Nurses’ Packet School Year 2018-2019

Contact Tracie or Cate at the Front Desk – 978 927 7070 x 200

Nurses' Packet - Current Students
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Emergency treatment and transport:

Please individually list all medication allergies and reactions first; followed by any food, insects and or seasonal allergies.


If yes, your child needs an order from his/her doctor and a pharmacy labeled epinephrine auto injector sent into school.

Seizure Activity:

Medications to be given at School:

I give permission for the School Nurse to administer the following standard, over the counter medications.

Please individually list all scheduled, and as needed medications to be given at school. (e.g. Prescription medications, inhalers, epinephrine, seasonal allergy medication, and over the counter medications not listed above.)

Omeprazole (example only)
20mg (example only)
10:00 am, as needed every 4 hours (example only)
By mouth (oral), g-tube, inhalations (example only)
Cold symptoms, stuffy nose, stomach pain. (example only)
*All medication, including over the counter medication, not previously listed, must have a Doctor’s order with clearly written instructions. These include: Medication name, dosage, when to be given, how to be given, and any potential side effects. For scheduled medications, a specific time must be on the order as well. Prescription medication must arrive at school in a pharmacy labeled container; over the counter medication must be sent to school in the original, unopened container. If we do not receive a complete order, we will not be able to administer the medication.
Medication given at Home:

Please individually list all medication given at home.

Omeprazole (example only)
20mg (example only)
7am, 6pm (example only)
By mouth (oral) (example only)
Cold symptoms, stuffy nose, stomach pain. (example only)

My child sees the following providers: (please include your pediatrician, specialists, outside SLP, PT,OT, Feeding Therapist, Care Coordinator, Mental Health provider, and Home Service providers.)


Annual screenings

My child may participate in the following state mandated screenings: I understand that these are only screenings and any abnormal findings will be referred back to me for follow up with my child’s Primary Care Provider.
I also understand hearing screenings are not performed at CCCBSD and should be done at my child’s primary care physician, specialist’s office or our home school district. Once my child has the hearing screening, I will forward the results to the School Nurse. Hearing screenings are needed for Kindergarten Grades 1st -3rd , 7th and 10th.
Please check all that apply
Grades 1, 4, 7, and 10 only
Open to all students
Grades 5-9 only

Please share with us who is living at home with your son/daughter (for example: mother, father, brother, grandparent, aunt or uncle. Please give the ages of Siblings only.)

Does your child have:

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Thank you for sharing your child’s information. The more information you provide us, the better we can understand your child’s individual medical needs.
If you have any questions please contact Carol Sheehan, R.N. via email: or Jessica Blanchette, R.N. or you can call either of us at (978) 927-7070 ext. 250