Chico Unified School District

Health Services Forms

FORM	NAME
HS-3	Release and Exchange of Information
HS-3-s	Spanish Release and Exchange of Information
HS-7	Field Trip - Consent to Treat Minor
HS-7-s	Spanish Field Trip - Consent to Treat Minor
HS-7a	Field Trip - Consent to Treat Adult Volunteer
HS-9a	Registration Health Record
HS-9a-s	Spanish Registration Health Record
HS-9b	Health History
HS-9b-s	Spanish Health History
HS-9h	Oral Health Assessment Form
HS-9h-h	Hmong Oral Health Assessment Form
HS-9h-s	Spanish Oral Health Assessment Form

HS-11a	Physician's Authorization to Administer Medication
HS-11b	Parent Request to Discontinue Medication at School
HS-13	Bee Sting History
HS-13-s	Spanish Bee Sting History
HS-32	Initial Health, Development and Social History - Full
HS-33	Triennial Health, Developmental and Social History
HS-33-s	Spanish Triennial Health, Development and Social History
HS-402	Scoliosis Information Sheet
IMM-222	Parent's Guide to Immunizations Required for School Entry
PM-171A	Report of Health Examination for School Entry - English and Spanish
MNIF_2	Medically Necessary Instruction Request
	Student Athlete Physical and Code of Conduct
	California Healthy Kids Survey Parent Permission Forms Food Allergy, Insect Allergy & Anaphylaxis Emergency Care Plan

FORM	NAME
HS-301	Diabetic Individualized School Healthcare Plan (ISHP) Contact Information
HS-302a	Diabetic Individualized School Healthcare Plan (ISHP) School Nurse Assessment page 1
HS-302b	Diabetic Individualized School Healthcare Plan (ISHP) School Nurse Assessment page 2
HS-303a	Diabetic - Physician's Orders page 1
HS-303b	Diabetic - Physician's Orders page 2
HS-304	Diabetic Care Plan Summary - Non-Pump
HS-305	Diabetic Care Plan Summary - Insulin Pump
HS-306	Diabetic Individualized School Healthcare Plan (ISHP) Equipment and Supplies
HS-307	Diabetes Information Letter for Parents
HS-308ab	Diabetes Protocol
HS-313	Hyperglycemia / Hypoglycemia Symptoms Chart
HS-314a	Weight Referral 5th Grade Student Referral
HS-314b	Weight Referral Secondary Student Referral

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