Delaware School Nurse Manual Forms
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- Accident Report Form
- Annual Summary of School Health Services
- Asthma Action Plan
- Delaware Emergency Treatment Card - PDF
- Delaware Emergency Treatment Card - Word
- Delaware Student Health Form – Adolescent, Grades 7 – 12
- Delaware Student Health Form – Children, PreK-Grade 6
- Emergency Action Plan - PDF
- Emergency Action Plan - Word
- Food Allergy Letter - PDF
- Food Allergy Letter - Word
- Food Allergy Prevention & Emergency Response for Students with Allergies
- Health Education Lesson Plan, Grades 3-5 Template - PDF
- Health Education Lesson Plan, Grades 3-5 Template - Word
- Health Education Lesson Plan, Grades 6-8 Template - PDF
- Health Education Lesson Plan, Grades 6-8 Template - Word
- Health Education Lesson Plan, Grades 9-12 Template - PDF
- Health Education Lesson Plan, Grades 9-12 Template - Word
- Health Education Lesson Plan, K-Grade 2 Template - PDF
- Health Education Lesson Plan, K-Grade 2 Template - Word
- Health Examination Letter for Parents and Providers
- Hearing Referral Letter - PDF
- Hearing Referral Letter - Word
- Immunization - Notarized Affidavit of Religious Belief
- Immunization - School Entry Letter - PDF
- Immunization - School Entry Letter - Word
- Immunization - School Vaccination Medical Exemption Form
- Immunization - Supplemental School Vaccine Exemption Form
- Individualized Healthcare Plan
- Individualized Healthcare Plan - PDF
- Individualized Healthcare Plan - Word
- Information for Substitute School Nurse - PDF
- Information for Substitute School Nurse - Word
- Interagency Consent to Release Information - PDF
- Interagency Consent to Release Information - Word
- Lead - Affidavit of Religious Belief - PDF
- Lead - Affidavit of Religious Belief - Word
- Medical Referral Form - PDF
- Medical Referral Form - Word
- Medication - Field Trip Record - PDF
- Medication - Field Trip Record - Word
- Medication - Medical Treatment Error Report
- Medication - Parental Permission for Assistance on Field Trip - PDF
- Medication - Parental Permission for Assistance on Field Trip - Word
- Medication - Parental Permission to Administer in School - PDF
- Medication - Parental Permission to Administer in School - Word
- Medication - Self Administration of Asthma Inhaler Student Agreement - PDF
- Medication - Self Administration of Asthma Inhaler Student Agreement - Word
- Medication - Self Administration of Emergency Medication Student Agreement - PDF
- Medication - Self Administration of Emergency Medication Student Agreement - Word
- Office Visit Log - PDF
- Office Visit Log - Word
- PE Temporary Medical Excuse
- Postural Gait Screening Letter - Follow up Phase II Referral - PDF
- Postural Gait Screening Letter - Follow up Phase II Referral - Word
- Postural Gait Screening Letter - Reporting Phase I Findings - PDF
- Postural Gait Screening Letter - Reporting Phase I Findings - Word
- Postural Gait Screening Referral Form
- Puncture Incident in School Setting
- Puncture Wound Letter to Parents - PDF
- Puncture Wound Letter to Parents - Word
- Referral to the School Nurse - PDF
- Referral to the School Nurse - Word
- Screening - Pre-screening Letter - PDF
- Screening - Pre-screening Letter - Word
- Seizure Action Plan
- Seizure Report
- Student Health History Update
- Suggested Schedule for the School Nurse - PDF
- Suggested Schedule for the School Nurse - Word
- Summary of School Health Services
- Treatment Parent Request for Specialized Nursing Care - PDF
- Treatment Parent Request for Specialized Nursing Care - Word
- Treatment Provider Approval of Procedure - PDF
- Treatment Provider Approval of Procedure - Word
- Tuberculosis - Questionnaire School Employee
- Tuberculosis - Questionnaire Student
- Tuberculosis - Questionnaire Symptom Screening Student
- Tuberculosis - Questionnaire Volunteer
- Varicella Immunity Statement
- Vision - Parent Teacher Checklist - PDF
- Vision - Parent Teacher Checklist - Word
- Vision Referral Letter - PDF
- Vision Referral Letter - Word
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Contact Information:
School Health Services Program OfficeDelaware Department of Education35 Commerce Way, Suite 1Dover, DE 19901Phone: 302-857-3356Fax: 302-739-6397Email:
Last Modified on August 5, 2020
