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Health Office

News Blast*

Contact Information

Name School Extension Email
April Forys EVW 2491 aforys@springfieldschools.com
Karen Blanchard-Salmon JC 4503 kblanchardsalmon@springfieldschools.com
Julia Buban TLS 3428 jbuban@springfieldschools.com
Dolores Luke FMG 1226 dluke@springfieldschools.com
Roxanne Graham JD 5258 rgraham@springfieldschools.com

Universal Child Health Record Form (non-athletic)

Form Description

Universal Child Health Record Form

New Jersey Administrative Code 6A:16-2.2 (2001) requires students to receive a medical examination upon school entry and recommends at least one time during each developmental stage (early childhood, pre-adolescence, adolescence). Upon enrollment into school, the school district requires parents to provide examination documentation of each student within 30 days upon initial enrollment into a New Jersey school. Students transferring into a New Jersey school from out-of-State or out-of-country may be allowed a 30-day period in order to obtain entry examination documentation.

Click here to download the Universal Child Health Record Form.

Parental Health History Form

Form Description

Health History Form

Each student is required to have a medical health history completed by a parent including allergies, past serious illnesses, injuries and operations, medications and current health problems.

Click below to download the appropriate Health History Form:
PreK - Grade 2
Grades 3 - 12

NJ State Physical Athletic Form

New Jersey Administrative Code 6A:16-2.1 states that:
Each school district shall ensure that students receive medical examinations:

  • Prior to participation on a school-sponsored interscholastic or intramural athletic team or squad for students enrolled in any of grades 6 to 12
  • The examination shall be conducted within 365 days prior to the first practice session
  • The medical examination shall include a health history questionnaire completed and signed by parent
  • The report of health findings of the medical examination for participation shall be documented on the Athletic Preparticipation Physical Form
Click here to download appropriate Physical Athletic Form.*

Medication Form

Form Description

Parental Request for Nurse to Administer Medication in School

Pupils requiring any medication at school must have a written statement from the family physician, which identifies the diagnosis, the medication, the dosage, the time(s) for administration, and, the number of days on which the medication is to be administered.  This applies to both prescription and over the counter medications.

Click here to download the Parental Request for Nurse to Administer Medication in School.

Asthma Forms

Form Description
Asthma Treatment Plan

New Jersey Administrative Code 18A:40-12.3 requires each student authorized to use asthma medication (inhaler of nebulizer treatment) shall have an Asthma Action or Treatment Plan prepared by the student's medical home and submitted to the school nurse.

Click here to download the Asthma Treatment Plan.

Self-Administration of Medication Form

New Jersey Administrative Code 18A:40-12.3 (2001) permits the self-administration of asthma medication by a student for asthma or another potentially life-threatening illness, provided that written authorization for self-administration of medication and written certification of the student's ability to self-administer from the parent is given, and written notification of the district's exemption from liability resulting from injury is given to and signed by the parents.

Click here to download the Request for Self-Administration of Medication Form.

Epinephrine Administration Forms for Life-Threatening Allergic Reactions

Form Description
Food Allergy & Anaphylaxis Emergency Care Plan

New Jersey Administrative Code 18A:40-12.3 requires each student authorized to use asthma medication (inhaler of nebulizer treatment) shall have an Asthma Action or Treatment Plan prepared by the student's medical home and submitted to the school nurse.

Click here to download the Food Allergy & Anaphylaxis Emergency Care Plan.

Parental Authorization of Emergency Administration of Epinephrine

Procedures specified in the “Protocol and Implementation for the Emergency Administration of Epinephrine by the Delegate Trained by the School Nurse” requires description of allergic reaction and treatment, as well as parental authorization for administration of medication by nurse or delegate and hold harmless documentation.

Click here to download the
Parental Authorization Emergency Administration of Epinephrine form.

Self-Administration of Medication (Epinephrine)

 

Form Description

Request for Self-Admnistration of Medication Form

New Jersey Administrative Code 18A:40-12.3 (2001) permits the self-administration of medication by a student for potentially life-threatening illness, provided that written authorization for self-administration of medication and written certification of the student's ability to self-administer from the parent is given, and written notification of the district's exemption from liability resulting from injury is given to and signed by the parents.

Click here to download the Request for Self-Admnistration of Medication.

Dental Form

Form Description

Report of Dental Examination Form

It is important for children to have periodic examinations by a dentist.  In order to document annual dental check-ups in the student health records, it is requested that family dentists complete the form reporting dental examinations each school year and submit completed forms to the school health office. 

Click here to download the Report of Dental Examination Form.

Resources*

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Contact Us
Springfield Public Schools
139 Mountain Avenue
Springfield, NJ 07081
Phone: 973-376-1025

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