SPS Health Services Forms

Some of these forms can be completed online, saved, and then attached to an email. Other forms must be printed then either scanned and emailed, faxed, or mailed.

Annual Student Health Information Update

• Annual Student Health Information Update (Amharic)
• Annual Student Health Information Update (English)
• Annual Student Health Information Update (Simplified Chinese)
• Annual Student Health Information Update (Somali)
• Annual Student Health Information Update (Spanish)
• Annual Student Health Information Update (Tagalog)
• Annual Student Health Information Update (Vietnamese)

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Authorization for Medications Taken at School

State and federal law requires that a form must be completed and signed by both parent/guardian and a licensed health care provider with prescriptive authority for ALL medications to be given at school, including over-the-counter (OTC) medications.
Medication must be labeled properly and in its original pharmacy container.
This form needs to be renewed at the beginning of each school year.

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Authorization for Treatments and Procedures Performed at School

Gives permission for an authorized person to assist a student by performing a specific treatment or procedure.

• Authorization for Treatments and Procedures Performed at School (Amharic)
• Authorization for Treatments and Procedures Performed at School (English)
• Authorization for Treatments and Procedures Performed at School (Oromo)
• Authorization for Treatments and Procedures Performed at School (Simplified Chinese)
• Authorization for Treatments and Procedures Performed at School (Spanish)
• Authorization for Treatments and Procedures Performed at School (Tagalog)
• Authorization for Treatments and Procedures Performed at School (Tigrigna)
• Authorization for Treatments and Procedures Performed at School (Vietnamese)

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Diet Prescription for Meals at School

Please contact your school nurse if your student has a food allergy or medical condition that requires food accommodations at school. School nurse will provide you with a prescription dietary form. Once signed and completed by parent/guardian and healthcare provider, return form to school nurse. School nurse will then provide the completed dietary prescription form to Culinary Services to process.

The form must be completed by a Licensed Physician when identifying a disability, or a Recognized Medical Authority (RMA) when identifying a non-disabling medical condition. For Diet Prescription purposes, a RMA includes a Licensed Physician, Doctor of Osteopathy, Licensed Physician’s Assistant, ARNP or Licensed Naturopathic Physician.

Extraordinary Nursing Support

• Healthcare Provider Cover Letter & Request Form
• Parent/Guardian Request for Extraordinary Nursing Services

Field Trip/Outdoor Education Information and Release

Field trips are an educationally sound and important component in the instructional and/or athletic programs of schools.

Your student’s teacher and school nurse will partner and communicate with you about required authorization and health forms.

Home/Hospital Instruction

• Home/Hospital Instruction – is a state (OSPI) program that provides funding for schools to provide limited scholastic support to students with a health issue. To qualify, students must be expected to miss at least four (4) weeks of school, but no more than eighteen (18) weeks. In case of chronic illness, the services can be intermittent (Please indicate this on the application form). The form must be signed by the parent/guardian and the health care provider.
• Pregnancy and Postpartum – the “usual and customary” weeks of postpartum service are six (6) for a routine vaginal delivery and eight (8) for a c-section. Please do not exceed those numbers without indicating a reason the student is unable to attend classes because of her own medical needs.
• Please note that Health Services merely verifies the student’s eligibility for services and serves as a pass through for funding from OSPI.  The school is responsible for finding a tutor and setting up the educational plan.
• There are strict requirements for reimbursement from OSPI for this funding so if/when the request is approved, please read the instructions carefully as  we cannot fund services until H/H is approved.  Buildings will be responsible for any expenses incurred beyond the limits of the program.
• Special Education Students – IMPORTANT: If a student cannot attend school because of a need related to his/her qualifying special education condition, do not submit a Home/Hospital application until after contacting the school’s Section 504 coordinator and the IEP responsible staff for that student.  Special Education manages funding for IDEA students who require Home Hospital support.
• Guidelines
• Home/Hospital Application (English)
• Home/Hospital Application (Spanish)
• Instruction Sheet

Immunizations

• Certificate of Immunization Status
• Certificate of Exemption

Release of Health Care Records (Mutual Exchange)

Gives Seattle Public Schools and a health care provider, hospital, or clinic permission to exchange information about a student.

*UW/Harborview requires authorizations in English

• Release of Health Care Records (Amharic)
• Release of Health Care Records (English)
• Release of Health Care Records (Simplified Chinese)
• Release of Health Care Records (Somali)
• Release of Health Care Records (Spanish)
• Release of Health Care Records (Vietnamese)
• Seattle Children’s Health Information Exchange (English and Spanish)

Sexual Health Education

• OSPI’s website for HIV and Sexual Health Education
• Sexual Health Education Student Waiver

Transportation for Medical Reasons

For students who are within the walk zone but who have a medical condition that makes transportation necessary.  May be for short-term or long-term conditions.

Application must be renewed annually.

Cannot be used to serve special education students for conditions related to their qualifying condition.  Contact Special Education in those cases.

• Medical Transportation Application