Healthcare IEP Pages

HEALTHCARE IEP PAGES

Student / Patient Information

Student Name:    DOB:    Gender:

Relationship:    Phone:

Insurance / Medical Coverage

Medical History & Clinical Information

It is the responsibility of the parent/guardian to provide accurate medical history and to notify the school of changes in health status, medications, or treatment. Health information provided below will be included in the student's IEP health appendix and shared with school personnel as required for safe provision of services.

Immunizations up to date: Yes    No    If no, explain:

Health Services / Nursing Supports Requested

The following health services are requested to be provided at school as part of the student's IEP. Check all that apply.

Medication administration as ordered by provider
Diabetes care (blood glucose monitoring, insulin administration)
Seizure management and rescue medication
Tube feeding / enteral care
Respiratory support (oxygen, suctioning, trach care)
Catheterization / toileting supports
Mobility assistance / transfers
Behavioral/mental health nursing consultation
Other:

Medication Administration Details

Medication 1 — Name:    Dosage:    Route:    Schedule:

Medication 2 — Name:    Dosage:    Route:    Schedule:

Medication 3 — Name:    Dosage:    Route:    Schedule:

Emergency Action Plan / Monitoring

Provider Responsibilities & Training

The district/school will arrange for appropriately trained personnel to perform the tasks listed above in accordance with medical orders. Where nursing staff are not available, designated, trained school personnel may perform delegated tasks under a written nursing delegation plan.

Consent, Release & Authorization

I acknowledge that I have provided complete and accurate health information to the best of my knowledge. I authorize school health personnel to provide and coordinate the health services documented in this IEP appendix, including administration of medications and emergency interventions in accordance with the student's health care provider orders. I understand that failure to provide accurate medical information may affect my child's safety.

I authorize the release of relevant medical information to members of the IEP team and authorized school personnel for the purpose of implementing health supports described herein. I understand that I may revoke this authorization at any time by submitting written notice to the school, except to the extent that action has already been taken in reliance on this authorization. This authorization will expire on:

By checking this box I authorize exchange of medical information as described above.

I decline the health services listed on these IEP pages. I understand that declining services may affect the student's ability to participate safely in school activities.

Acknowledgment & Certification

By signing below I certify that I am the parent/legal guardian or eligible student authorized to make health care decisions for the student named above. I have read and understand the information contained in these Healthcare IEP Pages. I understand my rights regarding authorization and revocation described above and consent to the provision of the specified health services in the school setting as indicated.

Sign Now