Common Forms

School nursing is a specialized practice of professional nursing that advances the well-being, academic success, and life-long achievement and health of students. To that end, school nurses facilitate positive student responses to normal development; promote health and safety, including a healthy environment; intervene with actual and potential health problems; provide case management services; and actively collaborate with others to build student and family capacity for adaptation, self-management, self advocacy, and learning (NASN, 2010)

Health Assessment Record/Physical Exam (pdf)

This form (also known as the blue form) is required for:

• New students (including all Pre-K and K students)
• All 6th and 9th graders
• Interscholastic sports (every year)

Medication Authorization Form (doc)

This form is required for the administration and self-administration of medication in school.

Immunization Exemptions

Medical exemptions (pdf) This form is required when a physician verifies that a student is exempted from immunization requirements for medical reasons.

Westport Health Services Questionnaire for New Students

This is the Westport Health Services Questionnaire for new students (English version)

Cuestionario de la Salud y Desarrollo: Estudiante Nuevo (doc)

This is the Westport Health Services Questionnaire for new students (Spanish translation)

Concussion Info and Physician Care Form (doc)

This form is to be filled out by the child's physician on return to school following an assessment for concussion.
 

Food Allergy Medication Authorization

This form is required for all students who have a medical order for Epinephrine (EpiPen) in school:

Word Document to be filled out using Microsoft Word