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![]() HS0001: Health HistoryHealth information to assist staff in responding to students' health needs Department: Health Services |
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![]() HS0002: Physical Examination, Visual Evaluation, and Immunization Requirements in Nebraska SchoolsThe legal requirements for physical examinations and immunization Department: Health Services |
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![]() HS0003: Immunization RequirementsState requirements for student immunizations Department: Health Services |
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![]() HS00073: Tdap NotificationTDAP Notification Letter Department: Health Services |
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![]() HS00074: HepB IntervalHepatitis B Interval Letter Department: Health Services |
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![]() HS0008: Student Assistance LogLog of students seen and actions taken Department: Health Services |
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![]() HS0012: Notification of Injury or Illness at SchoolNotification when student is injured or ill, and parent is not available by telephone Department: Health Services |
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![]() HS0017: Medical Recommendations for Physical Education Participation or School MobilityLetter to parents requesting additional information from medical provider for participation in physical education and sports Department: Health Services |
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![]() HS0019: Request to Provide medsParental request for school nurse to administer student medication Department: Health Services |
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![]() HS0020: Physical Examination RequirementsState statutes regarding physical examinations and form for physician to complete This form is also available through the Distribution Center (#526009) Department: Health Services |
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![]() HS0021: Asthma/Reactive Airway Action PlanInformation to be given to nurse by parents about child's medical condition Department: Health Services |
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![]() HS0023: Waiver of Physical ExaminationTo object to the legally required physical exam prior to beginner grade and seventh grade. Department: Health Services |
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![]() HS0024: Diabetes Action PlanInformation supplied by parent or guardian to assist in student diabetes management Department: Health Services |
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![]() HS0025: Life Threatening (Anaphylaxsis) or Severe Allergy Action PlanManagement plan for student severe allergies Department: Health Services |
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![]() HS0026: Seizure Action PlanInformation for school nurse about a child's seizures Department: Health Services |
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![]() HS0027: Immunization WaiverStatement of medical or religious objections to immunizations required by the state Department: Health Services |
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![]() HS0030: Request for Update of Student Health InformationInformation requested of parents to update school health records Department: Health Services |
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![]() HS0031: Nursing Assessment Sheet* Department: Health Services |
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![]() HS0032: Health Report for Special Education Evaluation Process* Department: Health Services |
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![]() HS0036: Specialized Care Procedure Consent for Non-district PersonnelForm to be completed when parent/guardian requests specialized procedures to be done by non-district personnel during the school day Department: Health Services |
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![]() HS0037: Parent/Guardian Request for Specialized Care ProcedureRequest and consent for school nurse to perform specialized procedure Department: Health Services |
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![]() HS0044: Varicella (Chickenpox) Disease DocumentationConfirmation that child has had chicken pox Department: Health Services |
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![]() HS0046: Head Injury Symptom Checklist (HISC)Checklist for evaluation of a head injury Department: Health Services |
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![]() HS0047: Health Services Action Plan* Department: Health Services |
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![]() HS0048: Report of Vision EvaluationEvaluation form required by state law when a child enters school. * Department: Health Services |
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![]() HS0049: Contract for Students Keeping Medications with them in schoolAgreement for students , parents and medical persons to sign * Department: Health Services |
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![]() HS0050: Self-Management of Diabetes at SchoolParent, student and physician agreement * Department: Health Services |
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![]() HS0051: Self-Management of Asthma and Severe Allergy (Anaphylaxis) at SchoolParent, student and physician agreement Department: Health Services |
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![]() HS0056: Waiver of Visual EvaluationForm for parents to protest the state-required vision evaluation for children entering school. Department: Health Services |
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![]() HS0057: Atlantoaxial MisalignmentTo record medical professional's recommendation for children with Down Syndrome. * Department: Health Services |
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![]() HS0059: Request to Provide Medication During School Hours: Acetaminophen and IbuprofenThe official name of this form is: Request to Provide Medication During School Hours: Acetaminophen and Ibuprofen * Department: Health Services |
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![]() HS0061: Report of Dental Examination* This form is also available from DC under the form number 526039 Department: Health Services |
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![]() HS0062: Independence Academy Student Action Plan* Department: Health Services |
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![]() HS0064: Dental Referral Letter* Department: Health Services |
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![]() HS0065: Hearing Referral Letter* Department: Health Services |
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![]() HS0066: Vision Referral Letter* Department: Health Services |
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![]() HS0067: Parent Notification of Injury to Head or Face* Department: Health Services |
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![]() HS0068: Cardiac Emergency Protocol* Department: Health Services |
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![]() HS0069: Cardiac Emergency Team* Department: Health Services |
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![]() HS0070: Drill Summary Checklist* Department: Health Services |
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![]() HS0071: SBAR Communication* Department: Health Services |
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![]() HS0075: Provisional ImmunizationsProvisional Immunizations Form
Department: Health Services |
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![]() HS0076: Immunization ExclusionImmunization Exclusion Form
Department: Health Services |
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![]() HS0077: Acute Ear Concern Notification Letter* Department: Health Services |
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![]() HS0078: Health-Related Dismissal from School* Department: Health Services |
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![]() HS0079: Formulary Notification* Department: Health Services |
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![]() HS0080: Oral Polio Vaccination Notification Letter* Department: Health Services |