LOS ANGELES UNIFIED SCHOOL DISTRICT
Month _____________ Year ________
SCHOOL NURSE HEALTH OFFICE DAILY LOG
District_____ School __________________________________ Location Code _________
PRINT
SCHOOL NURSE Name __________________________________________________
Signature __________________________________________________
Employee # ___________________
Comments
Assessments for suspect infect/diseases Assessment
Psych
(Use diagnosis or diagnosis
Health Ed for disease prevention
& Education
Social
Disposition
Special Ed
Q Q Q Q Q Q Q Q Q Q Q Q
code if administering meds)
A E N V V
S
S
Date
Print Student Name
Reason for Referral
Temp
MM DD
YY
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
.
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
DS
Eye ENT
GI
Hair Hyg Injr Orth Skin URI
UTI
Aud
DE
Nut
VS
CV
ORIGINAL Copy: Health Office confidential files
YELLOW copy: due the 5th day each month at District Nursing Services
Medi-Cal Form 308 Rev (6/03)