District Nurse: High School
Melissa Jenson, RN
218-335-2203 ext. 1310
Roberta Williams, RN
218-335-2203 ext. 1309
Rhonda Reimer, LPN
218-335-2201 ext. 5111
218-335-2201 ext. 5519
218-335-2203 ext. 1905
STUDENT ACCIDENT/INCIDENT REPORT FORM
KINSA'S FLUency SCHOOL HEALTH PROGRAM
ANNUAL HEALTH INFORMATION FORM
NON-PRESCRIPTION MED AUTHORIZATION FORM
PRESCRIPTION MED AUTHORIZATION FORM
More information about these forms and the Health Services is found below.
Annual Health Information
This form has been developed by the health service team to help ensure that health information is complete and remains confidential. As a parent/guardian you may choose to share as much or as little information as you want. When we are aware of health issues we are better prepared to respond to the health needs. Every student needs to have this form completed and returned to school prior to the first day. Please contact the health office if your child’s health needs change through the year.
Whenever possible, medication should be given before or after school. When medication is needed in school, a physician order is required before the medication can be administered. The medication is to be transported to and from school by a parent /guardian.
Authorization for Medication Administration: This form needs to be completed by the medical provider ordering the medication and a parent/guardian for a prescription medication and completed by the parent/guardian for a non-prescription medication. Prescription medications must be supplied in the original pharmacy labeled bottle. Non-prescription medication will only be given when supplied in the original bottle. Epi-pens and inhalers require a label on the device, not just the box it comes in. (Upon request, the pharmacist will provide two labeled bottles).
Authorization for Administration of Non-Prescription Medications Furnished by the Elementary School: This form needs to be completed by parent/guardian when a student is requiring administration of acetaminophen furnished by school district and is only furnished for students in grades K-4th grade. Administration of this medication will be given to student in accordance with the label directions as directed on the form.
Student Self-carry and Self-administration: This is a request for a student to carry a prescription medication or non-prescription medication needing to be taken during school hours. A physician and parent/guardian signature is required for prescription medication and parent/guardian signature is required for non-prescription medication. The student will need to meet with the LPN/LSN. This request will be considered on a case by case situation. (This is often requested for inhalers, Epi-pens, glucose monitoring and insulin).
Medication disposal: All medications will be disposed of after the expiration date and/or if not picked up on the last day of school. Parents/Guardians are responsible for supplying new and current medication/equipment and picking up medication/equipment on or before the last day of school.
Minnesota Statutes Section 121A.15 requires children enrolled in a Minnesota school to be immunized against certain diseases, allowing for specified exemptions. See the MDH Student Immunization Record form (http://www.health.state.mn.us/) for a list of required immunizations and specific information about exemptions.
Health Screening Information
Hearing and vision screening is done at school for students in grades 1, 3, 5, 8, & 10, new students and per parent or teacher request. Color vision screening will be completed for boys in 1st grade. Scoliosis screening is completed for girls in 6th grade. The health office will notify parent/guardian if a student does not pass a screening.
It is important for the school to know of any health conditions that may affect your child while in school. Forms to provide information to the health office are available in your school's health services office.
Please notify the health office if your child has any of the following or other health conditions:
Allergies (food, bee stings, etc.) - Cass Lake-Bena Schools follows the regulations in the National School Lunch Program Act for accommodating special diets. If your child needs special diet accommodations due to food intolerances or food allergies, the “Special Diet Statement” needs to be completed by a physician before accommodations are made. This form does not need to be completed on a yearly basis, but must reflect the child’s current needs.
Authorization for Administration of Non-Prescription Medications Furnished by the School District - The Parent/Guardian must complete and sign this form in order to Acetaminophen (Tylenol) or Tums may be given.
Parental Authorization for Administration of Prescription Medication at School - Parents/Guardians must complete and sign this form requesting students be administered prescription medication by the School Nurse or designee during school hours or requesting students be permitted to self-administer prescription medications during school hours.
Special Diet Statement for a participant without a Disability
Health and Safety School Announcement: