Health Services Request (Hsr) Form - Coordinated Student Health Services

(Revised 1/2014)

HEALTH SERVICES REQUEST (HSR) FORM

This form is to be used to request health services or to request training by registered nurse to provide training for school-based personnel who will be performing health procedures. This form needs to be

completed by the school and faxed along with the completed Authorization for Medication/Treatment form to Coordinated Student Health Services (CSHS) at 754.321.1687 For more information please

call CSHS at 754.321.1575.

Date: ______________

STUDENT AND SCHOOL INFORMATION:

Name of student: ___________________________________________

DOB/Age: _______________________

Grade: __________

Program enrolled: ESE (not in gifted program) ______________

504 ________________________

School: ________________________________

School Contact/Title: _________________________

Telephone Number: ______________________

Reason For Request:

_______________________________________________________________________________________________

PLEASE SUBMIT CURRENT MEDICATION/TREATMENT AUTHORIZATION FORM WITH REQUEST

Request For Health Training

Request For Direct Nursing Care for Student

List number of personnel who will attend training:

Potential Start date for Student:

If Education Support Professionals (ESP)will be trained and assigned to perform

Parent/Guardian Name: ____________________

a medical procedure, list names and designation:

Student’s address: ________________________

1. (Primary/Split) _________________________

All contact telephone numbers for parent/guardian:

2. (Back-up/Split) _________________________

________________________________________________________

List three dates and times for Registered Nurse to conduct training:

Transportation: Bus _____ Car _____

1. ____________________

Bus: Pick-up Time: __________

2. ____________________

Drop off Time:__________

3. ____________________

(For CSHS staff only) NURSING COVERAGE REQUEST: Name of Nurse Requesting Coverage: _______________________________________

School of Employment/Hours of service: ________________________________

Requested Dates Off: _________________________________

**Please complete the student and school information and submit form with student(s) Authorization for medication/treatment form(s).

___________________________________________________________________________________________________________________________________

Below to be completed by Coordinated Student Health Services: ___ RN

___ LPN

___ HST ___ Other

Date: ___________ Time: ___________ Agency: ________________ Agency Representative: _______________ Nursing Hours assigned: ________________

For Billing: Student is enrolled in the assigned program (please check):

ESE

ESE/Diabetes

504

504/Diabetes

__ SBBC Nurse Coverage: Send invoice directly to school