Forms
Physical, Dental and Over the Counter Forms
All health examinations must be on the required NYS Health Examination form or an electronic health record equivalent form.Physical Exam
Health History
Dental Form
OVER THE COUNTER FORM (OTC)
- IMPORTANT CHANGE TO THE USE OF OVER THE COUNTER PRODUCTS IN THE HEALTH OFFICE.
- In New York State the determination of what qualifies as an over the counter product (OTC) medication is based on the U.S. Food and Drug Administration (FDA) Active Ingredient List. If a product contains an active ingredient listed by the FDA, it is considered an OTC medication.
- There are certain common OTC products that the school nurse stocks that may be used with your permission to do so. This includes common over the counter items such as vaseline, lotion and other similar products. In accordance with New York State Education law and school heath regulations, the administration of these OTC products requires a written order from a heath care provider and written parent or guardian consent.
- If you would like your child to receive OTC products during the school day, please print the OTC form and have your primary care provider authorize along with your signature and return to your child's school nurse.
Medication Forms
Medication Administration Orders
Independent Carry and Use Medication Orders for Grades 6-12
Independent Carry and Use Rapid-Acting Rescue Medication Order Grades K-5
Healthcare Provider Attestation
KI Refusal/Opt-Out
Activity Restriction Forms
Elementary School PE Modification
Secondary School PE Modification (Generic)
Secondary School PE Modification (Sport-Specific)
Secondary School Building Level Clearance/Modifications
Immunization Exemption Forms
NYS requires a valid, specific medical exemption that must be signed by a NYS physician for school-aged children. Exemptions must be renewed annually and specify the contraindication and for how long. Immunization exemptions must be filled out on the official NYSDOH form.
