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Health Office

Last Updated: 11/16/2021 7:46 PM

 

Contact Information, Main Number: 973-376-1025

 Name                                         School    Extension    Email

 EVW

 EVW  2491  ewnurse@springfieldschools.com

 Karen Blanchard-Salmon

 JC  4503  kblanchardsalmon@springfieldschools.com 

 Patricia Mader-Karan

 TLS  3428  pmaderkaran@springfieldschools.com

 Renee Mowczan

 FMG  1226  rmowczan@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

 

  Immunization Requirements

 Form  Description

 K-12 Immunization

State of NJ Immunization Requirements for Public Schools
 

Click here to download the K-12 Immunization Requirement Form
Summary of NJ Childcare Pre-School Immunization Requirement 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 a 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 the 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 or 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 or 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” require a 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-
 Administration of
 Medication Form

New Jersey Administrative Code 18A:40-12.3 (2001) permits the self-administration of medication by a student for a 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

 

  Seizure Management Form

 Form  Description

 

These forms provide critical information for all students with seizures
Questionnaire for Parents of a Student with Seizures
Seizure Action Plan (SAP) Form for Students With Seizure Disorders

 

  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*

*Disclaimer - Links to Other Sites: You are about to leave the Springfield Public School website. You are subject to that site's privacy policy when you click the link below. Reference in this website to any specific commercial products, process, service, manufacturer, or company does not constitute its endorsement or recommendation by the Springfield Board of Education. The Springfield Board of Education is not responsible for the contents of any "off-site" web page referenced from this website.

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

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