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Escambia County Public Schools

Dedicated To Excellence

Clinic Forms

DIABETES FORMS

Blood Glucose Monitoring Form

Insulin Administration Carb Counting SMR

Insulin Administration Sliding Scale or Pump SMR

MEDICATION ADMINISTRATION FORMS

Dispersion of Medication Form

Medication Book Set Up Instructions

Medication Destruction Worksheet

Medication Error Form

Medication Protocol at School Parent Responsibilities

Medication Tick Sheet

Student Medication Record (PRN)

Student Medication Record (Scheduled)

PROCEDURE FORMS

Student Procedure Record

Student Peak Flow Record

Health Procedure / Treatment at School - Parent Responsibilities

MISCELLANEOUS FORMS

AED Operational Checklist

Communicable Disease Tracking Tool (Line List)

Emergency Evacuation Health Plan

Emergency Guidelines for Schools

Float Clinic Staff Info Sheet

Head Lice Log

Health Condition Monitoring Log

Health Folder Original_4 Pages (Size 11x17)

Health Folder_2 Pages (Size 8.5x11)

Health Records Referral

Mass Screening Worksheet

Meal Modification Request Form

Medical Event Report

Refrigerator Temperature Log

School Medical Emergency Information

Vision / Hearing Screening Request

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