En el caso de la diabetes tipo 2, las células del cuerpo resisten los efectos de la insulina y se elevan los niveles de glucosa en la sangre.
Con el tiempo, la glucosa alcanza niveles peligrosamente altos en la sangre, lo que se denomina hiperglicemia.
La hiperglicemia puede causar problemas de salud tales como enfermedad cardíaca, ceguera e insuficiencia renal.
Factores de riesgo asociados con la diabetes tipo 2: Rev. 07/01/08 I- 94 Se recomienda que a los alumnos que presenten o posiblemente experimenten factores de riesgo y signos de advertencia relacionados con la diabetes tipo 2, se les realicen estudios (pruebas) para detectar esta enfermedad.
Factores de riesgo:
Los investigadores no comprenden totalmente por qué algunas personas desarrollan diabetes tipo 2 y otras no. Sin embargo, los siguientes factores de riesgo se asocian con un aumento de los riesgos de desarrollar diabetes tipo 2 en niños:
Sobrepeso. El factor de riesgo más importante de la diabetes tipo 2 en los niños es el exceso de peso. En los EE. UU., aproximadamente uno de cada cinco niños tiene sobrepeso. Las posibilidades de que un niño con sobrepeso desarrolle diabetes tipo 2 son más del doble.
Antecedentes familiares de diabetes. Muchos niños y jóvenes que se ven afectados por esta enfermedad tienen al menos uno de sus padres con diabetes o tienen antecedentes familiares significativos de la enfermedad.
Inactividad. La falta de actividad reduce aún más la capacidad del cuerpo de responder a la insulina.
Determinados grupos raciales o étnicos. Los indios nativos americanos, los afroamericanos, los hispanos/latinos o los asiáticos/nativos de las islas del Pacífico son más propensos a desarrollar diabetes tipo 2 que otros grupos étnicos.
Pubertad. Los jóvenes en la etapa de la pubertad tienen más posibilidades de desarrollar diabetes tipo 2 que los niños, quizás debido al aumento normal de los niveles de hormonas que puede causar resistencia a la insulina durante esta etapa de rápido crecimiento y desarrollo físico.
Signos de advertencia y síntomas asociados con la diabetes tipo 2:
En los niños, los signos de advertencia y los síntomas de la diabetes tipo 2 se desarrollan lentamente, y al comienzo puede que no se presente ningún síntoma. Sin embargo, no todas las personas con resistencia a la insulina o con diabetes tipo 2 presentan los siguientes signos de advertencia, y no todas las personas que presentan los siguientes síntomas tienen necesariamente diabetes tipo 2.
Mayor apetito, aun después de comer.
Pérdida de peso inexplicable.
Más sed, boca seca y necesidad de orinar frecuentemente.
Rev. 07/01/08 I- 95 Mucho cansancio.
Visión borrosa.
Cicatrización lenta de llagas o cortes.
Zonas de piel arrugada u oscura, aterciopelada, especialmente detrás del cuello o debajo de los brazos.
Periodos irregulares o desaparición del periodo, y/o crecimiento excesivo de vello en el rostro y en el cuerpo, en el caso de las niñas.
Presión sanguínea alta o niveles anormales de grasa en la sangre.
Tratamientos y métodos de prevención de la diabetes tipo 2:
Un estilo de vida saludable puede ayudar a prevenir y tratar la diabetes tipo 2. Aun en caso de tener antecedentes familiares de diabetes, el consumo de alimentos sanos en cantidades adecuadas y el ejercicio regular pueden ayudar a los niños a alcanzar o mantener un peso y un nivel de glucosa en la sangre normales.
Consumir alimentos sanos. Realice buenas elecciones de los alimentos. Consuma alimentos bajos en grasa y calorías.
Realizar más actividad física. Aumente su actividad física hasta llegar, al menos, a 60 minutos diarios.
Tomar medicamentos. Si la dieta y el ejercicio no son suficientes para controlar la enfermedad, quizá sea necesario tratar la diabetes tipo 2 con medicamentos.
El primer paso para tratar esta enfermedad es visitar a un médico. El médico puede determinar si el niño tiene sobrepeso según su edad, peso y estatura. Además, el médico puede solicitar pruebas de glucosa en sangre para analizar si el niño tiene diabetes o pre-diabetes (una afección que puede causar diabetes tipo 2).
Tipos de pruebas disponibles de detección de la diabetes:
Prueba de la hemoglobina glicosilada (A1C). Es una prueba de sangre que mide el nivel promedio de azúcar en sangre durante dos o tres meses. Un nivel de A1C de 6.5 por ciento o mayor en dos pruebas diferentes es señal de diabetes.
Prueba de azúcar en sangre aleatoria (no en ayunas). Se extrae una muestra de sangre en cualquier momento. Un nivel de azúcar en sangre aleatoria de 200 miligramos por decilitro (mg/dL) o mayor puede indicar diabetes. Esta prueba debe confirmarse con un examen de glucosa en sangre en ayunas.
Rev. 07/01/08 I- 96 Prueba de azúcar en sangre en ayunas. Se extrae una muestra de sangre luego de una noche de ayuno. Un nivel de azúcar en sangre en ayunas menor que 100 mg/dL se considera normal. Un nivel que varíe entre 100 y 125 mg/dL se considera pre-diabetes. Un nivel de 126 mg/dL o mayor en dos pruebas distintas es indicador de diabetes.
Prueba de tolerancia oral a la glucosa. Es un examen que mide el nivel de azúcar en sangre después de una noche de ayuno y se realizan pruebas periódicas durante unas horas después de haber tomado un líquido azucarado. Un nivel de más de 200 mg/dL después de dos horas es señal de diabetes.
La diabetes tipo 2 en los niños es una enfermedad que puede prevenirse y tratarse. La información de este folleto tiene como objetivo crear conciencia acerca de esta enfermedad. Si tiene alguna pregunta, comuníquese con el proveedor de servicios de salud, el administrador de la escuela o la enfermera de la escuela del estudiante.
Referencias en línea en inglés:
American Diabetes Association Clinical Journal (Publicación clínica de la Asociación Estadounidense para la Diabetes) http://clinical.diabetesjournals.org/content/23/4/181.full
Helping Children with Diabetes Succeed: A Guide for School Personnel (Cómo ayudar a que los niños con diabetes vivan satisfactoriamente: Guía para el personal de la escuela) http://www.ndep.nih.gov/media/Youth_NDEPSchoolGuide.pdf
KidsHealth.Org http://kidshealth.org/parent/medical/endocrine/type2.html
The Mayo Clinic (Clínica Mayo) http://www.mayoclinic.com/health/type-2-diabetes-in-children/DS00946
National Library of Medicine (NLM) and National Institutes of Health’s (NIH) MedLine (Medline de los Institutos Nacionales de Salud [conocidos en inglés como NIH] y la Biblioteca Nacional de Medicina [conocida en inglés como NLM]) http://www.nlm.nih.gov/medlineplus/ency/article/000313.htm
US Centers for Disease Control and Prevention (Centros para el Control y la Prevención de Enfermedades de los EE. UU.) http://www.cdc.gov/diabetes/projects/cda2.htm
Si tiene alguna pregunta, puede llamar al Departamento de Salud al (626) 396-3600, extension 88240.
Atentamente,
Rev. 07/01/08 I- 97 Ann Rector Coordinadora del Departamento de Salud
Rev. 07/01/08 I- 98 Student ID# HEALTH RECORD PASADENA UNIFIED SCHOOL DISTRICT Glasses Pasadena, California M F Name Birthplace Date of Birth Address Telephone School Teacher Grade Pre K Date Height Weight EYES EOMs Ishihara: Snellen R 20/ Passed Snellen L 20/
Failed c GL R
C&C c GL L EARS Audiometer R Audiometer L Dental Screen TBC Skin Test Physical Exam Dates: X-Ray
Immunizations Complete Date Initial Insurance POLIO Health Concerns: DTP/DTaP 1. MMR/Measles 2. Hepatitis A 3. Hepatitis B Medication HIB Scoliosis Screening: Pass Varicella Recheck Refer
FAMILY INFORMATION Lives in Home: Occupation: Health: Father-Name Mother-Name Brothers-DOB Sisters-DOB Others MD/Health Insurance 175-152 WSN0668 H29-61 09/19/00
PROGRESS RECORD COMMENTS Date Date
Rev. 07/01/08 I- 99 HEALTH HISTORY Date Onset Be Specific Chicken Pox Asthma Pneumonia Scarlet Fever Blood Diseases Seizures Other Bone-Muscle Disorder Speech Disorders Cancer TBC-Child Diabetes Family Ear Infections Other Chronic Diseases Hearing Loss Serious Illness Heart Condition Kidney Disease Accidents/Fractures Allergies (specify)
Operations Medications-Now
Other
PHYSICAL EXAMINATION N=Normal X=Needs Attention 1=Minor 2=Major C=Corrected O=Over Orthopedic Abdomen t l t s s s s e e e a h n n r r e i a t i r s e g u n o Date Name a r P.E. Note a e e n i k u i y o n o e e t r r t e F E S i u v E s n e c N r H r
of of T Recom. to p t t o e L o l e H a u P d a G o
Exam Examiner N Parent n c r N n S h E m o i e T t t i s d y n S o C
DENTAL INSPECTION Date Nurse Cavities Cavities Note to Dental Hygienest Mouth Hygiene Permanent Teeth Temporary Teeth Malocclusion Parent
PROGRESS RECORD COMMENTS
Date Date
Rev. 07/01/08 I- 100 PUPIL HEALTH OFFICE VISIT CARD
Name ID# Birth Date Teacher Grade School Year TIME DATE REASON TEMP DISPOSITION EXAMINER In out
PUPIL HEALTH OFFICE VISIT CARD FM 591 WHS #6074 Rev. 7/02
Rev. 07/01/08 I- 101 HEALTH OFFICE PASS HEALTH OFFICE PASS Date Date Name Name Teacher Teacher Student Complains of: Student Complains of: Stomachache Stomachache Headache Headache A Cold A Cold Fever Fever Earache Earache Injury Injury Sore throat Sore throat Nosebleed Nosebleed Other Other
Teacher Time Teacher Time NURSE’S COMMENTS: NURSE’S COMMENTS: Return to Class Return to Class Going Home Going Home Rested Rested Feeling Better Feeling Better Other Other
Signature Time Signature Time
HEALTH OFFICE PASS HEALTH OFFICE PASS Date Date Name Name Teacher Teacher Student Complains of: Student Complains of: Stomachache Stomachache Headache Headache A Cold A Cold Fever Fever Earache Earache Injury Injury Sore throat Sore throat Nosebleed Nosebleed Other Other
Teacher Time Teacher Time NURSE’S COMMENTS: NURSE’S COMMENTS: Return to Class Return to Class Going Home Going Home Rested Rested Feeling Better Feeling Better Other Other
Signature Time Signature Time
Rev. 07/01/08 I- 102 PASADENA UNIFIED SCHOOL DISTRICT HEALTH PROGRAMS
EMERGENCY CARD INFORMATION
School Date
To the parents/guardians of: Grade
We were unable to contact you by phone today.
It is most important that the school be able to reach you in case of serious accident or illness of your child. We should also have the name of at least one or more other adults who could help if we cannot contact you. For the protection of your child, the school will only release him/her during school hours to whom you have designated on this card.
Please complete the attached emergency card and return it to school:
DISTRITO ESCOLAR UNIFICADO DE PASADENA PROGRAMAS DE SALUD
TARJETA DE INFORMACION DE EMERGENCIA
Escuela Fecha
A los padres/tutores de: Grado
La información en la tarjeta de emergencia de su nino(a) se necesitó hoy. Alguna o toda la informacion no parece estar al corriente.
Es muy importante que a la escuela le sea posible encontrarles a ustedes en caso de un serio accidente o enfermedad del(a) estudiante. Nosotros tambien debemos de tener por lo menos el nombre de uno o más adultos que puedan ayudar, si no podemos encontrarlos a ustedes. Para la protección de su niño/a, la escuela solo dejara ir a su niño/a con las personas quienes esten indicadas en la targeta.
Por favor complete la tarjeta de emergencia incluida y devuelvala a la escuela.
Rev. 07/01/08 I - 103 Pasadena Unified School District EMERGENCY INFORMATION – INFORMACIÓN DE EMERGENCIA
SCH # STUDENT # GRADE ROOM # TEACHER/COUNSELOR FAMILY # DWELLING # DATE ENTERED INTO COMPUTER
DATE – FECHA CHANGES TO INFORMATION? SPECIAL RELEASE INSTRUCTIONS – INSTRUCCIÓNES/RESTRICCIÓNES ESPECIALES PARA RECOGER EL ALUMNO HAY CAMBIOS A LA INFORMACIÓN? YES/SI NO STUDENT (LEGAL) NAME – NOMBRE (LEGAL) DEL ALUMNO FIRST – PRIMERO MI GENDER BIRTHDATE AGE GÉNERO FECHA DE NACIMENTO EDAD
HOME TELEPHONE SSN ETHNICITY LANGUAGE SPOKEN BIRTHPLACE (CITY STATE COUNTRY) TELÉFONO DEL HOGAR GRUPO ÉTNICO IDIOMA PREFERIDO LUGAR DE NACIMIENTO
ADDRESS – HOUSE #, DIRECTION (N S E W) STREET – DIRECCIÓN APT # – APTO # CITY – CIUDAD ZIP CODE CÓDIGO POSTAL
PARENT 1/GUARDIAN NAME: LAST FIRST – PRIMERO MI PARENT 2/GUARDIAN NAME: LAST FIRST– PRIMERO MI NOMBRE DE LA PADRE 1/GUARDIÁN: APELLIDO NOMBRE DEL PADRE 2 /GUARDIÁN: APELLIDO
GENDER – GÉNERO RELATIONSHIP TO CHILD LANGUAGE SPOKEN GENDER – GÉNERO RELATIONSHIP TO CHILD LANGUAGE SPOKEN RELACIÓN AL NIÑO/A IDIOMA PREFERIDO RELACIÓN AL NIÑO/A IDIOMA PREFERIDO
ADDRESS (IF DIFFERENT) – DIRECCIÓN (SI ES DIFERENTE) APT # ADDRESS (IF DIFFERENT) – DIRECCIÓN (SI ES DIFERENTE) APT # APTO # APTO.#
CITY – CIUDAD ZIP CODE CITY – CIUDAD ZIP CODE CÓDIGO POSTAL CÓDIGO POSTAL
EMAIL ADDRESS – DIRECCIÓN DE EMAIL EMAIL ADDRESS – DIRECCIÓN DE EMAIL
BUSINESS PHONE – TELÉFONO: EMPLEO CELL PHONE – TELÉFONO CELULAR BUSINESS PHONE – TELÉFONO: EMPLEO CELL PHONE – TELÉFONO CELULAR
EMPLOYER – NOMBRE DEL EMPLEADOR EMPLOYER – NOMBRE DEL EMPLEADOR
OCCUPATION – OCUPACIÓN OCCUPATION – OCUPACIÓN
NAME OF DOCTOR – NOMBRE DEL DOCTOR TELEPHONE – TELÉFONO
NAME OF OTHER RELATIVE – NOMBRE DE OTRO PARIENTE RELATIONSHIP TO CHILD – RELACION AL NIÑO/A TELEPHONE – TELÉFONO
OTHER EMERGENCY CONTACT – OTRO CONTACTO DE EMERGENCIA RELATIONSHIP TO CHILD – RELACION AL NIÑO/A TELEPHONE – TELÉFONO
Authorization for Release of Student Information (FERPA Privacy Authorization) ______I give consent for Pasadena Unified School District to submit information to the LEA billing option vendor, Paradigm, regarding school health services provided to my child for Initial the purpose of receiving federal reimbursement. This reimbursement helps to defray the cost of providing these health services. All information is kept confidential.
Other Health Coverage Inquiries ___ Yes ____ No Many private insurance companies do not pay for school health services but school districts must attempt to bill for those services. If your child has private health insurance (not Medi-Cal) do you give permission to Pasadena Unified School District to bill that insurance? If no, please note that school health services will continue to be provided and parents will never be billed. If yes, please fill out the following:
Name of Private Carrier ______Insurance Policy #______Group #______Phone #______
No treatment will be given other than in a serious emergency without contacting parent/guardian. No se dara tratamiento, al menos que sea una emergencia, sin antes haberse communicado con el padre/guardian. SIGNATURE OF PARENT/GUARDIAN – FIRMA DE PADRE/GUARDIAN DATE – FECHA
Emergency Card (Revised 7/2004)
Rev. 07/01/08 I - 104 FLAGGING OF HEALTH RECORDS
To maintain uniformity please flag health records as follows:
LEFT SIDE - Action Needed RIGHT SIDE - Chronic conditions or Follow- up needed
LAVENDER - incomplete immunization YELLOW with written notation - physical condition (i.e. heart condition, sickle cell, diabetes, non-correctable vision defects, etc.), ORANGE - physical exam needed (CHDP) obesity, waiver from treatment, glasses
GREEN - screening needed RED - Use for someone with serious or urgent needs
Post-It Tape Flags can be ordered through office supply catalogs. Metal tags may be used if desired (no suppliers known).
Rev. 07/01/08 I - 105 ORDERING HEALTH OFFICE SUPPLIES
How to obtain supplies It is the school nurse’s and health clerk’s responsibility to maintain adequate first-aid supplies for the health office and the classroom first aid boxes.
Supplies should be ordered at least 2 months prior to need. Supplies are usually ordered twice a year. Seventy-five cents per pupil is allotted for health supplies.
A warehouse catalog and supply forms are available from the main office. The list for warehouse supplies should include quantity, unit, warehouse number, description and price. The final form is to be initialed by the school nurse below the last item and sent to the principal at elementary level for approval. At secondary level the principal or designee signs the requisition and forwards it to the budget department and warehouse.
Sanitary Napkins School nurses provide sanitary napkins to girls who begin their menstrual period during the school day. The charge for the napkin should cover the cost of the napkin and not exceed twenty-five cents.
Ordering Supplies When ordering supplies, orders must be submitted by the deadline. Deadlines for outside requisitions usually take place in the month of April. Deadlines for warehouse requisitions usually take place in the month of May. See current bulletin for official dates.
Supplies may be ordered from Outside Vendor catalogs. Sources include but are not limited to: 1. William V. MacGill & Co., Phone: 1-800-323-2841 2. National Health Supply Corp., Phone: 1-800-645-3585 3. School Health Corporation, Phone: 1-800-323-1305
First aid kits for classrooms should be collected in June and restocked in September. The following supplies should be included:
1. Band Aids – Regular size 2. Band Aids – Junior size 3. 2 Sterile Gauze Pads, 3x3’s or 4x4’s 4. Gloves (1 pair) 5. Cotton balls 6. Germicidal soap 7. Applicator sticks 8. Copy of Infectious Disease guidelines
Rev. 07/01/08 I - 106 HEALTH OFFICE SUPPLY LIST (See Current Warehouse Stock List)
DESCRIPTION UNIT WSN PRICE
ALCOHOL Pint 70% BT 2771 .586
BAND - AIDS Plain, 1 in wide, 100/bx BX 2745 1.779
CUP, Paper Drinking 6 oz 100/pk PK 2751 2.777
KLEENEX 300 single BX 2769 .608
NAPKIN FEMININE-Maxi Pads 250/bx EA 1260 .093
PHISODERM SOAP BT 2774 8.707
THERMOMETER, Disposable Tempa Dot PK 2778 8.041 100/pk
As of February 2002, the following items must be ordered from outside sources, i.e. Office Depot, Southwest School & Office Supply, Medical Supply Catalogs
ADHESIVE TAPE
1/2 in x 10 yds 1 in x 5 yds
APPLICATORS, Cotton Tip 3 in 100/pk
BAND-AIDS Butterfly Closures 100/bx Sheer Strip Band-Aids 3/8 in x 1 1/2 100/bx
BANDAGE, Gauze 1 in x 10 yds 1 1/2 in x 10 yds 2 in x 5 yds 3 in X 10 yds
BANDAGE, Triangular Muslin For slings, etc.
BASIN, Wash 3 1/2 qt. #30
Rev. 07/01/08 I - 107 HEALTH OFFICE SUPPLY LIST (cont’d)
BOTTLES, Plastic Dropper 2 oz
CALAMINE LOTION 4 oz bt
COTTON Absorbent 1/4 lb pk Balls 500/pk (sterile) Balls 2000/bg
DEPRESSOR, Tongue 500/bx
FRACTURE SUPPORT Medium (Cardboard) Small (Cardboard)
PINS Safety Large No. 3 8/cd No. 2 8/cd
SCISSORS 5 in blade Sharp point Bandage 5 1/2 in chrome
SPLINT, Wooden 3X18in
STERIPADS 3” x 3” 100/bx
TELFA BANDAGES 100/bx 2” x 3” Curity Telfa (Note: Under “Pads” in Warehouse Book)
TWEEZERS, Clinical splinter forceps
VASELINE, White 1 oz tube
Rev. 07/01/08 I - 108