NANCY ZENNER, RN - SCHOOL NURSE

   In an effort to allow for more comprehensive health care here at Benold, the following forms may be downloaded from this site for parents to use when appropriate.

To download or view these documents, you will need Adobe Acrobat Reader. Adobe Acrobat Reader software is available for free download at the Adobe web site.

Central Texas ASTHMA ACTION PLAN:  This form allows the student to carry and administer his/her own asthma inhaler with proper authorization from parent and doctor.  Please present a copy of the completed form to me so that I may have a copy on file.  This form needs to be renewed annually.  Download page 1    

Conners' Teacher Rating Scale: This form allows parents/teachers to rate student's behavior to assess the possibility of Attention Deficit symptoms or to rate student's behavior after medication has been given over a period of time.  Download form  Further information about children's mental health issues may be obtained from the following website: Child and Adolescent Depression and Anxiety Tool Kit

Emergency Information sheet:  This form allows the parent/guardian to give updated information about a student's medical needs (e.g. - diabetic, asthmatic, seizure disorder, etc.)  This information is vital for the nurse to have in order to prepare an individualized health care plan for your child and share with teachers on a "need to know" basis.  Please feel free to set up a parent/teacher conference to discuss your child's health issues.  This is a two page form.  Please download both pages. Download page 1    Download page 2

Long term medication form:  This form needs to be completed by both the parent and physician when a student must take medication at school for a long term (longer than 4 weeks). The parent may bring the completed form to school or the parent may sign the portion at the bottom, leave for the doctor to complete and the doctor's office may fax the completed form to the school. Download form

PRN medication form:  This form is to be used for medication that is not routinely given but left in the clinic to be administered on a PRN or "as needed" basis.  Examples of medications would be medication for pain, asthma inhalers, allergy medications, etc.  Please remember that the medication must be in its original container, whether this is an over the counter medication or a prescription medication, and because of limited storage space, please bring small containers to school.  This medication will be left in the clinic for the student and administered by school personnel as is deemed necessary.   Download form

Physician form:  This form allows the physician to relay information to the school nurse and/or staff regarding health information on a student.  Please take this form when you see the doctor regarding health issues that would affect your child's performance or care during the school day. You may return this form or the doctor may fax the information to us here at school.  Download physician form

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Benold Middle School

Georgetown Independent School District

 updated:  05/29/08 12:46 PM