Department of Special Education / Student Support Team Compliance / Section 504

Department of Special Education / Student Support Team Compliance / Section 504

Authorization to Release Confidential Information

DATE: ______

TO:______

Doctor’s Name

______

Address

______

City, State, Zip

______

PhoneFax

RE: ______

Last Name First Name MiddleD.O.B School Attended

In order to assist in the educational / health planning and placement of the student named above, you are hereby authorized to release the following reports/information.

_____Psycho/Educational Evaluations_____Instructional Plans

_____ Section 504 Documentation _____ Accommodations Plans

_____Speech and Language Evaluations_____ Meeting Minutes

_____Audiological Report_____Eligibility Report

_____ Pre-Referral Intervention Information_____ Vision Report

_____ Other ______Completion of APS Medical Packet

These records should be sent to:______

______

• Parent(s) / guardian(s) by signature below acknowledges that the school is providing for the administration of medication / medical procedure as a courtesy to the parent(s) / guardian(s) and agrees to hold the school and school system harmless in its so doing.
• Additionally, authorization is granted to obtain pertinent medical and/or copies of records pertaining to my child’s medication and for this information to be shared with pertinent staff as needed for the purpose of educational / health planning.
• I understand that effective April 14, 2003, under the Health Insurance Portability and Accountability Act (“HIPPA”), disclosure of certain medical information is limited. However, I herein authorize disclosure of pertinent medical information for the provision of services for my child while in attendance in the Atlanta Public Schools District. This authorization expires as of the last day of this school year, including the summer/ extended year session.

______

Parent/Guardian SignatureDate

______

Relationship to Student

______

Student’s Name (Last, First, Middle) BirthdateSex

______

Home AddressApt.CityStateZip Code

______

Parent(s)/Guardian(s) Names(s) Phone

______

School (or previous school, if not yet enrolled in APS) Grade

______

Printed Name and Signature of Referring Party Date

Diagnosis/Summary of Medical History ______

Current Medication (if any)/Notable Side Effects ______

______

Check all descriptions which may interfere with this student’s school functioning:

_____ Frequent absences Limited ability to: ______move about

_____ Lack of strength ______sit

_____ Lack of vitality ______manipulate materials

_____ Lack of alertness

Sensory impairment(s) resulting in: Skeletal deformities affecting: ______ambulation

_____ limited vision ______posture

_____ limited hearing ______body use

_____ limited vision and hearing

Additional information regarding this student’s disabling condition ______

______

Medical Exam Report – page 2 Student: ______

Description of special health care or emergency procedures, if applicable: ______

Surgical History:Type of SurgeryDateResults

______

Prognosis/Precautions: ______

Speech Therapy evaluation follow-up permissible:______yes ______no _____ N/A

Occupational Therapy evaluation follow-up permissible:______yes ______no _____ N/A

Physical Therapy evaluation follow-up permissible:______yes ______no _____ N/A

Special instructions regarding physical, occupational, and/or speech therapies: ______

If applicable, name(s) and address(es) of other physicians or medical agencies providing health care to student: ______

______

Physician’s Signature

______

Physician’s Name (Print or Type)

______

Name of Clinic/Health Facility, if applicable

______

Address

______

Date

Return to: ______

______

______

Form # 67075-1/67075-3Rev. (8/16/MRG)

Student: ______ID: ______

School: ______DOB: ______

Teacher: ______Medicaid: ______

Physician: ______Preferred Hospital: ______

Description of Student’s Current Medical Condition, including Relevant Medical History:

______

Transportation:Can the student ride the school bus?(Circle One)YESNO

If yes, please describe any special assistance (personnel, equipment) or special training needed:

______

Nursing Specific Procedures/Treatments (Note – Board Policy allows for certain procedures/ treatments to be delegated to trained unlicensed personnel. Please document if/why procedure/treatment may only be performed by RN/LPN):______

Special Diet:Does the student require a special diet? (Circle One)YESNO

If yes, please list specific parameters and/or instructions (Diet Prescription form should also be completed): ______

Assistance with Activities of Daily Living:

The student requires assistance with: (Circle all that apply)Dressing Toileting Feeding None

If assistance is required, please explain: ______

Therapy:The student requires the following type of therapy: (Circle all that apply)

PhysicalOccupationalSpeechNone

If therapy is required, please give specific orders: ______

Health Care Management Plan – page 2Student: ______

Adaptive Physical Education:

Are there physical limitations on activities? (Circle One)YES NO

If yes, please explain which activities the student may participate in and what the limitations are:

______

Teaching:

Do school personnel require special training to care for the student? (Circle One)YESNO

If yes, please explain what is needed: ______

Monitoring:

Does the student’s health status need monitoring during the school day?(Circle One) YES NO

If yes, please explain: ______

Medication:(Administration of Medication form should also be completed)

What monitoring is needed for reactions to medication, altered mood or mental status, etc.?

______

Other Treatments/Procedures (procedures that may be performed by school staff):

______

Homebound Services / Modified School Attendance Recommendations:

Is it necessary for the student to be educated in the home? (Circle One)YESNO

Is it necessary for the student to attend school on a partial day schedule? (Circle One) YES NO

If yes, please explain (Referral for Homebound Services form should also be completed; this form can be used to request intermittent services):

______

Physician’s Signature ______Date ______

If you have any questions, please call the Office of Health Services 404.802.2674

Revised 8/16/MRG

PLEASE COMPLETE A FORM FOR EACH MEDICATION / MEDICAL PROCEDURE

Reference: APS Policy JGCD - Medication

ATLANTA PUBLIC SCHOOLS

ADMINISTRATION OF MEDICATION / MEDICAL PROCEDURES

Student’s Name______Homeroom______

Birthdate______Telephone#______Emergency #______

Address______

Medication / Medical Procedure______Diagnosis______

Starting Date of Medication / Medical Procedure ____________

Physician’s requirements of dosage / method of administration:

______

(Please indicate if student is responsible for self-administration and should carry medication/medical equipment

Student is capable and recommended to possess, and self-administer this medication / medical procedure:

NO______YES-Supervised______YES-Unsupervised______

Time medication / medical procedure is to be provided daily______

Precautions, possible side effects, interventions______

Drug / Food Allergies______

Termination date for administering the medication / medical procedure______

Physician’s Name______

Physician’s Address______

Telephone No.______Fax No:______

Physician’s Signature______Date______

• Parent(s) / guardian(s) by signature below acknowledges that the school is providing for the administration of medication / medical procedure as a courtesy to the parent(s) / guardian(s) and agrees to hold the school and school system harmless in its so doing.
• Additionally, authorization is granted to obtain pertinent medical and/or copies of records pertaining to my child’s medication and for this information to be shared with pertinent staff as needed.
• I understand that effective April 14, 2003, under the Health Insurance Portability and Accountability Act (“HIPAA”), disclosure of certain medical information is limited. However, I herein authorize disclosure of pertinent medical information for the provision of services for my child while in attendance in the Atlanta Public Schools District. This authorization expires as of the last day of this school year, including the summer/ extended year session.
• *Our school nurses are governed by the Georgia Nurse Practice Act and APS Policy JGCD – Medication, and they will only administer medication in accordance with written medical orders signed by a licensed physician, dentist, or podiatrist. APS nurses will not modify any dosage of medicine based solely on a request or recommendation by a parent or guardian.A parent or guardian seeking a dosage modification must provide the nurse with an appropriate medical order.

Parent(s) / Guardian(s) Signature______Date______

Principal Signature: ______Date_________

Dist: School Clinic – Student’s Personal Folder – Parent(s) / Guardian(s) - Health ServicesForm # 67071 REV 08/10/2016

Atlanta Public Schools

School Nutrition Department

Medical Statement & Diet Prescription for Meals at Schools

This form is for students who are and are not defined as “handicapped.” A handicapped person means any person who has a physical or mental impairment, which substantially limits one or more major life activities, has record of such impairments, or is regarded as having such impairments (7 CFR Part 15b and FNS Instruction 783-2). All sections of the form will need to be completed by a licensed physician if the student is diagnosed with a “handicap” per Federal law 7 CFR Part 15b and FNS Instruction 783-2 or one of the following medical authorities: physician, &/or physician assistant, nurse practitioner, registered/licensed dietitian if the student is not “handicapped,” but is unable to consume food(s) because of medical or other special dietary needs. The first section (“Describe the student’s handicap and the major life activity(s) affected by it”) does not have to be completed by the appropriate medical authority when a student is not diagnosed “handicapped”.

inlbs

Student’s Name: ______DOB: ______Ht:______cm Wt: ______kg

School: ______Grade/Teacher: ______

Diagnosis: ______

Describe the student’s “handicap” and the major life activities affected by it: ______

Please list any dietary restrictions or special diet: ______

Please list any allergies or food intolerances to avoid. Please indicate the child’s reaction to this food. ______

Please list the food(s) that may be substituted in the diet: ______

Physician recommended diet:

_____Nothing by mouth (NPO) *Prescription provided to family for formula supplement / Formula provided for school feeds by parent. Initial:_____

_____By mouth (PO) Type Diet: Regular ( ) Chopped ( ) Pureed ( )

Liquids:Regular_____Thickened_____ / Thickened Consistency: Nectar_____Honey_____ Pudding_____

_____Formula Supplement to school meal (ORAL ONLY)

_____Formula G-Tube Feed

Name of Formula______Substitute allowed? Yes No(CIRCLE ONE)

Amount at each feeding______

Time(s) to be fed______

Amount of water______CC

Amount of water to flush______CC

Type of G-Tube Feeding: Bolus______Slow Drip______Pump______/ Pump Setting: ______

Swallow study done? Yes No (CIRCLE ONE) (If yes, please attach if available and indicate Date:______/______/______)

Other information regarding the diet: ______

______

Signature of the M.D. or Authorized Medical AuthorityAddress Telephone # Date

______Parent’s Signature (*Initial formula line above) Date Telephone #

(REVISED 08/2016)

EMERGENCY PLAN FOR STUDENT WITH SPECIAL HEALTH CARE NEEDS

EMERGENCY PLAN / Diagnosis:______

Student:Date:

Birthdate:School:

Preferred Hospital in case of an emergency:

*In case of serious illness / injury, the school will render first aid as prescribed by School Board Regulations while contacting the parent. If neither the parent nor the designee can be reached and the situation is very serious, the school shall telephone the County Medical Emergency Unit (9-1-1) for immediate transportation to the nearest emergency treatment hospital. Whenever possible, the parent’s hospital preference will be observed.

Parent Contact Info: Name ______Best Phone # ______

Healthcare Provider(s):Phone:

Phone:

What is this disease / condition / disorder?

______

If You See This / Do This
IF AN EMERGENCY OCCURS:

1. If the emergency is life-threatening, immediately call 9-1-1.
2. Stay with student or designate another adult to do so.
3. Call or designate someone to call the School Nurse and/or Principal.

/ WHEN CALLING 9-1-1:

1. State who you are.
2. State where you are (street address and exact location in the building).
3. State problem (Note: have copy of clinic card record available to send to ER).

TRAINED EMERGENCY RESPONDERS:

______

Signature of Physician or Authorized Medical Authority Date