Health Forms

Please print forms, complete and return to your child's School Nurse.   If you have any questions, please call the School Health Office or the City School District's Health Services Department at 914.576.4264

Health Appraisal Form 

Allergy Action Plan 

Diabetes Management Plan 

Seizure Medical Management Plan

Report of Private Exam - Physical  

This form is to be completed by your Doctor or Nurse Practioner when your child goes for a check-up. Click here for H-1 Health Appraisal Form

Dental Health Form  Click here for Dental Health Form
This form is to be completed by your dentist.  We suggest children go for dental exams once a year.

Adaptive Physical Education Recommendations

If a child is to miss gym for longer than one month due to a temporary physical condition, such as a broken bone, then a physician must complete this form. This form is also submitted when a child needs an adaptive physical education program due to a medical, emotional, or learning factor such as a heart defect. Please call your child's School Health Office for more information.

PE-8 ES Click here for Elementary School
PE-8 MS Click here for Middle School
PE-8 HS  Click here for High School

Administration of Medication in School Click here for form

Every effort should be made to administer medications outside of the school setting.  However, School Nurses may administer medications which will allow the student to maintain an optimal state of health, remain in school, and participate in his or her complete educational program.

   The New York State Education Department (NYSED) and the City School District require the following for School Nurses to administer medications in school:

1)  A written statement from the parent or guardian requesting administration of medication in school as ordered by a licensed physician.

2)  A written order from a licensed physician for both prescription and non-prescription medications to be given in school.

3)  The parent or guardian must assume responsibility to have the medication delivered directly to the Health Office in a properly labeled original container.  For “over-the-counter” (non-prescription) medications, the original store container must be labeled with the student’s name and must have an expiration date on the manufacturer’s label.

   Please note, request for administration of both OTC and prescribed medicines in school can also be done via the physical exam form (H-1 Health Appraisal - Please see the back of form.  Parent and physician signatures required)