School District Forms
Anaheim City School District Forms ACSD State Preschool Physical Exam ACSD State Preschool Physical Exam-Head Start Authorization for Use and Disclosure of Health Information Emergency Medication Self-Administration Action Plan Fifth Disease Exposure Notice Hearing Referral (English and Spanish) Head Start in ACSD pamphlet OCDE Medication Request-English OCDE Medication Request-Spanish Report of Vision Screening Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: www.acsd.k12.ca.us January, 2006.
Capistrano Unified School District Allergy Action Plan Food Allergy Action Plan Health Exam For School Entry English/Spanish Management of Diabetes Oral Health Assessment Parent Guardian and Authorized Health Care Provider Request for Medication English Parent Guardian and Authorized Health Care Provider Request for Medication Spanish Physican Seizure Update Physician AND Dentist report English/Spanish Physician Clearance to Return to School School Readiness Health Screening Results English/Spanish Seizure Action Plan Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: http://capousd.ca.schoolloop.com. June, 2010
Centralia School District Forms CESD State Preschool Programs brochure-English CESD State Preschool Programs brochure-Spanish Danbrook Neighborhood Resource Center Clinic-English Danbrook Neighborhood Resource Center Clinic-Spanish HIPAA Privacy Authorization for Realease of Information-English HIPAA Privacy Authorization for Realease of Information-Spanish OCDE Medication Request-English OCDE Medication Request-Spanish New Student Registration Information-English New Student Registration Information-Spanish Physician's Order for treatment-Asthma Emergency Protocol Physician's Report-Child Care Centers Health Evaluation Physician's Report Project Bright Start Brochure-English Project Bright Start Brochure-Spanish Project E I E I O brochure-English Project E I E I O brochure-Spanish Referral for Asthma Evaluation Report of Health Appraisal-Hearing (English & Spanish) Report of Medical Referral Report of Vision Screening-English Report of Vision Screening-Spanish Seizure Disorder Update (Parents and Physicians) State Preschool Programs Registration the School-Based Health Care Center brochure Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: www.cesd.k12.ca.us . March, 2006.
Garden Grove Unified School District Authorization for Release of Confidential Information Inter-Agency Referral Report of Hearing Screening Report of Vision Screening Home/Hospital Teaching Physician Statement Home/Hospital Teaching Medical Release to Return to School Notification for Administration of Medication-English Notification for Administration of Medication-Spanish Notification for Administration of Medication-Vietnamese Parent & Authorized Health Care Provider Request for Treatment Request for Nebulizer Treatment Request for Oral & Gastrostomy Feeding Request for Modification of PE Program Preschool Registration Flyer--Eng, Span, & Viet Physician's Report--for Preschools Child's Preadmission Health History--for Preschools Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: http://www.ggusd.k12.ca.us/ January, 2009.
Huntington Beach City School District Forms Authorization for Use or Disclosure of Health Information to and from School Districts Emergency Medication Self-Administration Action Plan First Aid Follow-Up Instructions Hearing Referral (English and Spanish) OCDE Medication Request - English OCDE Medication Request - Spanish Physician's Report-Child Care Centers Health Evaluation Report of Health Examination for School Entry - English and Spanish Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: www.hbcsd.k12.ca.us. August, 2006.
Irvine Unified School District Forms Report of Health Examination for School Entry Medication Administration Request Side 1 and 2 Physician Release to Return to School Oral Health Assessment Form PADRE Diabetes Management Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: http://iusd.k12.ca.us/. January, 2010.
La Habra City School District School Forms Asthma Action Plan Request for Medication, English Request for Medication, Spanish Request for Medication, Vietnamese Report of Health Examination for School Entry Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: www.lhcsd.k12.ca.us . June, 2007
Magnolia School District Forms Administration of Medication-Spanish Administration of Medication BMI English & Spanish Dental History - Spanish Dental History Diabetes Parent-Physician Disaster Medication Spanish Disaster Medication First Aid Notification-Spanish First Aid Notification Food Allergy-Chronic Disease Health History- Spanish Health History Immunization Exclusion-Spanish Immunization Exclusion Immunizations Needed Spanish Immunizations Needed Medical Condition Spanish Medication For Chronic Conditions- Spanish Oral-Gastrostomy Feeding Physician Order for treatment Preschool BMI Parent Letter English & Spanish Preschool OAE referral letter Preschool Parents as Teachers Enrollment Preschool Pre-admission health history Parent Report (Span) Preschool Pre-admission health history Parent Report Preschool Registration flyer Reauthorization Special Care Release-Exchange of Information Special Procedures Spanish Special Procedures Vision-Hearing-Dental Parent Referral-Spanish Vision-Hearing-Dental Parent Referral Vision-Hearing-Dental Physician Referral Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: http://www.msd.k12.ca.us/ . June, 2009 Newport-Mesa Unified School District Forms Asthma Action Plan-Peak Flow Monitoring Authorization for Use or Disclosure of Medical or Educational Information-English Authorization for Use or Disclosure of Medical or Educational Information-Spanish Handout for Hope Healthy Start Program Medical Referral for Emergency Care or Routine Evaluation-English Medical Referral for Emergency Care or Routine Evaluation-Spanish Message From Your School Nurse-English Message From Your School Nurse-Spanish Management of Diabetes at School OCDE Medication Request-English OCDE Medication Request-Spanish Physician's Report-Child Care Centers Health Evaluation Preschool Student Registration Information-English Preschool Student Registration Information-Spanish Report of Health Examination for School Entry-English & Spanish Student Registration Information-English Student Registration Information-Spanish Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: www.nmusd.k12.ca.us. September, 2005.
Ocean View School District forms for Physician's office Authorization for use and/or disclosure of medical and/or educational information (english) Consent to exchange information and release of records (Eng/Span) Physician's report (Child's pre-admissions health evaluation) Medical referral-Physician's report Hearing examination report (Eng/Span) Vision examination report (Eng/Span) Immunizations report (Eng/Span) Oak View inter-agency collaberative referral form Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: www.ovsd.k12.ca.us. January, 2007
Orange Children and Parents Together (Head Start-Orange) OCTP Dental Form 2007 OCTP Flyer OCTP Health Referral OCTP Inadequate Immunization: English OCTP Physical Exam Form OCTP Physician's Request for Administration of Medication OCTP Vision and Hearing Screening Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: www.ocpt.org. February, 2007
Orange Unified School District Forms Management of Diabetes Authorization Parent and Physician Request for Medication- Spanish Parent and Physician Request for Medication- English Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: www.orangeusd.k12.ca.us/. February, 2007
Placentia-Yorba Linda Unified School District Forms Allergy Action plan-Peak Flow Monitoring Doctor's Form-Release For School Activities OCDE Medication Request Form-English OCDE Medication Request Form-Spanish Physician's Order for Tracheostomy Suctioning at School Report of Health Examination for School Activities- English/Spanish Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: www.pylusd.k12.ca.us. September, 2006
Saddleback Valley Unified School District Forms Administration & Request of Medicine at School - English Administration & Request of Medicine at School - Spanish Health Screening - Vision, Hearing, Dental and BMI - English Health Screening - Vision, Hearing, Dental and BMI - Spanish Oral Health Assessment - English Oral Health Assessment - Spanish Report of Health Examination for School Entry - English & Spanish Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: http://www.svusd.k12.ca.us May, 2010.
Santa Ana Unified School District Forms Request for Medication, English Request for Medication, Spanish Request for Medication, Vietnamese Authorization for Release of Medical Information and Records Individual Healthcare Service Plan-Anaphylaxis Individual Healthcare Service Plan-Convulsive Disorder Individual Healthcare Service Plan-Genera Individual Healthcare Service Plan-Shunt Failure Asthma Action Plan Report of Medical Referral Special Medical Request Report of Vision Appraisal, English Report of Vision Appraisal, Spanish Request for Assessment / Services, English Request for Assessment / Services, Spanish Report of Health Examination for School Entry, English and Spanish Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: www.sausd.k12.ca.us September, 2007.
Savanna School District Forms Consent to exchange info (Span Consent to exchange info Health Exam School Entry Health Exam waiver Hearing Referral Letter English Hearing Referral Letter Spanish Meal Restriction Form Medical Referral form Medication Request Spanish Medication Request Vietnamese Medication Request Oral Health Assessment Spanish Oral Health Assessment Vietnamese Oral Health Assessment Outdoor Science Medication Request (Span) Outdoor Science Medication Request Outdoor Science Release - Student with Special Need PE Activity Permisssion SELPA PE Restrictions Form Request to Carry Inhaler SRN Release of Info Vision Referral Letter English Vision Referral Letter Spanish Disclaimer: This list of forms is not inclusive. Other forms may be available through the school district website: http://www.savsd.k12.ca.us/ June, 2009.
