Louisiana Department of Health & Hospitals | Bruce Greenstein, Secretary

Final School Health Forms

The School Health Form Advisory Board was established by Act 685 (R.S.40:5.12) in the 2004 Regular Legislative Session to develop standardized school health forms. The goal of the forms is to eliminate the duplication of information submitted to schools and school nurses relative to health information and screenings, allergies, illnesses, sports physicals, medication administration, and prescribed procedures.

The Department of Education, in collaboration with the Department of Health and Hospitals, jointly promulgated rules and regulations for the use and distribution of the standardized school health forms. (See Bulletin 741, the Louisiana Handbook for School Administrators, also known as Title 28 of the Louisiana Administrative Code.) Effective August 2007, R.S. 40:5.12. requires all local educational agencies to implement the use of the standardized school health forms.

Five forms have been developed. The most current versions of the school health forms (below) replace all other forms used to obtain health information, including previously piloted versions of these forms. These forms shall not be changed or altered in any manner.

1. School Entrance & General Health Exam Form/Sports Physical Form - This form can be used for sports physicals* and/or other health evaluations provided to school nurses and school systems. This form includes detailed instructions for the medical provider, including a list of suggested screens to be done if medically indicated based on history or clinical findings. This form can also be used to meet the requirements of the KIDMED periodic and interperiodic assessments if the required reproductive health information is included.
2. Physician's Authorization for Special Health Care - For any procedure orders, i.e., blood glucose monitoring, catheterization, etc., prescribed by a licensed provider that a student must receive during the school day.
3. Medication Order For Louisiana Public Schools - For medication orders prescribed by a licensed provider that a student must receive during the school day.
4. Health Information Form - For pertinent health and emergency contact information provided by parents/legal guardians to the school district.
5. Authorization for Release of Confidential Information - Required to be signed by parent/legal guardian before health information can be shared between the school system and health care providers, i.e., hospital, physician, service agency, school RN, and/or other health provider.

Questions or comments may be directed to Maureen Daly, MD, MPH, Office of Public Health, Christine.Armand@la.gov. To download copies of the school health forms please click on the desired form above.

*This form or the Louisiana High School Athletic Association (LHSAA) form is acceptable by the LHSAA for sports physicals.