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Medical Forms
Health Care Plans
Students with chronic health conditions that may require intervention while attending school require an up-to-date health care plan each school year. Please fill out the associated health care form with your students health care provider and notify your school nurse to set up a meeting to review the health care information.
If your student requires a daily or emergency medication of epinephrine, asthma medications, seizure medications, or diabetic medications and supplies the medication forms are within the associated health care plans found below. For all other daily and emergency prescription medications please fill out the Prescription Medication Authorization Form found above.
Students may be allowed to assume responsibility for carrying and administering their own medications such as asthma medication, epinephrine, or diabetic supplies if approved by the student's health care provider, guardian and school nurse.
Allergies
Asthma
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Asthma Action Plan, Medication Authorization and Self-Administration
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Asthma Action Plan, Medication Authorization and Self-Administration (Spanish)
Diabetes
Generic Individualized Healthcare Plan/Emergency Healthcare Plan
Seizures
Immunizations
All children who attend school are required by the Utah Immunization Rule for Students to provide proof of immunization, an exemption, or proof of immunity against a disease for which vaccination is required. Please submit all up-to-date immunization information to your school nurse. You can find more information on Immunizations and Utah requirements at https://immunize.utah.gov/school-early-childhood-program-requirements/
Over-the-Counter Medication Form & Information
Over-the-counter medications can be provided by trained staff during the school day if the form below is submitted for your student(s).
Prescription Medication Form, Checklist & Information
Please email your school nurse (contact information listed below) to schedule a time to drop off the prescribed medication with the Prescription Medication Authorization Form signed by your students health care provider and guardian.
Other Forms/ Policies
If you have any questions or concerns please contact:
Natasha Breakall RN, BSN
School Nurse
North Salt Lake Spectrum Academy
801-936-0318 x 7012
natasha.breakall@spectrumcharter.org
Anna M Deltejo RN, BSN
School Nurse
Pleasant Grove Spectrum Academy
anna.deltejo@spectrumcharter.org