HS0001: Health History

Health information to assist staff in responding to students' health needs

Department: Health Services
Last revised: 7/2018
Where available: On line
Form Type: Interactive
File Type: Acrobat PDF Form

HS0002: Physical Examination, Visual Evaluation, and Immunization Requirements in Nebraska Schools

The legal requirements for physical examinations and immunization

Department: Health Services
Last revised: 03/2017
Where available: On line
Form Type: Print - information only
File Type: Acrobat PDF Form

HS0003: Immunization Requirements

State requirements for student immunizations

Department: Health Services
Last revised: 12/2021
Where available: on-line
Form Type: Print & Fill
File Type: Acrobat PDF Form

HS00073: Tdap Notification

TDAP Notification Letter

Department: Health Services
Last revised: 07/27/2022
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS00074: HepB Interval

Hepatitis B Interval Letter

Department: Health Services
Last revised: 07/27/2022
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0008: Student Assistance Log

Log of students seen and actions taken

Department: Health Services
Last revised: 02/2004
Where available: On line
Form Type: Interactive
File Type: Acrobat PDF Form

HS0012: Notification of Injury or Illness at School

Notification when student is injured or ill, and parent is not available by telephone

Department: Health Services
Last revised: 03/2024
Where available: On line
Form Type: Interactive
File Type: Acrobat PDF Form

HS0017: Medical Recommendations for Physical Education Participation or School Mobility

Letter to parents requesting additional information from medical provider for participation in physical education and sports

Department: Health Services
Last revised: 10/2020
Where available: On line
Form Type: Interactive
File Type: Acrobat PDF Form

HS0019: Request to Provide meds

Parental request for school nurse to administer student medication

Department: Health Services
Last revised: 01/2017
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0020: Physical Examination Requirements

State statutes regarding physical examinations and form for physician to complete

This form is also available through the Distribution Center (#526009)

Department: Health Services
Last revised: 04/2018
Where available: On line
Form Type: Interactive
File Type: Acrobat PDF Form

HS0021: Asthma/Reactive Airway Action Plan

Information to be given to nurse by parents about child's medical condition

Department: Health Services
Last revised: 7/2022
Where available: On line
Form Type: Interactive
File Type: Acrobat PDF Form

HS0023: Waiver of Physical Examination

To object to the legally required physical exam prior to beginner grade and seventh grade.

Department: Health Services
Last revised: 03/2017
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0024: Diabetes Action Plan

Information supplied by parent or guardian to assist in student diabetes management

Department: Health Services
Last revised: 9/2023
Where available: Online
Form Type: interactive
File Type: Acrobat PDF Form

HS0025: Life Threatening (Anaphylaxsis) or Severe Allergy Action Plan

Management plan for student severe allergies

Department: Health Services
Last revised: 7/2022
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0026: Seizure Action Plan

Information for school nurse about a child's seizures

Department: Health Services
Last revised: 7/2022
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0027: Immunization Waiver

Statement of medical or religious objections to immunizations required by the state

Department: Health Services
Last revised: 03/2019
Where available: Online
Form Type: Print and Fill
File Type: Acrobat PDF Form

HS0030: Request for Update of Student Health Information

Information requested of parents to update school health records

Department: Health Services
Last revised: 01/2021
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0031: Nursing Assessment Sheet

*

Department: Health Services
Last revised: 4/2018
Where available: Online
Form Type: Print and Fill
File Type: Acrobat PDF Form

HS0032: Health Report for Student Assistance Process

*

Department: Health Services
Last revised: 5/2017
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0036: Specialized Care Procedure Consent for Non-district Personnel

Form to be completed when parent/guardian requests specialized procedures to be done by non-district personnel during the school day

Department: Health Services
Last revised: 11/2005
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0037: Parent/Guardian Request for Specialized Care Procedure

Request and consent for school nurse to perform specialized procedure

Department: Health Services
Last revised: 10/2005
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0044: Varicella (Chickenpox) Disease Documentation

Confirmation that child has had chicken pox

Department: Health Services
Last revised: 11/2005
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0046: Head Injury Symptom Checklist (HISC)

Checklist for evaluation of a head injury

Department: Health Services
Last revised: 09/2016
Where available: Online
Form Type: Print and Fill
File Type: Acrobat PDF Form

HS0047: Health Services Action Plan

*

Department: Health Services
Last revised: 7/2022
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0048: Report of Vision Evaluation

Evaluation form required by state law when a child enters school.

Department: Health Services
Last revised: 01/2007
Where available: Online
Form Type: Print and fill
File Type: Acrobat PDF Form

HS0049: Contract for Students Keeping Medications with them in school

Agreement for students , parents and medical persons to sign

Department: Health Services
Last revised: 04/2014
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0050: Self-Management of Diabetes at School

Parent, student and physician agreement

Department: Health Services
Last revised: 05/2014
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0051: Self-Management of Asthma and Severe Allergy (Anaphylaxis) at School

Parent, student and physician agreement

Department: Health Services
Last revised: 05/2019
Where available: Online
Form Type: Print and Fill
File Type: Acrobat PDF Form

HS0056: Waiver of Visual Evaluation

Form for parents to protest the state-required vision evaluation for children entering school.

Department: Health Services
Last revised: 03/2017
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0057: Atlantoaxial Misalignment

To record medical professional's recommendation for children with Down Syndrome.

Department: Health Services
Last revised: 04/2007
Where available: Online
Form Type: Print and Fill
File Type: Acrobat PDF Form

HS0059: Request to Provide Medication During School Hours: Acetaminophen and Ibuprofen

The official name of this form is: Request to Provide Medication During School Hours: Acetaminophen and Ibuprofen

Department: Health Services
Last revised: 03/2023
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0061: Report of Dental Examination

*

This form is also available from DC under the form number 526039

Department: Health Services
Last revised: 1/2016
Where available: Online and at DC
Form Type: Interactive
File Type: Acrobat PDF Form

HS0062: Independence Academy Student Action Plan

*

Department: Health Services
Last revised: 10/2020
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0063: Request for Current Health Information

Request for health information as part of Student assistance process Tier 1 referral or gifted evaluation.

Department: Health Services
Last revised: 12/2022
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0064: Dental Referral Letter

*

Department: Health Services
Last revised: 12/2018
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0065: Hearing Referral Letter

*

Department: Health Services
Last revised: 10/2022
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0066: Vision Referral Letter

*

Department: Health Services
Last revised: 09/2020
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0067: Parent Notification of Injury to Head or Face

*

Department: Health Services
Last revised: 7/2018
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0068: Cardiac Emergency Protocol

*

Department: Health Services
Last revised: 11/2018
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0069: Cardiac Emergency Team

*

Department: Health Services
Last revised: 11/2018
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0070: Drill Summary Checklist

*

Department: Health Services
Last revised: 11/2018
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0071: SBAR Communication

*

Department: Health Services
Last revised: 4/2020
Where available: Online
Form Type: print and fill
File Type: Acrobat PDF Form

HS0075: Provisional Immunizations

Provisional Immunizations Form

Department: Health Services
Last revised: 08/02/22
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0076: Immunization Exclusion

Immunization Exclusion Form

Department: Health Services
Last revised: 08/02/22
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0077: Acute Ear Concern Notification Letter

*

Department: Health Services
Last revised: 11/22
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0078: Health-Related Dismissal from School

*

Department: Health Services
Last revised: 2/2023
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form

HS0079: Formulary Notification

*

Department: Health Services
Last revised: 04/2023
Where available: Online
Form Type: Interactive
File Type: Acrobat PDF Form