Health Clinic Forms for Download

-CCS Clinic Information/Emergency Form
-For Administration of Non-Prescription Medication
-For Administering Prescription Medication

See Medication Administration Policy section below for full details about these and other necessary clinic forms.

HEALTH

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The school clinic must have an updated CCS Clinic Information/Emergency Form for every student each school year.


MISSION STATEMENT

The nurse staffing the CCS Clinic works to promote the health and education of CCS students, families, faculty and staff regarding health issues that can impact the school experience.

GOALS

The nurse provides initial assessment of injuries and symptoms of illness that present themselves during the school day. (S)he provides care, comfort, and treatment of minor injuries (first aid) and symptoms of illness. The nurse advises parents when a student needs to go home due to illness or injury, and of the need to seek medical attention for the student if an injury or symptoms of illness warrant further medical care.

The nurse will notify faculty, staff, and parents if and when infectious outbreaks occur in the school setting (examples: fifths disease, lice, strep throat, chicken pox, etc.) (S)he will also provide educational information regarding the particular outbreak (instructions regarding incubation periods, symptoms to be to be aware of, and course of action necessary should a student become infected).

The school nurse will complete a CCS Clinic Visit form in triplicate for clinic visits requiring documentation. This form will indicate the reason for the visit and any care and treatment provided. The original will be placed in the student's clinic file and a copy will be given to the student's teacher. A copy will also be sent home with the student for the parent to review.

The nurse will contact a student's parent or guardian by phone whenever concerns about the student's health status warrant immediate parent notification or when consultation regarding a student's symptoms would be helpful.

HEALTH SERVICES

In case of injury or accident, basic first aid is administered until the parent/guardian can be reached to take the child home, to the doctor, or to the hospital unless the school deems that more immediate measures are needed. Emergency numbers are kept for each child. It is imperative for parents/guardians to keep this information up-to-date. Physical examinations are required before your child enters school for the first time and health records must accompany new transfers into CCS from another school system. Students born outside the U.S. must have a recent TB test. Hepatitis B shots are now mandatory for all rising 6th graders.

The policy for contagious conditions (i.e. lice, conjunctivitis, fever, etc.) is that the affected child will be isolated to wait for parental pick up.

ILLNESS and INJURY

PLEASE NOTE: If a child is ill in the morning or has had a fever of 101 within the past 24-hour period, they should not come to school. Parents are notified when a child's illness is detected, and they may be asked to take the student home. Any significant injury occurring during the school day is reported to the parent. At the direction of parents, the school will treat minor injuries, or the parents may take the child to attain medical attention. In case of serious injury, the school will call 911 to have the Charlottesville-Albemarle Rescue Squad transport the student to a hospital for emergency treatment. Parents will be notified as soon as practical. However, the child's welfare is the first and foremost focus of the CCS faculty and staff.

MEDICATION ADMINISTRATION POLICY

(The forms referenced below are PDF files. You need Adobe Acrobat to open them. Your computer may already have Acrobat, if not, you can download it for free from Adobe's website.)

  1. At the beginning of each school year or whenever a student is enrolled at CCS, his or her parent or guardian will fill out the CCS Clinic Information/Emergency Form. This form includes a release/authorization for the administration of Tylenol, Tums, cough drops, and topical ointments (such as Benadryl Gel, triple antibiotic ointments, Caladryl) by clinic personnel, the administrators, and the school office staff. This authorization does not allow for the administration of any medications other than those noted above. If this authorization is not signed, none of the above medications can be administered to the student. The nurse will contact a parent prior to giving a student Tylenol or other pain medication.
     
  2. Parents who indicate on the CCS Clinic Information/ Emergency Form that their student has Asthma or Severe Allergies will be asked to fill out an Individualized Health Care Plan that will be utilized by clinic personnel in the event of an asthma attack or an allergic reaction. These forms are available in the CCS office/clinic.
     
  3. In cases when the administration of over-the-counter (non-prescription) medications (other than those listed on the release noted in #1) is necessary at school, the parent or guardian must complete and return the Parent Release For Administration of Specific Non-Prescription Medication form with an unopened package of the medication labeled with the student's name. Examples might include Ibuprofen, Tylenol Sinus. This form is available in the CCS office or can be downloaded using the above link.
     
  4. In cases when the administration of prescription medication is or may be required during the school day, the Authorization/Parental Consent for Administering Prescription Medication form must be completed by BOTH the parent and the prescribing physician. This form is available in the CCS office or or can be downloaded using the above link.
     
  5. ALL medications must be transported to and from school by the student's parent, guardian, or carpool driver (as long as the proper authorization has been filled out by the parent or guardian). STUDENTS MAY NOT TRANSPORT THEIR OWN MEDICATIONS TO OR FROM SCHOOL UNDER ANY CIRCUMSTANCES.
     
  6. Medication must be in its original container. Prescription medications must have an up to date pharmacy label. This allows the clinic personnel to compare the physician authorization with the pharmacy label. This is an important step in assuring the proper medication and dose are being administered, thus avoiding medication errors.
     
  7. The nurse will notify parents when refills of any student medications are needed.
     
  8. A student's parent or guardian should administer the first dose of any new medication unless it is an "in school only" medication.
     
  9. For any changes in medication, including dosage changes, the parent/guardian must provide a new Authorization/Parental Consent for Administering Prescription Medication form signed by both the parent/guardian and prescribing physician. A new bottle of the medication should have a pharmacy label that reflects these changes. Again, this aids in the prevention of medication errors.
     
  10. Medications not retrieved from the CCS clinic within 2 weeks of the last day of school will be discarded.
     
  11. Students with allergies will be accommodated based on physician documented conditions. CCS reserves the right to determine if any occomodations are too expensive, unrealistic, or too disruptive to implement.
     
Charlottesville Catholic School
1205 Pen Park Road  |  Charlottesville, VA 22901
434-964-0400  |  info@cvillecatholic.org
Map to CCS