School Health Sample Forms

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In alignment with supporting a culture of innovation and continuous improvement, the following tools have been created for and may be used by school nurses. These culturally responsive, readily available translated forms provide equity through language access.

Sample Forms & Templates for the Health Office

Form Last Updated
List of Trained Unlicensed Assistive Personnel 08/22/2024
Maine School Health Advisor Role Template 06/06/2024
Medication Administration Procedure for Field Trip 08/22/2024
Medication Error Reporting Form 08/22/2024
Medication Training Competency Checklist 08/22/2024
Medication Training for Field Trip Checklist 08/22/2024
Reading a Medication Label 7/29/2024
Refrigeration Temperature Log 08/22/2024
Sample Medication Administration Procedure 08/22/2024

 

Sample Forms for Families

 
Language Welcome Letter Annual Health Form Asthma Interview Seizure Interview Diabetes Interview Medication Authorization Immunization Requirements  Vaccine Consent Form
Arabic مكتب الصحة المدرسية الخاص بك يرحب بك!  النموذج الطبي السنوي المقابلة الشخصية للربو لمقابلة الشخصية للنوبات المقابلة الشخصية لمرض السكري التصريح بالدواء متطلبات التلقيح المدرسي في ماين نموذج فحص صحة لقاح األوالد والموافقة
Chinese 学校卫生办公室欢迎您！ 年度医疗表 哮喘问诊 癫痫发作问诊 糖尿病问诊 用药授权 缅因州学校免疫接种要求 儿童疫苗接种健康筛查及同意书
English Welcome Letter Annual Health Form Asthma Interview Seizure Interview Diabetes Interview Medication Authorization Immunization Requirements Child Vaccine Health Screen & Consent Form
French Lettre de Bienvenue Formulaire Médical Annuel Entretien sur l’asthme Entretien sur les crises d’épilepsie Entretien sur le diabète Autorisation de Prise de Médicaments Exigences de vaccinations Questionnaire et consentement pour Les Vaccinations de L'Enfant
Khmer             ភាពតម្េូវកនុងការចាក់ថ្ន ាំបង្កា រមោគច្ាំម ោះសិសសមៅសាលាមរៀនរដ្ាមេន ការពិនិត្យសុខភាពននការចាក់ថ្ន ាំបង្កា រជាំងកឺ ុមារ និងបបបបទផ្តល់ការយល់ព្ពម
Kinyarwanda Ibaruwa ikaze Ifishi Y'ubuvuzi Y'umwaka Ibazwa kuri Asima Ibazwa ku Kugagara Ibazwa kuri Diyabeti Uruhushya Ku Miti 
 
  
Lingala Mokanda ya Boyambi Formule ya Monganga na Mbula Moko Formule na ntina na Asthme Mituna-lisolo na ntina na kokangama

Mituna na ntina yDiabeti

Kopesa Ndingisa ya Kosalela Nkisi    
Portuguese Carta de boas vindas Formulário Médico Anual Entrevista sobre asma Entrevista sobre convulsões Entrevista sobre diabetes Autorização para a administração de medicamentos

Requisitos de imunização

  
Russian             Требования к иммунизации в школах штата Мэн

Форма обследования здоровья ребёнка и согласия на вакцинацию
Somali Warqad soo dhawayn ah Foomka caafimaadka ee Sannadlaha ah Wareysiga Neefta Wareysiga Suuxdinta Wareysiga Sonkorokwga Ogolaanshaha Daawooyinka Shuruudaha Tallaalka ee Dugsiga

Foomka baaritaanka iyo oggolaanshaha caafimaadka tallaalka ilmaha
Spanish Carta de Beinvenida Formulario Mèdico Anual Entrevista en caso de asma

Entrevista en caso de convulsions

Entrevista en caso de diabetes Autorização para a administração de medicamentos

Requisitos de vacunación

Examen de salud y formulario de consentimiento para la vacunación del niño
Vietnamese 
Thư chào mừng
 Giấy thông tin sức khỏe hàng năm Phỏng vấn về hen suyễn Phỏng vấn về tình trạng co giật Phỏng vấn về bệnh tiểu đường Giấy cho phép cho dùng thuốc

Yêu cầu tiêm chủng

Phiếu kiểm tra sức khỏe và chấp thuận cho trẻ em chủng ngừa

Contact

Emily Poland, MPH, RN, NCSN 
School Nurse Consultant
Coordinated School Health Team Leader
Email: Emily.Poland@maine.gov