Health Office Forms AND Emergency Care Plans

Students requiring an emergency care plan(s) and/or medication(s) that need to be given during school hours will need one or more of the following forms completed. All emergency care plans and medication authorizations need to be received prior to the beginning of the school year and renewed on an annual basis with your school nurse, Holly Todd RN, LSN. The forms are listed below, with a description under each form. Click on the name of the form that you wish to complete. Completed forms can be dropped off at any building health office, emailed to htodd@isd2899.k12.mn.us, or faxed to 507-534-0132. 

Medication Authorization FORM: Complete this form if your child needs a medication(s) given during school hours. A health care provider's signature is required for all prescription medications and for over-the-counter medications exceeding package recommendations.

Please note that medication must be brought to school by an adult in the original labeled prescription container or unopened over-the-counter packaging. Students cannot carry their own medication to the health office. Please bring no more than a 30 day supply at a time. More information about medication administration is available online within the Plainview Elgin Millville School Board Policy 516 Student Medication.  

Self Administration Medication FORM: This form is for students in grades 7-12 who wish to self carry non prescription over-the-counter pain relief medication. A physician’s order is required if the medication is not given according to package label. The form must be signed by a parent and the student, and is filed in the health office. 

Student Health Survey FORM: The form should be completed for all students in grades Kindergarten, 2nd, 4th, 6th, 8th, 10th, and returned to the Nurse's Office. If there are no changes please indicate this on the form. If you do not receive a form and your child has health changes please complete a form and return it to the Health Office. The form is also needed for any new student to the district or for students who are being evaluated for special needs or a 504 plans. 

PAPER COPY to print and fill out for the STUDENT HEALTH SURVERY

Asthma Action Plan (AAP) FORM: Asthma Action Plans need to be completed for all students with asthma. This form gives authorization for asthma medications to be given at school. Asthma Action Plans can be requested from your Health Care Provider. It is electronically signed by a physician and is valid for one year from the signature date.

Diabetes Medical Management Plan (DMMP) FORM: This form should be completed for a student with diabetes. An authorization for Medication Administration form or a written order signed by a physician for medications (e.g. insulin, glucagon) is also required. Parents are responsible for bringing all diabetic supplies (e.g. test strips, meter, insulin, needles, syringes, glucagon, snacks, glucose tabs, ketone strips) to the health office prior to the beginning of the school year.

Food Allergy Anaphylaxis Care Plan FORM: This form provides all staff with guidelines to manage a student’s food allergy/intolerance (e.g. nursing, classroom teachers, dietary, special areas) **Below you can find a Special Diet form.

Anaphylaxis Emergency Care Plan FORM: This form gives the school authorization to administer epinephrine (e.g. EpiPen, Auvi-Q) to a child during an anaphylactic reaction (life-threatening allergic reaction) during the school day. A doctor’s order and signature is required.

Seizure Emergency Care Plan FORM: This form should be completed for students with a seizure disorder.