This pleat is for Referral for Assessment

REFERRAL FOR ASSESSMENT OF SPECIAL HEALTH CARE SERVICES

(the following are all yes/no questions)

Note: If any indicators of significance have been selected as yes, the student will be referred to the school nurse for further evaluation.

Please complete the following by selecting yes or no at each item that may apply to your child.

Does your child have a history of significant medical problems?

Has a birth defect or developmental disability. (Ex: Spina Bifida, Intellectual Disability, Down Syndrome)

Takes medication(s) which may need monitoring or administration at school. (Ex: topical, injectable, oral, inhaled, or rectal medication)

Has been or presently is under the care of a doctor for a significant medical condition. (Ex: seizure condition, diabetes, uses oxygen, gastrointestinal tube, tracheostomy, acute allergic reaction)

Has a significant physical impairment. (Ex: uses orthopedic devices or a wheelchair; has impaired vision or hearing)

Requires special health care procedures to be performed at school. (Ex: intermittent catheterization, suctioning, tube feeding, percussion)

Requires special medical equipment or appliances at school. (Ex: oxygen tank, feeding tubes, suctioning machine, slow volume nebulizer [svn] machine)

Has a significant history of medical problem(s) which could affect his/her health status at school.

Has a behavioral concern that may impact school performance.

List any concerns about your child's health status. -open text box

Parent/Guardian Initials:*

Date:*

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