Clinic Information Notice/pass Template
ADVERTISEMENT
1St. Lucie Public Schools
St. Lucie Public Schools
Clinic Information Notice/Pass
Clinic Information Notice/Pass
DATE _________________ TIME LEAVING CLASS___________________
DATE _________________ TIME LEAVING CLASS___________________
STUDENT______________________________________________________
STUDENT______________________________________________________
TEACHER______________________________________________________
TEACHER______________________________________________________
COMPLAINT___________________________________________________
COMPLAINT___________________________________________________
------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------
TIME LEAVING CLINIC__________________________________________
TIME LEAVING CLINIC__________________________________________
_____ RETURN TO CLASS
_____ RETURN TO CLASS
_____ No significant problem noted/No fever
_____ No significant problem noted/No fever
_____ Ice/bandage applied
_____ Ice/bandage applied
_____ Parent notified/Student will remain in school
_____ Parent notified/Student will remain in school
_____ Student rested
_____ Student rested
_____ Unable to contact parent/guardian
_____ Unable to contact parent/guardian
_____ GOING HOME
_____ GOING HOME
_____ Please send student back to clinic with bookbag
_____ Please send student back to clinic with bookbag
_____ Please allow to sit quietly in classroom until parent arrives
_____ Please allow to sit quietly in classroom until parent arrives
_____ Other ___________________________________________________
_____ Other ___________________________________________________
White: Clinic
Yellow: Teacher
STS0103
White: Clinic
Yellow: Teacher
STS0103
St. Lucie Public Schools
St. Lucie Public Schools
Clinic Information Notice/Pass
Clinic Information Notice/Pass
DATE _________________ TIME LEAVING CLASS___________________
DATE _________________ TIME LEAVING CLASS___________________
STUDENT______________________________________________________
STUDENT______________________________________________________
TEACHER______________________________________________________
TEACHER______________________________________________________
COMPLAINT___________________________________________________
COMPLAINT___________________________________________________
------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------
TIME LEAVING CLINIC__________________________________________
TIME LEAVING CLINIC__________________________________________
_____ RETURN TO CLASS
_____ RETURN TO CLASS
_____ No significant problem noted/No fever
_____ No significant problem noted/No fever
_____ Ice/bandage applied
_____ Ice/bandage applied
_____ Parent notified/Student will remain in school
_____ Parent notified/Student will remain in school
_____ Student rested
_____ Student rested
_____ Unable to contact parent/guardian
_____ Unable to contact parent/guardian
_____ GOING HOME
_____ GOING HOME
_____ Please send student back to clinic with bookbag
_____ Please send student back to clinic with bookbag
_____ Please allow to sit quietly in classroom until parent arrives
_____ Please allow to sit quietly in classroom until parent arrives
_____ Other ___________________________________________________
_____ Other ___________________________________________________
White: Clinic
Yellow: Teacher
STS0103
White: Clinic
Yellow: Teacher
STS0103
ADVERTISEMENT
0 votes
