Skip to main content
You are currently in a sub-section of washk12.org

Health Forms / Documents

Diet Requests

Both forms below must be filled out and signed by a parent/guardian and a licensed healthcare provider for students that need food related accommodations for meals/snacks at school. Completed forms are to be faxed to Nutrition Services and shared with the kitchen manager at the school the student attends. These diet forms only need to be updated if  a change is necessary.

Head Injury – Concussion

A concussion is caused by a bump, blow, or jolt to the head. Concussions can also occur from a fall or blow to the body that causes the head to move rapidly back and forth. Even what seems to be a mild bump to the head can be serious.

Head injuries or bumps should be monitored for signs and symptoms of a concussion.  Use the Flow Chart, Checklist, Parent Notification Letter, and Signs/Symptoms Poster linked below to guide you.

Health Office Tools
Illness/Communicable Disease

The WCSD follows the guidance and recommendations provided by the Utah Department of Health and the American Academy of Pediatrics in regards to illness and communicable disease. Consult with your assigned school nurse as needed. 

Chicken Pox

Immunizations
Injury

FOR STUDENT INJURIES: 

A student injury severe enough to cause the loss of one-half day or more of school and/or warrant medical attention and treatment needs to be reported by school secretaries to the Utah Dept. of Health “Student Injury Report –  Violence and Injury Program online:

FOR STAFF INJURIES:

Lice / Bedbugs

Lice

Coordinate with your assigned school nurse for assistance with challenging cases and re-infestations. Provide parents with instructional materials linked below. Each school may order lice treatment kits  through the warehouse.

Bed Bugs

Logs

Diabetes Logs

Other logs

Maturation

Coordinate with your assigned school nurse, the PTA, and a male presenter to schedule a date/time for the 5th grade Maturation presentation. Boys and girls are taught separately. Schools typically prefer presentations to be in the  afternoon, right before a holiday or break.

Per Utah State Board of Education (USBE), parents must receive the consent form linked below no later than two weeks prior to the beginning of instruction.

Medication / Medical Forms

Medical forms must be filled out and signed by a parent/guardian, and a licensed healthcare provider if medication is to be administered.  Click links below for individual forms. Quick access to all Utah Department of Health medical forms found here.

Medication Authorizations (Orders)/IHP/EAP Forms  – UDOH

Procedure Forms – WCSD

 Miscellaneous Forms-WCSD

WCSD Medication Policy

Scoliosis

The WCSD school nurses perform spinal/scoliosis screenings at the request of a parent/guardian. The Utah Department of Health recommends against mass routine school scoliosis screening. The Spinal Research Society recommends that girls be screened twice at  ages 10 and 12 (5th & 7th grade), and boys be screened once at either age 13 or 14 (8th or 9th grade).

Coordinate with your assigned school nurse to  determine when to send home the Parent  Scoliosis Letter and Instructional Handout.

Standards of Care

Listed below are the Utah Department Health (UDOH) general standards of care for students with medical concerns. The student’s  health care provider may indicate exceptions to these standards on the student’s individual medication authorization (order)/IHP/EAP forms. The school nurse ultimately determines if the authorization/order is safe and appropriate to delegate to unlicensed school staff.

Standing Orders

The Medical Director for the WCSD has written orders for a variety of Over The Counter (OTC) products that can be used by trained staff to treat students.  School staff must obtain parent/guardian permission each time a Standing Order OTC product is administered, unless the student has a specific medication authorization form (order) completed and  signed by a parent/guardian and their healthcare provider. Documentation of each medication administration in the student’s personal educational record is required.

Additionally, the WCSD Medical Director has written Standing Orders for emergency use of stock Epi-Pen (for severe allergic reaction) and naloxone (for opioid over-dose)  that can be administered by trained staff to any student, staff, and visitors. These emergency medications are to be administered as per the Standing Orders, then emergency services and parent/guardian are to be contacted. If a student has a specific medication authorization for Epi-Pen or naloxone, follow the student’s specific medication authorization form (order) completed and  signed by a parent/guardian and their healthcare provider. 

For quick reference, print the Standing Orders below and keep accessible.

Vision Screening

The Utah Department of Health (UDOH) requires Tier 1 screening of students for distance visual acuity for pre-kindergarten, kindergarten, and grades 1, 3, 5, 7 or 8, and 9 or 10. Tenth grade students may be screened as part of their driver education class. Students referred by a parent or school personnel should also be screened during any grade. Students in the grades listed above must be screened annually.

Tier 2 vision screening is a higher-level evaluation which should include screening of distance (if not done in the current year) and near vision. Optional screening includes eye focusing or tracking problems, and convergence insufficiency. Tier 2 vision screening can be classified as mandatory (students needing educational intervention, special education referral, or failing benchmark assessment) or optional (teacher or parent concern).

For financial assistance for a professional eye exam and if needed, glasses, contact your assigned school nurse or the WCSD Support Services Coordinator/ Homeless Liaison.