School Nurse Procedure Manual - The School District of Philadelphia

“Although the primary functionof schools is to educate ouryoung people, when health andsocial problems impedestudents’ ability to learn,schools must assist thestudents and their families insecuring the services they needto succeed by linking studentswith health and socialservices.”**Children Achieving Action Design

School Reform CommissionJames E. Nevels, ChairmanSandra Dungee GlennJames P. Gallagher, Ph.D.Michael MaschDaniel J. Whelan****************************Paul J. VallasChief Executive OfficerFlora TurnerExecutive DirectorOffice of Specialized Services

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALTable of Contents (Sep. 02)MANDATED PROGRAMS___________________________________________ 3REQUIREMENTS AND PURPOSE (SEPT. 01)___________________________________________________4GROWTH SCREENING (SEP. 02) ___________________________________________________________5HEARING SCREENING (SEP. 02)____________________________________________________________8PHYSICAL EXAMINATIONS FOR STUDENTS (SEPT. 02)________________________________________13DENTAL EXAMINATIONS FOR STUDENTS (SEPT. 02)________________________________________ 20SCOLIOSIS (SEP. 02)______________________________________________________________________23VISION SCREENING - MYOPIA (SEP. 02) _____________________________________________________31VISION SCREENING - HYPEROPIA (SEP. 02)__________________________________________________33GENERAL PROCEDURES__________________________________________ 36ACCIDENTS/ ILLNESS (SEP. 02)____________________________________________________________37CATEGORIES OF EMERGENCIES (DEC. 98) _________________________________________________39RELEASE FROM SCHOOL FOR ACCIDENT / ILLNESS (SEP. 01) _________________________________42RETENTION OF STUDENT IN SCHOOL (ACCIDENT / ILLNESS) (DEC. 98) ________________________44SERIOUS HEAD AND NECK INJURY (DEC. 98)________________________________________________45MINOR HEAD AND NECK INJURY (SEP. 01)__________________________________________________46CHILD ABUSE / NEGLECT ________________________________________ 49CHILD ABUSE (BOARD POLICY) (DEC. 98)____________________________________________________50INVESTIGATION OF ALLEGED MISCONDUCT WITH CHILDREN BY EMPLOYEES (DEC. 98) _______52CHILD PROTECTIVE SERVICES (DEC. 98) ___________________________________________________57RESPONSIBILITIES OF PRINCIPAL (DEC. 98)_________________________________________________59RESPONSIBILITIES OF THE SCHOOL NURSE (DEC. 98) _______________________________________60PROCEDURE FOR REPORTING (SEP. 01) ____________________________________________________61NOTIFICATION OF PARENTS (DEC. 98) _____________________________________________________63COOPERATION WITH LAW ENFORCEMENT (DEC. 98) ________________________________________64EARLY CHILDHOOD PROGRAMS (DEC. 98) _________________________________________________65RESPONSIBILITIES OF SCHOOL COUNSELORS (DEC. 98) ______________________________________66DOMESTIC VIOLENCE-SPOUSAL & DATE ABUSE (SEP. 01)____________________________________67COMMUNICABLE DISEASE CONDITIONS ___________________________ 69AIDS/HIV INFECTION (DEC. 98)____________________________________________________________70INTERAGENCY PROTOCOL, SD & DEPARTMENT OF HEALTH (SEP. 02) ________________________72IMMUNIZATION (SEP.02) ________________________________________________________________74PEDICULOSIS CAPITIS (SEP. 01)___________________________________________________________78SEXUALLY TRANSMITTED DISEASES (DEC. 98) _____________________________________________83MEDICATION ADMINISTRATION__________________________________ 85ACETAMINOPHEN STANDING ORDERS (SEP. 02) ___________________________________________86IBUPROFEN - STANDING ORDER (SEP. 02) __________________________________________________89ADMINISTRATION OF LONG TERM MEDICATION - SCHOOL BOARD POLICY (DEC. 98) __________92USE OF MEDICATION/MEDICAL EQUIPMENT SCHOOL BOARD POLICY (DEC. 98)_______________93PRESCRIBED MEDICATION (SEP. 02)_______________________________________________________94NON-COMPUTERIZED HEALTH ROOM_____________________________ 107RECORD OF ILLNESS AND/OR INJURY (M98) (DEC. 98)_______________________________________108SCREENING WORKSHEETS (DEC. 98)______________________________________________________117TEMPORARY PROBLEM LIST (DEC. 98)____________________________________________________123September 1, 2002 Page 1

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALRESOURCES____________________________________________________ 124PUBLIC SCHOOL HEALTH FUND: PURPOSE AND ELIGIBILITY STANDARDS (SEP. 02)____________126PUBLIC SCHOOL HEALTH FUND: DENTAL SERVICES (SEP. 01) _______________________________128PUBLIC SCHOOL HEALTH FUND: ORTHODONTIA (SEP. 02) __________________________________129STUDENTS WITH SPECIAL NEEDS________________________________ 132LEGAL BASIS / PURPOSE (DEC. 98) _______________________________________________________133DO NOT RESUSCITATE ORDERS - SCHOOL BOARD POLICY (DEC. 98) __________________________135SERVICES OF SPECIAL EDUCATION CONSULTANT (SEP. 01) ________________________________136PROTECTED HANDICAPPED STUDENTS: HEARING PREPARATION (SEP. 01)___________________138REFERRAL TO STUDENT SUPPORT TEAM (SST) (DEC. 98)_____________________________________140PROTECTED HANDICAPPED STUDENTS (SEP. 02) __________________________________________141SPECIAL CASE FILE (SEP. 02) ____________________________________________________________145EXTENDED SCHOOL YEAR (ESY) (SEP. 02)___________________________________________________150PREGNANT STUDENTS (SEP. 02)__________________________________________________________151TRANSPORTATION REQUESTS FOR MEDICAL REASONS (SEP 01)______________________________152TRANSPORTATION REQUESTS, AUTHORIZATION LETTER (DEC. 98)___________________________155HOMEBOUND INSTRUCTIONAL PROGRAMS (SEP. 02)_______________________________________156SUICIDE PREVENTION/INTERVENTION GUIDELINES (SEP. 02)_________________________________161VISUALLY IMPAIRED (DEC. 98)___________________________________________________________166MISCELLANEOUS_________________________________________________169ACCESS BILLING PROCEDURE (SEP. 02 )__________________________________________________ 170CALENDAR OF ACTIVITIES (SEP. 02)______________________________________________________172INFECTION CONTROL PRECAUTIONS: CONTACT WITH BODILY FLUIDS (APR. 02)______________175September 1, 2002 Page 2

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALMANDATED PROGRAMSSeptember 1, 2002 Page 3

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT:MANDATED PROGRAMSNUMBER 100CLASSIFICATION:REQUIREMENTS AND PURPOSE (SEP. 01)REQUIREMENTS1. Section 1402 (a) of the School Code requires:a. Physical examinations upon entry and in grades 6 and 11b. Annual vision screeningc. Annual growth screeningd. Audiometric screening in grades K, 1, 2, 3, 7, 11 as well as annual testing for childrenwho have failed previouslye. Scoliosis Screening in grades 6 and 72. Section 1403 (a) requires:a. Dental examinations upon entry and in grades 3 and 73. Section 1402 (f) allows the School District of Philadelphia to modify the School Health Program withthe approval of the Pennsylvania Secretary of Health. The School District of Philadelphia requirea. Growth screening every other yearb. Audiometric screening in 6th rather than 7th grade, in 9th rather than 11thc. In some schools, School Nurse Practitioners may provide a modified program which isadapted to meet the needs of the school/community.d. Tuberculin Testing in schools and grades selected in collaboration with the City ofPhiladelphia Department of Public Health.e. Physical examinations in 9th rather than 11th grade.DEFINITION AND PURPOSE1. Screening is a method of testing large numbers of persons, quickly against a standard pass/fail criteria.It is possible for an individual to fail a screening test and be found normal upon completion of acomprehensive examination. It is also possible for an individual who has a problem to pass ascreening test.2. The purpose of height, weight, vision and hearing screening tests is:a. To identify students who may have acquired or been born with problemsb. To provide an opportunity for health education and health counseling for the studentc. To bring about care or remediation of identified problemsd. To teach students and parents to be informed health care consumerse. To comply with School Code Section 1402September 1, 2002 Page 4

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MANDATED PROGRAMS NUMBER 104CLASSIFICATION:GROWTH SCREENING (SEP. O2)I. PurposeA. To assess physical growth.B. To assess nutritional status.C. To identify students with possible growth or nutritional problems.D. To standardize growth assessment and results.E. To standardize case management of the at risk student.II. FrequencyA. Bi-annuallyB. Growth above the 90th percentile or below the 10th percentile should be assessed annuallyIII. ProcedureA. Measure and weigh student without shoes and with indoor clothing.B. Measure with wall chart or stadiometer.C. Student should stand against wall with arms at sides and heels back against wall.D. Student should face forward with chin in neutral position.IV. Calculation of height to weight percentiles.A. For students in whom a problem is identified, initiate a graph growth record.B. Abnormal or questionable findings should be rechecked for accuracy and rechecked in threemonths.C. Complete documentation.1. Document results in screen H5 in Main Menu #2, Health Inquiry and Maintenance. Where HISis unavailable, use MEH-3.V. Interpretation of MeasurementsA. Measurements between the 25th and 75th percentiles are likely to represent normal growth.B. Measurements between the 10th and 25th, and the 75th and 90th percentiles may or may not benormal. Previous and subsequent measurements and genetic factors need to be considered.C. Measurements above the 90th and below the 10th percentiles should be checked for accuracy andreferral for further evaluation should be considered.D. Measurements above the 95th or below the 5th percentiles are of priority concern and warrantreferral and follow-up.E. Measurements indicating a percentile shift of 25 percentile or more should be rechecked. Carefullyevaluate for cause and refer appropriately.F. When there is considerable difference in height and weight percentiles, careful assessment of thestudent is warranted.September 1, 2002 Page 5

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSeptember 1, 2002 Page 6

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSeptember 1, 2002 Page 7

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MANDATED PROGRAMS NUMBER 106CLASSIFICATION:HEARING SCREENING (SEP. 02)HEARING SCREENING PROGRAMI. PurposeA. To identify students with hearing lossB. To refer failures for further evaluationII.FrequencyA. Sweep Check Test @25 dB1. All students in grades K, 1, 2, 3, 6, 9, and ungraded age-equivalent.2. All newly admitted students who have not been screened by the sending school.3. On referral.B. Pure Tone Threshold Test1. Students who have failed the Sweep-Check Test2. All students, regardless of grade, whose previous hearing test has shown a loss.III.Equipment requiredA. Pure Tone AudiometerB. Testing TableC. ChairsD. Benzalkonium Chloride 1:5000IV. PreparationA. Assure that the audiometer is in good working condition by:1. Checking all wires, knobs, and ear phones.2. Being certain a threshold done on self is consistent with pre-established data.B. Assure a setting as free of noise-producing activity as possible. (Do not schedule other healthroom activities which might impact on the hearing screening)C. Place a chair for the student to be screened in a direction facing away from the screener.V. Hearing Screening ProceduresA. Sweep Check Test1. Explain the screening procedure to student. Allow student to practice “raising their hand” tothe sound of the tone. Seat the student to be screened in the chair near the testing table.2. Instruct the student to remove all objects which might interfere with proper fit of theheadband, i.e., eyeglasses, earrings, hair ornaments. Briefly review the procedure with thestudent.3. Face the student and place the earphones directly over the external ear canal with the redearphone over the right ear.4. Be certain the student being screened cannot watch the tester.September 1, 2002 Page 8

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL5. Screen the RIGHT ear first as below:Decibel Level Frequency Hears The Tone55 1000 once40 1000 once25 1000 2 out of 325 2000 2 out of 325 4000 2 out of 325 1000 once25 500 2 out of 325 250 2 out of 36. Screen the LEFT ear.Decibel Level Frequency Hears The Tone25 1000 2 out of 325 2000 2 out of 325 4000 2 out of 325 1000 once25 500 2 out of 325 250 2 out of 350 1000 Return machine to red ear.Note: Always screen the right ear first.7. Record the test results on the HIS, Main Menu #2, Health Inquiry andMaintenance, screen H4. Where HIS is unavailable, use the MEH-3.a. Pass is the ability to hear all or all except one frequency at 25 decibels.b. Fail is:1). Failure to hear two (2) or more frequencies at 25 decibels.2). Failure to hear the same frequency in both ears.8. A student who fails requires further assessment by the school nurse.a. A student who fails should receive a second Sweep Test within one (1)month.b. Failure of the second sweep test will result in a Threshold Test that sameday.September 1, 2002 Page 9

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALB. Pure-Tone Threshold Hearing Test Procedure1. Begin the testing in the right ear. Begin testing at 50 dB, 1000 Hz. If the child hears this toneset the decibel dial to 40 and repeat this procedure, decreasing the decibel dial by 10 dB stepsuntil the child no longer indicates that he hears. Then increase the decibel dial by 5 dB stepsuntil he hears the tone again. This is the threshold for that frequency.2. Repeat the same procedure until the following frequencies have been tested in the right ear:250, 500, 1000, 2000, 4000, and 8000 Hz. Use this same procedure in the left ear.3. Record the lowest decibel level that the student is able to hear on the Student School HealthRecord/ Health Information System.4. Failure constitutes any one of the following:a. Failure to hear 30 dB or more for two or more frequencies.b. Failure to hear 35 dB or more for one (1) frequency.5. A referral for a complete ear examination for otologic assessment and audiometric tests shouldbe initiated (M117 - Hearing Test Report to Parents and Physician) and documented on theStudent Health Record/Health Information System.September 1, 2002 Page 10

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLESeptember 1, 2002 Page 11

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MANDATED PROGRAMS NUMBER 103CLASSIFICATION:PHYSICAL EXAMINATIONS FOR STUDENTS (SEP. 02)I. “Although the primary function of schools is to educate our youngpeople, when health and social problems impede students’ ability to learn,schools must assist the students and their families in securing the servicesthey need to succeed by linking students with health and social services.”*II.Section 1402 (a) of the School Code requires:A. All students must be examined upon entry to school, in sixth grade, and again in eleventh grade orage equivalent.B. In accordance with Section 1402 (f) of the School Code, the School District ofPhiladelphia requires physical examinations upon entry to school, in sixth grade, and again inninth grade or age equivalent.C. Students in any grade, who have never been examined, or who have no record of an examinationshall be part of the mandated physical examination program.III.The purpose of the Physical Examination Program is as follows:A. to insure that students are ready to learn.B. to identify important health problems which may prevent the student from maximizing his/herlearning experiences.C. to provide an opportunity for health education and health counseling for the student and parent.D. to bring about care or remediation of identified health problems.E. to teach students and parents to be informed health care consumers.F. to increase access to and utilization of primary care providers by families.G. to comply with School Code Section 1402.IV. School Nursing Practice Roles and Standards state:A. The school nurse collaborates with other school professionals, parents, and caregivers to meet thehealth, developmental, and educational needs of clients. (Number 6)B. The school nurse collaborates with members of the community in the delivery of health and socialservices, and utilizes knowledge of community health systems and resources to function as aschool-community liaison. (Number 7)V. Rules and Regulations of the Commonwealth of Pennsylvania Department ofA. Health Chapter 3, Article 322, School Health, Section 1 A state:B. “Medical examinations shall be done carefully and in such detail as to command medical respectand to provide an educational experience for the child and his parents. Examinations will bescheduled so that on an average no more than four children will be examined in an hour. Resultsof vision, hearing, and growth screening tests will be available to the physician at the time of theexamination.”* Children Achieving Action DesignSeptember 1, 2002 Page 13

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALVI. Confidentiality :A. The Physical Examination Report is confidential and shall be retained by the school nurse.VII. Process :A. All parents and caregivers should be referred to their primary care provider to obtain physicalexaminations for their children.B. Form MEH-2 Student Medical History and Form MEH-1, Private Physicians Report must begiven to parents to take to their provider.C. Encourage the parent to have the examination done within a reasonable amount of time.D. Instruct the parent or student to return the completed MEH-2 and MEH-1 to the School Nurse.E. A Physical Examination Report completed by a primary care provider, other than an MEH-1 isacceptable for purposes of meeting this mandate provided it contains all of the requiredinformation. One example of an acceptable form is the EPSDT Physical Form.VIII. School Physician Service :A. School Physician Service is available for physical examinations of students in accordance with thefollowing criteria:1. The student has no other means of obtaining a physical examination, e.g., has no healthinsurance.2. The student is in a mandated grade (or age equivalent) or never had a physical.3. The health history and parent consent are on file.B. School nurses may also request school physician service for these reasons:1. Consultation with Nurse Practitioner.2. Consultation with School Nurses, School Nurse Practitioners, and/or School Support Teamsregarding, for example, case management of unresolved health problems or to assist the teamwith decisions regarding homebound instruction etc.3. Support for Health Education and Health Promotion Activities, e.g., staff development,assemblies, health fairs, and other programs.IX. Requesting School Physician Service :A. Written requests for school physician service shall be submitted to:The School District of PhiladelphiaSchool Health ServicesJFK Center, Room 500734 Schuylkill Ave., Phila. PA 19146).1. The request must include School name; Location number; Academic Area; type of servicerequested; Day of the week requested; Name and phone number of the School Nurse.2. Requests will be honored on a first come, first serve basis.3. Schedules will be mailed ONLY to nurses and schools which are listed on the schedule.4. If you wish to contact a School Physician you may obtain information by contacting 215-875-3490.X. Medical Examination in School :A. The parent MUST be notified of the date, time and place of the physical examination, and beencouraged to be present.B. Schedule students at 15 minute intervals.C. Notify appropriate school personnel that students will be examined.September 1, 2002 Page 14

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALD. The physical examination should be done in a space where there is running water and privacy forthe student to disrobe. No other students should be in the room. There should be acousticalprivacy to permit the physician, nurse, student and/or parent to talk confidentially.E. The school nurse shall remain with the physician throughout the entire physical examination.F. The results of the examination shall be explained to the parent and student, including discussion ofany health problems which require further evaluation.G. The following equipment shall be available to the school physician:examining paper table or desk and chair waste basketalcohol sponges tongue depressors thermometersigned consent and physical exam form M-34, Report ofhistory (MEH 1) Visit to the Health RoomXI. Problem Management :A. Problem Management is the responsibility of the Family and the Primary Care Provider. TheSchool Nurse and, where appropriate, the School Support Team will monitor progress towardfurther evaluation and treatment or management of health conditions.B. Maintain communication with the parent/student to facilitate treatment of health problems identifiedby the primary care provider.C. Facilitate linkages to all resources which will make it possible for the parent to follow-through.D. When necessary, and with parent or guardian consent, contact the HMO hotline for assistance.E. Document all contacts on Screen H-7, using the appropriate note code. (If there is no computer,use Nurses Notes in the Student Health Record). Type your name at the end of the notes.XII. Documentation by school nurses :A. All pertinent information should be documented using the appropriate screens (e.g. physical examscreen H2, hearing screen H4, vision screen H3, growth screen H5) and relevant codes in theHIS.B. It is not necessary to transcribe results which are recorded electronically on to an MEH-3 (StudentHealth Record).XIII. Hard Copy MEH-3 Student Health Record:A. School Nurses who do not have a computer shall use the Student Health Record and ScreeningWorksheets to record the results of Private Physical Examinations.September 1, 2002 Page 15

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLESAMPLESeptember 1, 2002 Page 16

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLE FORM SIDE 1 OF 2September 1, 2002 Page 17

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLE SIDE 2 OF 2September 1, 2002 Page 18

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALREQUEST FOR SCHOOL PHYSICIAN SERVICETo:School District of PhiladelphiaSchool Health ServicesJFK Center, Room 500734 Schuylkill Ave.Philadelphia, PA 19146School:______________________________________Location number:_________Academic Area:_____________________________________Type of service requested:_______ Physical examinations for students._______ Consultation with Nurse Practitioner._______ Consultation with School Nurses, School Nurse Practitioners, and/or School SupportTeams regarding, for example, case management of unresolved health problems or to assist theteam with decisions regarding homebound instruction etc._______ Support for Health Education and Health Promotion Activities, e.g., staff development,assemblies, health fairs, and other programs._______ Other-(Please be specific)________________________________________________________________________________________________________________________________________________Day of the week requested:_______________________________Name of School Nurse: _____________________ Signature:____________________________Phone number:___________________________Date of request:___________________________• Requests will be honored on a first come, first serve basis.• Schedules will be mailed ONLY to nurses and schools which are listed on the schedule.• If you wish to contact a School Physician you may obtain information by contacting 215-875-3490.September 1, 2002 Page 19

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MANDATED SERVICES NUMBER 107CLASSIFICATION:DENTAL EXAMINATIONS (SEP. 02)I. “Children whose dental needs are not met experience pain that often keeps them out of school.Schools must assist students and their families in accessing dental care.”II.Section 1403(a) of the School Code requires:A. All students must have a dental examination upon entry to school, in third grade and seventh gradeor age equivalent.B. In accordance with Section 1403 of the School Code the School District of Philadelphia requiresdental examinations upon entry to school, third grade and seventh grade or age equivalent.C. Students in any grade, who have never been examined, or who have no record of an examinationshall be part of the mandated dental examination program.D. The School Code urges administrators to have as many children privately examined as possible toprovide for continuity in the dental care of the child. Children examined privately will be countedin the mandated program.III.The purpose of the Dental Examination is to:A. Insure students obtain regular dental care to help prevent school absence.B. Provide an opportunity for regular dental education and counseling.C. Bring about care or remediation of identified dental problems.D. Comply with the School Code Section 1403.IV. Confidentiality:A. The Dental Examination Report is confidential and shall be retained by the Certified School Nurse.The results will be documented in the dental examination screen of the Health InformationSystem, or in non-computerized Health Rooms, in the student’s MEH-3 (Health Record).V. ProcessVI. All parents/guardians should be referred to their dentist to obtain dental examinations for theirchildren.VII. The Form “Report of Dental Examination” (MEH-155) must be given to parent guardian to take totheir dentist.VIII. Encourage the parent/guardian to have the dental examination done within a reasonable amount oftime.IX. Instruct the parent/guardian or student to return the completed Dental Examination form to theSchool Nurse.X. A dental report completed o n other than the “Report of Dental Examination”, is acceptable inmeeting this mandate.XI. ReferralA. The Certified School Nurse will assist families in obtaining dental care as needed. The SchoolNurse will utilize the attached list for the referral process.September 1, 2002 Page 20

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALXII. Problem ManagementProblem Management is the responsibility of the family and the dentist. The Certified School Nursewill monitor progress, as needed, by:A. Maintaining communication with the family.B. Facilitating linkages to appropriate resources.C. Documenting all contacts and problem resolution, as appropriate, to the HIS, screen H10 (orMEH-3, in non-computerized health rooms).September 1, 2002 Page 21

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSeptember 1, 2002 Page 22

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MANDATED PROGRAMS NUMBER 105CLASSIFICATION:SCOLIOSIS (SEP. 02)I. PurposeA. To assess spinal abnormalities.B. To screen the most at risk student populations.C. To identify students with possible spinal abnormalities.D. To implement early intervention in spinal abnormalities.E. To standardize the case management of the student identified as having potentialfor scoliosis and/or other spinal problems.II. FrequencyA. Yearly for all 6th and 7th grade students.B. Yearly for all age appropriate students in ungraded classes (11 and 12 years of age).C. The student already under care for spinal abnormalities by a private health care providerdoes not need to be screened in the school screening. The parent/guardian will be asked tosubmit a written report of this care.D. Students whose parents object in writing to scoliosis screening will be excused fromthe screening. The parent/guardian will be asked to seek a screening with a private healthcare provider and submit a written report.E. Students who have scoliosis screening done by a private health care provider in responseto the mandated physical examination for 6th grade and age-appropriate will be excusedfrom the school based screening program.III. ProcedureA. Preliminary Activities1. Select a date and time for scoliosis screening, with consideration of studentschedule and in collaboration with teachers and any other school staff consideredappropriate.2. Provide an instructional program, including information about scoliosis and otherspinal abnormalities as well as the details of the screening procedure for studentsand staff, and as requested by parents/guardians.3. Issue Parent Information Letter with selected date to parents/guardians of studentsscheduled for screening.B. Screening Concerns1. Initial screening will be done by the Certified School Nurse.2. The screening area will be located where the students will have complete privacy.3. At the time screening is in progress, this area will not be used for any otherpurpose.4. The area selected will be warm and well-lit.5. Boys and girls will be screened separately.6. Students will be screened with shoes off and with outer clothing off to the waist.7. Girls will be allowed to keep on their bras and have the option, as stated in theparent letter, to wear a bathing suit top, or halter under their clothing.C. Screening technique1. Facing the screener, the student will stand in the erect position with feet togetherand arms hanging relaxed at sides. The screener will observe for the following:a) Level shouldersb) Equal distances between the arms and the body.c) Breasts of equal sized) Nipples equal in height on chest.September 1, 2002 Page 23

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL2. With the student in the erect position, the screener should move to the student’sback and run the index finger on each hand under the scapula and towards themiddle of the back observing for equal height of scapula. This technique shouldbe employed at the waist to observe for equal level of the pelvis.3. Facing the screener, the student will bend over slowly with palms of handstogether and arms hanging relaxed from shoulder, head hanging down. Thescreener will observe the student in this position from both sides and the back,observing for any fullness (rib hump) in the right/ left thoracic area or in theright/left lumbar area.D. Positive findings at initial screening1. Any student who is found to have any positive signs of spinal abnormality will berescreened by the Certified School Nurse and a second screener, who may beanother Certified School Nurse or a School Physician.2. Any student who is scheduled to be rescreened will receive a Report of Visit toHealth Services card (M34) with the appointment for rescreening and a briefexplanation of the purpose of rescreening. In addition an effort to contact theparent/guardian by phone should be made to alleviate any anxiety the rescreeningmay cause.E. Positive findings at second screening1. Students with positive findings following rescreening must be referred to theirprivate health care provider.2. A positive finding for RIB HUMP in any location in the forward bending positionis the major criteria for scoliosis referral. Other observations made by the screenerare merely supportive of the rib hump finding.3. The Certified School Nurse will speak to any student with positive findings toallay fears and encourage cooperation.4. Every effort must be made to notify, by phone, parents/guardians of students withpositive findings and encourage further medical evaluation.5. The “Parent-Physician Letter” form with the findings of both screeners will becompleted and signed by both screeners and sent to parent/guardian.6. The Certified School Nurse will assist parents/guardians needing guidance inmaking arrangements for further evaluation.7. The Certified School Nurse will contact parents/guardians who do not returnevidence of further medical evaluation within four weeks of the initial referral. Thefollowing methods are suggested;a) Telephone call or personal interview.b) Repeat referral letter. Send home by U.S. mail.c) M34 form sent with student or U.S. mail.8. Upon receipt of the completed private health care providers’ report the appropriatedocumentation will be made.9. It is appropriate for the Certified School Nurse to contact the private health careprovider if the form is incomplete or additional information is needed regardingthis student.F. Documentation1. Record all results in the HIS, Main Menu #2, Health Inquiry and Maintenance,screen H11 (where HIS is unavailable, use MEH-3).September 1, 2002 Page 24

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALFig. 1September 1, 2002 Page 25

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALFig. 2September 1, 2002 Page 26

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALFig. 3September 1, 2002 Page 27

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALTHE SCHOOL DISTRICT OF PHILADELPHIABOARD OF EDUCATION21ST STREET S. OF THE PARKWAYPHILADELPHIA, PENNSYLVANIA 19103SCHOOL HEALTH SERVICES(215) 875-3490Dear Parent/Guardian:School law requires that a screening for scoliosis be performed on all children in grades 6 and 7.The purpose of the screening program is to detect possible curvature of the spine in children. Ifthe condition is detected early and appropriately treated, progressive spinal deformity may be prevented.The school nurse/school nurse practitioner will check your child’s back by observing it while yourchild is standing and bending forward. To assure a view of the spine, we request that students exposetheir backs during the screening. It is recommended that boys wear a shirt that can be easily removed.Girls should wear a bathing suit top or halter under a blouse or sweater. The date of screening is.You will be contacted if there is any reason to have your child examined by a pediatrician, familyphysician, or orthopedist.If your child is currently under active treatment for a spinal problem, or if you have any objectionto having your child participate in the screening program, please inform your school nurse in writing. Areport from your physician is requested.School Nurse/ SNP___________________PrincipalH511.400 (5/82)September 1, 2002 Page 28

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSchool DistrictIntermediate UnitNAME OF CHILD SEX DATEADDRESSGRADESCHOOLDear Parent/Guardian:In a recent screening program your child displayed possible scoliosis, or curvature of the spine.Further evaluation is recommended to determine if treatment is necessary. The effect of scoliosis dependson its severity, how early it is detected, and how promptly it is treated. Please have your child examinedby your family physician or check with the school nurse for other sources of treatment.Please have the examining physician complete the form on the back of this letter and return it tothe school nurse.School NurseTelephone NumberPhysical Therapy Consultant,Pennsylvania Department of Healthor Qualified RescreenerSeptember 1, 2002 Page 29

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSeptember 1, 2002 Page 30

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MANDATED PROGRAMS NUMBER 101CLASSIFICATION:VISION SCREENING - MYOPIA (SEP. 02)I. ApparatusA. Snellen or Good-Lite Chart1. Letter chart2. An illiterate “E” chart or a picture chart may be used as needed for pre-literate or specialeducation students.B. Adequate Lighting1. Light should shine without glare on chart.2. Room illumination should be constant without light shining into student’s eyes.C. Room space1. The student should sit or stand twenty feet from the chart. Distance should be accuratelymeasured and clearly marked.2. In smaller rooms it may be necessary to use a 10 foot distance. In those instances, a 10 footchart should be used.D. OccluderII.ProcedureA. Place occluder before the student’s eye with both eyes open.1. If a student wears corrective lenses, test child with lenses in place.2. Test each eye separately. Always begin with the right eye.3. Student should identify characters by pointing when using E chart or naming letters if lettersare used. Be alert in noting those young children still unsure of letter names. Verify the resultsof testing by using the E chart.4. Begin with the top line on the chart. Proceed downward to the child’s limit.5. Stop test when evidence of eyestrain appears. Record last line read. Evidence of eyestrain mayinclude:a. Thrusting head forwardb. Tilting headc. Watering eyesd. Frowning or scowling6. All students in first and second grades who Pass the Myopia screening are to be screened withthe plus lens (+2.25). Follow Hyperopia Screening Procedure (Below).B. Recording Measurements1. Visual acuity is represented as a fraction. The numerator indicates the distance from the chartat which the test was conducted. The denominator means the smallest line of letters that astudent can read from the testing distance. -1 or -2 after the fraction indicates number ofmistakes by the student while reading that line.2. In cases where the student is unable to read the uppermost letter on the chart, he should walkforward until he can see the top line or symbol. The distance between student and chartbecomes the numerator and vision is recorded as such: i.e.: 10/100, 5/200, 2/100.3. If the student does not recognize the top letter from a distance of less than one foot from chart,vision is recorded as 0/0 and the results documented in the nurse’s notes.September 1, 2002 Page 31

III.SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALCriteria for referralA. Kindergarten through Gr. 3: vision that is no less than 20/40-3 in one or both eyes.B. Grade 4 and up: vision that is no less than 20/30-3 in one or both eyes.C. In any grade, when the difference between both eyes is two lines or more, the student has failed.This is true even if the visual acuity for each eye is within the passing range. For example, astudent who reads 20/20 in the right eye,, and 20/30 in the left eye has failed the vision screening.IV. ReferralA. Screen initial failures a second time before sending Vision Screening Referral.B. Initiate a Vision Screening Referral for all students who fail screening.C. Explain use of referral form to student and/or parent/guardian.D. When referral or follow-up indicate need, Public School Health Fund vision appointments can bemade for public school students.V. Complete documentation on the student’s record.A. The HIS, screen H3 in Main Menu #2, Health Inquiry and Maintenance, is to be used unless it isnot available in the school.B. In the event that the HIS is not available, document on the MEH 3, Student Health Record, and onthe Vision Screening Worksheet or Program Control Sheet.VI. When a child’s corrected vision is 20/70 or less in the better eye the student is considered visuallyimpaired. Follow procedure for Students with Special Needs/Visually Impaired.VII.Rescreen student with new glasses to verify a correction as reported. Document this screening.September 1, 2002 Page 32

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MANDATED PROGRAMS NUMBER 102CLASSIFICATION:VISION SCREENING - HYPEROPIA (SEP. 02)I. All students in first and second grades who do not already wear corrective lenses, and who havepassed the standard vision screening are to be screened with the plus lens (+2.25).II. Instruct the student to remain at the same testing distance from the Snellen chart as for standardscreening.II.III.IV.Instruct the student to keep both eyes open.Place the plus lens in front of eyes.Instruct the student to read the 20/20 line on the Snellen chart.V. Criteria for Pass/Fail (All Students)A. Passing Criteria: Passing is the INABILITY of the student to read the 20/20 line on the SnellenChart with the use of the Plus Lens, i.e.: if the student cannot read the 20/20 line with the PlusLens, she/he has passed the screening.B. Failure Criteria : Failure is the ABILITY to read the 20/20 line on the Snellen Chart with the useof the Plus Lens: i.e.: if the student can read the 20/20 line with the Plus Lens, he/she has failedthe screening.VI.ReferralA. All students who fail the Plus Lens screening, with or without corrective lenses, should bereferred using standard procedure.1. Initiate Vision Screening Referral.2. Indicate “vision referral issued” on the student health record.a. The HIS, screen H3 in Main Menu #2, Health Inquiry and Maintenance, is to be usedunless it is not available in the school.b. In the event that the HIS is not available, document on the Student Health Record (MEH3) and on the Vision Screening Worksheet or Program Control Sheet.B. Keep returned Vision Referral on file for one year.VII. Since the vision screening program is a State mandated program, the consent of the parent is not aprerequisite.September 1, 2002 Page 33

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLE SIDE 1 OF 2September 1, 2002 Page 34

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLE SIDE 2 OF 2September 1, 2002 Page 35

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALGENERAL PROCEDURESSeptember 1, 2002 Page 36

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: GENERAL PROCEDURES NUMBER 511CLASSIFICATION:ACCIDENTS/ ILLNESS (DEC. 98)ACCIDENTS / ILLNESSEmergency care for students who become sick or who are injured at school or at school sponsoredfunctions away from school, is the responsibility of school personnel and an integral part of healthservices provided for school.Fundamental to any accident and/or illness treatment plan is acceptance by school personnel ofresponsibility for:> providing immediate care> notification of student’s parent/guardian> arranging for disposition and/or transportation to home or hospital> guiding parent/guardian, when necessary, to sources of careRESPONSIBILITIESA. The principal is to develop a plan for the care of ill or injured persons within the school.1. To provide for the maximum safety of all students in cases of fire or other disasters, theprincipal must plan for the care and welfare of every ill or injured student and for everystudent with chronic or recurrent medical disorders.2. The Physical Health Office is available for consultation in the development of the plan.3. The principal is to develop a cooperative relationship with the district police captain to ensure aworkable procedure in emergency situations.4. The principal, or designee, upon notification of an ill or injured person, must act promptly toprovide immediate care.5. The principal must have on file an employee information card containing the name, address,and telephone number of each employee’s physician and the person to notify in case ofemergency.6. All students are to participate in all school safety drills.B. The principal is to post in the school office and health suite a list of persons to be called upon torender first-aid.1. A school employee is to render necessary first-aid in extreme emergencies; reference is to bemade to the official wall chart “FIRST-AID AND EMERGENCY CARE,” Form MEH50, which must be posted in the school office, the health suite, and every classroom.2. First-aid by non-medical personnel is to be guided by the care listed on the chart.3. As a minimum, one staff member, in addition to the Certified School Nurse should be trainedto render first-aid.C. TO PROVIDE PROMPT EMERGENCY CARE FOR LIFE THREATENINGCIRCUMSTANCES CALL 911 TO ACTIVATE EMERGENCY MEDICALSERVICES (EMS).D. The principal or designee is to promptly notify the parent, guardian or person designated in caseof the emergency, by phone, messenger, or police; if the parent, guardian or person designated incase of emergencies cannot be reached, the principal is to act in place of the parent to secureadequate medical attention.September 1, 2002 Page 37

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALE. Responsibility for further medical attention in the case of students rests with the parent/guardianor person designated for emergencies; adults are responsible for their own further care.F. The principal is to inform the Academic Area Leader regarding details of all the serious casesbefore the end of the school day.G. The Incident Control Desk is to be notified by the principal and a serious incident report is to befiled.H. All activities must be documented.1. If the school nurse is in the building, the HIS, Main Menu #8, Health Room Log, must beused (where not available, use the MEH-3 or M-100).2. If the school nurse was not in the building when a serious incident occurred, the school nurseshould summarize pertinent details as to the event and any follow-up, in the student's healthrecord on the HIS, screen H7, or in Main Menu #9, Health Log for a Student, upon thenurse's return. Written and verbal sources of information and providers of service to thestudent should be clearly identified. The note should indicate that it is a summary of eventsoccurring on another day (provide actual date of service).September 1, 2002 Page 38

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: GENERAL PROCEDURES NUMBER 511.1CLASSIFICATION:CATEGORIES OF EMERGENCIES (DEC. 98)Students, teachers, other School District of Philadelphia employees, and visitors may have medicalemergencies at school or off school premises, but on school business (e.g., on the school bus, field trips,etc.). All personnel should be familiar with the School District of Philadelphia First Aid Chart ANDshould know how to access the Emergency Medical System (EMS) by calling 911.While most emergency situations encountered in schools are not life threatening, the possibility exists thatthey may be. It is appropriate to develop plans for immediate treatment and mobilization of emergencyservices. EACH SCHOOL SHOULD HAVE AN EMERGENCY PLAN IN PLACE. The CertifiedSchool Nurse should be involved in the development of the plan.The Following triage plan was developed for schools by the Connecticut American Academy of PediatricsSchool Health Committee. It is adapted and included here as a guide in the development of the SchoolEmergency Plan.Emergencies are divided into categories, depending upon the amount of time which is allowed to elapsebefore intervention is necessary to save lives or prevent death. School Emergency Plans should takethese categories into consideration.I. CATEGORY I Emergencies are Emergent or Life Threatening.A. In these situations:1. The first person on the scene should Call 911 immediately for transport to the nearestemergency room. No time should be wasted making contacts with the school nurse, families,or physicians until 911 has been called.2. Send for assistance and remain with victim.3. Administer any authorized medication at once, e.g. epi - pens or glucagon.4. Administer first-aid to the level of competence.5. Initiate CPR; if CPR certified staff is available.6. Once EMS takes over, notify parents/guardians.7. Notify principal or person in charge.8. Document all activities.9. File Incident Report.B. Examples of CATEGORY I Emergencies are:1. Acute airway obstruction2. Cardiac arrest ( no heartbeat)3. Respiratory arrest (not breathing)4. Drowning or near drowning5. Massive bleeding, internal or external6. Poisoning internal or external7. Anaphylaxis8. Neck or back injury (possible spinal cord injury)9. Chemical burns of the eye10. Heat stroke11. Penetrating (stab) or crushing chest wounds12. Severe acute asthma attackSeptember 1, 2002 Page 39

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALII.CATEGORY II Emergencies are urgent.III.A. In these situations:1. Arrange for immediate transportation to the nearest hospital.2. Administer any authorized medication at once, e.g. asthma medication.3. Administer first-aid to the level of competence.4. Notify principal or person in charge.5. Document all activities.6. File Incident Report.B. Examples of CATEGORY II Emergencies are:1. Internal bleeding2. Angina or chest pain3. Unconscious states4. Heat cramps5. Major burns6. Drug overdose and reaction7. Head injury with loss of consciousness8. Penetration eye injuries9. Seizure in a person who is not known to have seizures10. Bee stings with rash but no breathing difficultiesCATEGORY III Emergencies: Medical consultation is desirable within an hour, although delayswill not seriously affect the outcome.A. In these situations staff can render care:1. In accordance with the School District First Aid Chart.2. Parents/guardians should be contacted to arrange further care by their primary care provider.3. All actions should be documented.B. Examples of CATEGORY III Emergencies are:1. Lacerations (cuts) that require sutures2. Animal and human bites3. Burns with blisters4. Tooth loss or fracture as a result of fracture5. Bone fractures and dislocations6. Acute emotional state7. Moderate reactions to medications8. Fever above 103 degrees9. Asthma/wheezing (Yellow Zone Peak Flow, if available)10. Non-penetrating eye injuryIV.CATEGORY IVA. Emergencies: In these instances some students will have care plans which were developed by theschool nurse. Otherwise:1. Staff can render care according to the School District First Aid Chart.2. Notify principal or person in charge.3. Document all activities.September 1, 2002 Page 40

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALB. Examples of CATEGORY IV Emergencies are:1. Seizure in a person known to have a seizure disorder2. Insulin reaction in diabetic3. Abdominal pain4. Fever 100 degree to 103 degree5. Sprains6. StrainsV. CATEGORY VA. Emergencies1. Emergencies can be handled by referring to the School District First Aid Chart.2. All activities should be documented.B. Examples of CATEGORY V Emergencies are:1. Abrasions, minor cuts, and scratches2. Minor burns3. Nosebleeds4. Minor illnesses and complaints (no fever, no vomiting)September 1, 2002 Page 41

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: GENERAL PROCEDURES NUMBER 511.2CLASSIFICATION:RELEASE FROM SCHOOL FOR ACCIDENT / ILLNESS(SEP. 01)I. RELEASE FROM SCHOOL FOR ACCIDENT / ILLNESSThe professional judgment of the School District of Philadelphia Certified School Nurses, and the“FIRST-AID AND EMERGENCY CARE CHART” (MEH 50) are to assist the principal in thecare of the ill or injured person. No ill or injured student is to be permitted to go home or to the hospitalwithout being accompanied by a member of the school staff in the absence of a parent or guardian. Nostudent is to be left at home unless there is a responsible adult to receive him/her.A. EARLY DISMISSAL OF ILL OR INJURED STUDENTS TO HOME1. It is advisable to send an ill or injured student home provided:a. The illness or injury warrants dismissal in the opinion of the Certified School Nurse or theindividual designated by the principal.b. A responsible adult is at home to receive the student.2. When a student needs home care, every effort is to be made to have the parent/guardian (or ifunable to do so, the person designated as emergency contact) come to school to pick up thestudent; if a taxi is required, the parent/guardian is to request the taxi, as they are responsiblefor the fare.3. If no responsible adult can come to the school for the student and if, in the opinion of theprincipal, the illness or injury is sufficiently serious to warrant an escort, such service is to beprovided.a. A student who is ill or injured may not be sent home without an escort.b. The escort may be school staff or the principal; students are not to be used for thispurpose.c. The escort is to report to the principal the disposition of the case, and a record is to bemade.d. In cases of serious injury a serious incident report should be completed.e. Under Pennsylvania law, the School District assumes no responsibility for thetransportation of students or employees in private automobiles; insurance coverage isprovided only by the escort’s own automobile insurance.B. STUDENTS SENT TO THE HOSPITAL1. It is advisable to send an ill or injured student to a hospital emergency room as soon aspossible in any case in which:a. The parent/guardian and other responsible persons concerned with the incident agree thatthe illness or injury is not compatible with home care.b. The parent /guardian of a student whose condition apparently demands prompt medicalcare cannot be located within a reasonable time.c. Extreme emergencies may demand immediate action without preliminary attempts to locateresponsible adults; however, these adults are to be notified as promptly as possiblethereafter.2. Transportation to the Hospitala. The Emergency Medical System (EMS) should be activated by calling 911.b. A member of the school staff must accompany the student in the emergency vehicle, and isSeptember 1, 2002 Page 42

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALto remain at the hospital with the student until the parent/guardian or parent designatedemergency contact arrives at the hospital. The principal or designee should make sure thattransportation from the hospital is provided to the staff member.c. In case of a serious illness or injury occurring when the Certified School Nurse is notavailable, he/she should be notified.d. The Incident Control Desk is to be notified and a serious incident report completed.September 1, 2002 Page 43

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: GENERAL PROCEDURES NUMBER 511.3CLASSIFICATION:RETENTION OF STUDENT IN SCHOOL (ACCIDENT /ILLNESS) (DEC. 98)II.RETENTION OF STUDENT IN SCHOOLA. If an ill or injured student is to remain in school until the end of the school day, but is unable toreturn to class, the student is to be placed under the supervision of an adult designated by theprincipal.B. The nature of the illness or injury is to guide the principal in the selection of the person tosupervise the ill student.C. At dismissal time, the principal will make a decision concerning the necessity of providing escortservice for the student.September 1, 2002 Page 44

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: GENERAL PROCEDURES NUMBER 511.4CLASSIFICATION:SERIOUS HEAD AND NECK INJURY (DEC. 98)SERIOUS HEAD, NECK OR SPINE INJURYI. The School Nurse/Practitioner shall:A. Refer a student with a serious head, neck or spine injury to a hospital immediately: Phone 911Fire Rescue for emergency transportation.B. Position the student:1. For head or neck injury keep student flat and immobilize the affected part.2. If fracture of the neck is suspected, place rolled up clothing, blankets, etc. around thestudent’s head, sides of neck and shoulders to prevent movement.3. If fracture of the spine is suspected keep student in the position in which found to avoidfurther damage to the spinal cord resulting in paralysis.C. Control hemorrhage immediately with application of a sterile dressing (without cleansing). (Avoidusing excessive pressure due to possible skull fracture).D. Ensure an open airway.E. Offer calm reassurance.F. Notify school principal or designee and teacher.G. Notify parent of nature of injury and name of hospital to which student has been taken.H. Send M-34 Report of Visit to Health Services, with a thorough and accurate account of accidentand observations along with student to the hospital.I. Provide documentation to the principal or designee for use in filing a serious incident report.J. Document all relevant data, including reports from the treating agency.K. Monitor and document the progress of recovery.September 1, 2002 Page 45

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: GENERAL PROCEDURES NUMBER 511.5CLASSIFICATION:MINOR HEAD AND NECK INJURY (SEP. 01)MINOR HEAD, NECK OR SPINE INJURY TREATMENTI. The School Nurse/Practitioner shall:A. Control any bleeding immediately.B. Detain in health room (under adult supervision) for at least 15 minutes for observation.1. If signs of serious injury develop keep the person in the health room for further observationand follow procedure for serious head injury.2. If at the end of at least 15 minutes no signs of serious injury are observed, student may returnto classroom with a note to:a. Instruct student and teacher that student is to report back to the nurse for a brief follow-upone hour after he returns to the classroom (or sooner if needed)b. Instruct teacher to observe student and contact the nurse if signs of serious injury developafter return to the classroom. If this occurs, procedures for serious injury should befollowed.C. Every reasonable effort must be made to contact the parent by telephone,D. Inform parent of head injury by completing the Head Injury Letter to Parent, MEH-51 and makingcertain that it is taken home by the student.E. In the event that school is dismissed prior to the 15 minutes of observation, inform parents totransport student home and to continue observation.F. Monitor the progress of the student’s recovery.G. Record all data.September 1, 2002 Page 46

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLE SIDE 1 OF 2September 1, 2002 Page 47

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLE SIDE 2 OF 2September 1, 2002 Page 48

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALCHILD ABUSE / NEGLECTSeptember 1, 2002 Page 49

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: CHILD ABUSE / NEGLECT NUMBER: 806CLASSIFICATION:CHILD ABUSE (BOARD POLICY) (DEC. 98)806. CHILD ABUSEDate Adopted: April 27, 1981Date Revised: April 25, 19881. PurposeThe Board of Public Education recognizes that successful school achievementdepends both on the quality of instruction and the physical and emotionalwell-being of the learner.This policy reflects concern regarding child abuse and accepts the role ofthe School District in:2. DefinitionProviding all possible assistance to students who suffer abuseRequiring the reporting of suspected child abuse in accordance with the lawCooperating with appropriate community agenciesMandating staff development to fulfill the purpose of this policyEvaluating school environment continually for the purpose of timelyidentification and reporting of suspected child abuse.Child Abuse shall be defined in accordance with the provisions of the ChildProtective Services Law, the regulations of the Pennsylvania Department ofWelfare, and the decisions of the Courts of this Commonwealth. Thisdefinition shall be implemented in the directives of the School OperationsManual.3. Delegation of ResponsibilityThe Superintendent shall set forth the legal definition of child abuse andprovide regulations for compliance with the statutory requirements thatinstances of child abuse be reported. Such regulations shall:inform all staff members having contact with students of theirresponsibility to report all cases of abuse, abandonment, cruelty or neglectresulting in physical or mental injury by other than accidental meansSeptember 1, 2002 Page 50

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALReferences:designate the school principal as the staff member who shall reportsuspected instances of child abuse to the appropriate county welfare agencyrequire prompt attention to injuries which result from abuse as to protectthe health of the childprovide for the release to the appropriate county child welfare agency thename and age of the child as well as the name and address of the parent(s)or guardian(s) and information regarding the nature and extent of thechild's injuries, abuse or maltreatment and such information which, in theopinion of the Superintendent, has a bearing on the suspected child abuse.School Code: SS 1319 Act 124 of 197511 P.S. SS 220355 PA Code 3490.4School Operations Manual 504September 1, 2002 Page 51

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: CHILD ABUSE / NEGLECT NUMBER 111.5CLASSIFICATION:GUIDELINES FOR REPORT ANDINVESTIGATION OF ALLEGED SEXUAL ANDSERIOUS PHYSICAL MISCONDUCT WITHCHILDREN BY EMPLOYEES (DEC. 98)PA Law (Act 151 of 1994) requires that all allegations by students "of serious bodily injury, sexualabuse, or sexual exploitation," by school employees or the employees of independent contractors workingin the schools or with students, be reported to the authorities set forth below. As previously provided forin the PA Child Protective Services Act (see #111.6 through #111.13), good faith reports by schoolemployees are subject to civil immunity, and the failure to report is subject to criminal sanctions.I. DEFINITIONSA. Sexual Abuse or ExploitationThe rape, molestation, incest, prostitution or other form of sexual exploitation of children,including the employment, use, persuasion, inducement, enticement or coercion of anychild to engage in or assist any other person to engage in any sexually explicit conduct, orany simulation of any sexually explicit conduct, for the purpose of producing any visualdepiction of any sexually explicit conduct.B. Serious Bodily InjuryBodily injury which creates a substantial risk of death or which causes serious permanentdisfigurement or protracted loss or impairment of function of any bodily member or organ.NOTE:In addition to the technical definition contained in the statue the DistrictAttorney’s Office has provided the School District with the followingsupplemental definitions:1. Substantial Risk of Death - Injury or neglect requiring admission to an Intensive care Unitor which in the opinion of the health care provider’s judgment poses a substantial risk ofdeath; any physical injury caused by a deadly weapon; suspected intentional poisoning;abandonment which consists of prolonged or repeated lack of supervision that endangers achild’s life or development; starvation; internal bleeding or trauma; or head injury/braindamage2. 2.Serious Permanent Disfigurement - Genital disfigurement; amputation; ear or eyedisfigurements; branding/burns; loss of permanent teeth; or cuts or scrapes that will causenoticeable scars.3. Protracted Loss or Impairment of the Function of a Body Member or Organ - Damage tosight; hearing or esophagus; internal injuries, including kidney or liver damage; cuts thatsever nerves or ligaments; broken bones; starvation; or sexually transmitted diseases.September 1, 2002 Page 52

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALII.III.REPORTING REQUIREMENTSA. Any school employee receiving a report from a student, or who by virtue of their trainingor experience, reasonably suspects that a student coming before him/her is a victim of sexualabuse or sexual exploitation, or serious bodily injury by a school employee must notify thebuilding or program administrator. If the accused employee is the administrator, the employeeshall make the reports set forth in Section B (below) him/herself (See Section IV onConfidentiality).The principal or other administrator in charge must make the following calls in the order shown:1. Police Department - 9112. The Philadelphia District Attorney's Office – 215-686-8096, 8014, 80803. Parent or emergency contact4. Incident Control Desk – 215-875-3613 - 36155. Administrator to whom the school directly reports6. Office of General Counsel – 215-299-7676The report shall include:a) the name, age, address and school of the student(s);b) name and address of the student's parent or guardian;c) name and address of the person making the report;d) name, work and home address of the employee who is the subject of the report;e) the nature of the alleged offense;f) any specific comments or observations directly related to the alleged incident orthe parties involved.The content or existence of an allegation or report may not be disseminated to any otherperson or agency without the approval of the Office of General Counsel. (Note: formalinvestigations will be carried out jointly by the police and Department of Human Services,and cooperation with that investigation is required).INTERNAL DISCIPLINARY INVESTIGATIONSA. Following compliance with the reporting requirements set forth in Section II above, the principalor administrator in charge must conduct an investigation of all allegations to determine whether aclear accusation of intentional misconduct has been made. The investigation shall includeinterviews with the victim, all possible witnesses and, where appropriate, the accused. The victimshould be the first person interviewed. The initiation of the internal investigation should not bedelayed to await completion of the police or District Attorney’s investigations, which may take upto 60 days. Under no circumstances should the principal’s investigation jeopardize thepreservation of physical evidence. For instance, if a complainant alleges a contemporaneousSeptember 1, 2002 Page 53

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALincident and the possibility exists that a medical examination could prove or disprove the existenceof body secretions, bruises or abrasions, a report should not be delayed overnight or for anylessor period of time which could affect the outcome of such tests.B. The Initial Report of Serious Incident Follow-up Reports and any memoranda must be markedconfidential. (See Section 111.1 of the School Operations Manual for additional procedures).File an Initial Report of Serious Incident the same day that any accusations come to the attention ofthe principal or person in charge of the School District facility. The report must contain:1. Complainant’s name, age, address and relationship to the victim if thecomplainant is not the victim.2. Name, age, sex, and job title of the accused employee.3. Name, address, age, grade in school and sex of the victim.C. An incident Follow-up Report shall be filed after the investigation. This report shall include thefollowing information:1. Name, age, address of the complainant2. Name, age, address and grade of victim3. Name and job title of accused employee4. Name, age, address, and job title or age and grade, if applicable, of allwitnesses5. Description of place(s) where events allegedly occurred6. Date(s) and time(s) when events allegedly occurred7. Verbatim transcription of child's allegations. The transcription should be madeby someone other than the interviewer (e.g., secretary) to ensure accuracy andfacilitate questioning. Whenever possible a staff member who is the same sex asthe child (e.g., nurse, counselor, vice principal) should be present. In somesituations, it may be advisable for this staff member to conduct the questioning,depending upon the age and personal modesty of the child.8. The names, addresses or locations of any witnesses revealed by theinvestigation or identified by the student or employee.9. Record names and job titles of all employees who participate in theinvestigation.September 1, 2002 Page 54

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALD. Interview of Accused EmployeeAny interview with an employee must be conducted in accordance with dueprocess requirements, i.e., notice of the charges and an opportunity to be heard inperson or in writing. Compliance with proper procedure will ensure that anydisciplinary action, e.g., SEH-204, will be upheld upon later review. It isrecommended that the principal or person in charge of the investigation refer to theappropriate collective bargaining agreement regarding notice provisions and referany questions to Labor Relations or the Office of General Counsel prior to theinterview with the accused employee.E. Cooperation with Law EnforcementSchool District policy requires full cooperation with the police, District Attorneyand/or DHS in any investigation. Refer to #109.0 of the School OperationsManual. In some sexual molestation cases, the parents may impede a fullindependent investigation by School District officials by preventing access to thechild. It is still the responsibility of the principal or the person in charge of theinvestigation to make an assessment of the situation and make a recommendationregarding the status of the employee even if he/she has not had a full opportunity tointerview the child. Factors to be considered include, but are not limited to, initialdiscussion with child, interview with accused employee, interviews with witnessesand police reports.F. Removal of Employee from School - Suspension1. In some circumstances, it may be necessary to remove the employee from thebuilding pending the School District’s internal investigation. As in the case ofsuspension, removal of an employee can only be done with the approval of theAcademic Area Leader and Chief of Staff’s Office.2. The School District should not postpone its decision regarding removal orsuspension of an employee (with or without pay) because of a delay in thecompletion of the police or DHS investigation. Suspension of an employee mustfollow appropriate due process. Any questions should be referred to LaborRelations or the Office of General Counsel. In the event an employee is suspended(with or without pay) it is imperative that the Office of Human Resources isnotified. Under no circumstances may an employee be suspended without firstbeing given notice of the charges and opportunity to respond to those charges.The parent(s) of the accusing student(s) should be advised that without a criminalconviction their child's testimony will be needed if the case reaches the arbitrationlevel regarding the accused's status as a School District employee. They shouldunderstand that the criminal and administrative processes are separate and apart.September 1, 2002 Page 55

IV.SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALCONFIDENTIALITY OF INVESTIGATIONAccusations, the nature of which are the subject of these reporting procedures, can severelydamage the reputation of the accused. These accusations may also disrupt a school communityand result in additional trauma to a victim. It is, therefore, imperative that only those people witha need to know be involved in the investigation. Anyone involved in the investigation must becautioned that any breach of confidentiality could result in personal liability (civil and monetary)for the employee as well as disciplinary action.V. NON-REPORTABLE PHYSICAL CONTACTWhile the reporting requirements for physical assault set forth in Section II above only apply toinstances where serious bodily injury occurs, the internal investigative procedures set forth inSection III are also to be applied to allegations of corporal punishment which is specificallyprohibited by Board Policy #218, Section 2.121. Corporal punishment means any physicalcontact designed to punish a student for any school infraction or to deter a student from futureviolations. Corporal punishment does not include reasonable physical contact or restraintnecessary to protect the safety and welfare of any member of the school community including theoffending student, or to terminate any on-going serious disruption of the school or its programs.September 1, 2002 Page 56

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: CHILD ABUSE / NEGLECT NUMBER 111.6/504.0CLASSIFICATION:CHILD PROTECTIVE SERVICES (DEC. 98)It is the Policy of the School District of Philadelphia that all of its employees are to be aware of andcomply with the Child Protective Services Law, P.L. 438, Act 124, 1975, as amended by Act 33 (1985)and Act 151 (1994).A. Under the Act, any person who, in good faith, reports suspected child abuse or cooperates withan investigation or court proceeding, shall have immunity from civil and criminal liability thatmight otherwise result by reason of those actions. The good faith of all persons required to reportunder the Act is presumed. Where abuse is suspected and the student is 18 years of age or older,or where the Child Abuse Hotline rejects a report because the alleged abuse did not occur in thefamily or home unit (e.g. by a boy/girlfriend) please refer to procedure #111.14.B. Under the Act, any person who is required to report a case of suspected child abuse and fails to doso "shall be guilty of a misdemeanor”.C. The privileged communication between any professional person required to report and the patientor clients does not apply to situations involving child abuse and does not constitute grounds forfailure to report suspected child abuse.D. Persons Required to Report:1. School personnel, because of their sustained contact with pre-school and school-age children,are in a position to identify children who may be abused or neglected.2. Thus, School District employees are required to report, whenever they have reasonable causeto suspect child abuse and/or neglect.E. Definitions contained in the Act:1. Child Abusea) Any recent act or failure to act by a perpetrator which causes non accidental seriousphysical injury to a child under 18 years of age.b) An act or failure to act by a perpetrator which causes non accidental serious mentalinjury to or sexual abuse or sexual exploitation of a child under 18 years of age.c) Any recent act, failure to act or series of such acts or failures to act by a perpetratorwhich creates an imminent risk of serious physical injury to or sexual abuse orsexual exploitation of a child under 18 years of age.d) Serious physical neglect by a perpetrator constituting prolonged or repeated lack ofsupervision or the failure to provide essentials of life, including adequate medicalcare, which endangers a child’s life or development or impairs the child’sfunctioning.September 1, 2002 Page 57

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL2. “ Serious Physical Injury ” An injury thata) causes a child severe pain; orb) significantly impairs a child’s physical functioning, either temporarily orpermanently3. " Serious Mental Injury "- A psychological condition, as diagnosed by a physician or licensedpsychologist, including the refusal of appropriate treatment, that:(a) renders a child chronically and severely anxious, agitated, depressed, sociallywithdrawn, psychotic or in reasonable fear that the child's life or safety is threatened; or(b) seriously interferes with a child's ability to accomplish age-appropriate developmentaland social tasks.4. " Sexual abuse or exploitation " - The employment, use, persuasion, inducement, enticement orcoercion of any child to engage in or assist any other person to engage in any sexually explicitconduct or any simulation of any sexually explicit conduct, for the purpose of producing anyvisual depiction of any sexually explicit conduct, or the rape, molestation, incest, prostitutionor other form of sexual exploitation of children.5. " Perpetrator " - A person who has committed child abuse and is a parent of a child, a personresponsible for the welfare of a child, an individual residing in the same home as a child or aparamour of a child's parent.6. " Person responsible for the child's welfare " - A person who provides permanent or temporarycare, supervision, mental health diagnosis or treatment, training or control of a child in lieu ofparental care, supervision and control. The term does not include a person who is employedby or provides services or programs in any public or private school, intermediate unit or areavocational-technical school.7. “ Individual residing in the same home as the child” - An individual who is 14 years of age orolder and who resides in the same house as the child.8. “ Recent acts or omissions” - Acts or omissions committed within two years of the date of thereport to the Department of Public Welfare or country agency.9. “ School employee” - An individual employed by a public or private school, intermediate unitor area vocation-technical school. The term includes an independent contractor and employees.The term excludes an individual who has no direct contact with students.September 1, 2002 Page 58

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: CHILD ABUSE / NEGLECT NUMBER 111.7/504.1CLASSIFICATION:RESPONSIBILITIES OF PRINCIPAL (DEC. 98)The principal, or person in charge of a School District facility, when informed of a suspected case of childabuse and/or neglect is to:A. Complete a report of suspected child abuse and/or neglect; please refer to Section 111.9. Note: Thebuilding administrator has the legal obligation to report allegations received from staff members. Wherethere is a serious question concerning whether the report was made in good faith or whether the conductis reportable the administrator should, without delay, contact the Office of General Counsel.B. Refer the pupil to the school or program nurse. If the nurse is not present on the day when the pupilpresents evidence of abuse and/or neglect, the principal or person in charge of the facility is to proceedwith the referral. If the injury is one which should be documented by a trained care-giver the nurseshould be called to the school from her/his other assignment or the nursing supervisor is to be notifiedthat a nurse is unavailable. If such documentation is not required or where the child is being taken to ahospital the school nurse is to be notified at her/his next visit.C. Reports to DHS and/or CHILD LINE should be made immediately upon learning of the suspectedabuse. This is particularly critical where the child indicates a reluctance or refusal to return home as DHSneeds as much time as possible to obtain a court order and to arrange to have the child picked up.D. A staff member must be assigned to stay with the child until a DHS worker can take over custody. Ifthe DHS worker does not arrive as promised within a reasonable time after school is dismissed,arrangements should be made with School Safety or the Philadelphia Police to transport the child to DHS.If such arrangements are made DHS should be so informed.September 1, 2002 Page 59

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: CHILD ABUSE / NEGLECT NUMBER 111.8/504.2CLASSIFICATION:RESPONSIBILITIES OF THE SCHOOL NURSE(DEC. 98)A referral of the suspected case of child abuse and/or neglect is to be referred to the school nurse if one isavailable.A. The pupil is to be examined and interviewed.B. The teacher, counselor and principal are to be consulted regarding the injury and/or neglect.C. The existence of previous indices of possible abuse and/or neglect are to be checked.D. The Pupil Health Record, "is to be completed with facts relevant to the situation." This shallinclude a professional description of the injuries and/or chief complaint, and a note that State FormCY-47, "Report of Suspected Child Abuse," has been filed.E. The school nurse is to make a referral to the counselor, if the pupil is not known to thecounselor.F. Where the suspected abuse involves health issues (physical or mental) any written documentationincluding reports to the parent or guardian, requests for examinations, referrals, and the response (or lackthereof) from the caregiver is to be included with the CY-47 filed in the case.September 1, 2002 Page 60

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: CHILD ABUSE / NEGLECT NUMBER 111.9/504.4CLASSIFICATION:PROCEDURE FOR REPORTING (SEP. 01)When informed of a case of suspected child abuse and/or neglect, the principal or person in chargeof a facility is to:A. Telephone the Pennsylvania Department of Public Welfare, Bureau of Child Welfare:CHILD LINE 1-800-932-0313.1. Principal is to identify himself/herself.2. Provide as much of the following information as possible:a. the names of the child and adults being reportedb. the date, nature, and extent of the alleged child abuse and/or neglectc. the home addresses of persons in the reportd. the age(s) and sex of the child(ren) suspected of being abused and/or neglectede. the locality in which the alleged abuse and/or neglect occurredf. any evidence of prior abuse by the alleged perpetrator(s)g. the source of the reporth. actions taken (medical test, exam, photographs)i. seek directions whether the school should notify the parent or guardian of thereport of abuse, or whether the child care agency wishes a delay in the notificationand will take over responsibility for the notification. (See Procedure #111.10)B. Telephone the Philadelphia Department of Human Services Child Abuse HOT LINE: 215-683-6100. Inform them that the State Child Line has already been called. Provide thesame information as was given to the state and any additional information requested.Failure to place this call will delay DHS's response as there is frequently a 2 to 3 hourdelay before they are notified by the state agency.C. Form CY-47, “Report of Suspected Child Abuse” with an accompanying letter if neededare to be sent within 48 hours to:SupervisorChild Abuse HotlinePhiladelphia County Children and Youth Agency1515 Arch StreetPhiladelphia, PA 19102September 1, 2002 Page 61

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALD. No copies of the CY-47 are to be made or maintained in any file. An Incident Report isto be prepared documenting the allegations and that steps A, B, and C above werefollowed. The name of the alleged perpetrator is NOT to be included. The Child is only tobe referred to by his/her I.D. Number.E. Still photographs of the child, showing injuries MAY be taken. The photographs are to beretained in the school and made available to DHS workers upon request. They are NOT tobe sent with the CY-47. The fact that photographs were taken is to be noted on the CY-47.F. In the event that questions regarding the referrals persist after a report is filed, consult witheither School Health Services (215-875-3490) or the Office of General Counsel (215-299-7676).September 1, 2002 Page 62

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: CHILD ABUSE / NEGLECT NUMBER 111.10/504.5CLASSIFICATION:NOTIFICATION OF PARENTS (DEC. 98)After the referral of a suspected case of child abuse and/or neglect is made, every effort must bemade to notify the parents of the fact. However, where the parent or guardian is the suspectedabuser, the Department of Human Services (DHS) shall be consulted prior to informing the parentor guardian of the referral. Where the DHS investigator requests that notice not be made, becauseit may compromise the investigation or endanger the child, the principal may allow DHS to assumeresponsibility for the above notice.Premature notice has, in the past, resulted in the suspected abuser removing the child from theschool, prior to the arrival of an investigator, in an effort to hide the child from authorities.September 1, 2002 Page 63

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: CHILD ABUSE / NEGLECT NUMBER 111.11/504.6CLASSIFICATION:COOPERATION WITH CHILD AND YOUTH AGENCYWORKERS AND LAW ENFORCEMENT (DEC. 98)A. Properly identified caseworkers from the Philadelphia Children Youth Agency (DHS) mayrequest the assistance and cooperation of school personnel, such as:1. Releasing the pupil to the DHS worker upon an order from a judge.2. Arranging a private interview of the pupil, with the caseworker and pupil alone, onschool premises.3. Providing information in the pupil pocket to the DHS worker, assigned lawenforcement agent, or court appointed guardian.B. Any questions regarding information requests are to be referred to the Office of GeneralCounsel, (215-299-7676).C. The permission of parents is not required for the compliance of school personnel withauthorized child abuse investigators.September 1, 2002 Page 64

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: CHILD ABUSE / NEGLECT NUMBER 111.12/504.7CLASSIFICATION:EARLY CHILDHOOD PROGRAMS (DEC. 98)A. In ALL Early Childhood Programs : In Get Set, Day Care, Child Care Programs,Prekindergarten Head Start, and Parent Cooperative Nursery Program, staff members are to reportsuspected cases of abuse/neglect to any of the following persons: head teacher, lead or resourceteacher, caseworker, supervisors, social service coordinator, instructional coordinator or nurse.B. Procedures listed in section 111.9 are to be followed by the person receiving the report.September 1, 2002 Page 65

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: CHILD ABUSE / NEGLECT NUMBER 111.13/504.9CLASSIFICATION:RESPONSIBILITIES OF SCHOOL COUNSELORS(DEC. 98)I. A referral of a suspected case of child abuse and/or neglect may be referred to the schoolcounselorA. The pupil may be interviewed by the counselor.B. The principal, teacher and counselor are to be consulted regarding the injury and/orneglect.C. The counselor and school nurse are to work in collaboration to complete the referral.D. The counselor may provide follow-up counseling service to the pupil and/or the familyif indicated.II. Recognizing that feedback to school personnel is desirable to allow for evaluation of, planningfor, sensitivity to, a child's needs, an amendment to the Child's Protective Services Act (effectivedate 1/5/88) allows School Personnel who have filed a report of abuse to obtain from DHS:A. The final status of the report following the investigation (indicated, founded orunfounded); andB. Information identifying any services provided, arranged for, or to be provided, byDHS to protect the child from further abuse.III. To obtain this information, the counselor should contact the social worker or the socialworker's supervisor who investigated the report.September 1, 2002 Page 66

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: CHILD ABUSE / NEGLECT NUMBER 111.14/504.9CLASSIFICATION:DOMESTIC VIOLENCE-SPOUSAL & DATE ABUSE(SEP. 01)A. Students 18 years of age or older or employees may be the victim of physical or sexual abuse atthe hands of spouses, dates or significant others. While the Child Abuse reporting provisionsset forth in the preceding policies and procedures do not apply to victims who are 18 years ofage or older, other legal safeguards and services are available. Where a student is the victim ofsuch abuse the procedures set forth in the following paragraphs must be followed. Theseprocedures may also be followed for staff members and other members of the schoolcommunity. Where a child under the age of 18 is suspected of being the victim of abuse by aboy/girlfriend whom they do not reside with and the Child Abuse hotlines decline to act on thereport because the abuse is not related to the home living conditions, the procedures set forthabove must be followed. A CY-47 should still be filed even if the Child Abuse Agencydeclines the oral report.B. Whenever a staff member becomes aware that a student age 18 or older, may be the victim ofphysical or sexual abuse the principal or the person acting in his/her stead is to be immediatelynotified.1. The principal, taking into consideration the nature of the suspected abuse, anyspecial relationship of trust existing between the victim and professional staffmembers, the availability of school specialists such a nurse, counselor,psychologist, S.A.P. team members, etc., shall immediately assign staff to meetwith the student.2. The assigned staff member(s) shall meet with the student and conduct an interviewto try to determine the nature of the problem and, where appropriate, to arrange forthe nurse to conduct a physical examination.3. If the student is receptive to seeking social services and/or police or judicialintervention, referrals shall be made to the appropriate agencies set forth in section'B.4' and 'B.5.' below.4. If the student is reluctant or resistant to seeking help from outside agencies, theassigned staff member(s) shall, before the student leaves, consult with one of theCity’s approved counseling agencies for further guidance or assistance. Theseagencies are:a. Women Against Abuse Hot Line - 215-386-7777 (24 Hours)b. Women Organized Against Rape - 215-985-3333 (24 Hours)c. Women in Transition - 215-751-1111 (24 hours)d. Service and Education for Asian Abused Women - 215-627-3922e. Congresso de Latino Unidos, Latino Domestic Violence Program - 215-978-1174September 1, 2002 Page 67

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALf. Lutheran Settlement House - 215-426-8610These agencies can provide or refer victims to trained counseling staff, legalassistance for obtaining protective orders, temporary housing and other supportservices.5. While the Police Department usually will not get involved in assault cases unless thevictim is ready to press charges, the Philadelphia Police Department has specialDomestic Violence Response Teams in each police division. These specially trainedteams will look into such reports. Even if the victim is not ready to seek an arrest,these teams will inform the victim of his/her options and will make it clear that apresent refusal to press charges does not foreclose a later change of mind.The appropriate team should be notified whenever there is concern for the safety of the student.They may be reached at:a. Central Division- 215-686-3230, 215-686-3231b. Southwest Division – 215-686-3185c. South Division – 215-685-1659d. East Division – 215-686-3242, 215-686-3245e. North Division – 215-686-3352f. Northeast Division – 215-686-3153 or 215-686-3154g. Northwest Division – 215-686-3395September 1, 2002 Page 68

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALCOMMUNICABLEDISEASE CONDITIONSSeptember 1, 2002 Page 69

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: COMMUNICABLE DISEASE CONDITIONS NUMBER 304CLASSIFICATION:AIDS/HIV INFECTION (DEC. 98)I. Definition 1AIDS is an acronym for acquired immune deficiency syndrome. As used in this policy,AIDS includes all levels of infection, from asymptomatic to ... “classic” AIDS, caused by theAIDS virus. This virus has been designated by scientists and medical authorities as the HumanImmunodeficiency Virus (HIV).II. PurposeA. To protect the health and safety of all students and employees who are diagnosed ashaving AIDS/HIV Infection.B. To protect the confidentiality of all students and employees who are diagnosed as havingAIDS/HIV Infection.C. To inform staff of steps to be taken when staff become aware of or suspect a student oremployee has AIDS/HIV Infection.III. ConfidentialityA. When a staff member becomes aware, by any means, that a student or employee hasbeen or is rumored to be AIDS/HIV positive, NO DISCUSSIONS ARE TO TAKEPLACE AND NO OTHER PERSON IS TO BE CONTACTED.B. The strictest rules of confidentiality are to be followed as indicated in this procedure.IV. Methods of Transmission 2A. The HIV Virus is transmitted through these methods:1. Sexual exposure and exposure to blood or tissues. (The routes are analogous tothose of the Hepatitis B virus.)2. Children may also acquire the HIV Virus from their infected mothers in theperinatal period.B. The HIV Virus has been found in saliva, tears, urine, and bronchial secretions, buttransmission after contact with these secretions has not been reported.C. Routine social, community, or school contact with an HIV-infected person carries norisk of transmission.1 School District of Philadelphia Policy: Section-Students; No. 236, AIDS/HIV Infection:Adopted November 18, 1985, Revised September 1, 1987 and December 17, 1990.2 Benenson, Abram, editor; Control of Communicable Diseases in Man: American PublicHealth Association, 1990, p3.September 1, 2002 Page 70

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALD. The incubation period varies. “Although the time from infection to the development ofdetectable antibodies is generally 1-3 months. The time from HIV infection to diagnosis ofAIDS has an observed range of about 2 months to 10 years or longer.” 3E. The period of communicability is unknown. It is presumed to begin early after onset ofHIV Infection and extend throughout life. 4V. Prevention of Opportunistic InfectionA. Immunosuppressed children (and adults) are at greater risk of suffering severecomplications from such infections as chickenpox, cytomegalovirus * , tuberculosis, herpessimplex, and measles. 5B. All persons known to be immunosuppressed are to be excluded from school in the eventthat there is an outbreak of the above diseases.3. Benenson, Abram, editor: Control of Communicable Diseases in Man: American PublicHealth Association, 1990. p. 4.4. Benenson, Abram, editor: Control of Communicable Diseases in Man: American PublicHealth Association, 1990. p. 4.5. MMWWR: (Morbidity and Mortality Weekly Report) U.S. Department of Health andHuman Services/Public Health Service; Vol. 34, No 34 August 30, 1985* Also termed salivary gland virus.September 1, 2002 Page 71

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: COMMUNICABLE DISEASE CONDITIONS NUMBER 300CLASSIFICATION:INTERAGENCY PROTOCOL BETWEEN SCHOOLDISTRICT & DEPARTMENT OF HEALTH (SEP. 02)INTERAGENCY PROTOCOLBetweenTHE SCHOOL DISTRICT OF PHILADELPHIAAndTHE CITY OF PHILADELPHIA DEPARTMENT OF PUBLIC HEALTHThe control of communicable diseases is a function of the State and City Departments of Health, governed by Statelaws and local Department of Public Health regulations. The School District of Philadelphia is a key partner in thiseffort.When The School District of Philadelphia learns of a reportable communicable disease in a member of the schoolcommunity the Philadelphia Department of Public Health (PDPH) must be notified @ 215-685-6740. Cases ofpossible Tuberculosis are reported to 215-685-6744. Conversely, when the Philadelphia Department of Public Health(PDPH) knows of a case of communicable disease in a member of the school community, an appropriate SchoolDistrict official will be notified. Such notice shall occur at the earliest possible opportunity during normal businesshours.However, there are a small number of special situations which require immediate sharing of information betweenboth agencies, even during evenings, weekends and holidays. These special situations are:• Death of a student from any reportable communicable disease.• Any case of bacterial meningitis.• Any case of polio.Confidentiality regarding the identity of the case being reported will be maintained at all times by all parties.COMMUNICATION PROCEDURES FOR SPECIAL SITUATIONS -OUTSIDE NORMAL BUSINESS HOURSWhen the Health Department learns of a Special Situation outside normal business hours the personon duty at the Health Department will telephone the School District of Philadelphia Designee @ 215-299-7233.The School District Designee will immediately notify the Chief of Staff and AAO who, in turn,will notify the School Principal.When the School District of Philadelphia hears “word” of a possible Special Situation outside normalbusiness hours the person on duty at The School District will contact the City of Philadelphia Department ofPublic Health by calling 215-686-5665 and asking for the Disease Control “on call person”.September 1, 2002 Page 72

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALCOMMUNICATION PROCEDURES-DURING NORMAL BUSINESS HOURSWhen the Health Department learns of a Special Situation during normal business hours the person onduty will telephone one of School Health Services Coordinators below:1. Ms. Jacqueline Guynn @ 215-875-5034 (pager 215-899-6007)2. Ms. Connie Williams @ 215-875-5033 (pager 215-899-8626)3. Ms. Shelley Applegate @ 215-875-5032 (pager 215-899-8637)4. Ms. Rhona Cooper @ 215-875-5035 (pager 215-899-2420)School Health Services Coordinators will notify the school principal and the School Health Services Director.• The school principal will inform the Academic Area Office.• The Academic Area Office will notify the Deputy Superintendent.• The School Health Services Director or designee and the Chief of Staff or designee will collaborate andmonitor the situation.In the event, during normal business hours, there is no response within one hour, HealthDepartment staff will contact the school directly.COMMUNICATION PROTOCOL FOR REPORTING OTHER POSSIBLE COMMUNICABLE DISEASESREPORTABLE COMMUNICABLE DISEASESWhenever a school hears “word” of possible communicable diseases, regardless of the source:• The School Nurse must be notified.• The School Nurse will gather all relevant information and contact the City of Philadelphia Departmentof Public Health.• The School Nurse will notify a School Health Services Coordinator.• The City of Philadelphia Department of Public Health will investigate to confirm the diagnosis.ALL CASES MUST BE DISCUSSED WITH THE CPDPH BEFORE ANY ACTIONS ARE TAKEN BYSCHOOL STAFF.ROLE OF THE CITY OF PHILADELPHIA DEPARTMENT OF PUBLIC HEALTHIn all instances The Health Department will:• describe to the school district’s designee the Health Departments’ intended response to the situation.• advise the school district’s designee regarding appropriate and necessary health actions needed to betaken by the school district to protect the public health of the school community.• draft a letter or notice to be sent home to the school community when necessary.• make known their availability for continued consultation.• remind the SDP of the confidential nature of all information being exchanged.ADDITIONAL INFORMATION IS AVAILABLE TO SCHOOL STAFF IN THE CITY OFPHILADELPHIA DEPARTMENT OF PUBLIC HEALTH DIVISION OF DISEASE CONTROLMANUAL IN ALL HEALTH ROOMS (“THE YELLOW BOOK”)September 1, 2002 Page 73

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: COMMUNICABLE DISEASE CONTROL NUMBER 303CLASSIFICATION:IMMUNIZATION (SEPT. 02)Immunization requirements1. Pennsylvania Department of Health School Immunization Regulations, Title 28, chapter 23,and Philadelphia Health Code, Title 6, Section 6-210 require that: All pupils must beimmunized or exempted before admission to any public, Parochial, or private school inPennsylvania.2. Written proof of immunization from a physician or other health professional is to be requestedfrom the parent. In the absence of written proof, the parent may provide a history of thechild’s immunization including the month, day, and year of each immunization. UnderPennsylvania law, an oral history by the parent is acceptable proof.3. Requests for immunization information directed to the child’s health care provider should besubmitted on a 'Consent for Release of Information '(Form M-68) signed by the parent orlegal guardian. This request may be submitted to the provider by the parent, by mail, or byfax, whatever is most expedient.4. Children may be registered without proof of immunizations prior to the start of school.However, parents and guardians must be informed that in order to attend school, writtenproof of a minimum of at least one dose of each required vaccine will be required. This iscalled a PROVISIONAL admission .When a pupil has been admitted provisionally, a plan for completing the immunizationsshall submitted by the parent. This plan may be developed in consultation with the schoolnurse. Provisional records must be reviewed every sixty days. If the plan is not followed orthe provisional period expires before immunizations have been completed, the pupil may beexcluded from school until evidence of immunization or exemption is submitted. Allimmunizations MUST be completed within 8 months after the first day the child attendedschool.5. At the time of registration, the person registering the pupil must enter the requiredimmunization information into the Pupil Information Network, Screen S61. If the electronicrecord is completed, it is not necessary to generate a hand-written “Certificate ofImmunization”. Screen S61 also serves as acceptable documentation of immunization in thestate auditing process. In the HIS, Screen S61 may be accessed in Main Menu #1,Immunization and Contact Information.Immunization data must be entered for all pupils entering Kindergarten or Grade 1 for thefirst time. This includes any pupils entering Head Start, Comprehensive Day Care, or otherPre-Kindergarten programs , even if these students already have a School District ofPhiladelphia identification number.As of October 1, 2000 immunization information for all pupils is to be stored electronically inScreen S61 and must be kept current. It must also be readily available for auditing or foridentification of exempted pupils in the event of a disease outbreak.September 1, 2002 Page 74

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALIt is no longer necessary to generate a Pupil Health Record (Form MEH-3). When the pupilis added to the school enrollment, an electronic record is automatically generated in the HealthInformation System (HIS) accessed by the school nurse. Existing Certificates ofImmunization and MEH-3 forms should be stored in the pupil pocket.The record of immunization shall follow the pupil when he/she transfers, graduates, ispromoted, or leaves the school district. The electronic record will be transferred with thepupil to any other Philadelphia public school. When a pupil transfers to another schooldistrict, a printed copy of the immunization record should be placed in the official pupilpocket prior to deleting the pupil’s data from the Pupil Information Network6. There are two categories of EXEMPTION from the immunization requirements which mustbe entered in the exemption screen accessed via the Screen S61:Religious exemption – Pupils need not be immunized if the parent or guardian objects,in writing, to the immunization on religious grounds or a strong moral or ethical convictionsimilar to a religious belief.Medical exemption – Pupils need not be immunized if a physician or his/her designeestates, in writing, that immunization may be detrimental to the health of the child. This maybe either a temporary or permanent status. When the physician determines that theimmunization is no longer detrimental to the health of the child the exemption ceases to bevalid and the child must be immunized. Temporary exemptions are also granted for alimited period of time when it has been verified that the supply of vaccine is not available orwhen the spacing between doses in a vaccine series has been exceeded. Temporaryexemptions must be manually deleted from the exemption screen accessed via Screen S61.Parents of all exempted pupils should be informed that if the PhiladelphiaDepartment of Public Health declares an epidemic of a disease for whichimmunization is an admission requirement, pupils who are exempted willnot be permitted to attend school for the duration of the epidemic.A “CERTIFICATE OF IMMUNIZATION” WITH THE PARENT’S OR PHYSICIAN’SSTATEMENT OF EXEMPTION AND SIGNATURE SHOULD BE KEPT ON FILE.Questions regarding the immunization status of an individual pupil should bediscussed and resolved in consultation with the school nurse or School Health Servicesstaff at (215) 875-3490 or (215) 875-3749.September 1, 2002 Page 75

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL8. IMMUNIZATION REQUIREMENTS 2002-2003 ALL GRADES (K-12)This table represents a summary of the Pennsylvania Department of Healthand the Philadelphia Department of Public Health Immunization Requirementsfor School Entry, September 2002GRADES Requirements (Recommended Vaccines)K-2 ND DiphtheriaTetanusPolioMeaslesMumpsRubellaHepatitis B4 Doses: at least one dose after the 4 th birthday (DTaP/DTP/DT/Td)*4 Doses: at least one dose after the 4 th birthday (DTaP/DTP/DT/Td)*3 Doses (OPV/IPV)2 Doses: both after the 1 st birthday (MMR)*1 Dose: after the 1 st birthday (MMR)*1 Dose: after the 1 st birthday (MMR)*3 Doses: properly spaced (HBV)*Varicella (Chickenpo 1 Dose: after the 1 st birthday OR a history of disease (VARIVAX)***3 RD -5 TH DiphtheriaTetanusPolioMeaslesMumpsRubellaHepatitis B6 TH -7 TH DiphtheriaTetanusPolioMeaslesMumpsRubellaHepatitis BVaricella (Chickenpo8 TH -10 TH DiphtheriaTetanusPolioMeaslesMumpsRubellaHepatitis B11 TH -12 TH DiphtheriaTetanusPolioMeaslesMumpsRubella4 Doses: at least one dose after the 4 th birthday (DTaP/DTP/DT/Td)*4 Doses: at least one dose after the 4 th birthday (DTaP/DTP/DT/Td)*3 Doses (OPV/IPV)2 Doses: both after the 1 st birthday (MMR)*1 Dose: after the 1 st birthday (MMR)*1 Dose: after the 1 st birthday (MMR)*3 Doses: properly spaced (HBV)*3 Doses (DTaP/DTP/DT/Td)* (6 th grade students who entered school since 1997must have a total of 4 doses with one dose after the 4 th birthday)3 Doses (DTaP/DTP/DT/Td)3 Doses (OPV/IPV)2 Doses: both after the 1 st birthday (MMR)*1 Dose: after the 1 st birthday (MMR)*1 Dose: after the 1 st birthday (MMR)*3 Doses: properly spaced (HBV)**1 Dose OR a History of disease**** (if ≥ 13 yrs: 2 doses separated by 28 days)3 Doses (DTaP/DTP/DT/Td)3 Doses (DTaP/DTP/DT/Td)3 Doses (OPV/IPV)2 Doses: both after the 1 st birthday (MMR)*1 Dose: after the 1 st birthday (MMR)*1 Dose: after the 1 st birthday (MMR)*3 Doses: properly spaced (HBV)**3 Doses (DTaP/DTP/DT/Td)3 Doses (DTaP/DTP/DT/Td)3 Doses (OPV/IPV)2 Doses: both after the 1 st birthday (MMR)*1 Dose: after the 1 st birthday (MMR)*1 Dose: after the 1 st birthday (MMR)*References: ****2001 Philadelphia Board of Health Regulation RE: Adolescent Varicella*** 2000 Philadelphia Board of Health Regulation RE: Varicella Vaccine** 1998 Philadelphia Board of Health Regulation RE: Adolescent Hepatitis B Vaccine* 1997 Pennsylvania School Immunization LawSeptember 1, 2002 Page 76

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL9. Recommended Practices to Facilitate Management of the School ImmunizationProgramASSESSMENT:• Utilize data from the Health Information System (HIS), Certificates of Immunization, and theReports of Private Physical Examination (MEH-1) to:• Identify students who are inadequately immunized and refer these students for update of theirimmunizations immediately.• Identify students who are provisionally admitted and develop plans with their families forcompletion of required immunizations;• Identify students who are admitted with medical and/or religious exemptions:PLANNING:• As early as possible, arrange to meet with the principal or the principal’s administrative designeeto discuss the findings of the assessment process.• The principal or designee should be able to identify all exempted students in the event that thereis an outbreak of a vaccine-preventable disease for which exempted students must be excludedfrom school attendance.• The priority activities should be focused on students whose records indicate an inadequateimmunization history.• All students who are provisionally admitted should have a plan for the completion of the requiredimmunizations submitted by their parents. The plan must be in writing and made a part of thestudent’s health record and be reviewed every 60 days.IMPLEMENTATION:• Contact families of students with inadequate immunization histories immediately in an attempt tobring every student to at least provisional status.• Assist parents to gather the required information from all current and previous sources of primaryhealth care.• A Consent for Release of Information (M-68) may be completed by the parent and submittedto the provider directly or by the school via fax to expedite the exchange of medicalinformation.• School nurses may utilize the immunization database maintained by the PhiladelphiaDepartment of Public Health at (215) 685-6784.• Refer families to either their primary providers or the nearest public health center forimmediate immunization update.• Monitor/review the records of students admitted provisionally and remind parents at appropriateintervals to visit their health providers for update of the required immunizations.• Take advantage of all opportunities to interact with parents such as Back to School Nights, SchoolAssemblies, Home and School gatherings, Report Card Conferences, etc.• Update the student’s record in the HIS immediately upon receipt of data from the student’s primaryhealth care provider.EVALUATION:• By October 15 of each school year, all students will be attending school with at least provisionalimmunization status.• The status of all provisionally admitted students will be monitored at least every 60 days and parentalcontact will be maintained until all required immunizations are obtained.• All required immunizations will be obtained within 8 months of the date of provisional admission.If not, the principal will be advised to undertake suspension procedures, in accordance with thePA School Code.School nurses should use every contact with parents as an opportunity to assurethat every student has health insurance and access to primary health care.September 1, 2002 Page 77

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: COMMUNICABLE DISEASE CONTROL NUMBER 301CLASSIFICATION:PEDICULOSIS CAPITIS (SEP. 01)I. PURPOSEA. To prevent the spread of pediculosis (lice) among school children.B. To detect pediculosis in the early stages in order to prevent secondary bacterialinfections caused by scratching.C. To comply with state regulations regarding communicable disease control: TITLE28 Health & Safety (28 Pa. Code ch. 27) Section 27.71. Exclusion for specifieddiseases and infectious conditions.“Each teacher, principal, superintendent, or person in charge of any school shallexclude students from school who have been diagnosed by a physician orare suspected of having the disease by the school nurse for the indicatedperiod of time...”“Pediculosis capitis- following the first treatment with an effective pediculicide.Removal of nits is not required if effective treatment has been given.”I. DEFINITIONS/ TRANSMISSIONA. Pediculosis Capitis is an infestation of the scalp and hair by the head louse. It feedson the host and perishes within two to three days after removal. The eggs are laidattached to the hair shaft and reach maturity within two to three weeks.B. Transmission is by direct contact with an infested person, especially their clothing,bedding, hats, hairbrushes or combs.C. Transmission by fomites is highly unlikely, but possible.II. SCHOOL MANAGEMENTA. Screening for head lice of an entire school is not generally indicated. The schoolnurse will discuss the degree of infestation with the principal and will determine ifthe infestation situation warrants more extensive screening and how that will beaccomplished.III. SYMPTOMSA. Severe itching of scalp.B. Scratch marks or rash on scalp or nape of neck.C. Infected sores on scalp.D. Presence of eggs (nits)A nit is a louse egg. Nits are teardrop in shape, approximately 1/8 inch in length,and vary in color from yellowish-brown to white. They are attached to thehair shaft with a waterproof, cement-like substance. Clusters of nits may befound in any section of the hair, often near the scalp at the nape of the neckand/or behind the ears. In light infestations, a careful examination of theentire scalp may be necessary to detect them. Nits cannot be washed out orbrushed out like dandruff.September 1, 2002 Page 78

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALA. Presence of liceHead lice are elongated insects approximately 1/4 inch in length, and are grayishwhite with dark margins. Lice do not have wings and cannot fly. Theymove quickly, but do not jump. This quickness makes them difficult to seeand an infestation identification is often made on the basis of nits only.I. ROLE OF THE SCHOOL NURSEA. Suspected cases of head lice1. Examine the student for lice or nits by using a tongue blade or woodenapplicator stick, part the hair and look for marks, redness and/or nits.Utilize sufficient strong lighting to make identification easier.2. If a suspected nit is identified, use the tongue blade or applicator to try anddislodge the nit. If it adheres to the hair shaft, it is much more likely to be anit than dandruff, skin or hair spray flakes or other debris in the hair.B. Discard the tongue blade or wooden applicator after each individual student; using anew one for each student.C. Differentiate between active and inactive infestation.1. Active: actual lice seen, and or the presence of whitish nits within 1/4 inchof the scalp.2. Inactive: nit shells which appear translucent and are farther than 1/4 inchfrom scalp.D. All students free of infestation may return to the classroom.E. Immediately exclude any student who has an active case of head lice until evidenceof appropriate treatment is submitted to the school or until the school nurse indicatesthe student is infestation free.1. Notify the parent/guardian of the infestation and the exclusion.2. Issue the Pediculosis Letter to Parent when the parent/guardian picks thestudent up at school.F. Examine all students in the same classroom as the infested student. Exclude asindicated.G. Examine all siblings or other students who live in the same home. Exclude asnecessary. Examine that classroom in its entirety as indicated.H. Notify other schools of siblings or home mates if indicated.I. Notify the teacher of the screening results. Emphasize to the teacher that anexcluded student may not return to class until evidence of effective treatment hasbeen submitted.J. Provide a list of excluded students to the principal.K. Rescreen students excluded for pediculosis, and all students in that classroom oncea week for three weeks or until in the school nurse’s judgment the classroom isinfestation free.L. In a situation of chronic infestation or multiple students being infested, the schoolnurse will bring it to the principal’s attention. The nurse will discuss with theprincipal the advisability of sending a letter of notification of the infestation problemto the parents of all students not known to be infested at the present time. It is theprincipal’s responsibility to inform the parents of non-infested students of theinfestation problem.September 1, 2002 Page 79

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALII.PREVENTIVE MEASURES DURING A PEDICULOSIS OUTBREAKA. Classroom activities involving frequent body contact between students should betemporarily suspended. This includes in-class dance activities, certain games,wrestling in physical education classes, etc.B. Group work activity around classroom tables should either be temporarilysuspended or children should be allowed to occupy only every other seat at the tablein order to minimize person-to-person contact.C. Clothing and equipment1. A policy of assigning hooks in cloakrooms should be initiated.2. Hats should be kept in coat sleeves or pockets rather than in piles on shelvesor on the floor3. Separation of clothing should occur in those areas in which facilities forhanging coats are not available (i.e. Gymnasium, cafeteria, workshops,etc.).4. Classroom dress-up activities should be curtailed temporarily.5. Resting mats, towels, and pillows for students should be permanentlyassigned and be kept separated during use and storage.Carpeted classrooms should be vacuumed daily. This is more important in pre-k,kindergarten and first grade classes because of the time the lower grades spend on thefloor.September 1, 2002 Page 80

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLESCHOOL DISTRICT OF PHILADELPHIASCHOOL HEALTH SERVICESDear Parent/Guardian of________________Room/Grade_________Upon examination, the school staff has found that your child has HEADLICE/NITS (eggs).• Having head lice is not something to be ashamed of and DOES NOT mean yourchild is dirty.• Head lice do not carry disease.• Head lice do spread to others and must be treated at once.YOUR CHILD CANNOT COME BACK TO SCHOOL UNTIL HE/SHE HAS BEENTREATED! AN ADULT MUST bring the child and proof of treatment to a schoolstaff member, who will recheck the child’s hair.Treatment for Head Lice• There are lice killing treatments which you can buy at the drug store or health foodstore. You can also get a prescription from your doctor.• Be sure to follow ALL the instructions on the box\bottle EXACTLY!• Check everyone in the house for lice/nits. Treat everyone who has head lice/nits atthe same time.• The BEST WAY TO STOP HEAD LICE from coming back is to pull out all the nits(eggs) from the hair. You can use a fine-tooth comb or pull them out with yourfingers.Cleaning the Home and Household ItemsEverything that touches the head or shoulders can spread lice and should be cleanedas follows:• All hats, hair ribbons, scarves, clothes, pajamas, coats, towels, sheets, blanketsand bedspreads should be cleaned by machine washing in hot water and driedusing the hot cycle of a dryer for at least 20 minutes.• Anything that cannot be washed such as stuffed animals or pillows would be drycleanedor sealed in a plastic bag for 2 weeks.• Combs and brushes should be cleaned by soaking in very hot water for 10minutes.• Vacuum everywhere including rugs, mattresses, upholstered furniture and carseats.Certified School Nurse_____________________Date_________M-45 (Rev. 5/2000) – COMM. CODE 61602445243September 1, 2002 Page 81

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSample Parental Letter for Schools with Pediculosis Capitis InfestationDear Parent/Guardian:A growing number of cases of head lice have recently been detected in our school. Of allcommunicable childhood diseases, only the common cold occurs more often than head lice.Consequently, whenever we learn that a student has head lice, that student is excluded from schooluntil adequate treatment has begun.Lice infestations can happen to anyone. In fact, clean heads are more likely to become infested thandirty or dandruffed ones. Lice do not normally spread disease, but they can spread rapidly ifpreventive measures are not taken as soon as the lice or their eggs have been detected. Carefulparents can, and must, help us to eliminate this problem at our school and in our community.Head lice are generally transmitted from one person to another by direct personal contact and bysharing of personal items such as combs and brushes, hats, scarves, and coats.I am asking for your cooperation and request that you please follow the instructions below:Examine your children for indication of infestation. Head scratching and intense itching of thescalp are the main signs of head lice. Use good light and a magnifying glass to inspect the hair andscalp. Look for tiny grayish crawling forms and/or tiny whitish oval eggs stuck to the hair shaftsabout 1/4” from the scalp.ALTHOUGH AN ANNOYING PROBLEM, HEAD LICE INFESTATION SHOULD NOTTRIGGER UNDUE ALARM...JUST IMMEDIATE ACTION. In most cases, all that is requiredis shampooing with a good anti-lice preparation, a medicated shampoo available at your localpharmacy without a prescription, or by prescription from your family doctor. All persons in theinfested individuals household should also be examined for the presence of lice and eggs. Allinfested persons should undergo treatment.In addition to shampooing, where possible, all combs and brushes, clothing, bedding, andupholstery should be disinfected.Infestations usually occur when infested people fail to report them due to a misguided notion of asocial stigma attached to the problem. But once detection, immediate reporting, and propertreatment procedures are instituted, the problem can be quickly and easily eliminated.For further information on lice detection and prevention, contact your school nurse.Sincerely,PrincipalSeptember 1, 2002 Page 82

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: COMMUNICABLE DISEASE CONTROL NUMBER 302.0CLASSIFICATION:SEXUALLY TRANSMITTED DISEASES (DEC. 98)PURPOSE1. To make certain that students with sexually transmitted diseases obtain treatment.2. To prevent the spread of sexually transmitted diseases.3. To expedite the investigation of contacts of students who have or have been exposed tosexually transmitted diseases.4. To facilitate cooperation with the City of Philadelphia, Department of Public Health .I. RationaleSexually transmitted diseases (STDs) constitute a large public health problem which affectsa substantial number of teens and young adults. The certified school nurse may be the firstmedical person the student approaches with suspected symptoms. STDs which must bereferred for treatment are:SyphilisGonorrheaGenital HerpesGenital WartsChlamydiaHepatitis BHIVII. SymptomatologyEarly symptoms vary depending on the specific STD. Complaints of urethral or vaginaldischarge, pain or burning when urinating, genital lesions, painful sores, or meatalswelling and redness, need to be investigated. Symptoms of HIV and Hepatitis B are notlocalized and may be more difficult to recognize. Unlike the other STDs, these two may ormay not have been contracted through sexual activity.The school nurse should keep in mind that an STD may be present without causingsymptoms. Therefore, any student known to be sexually active should be warned aboutthe possibility of undetected disease.III. Role of the Certified School NurseA. A referral to a city STD clinic should be made when the school nurse suspects the presenceof, or exposure to an STD.Note : In accordance with Pennsylvania Law [35 PS 521.14 (a)], School Districtpersonnel need not notify parents of students who are referred to health centers fortreatment of STDs. It is, however, School District policy that students beencouraged to involve their parents in their treatment programs.September 1, 2002 Page 83

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALB. The school nurse should assist the student in making an appointment for evaluation andtreatment. A “Report of Visit to Health Services” (M34) should be completed and sentwith student to clinic. Follow the regular early dismissal procedure.Note: No student may be excused from school to attend an STDclinic without parental permission.C. STDs found in children under the age of twelve are generally evidence of sexual abuse. A“Report of Suspected Child Abuse and Neglect” (CY47), must be made.D. Students will not be excluded from school unless otherwise instructed by treating agency.E. The school nurse should monitor the need for, and adherence to, additional clinicappointments.F. Student contacts whom the Department of Public Health have not been able to locate athome, may be interviewed at the school. Arrangements will be made through anadministrator or the school nurse.September 1, 2002 Page 84

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALMEDICATIONADMINISTRATIONSeptember 1, 2002 Page 85

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MEDICATION ADMINISTRATION NUMBER 400CLASSIFICATION:ACETAMINOPHEN STANDING ORDERS (SEP. 02)I. Who May AdministerII. PurposeIII. ProcedureSchool District supplied acetaminophen maintained in the Health Room may be administered onlyby the Certified School Nurse or School Nurse Practitioner.The health room management of a student or school staff member with a non-chronic complaintmay be facilitated by providing medication for the relief of apparently minor symptoms. In mostinstances, this will make it possible for the students to return to the classroom or the staff memberto work.For persistent or recurrent complaints, students or staff must be referred to their family physicians.The Certified School Nurse will:1. Take a history to determine:a. The nature of the complaint.b. The degree of discomfort and/or disability.c. Duration of symptoms.d .The likelihood of a more serious problem existing, e.g., in case of a headacheinquire about head injury, vision problems, dizziness, etc. For abdominal paininquire about food eaten, nausea, vomiting, diarrhea, location of pain,tenderness, fever, etc.e. The presence or absence of allergies or drug reactions.f. Whether or not the student/staff is taking any other medication, and for whatpurpose.g. The presence of conditions that may be compromised by usingacetaminophen.h. Acetaminophen should not be administered without consulting the primary careprovider or parent of persons who:1). Have allergies.2). Are taking other medications3). Who have conditions that may be compromised by usingacetaminophen.2. Administer acetaminophen3. Record in the Electronic Health Information Systema. Go to 'Health Log Inquiry and Maintenance'1). In the 'treatment' field enter;a) 'TY1' for one 325 mg Tablet of Acetaminophenb) 'TY2' for two 650 mg Tablets of AcetaminophenSeptember 1, 2002 Page 86

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL2). In the Notes field, document the nursing assessment and all otherrelevant information. Be sure your name appears in the note.4. Where the Electronic Health Information System is not available, record on the StudentHealth Record.a). Use the MEH 3 or Temporary Problem List.1). Document the nursing assessment and all other relevant information.2). Record the visit on the M-98 [Record of Illness or Injury]5. For employees record all relevant information on the M-98.IV. STANDING ORDERS (See Next Page)September 1, 2002 Page 87

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALTHE SCHOOL DISTRICT OF PHILADELPHIASchool Health ServicesSUBJECTADMINISTRATION OFMEDICATIONPOLICY AND PROCEDURECLASSIFICATIONACETAMINOPHENSTANDING ORDERSDATE ISSUEDSEPTEMBER 2002NUMBER400If indicated, acetaminophen may be administered as follows:Acetaminophen 325 mgm tabletDose:Dispense:Instructions:Student / staff under 125 pounds = 1 tabletStudent / staff over 125 pounds = 2 tabletsTwo dose maximumOne - Two tablets every 4 to 6 hoursPhysician’s Signature on File in Student Health Services OfficeISSUED BYSCHOOL HEALTHSERVICESSUPERSEDESREVIEW BEFOREAS NEEDEDPAGE1 OF 1September 1, 2002 Page 88

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MEDICATION ADMINISTRATION FORRELIEF OF DYSMENORRHEACLASSIFICATION:NUMBER 404IBUPROFEN - STANDING ORDER (SEP. 02)I. Who may administerSchool District supplied ibuprofen maintained in the Health Room may be administered bythe Certified School Nurse only.II.III.PurposeThe Health Room Management of a student or school staff member with nonchronicdysmenorrhea may be facilitated by providing medication for the relief ofminor discomfort associated with menses. In most instances, this will make itpossible for the student to return to the classroom or the staff member to work.ProcedureA. The Certified School Nurse will:1. Take a history to determine:a) Symptomsb) The degree of discomfort and/or disabilityc) Duration of symptoms.d) Health care previously sought for dysmenorrhea in past.e) What the student/staff has done for dysmenorrhea at home and theresponse to that therapy.f) The presence or absence of allergies or drug reactions.g) The presence or absence of pre-existing conditions in whichIbuprofen would be contraindicated.h) Whether or not the student/staff is taking any other medication, andfor what purpose.2. Ibuprofen should not be administered without consulting the primary careprovider or parent of student or staff who :a) Have allergies.b) Are taking other medications.c) Who have conditions that may be compromised by using ibuprofen.3. Administer ibuprofen.4. Students or staff seen for three consecutive menstrual cycles fordysmenorrhea requiring ibuprofen for relief of symptoms will be referredfor gynecological evaluation. Ibuprofen will not be administered to theseindividuals until the referral is complete and MED 1 is completed for PRNadministration of ibuprofen.September 1, 2002 Page 89

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL5. Record in the Electronic Health Information System.a) Go to ‘Health Log Inquiry and Maintenance’(1) In the ‘treatment’ field enter;(a) ‘IB 1’ for one 200 mg. Tablet of Ibuprofen.(b) ‘IB 2’ for two 200 mg Tablet of Ibuprofen.(2) In the Notes field, document the nursing assessment and allother relevant information. Be sure your name appears inthe note.6. Where the Electronic Health Information System is not available, documentthe nursing assessment and intervention on the Student Health Record.Record the visit on the M-98 [Record of Illness or Injury.7. For employees, record all relevant information on the M-98.IV.Standing Orders (See next page)September 1, 2002 Page 90

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALTHE SCHOOL DISTRICT OF PHILADELPHIASchool Health ServicesSUBJECTMEDICATIONADMINISTRATION FORRELIEF OFDYSMENORRHEAPOLICY AND PROCEDURECLASSIFICATIONIBUPROFENSTANDING ORDERSDATE ISSUEDSEPTEMBER 2002NUMBER404STANDING ORDERSIf indicated , Ibuprofen may be administered for dysmenorrhea as follows:Student or staff over 125 pounds: 400 mg P.O. q 4 to 6 hours prnStudent or staff under 125 pounds: 200 mg P.O. q 4 to 6 hours prnPhysician’s Signature on File in Student Health Services OfficeISSUED BYSCHOOL HEALTHSERVICESSUPERSEDESREVIEW BEFOREAS NEEDEDPAGE1 OF 1September 1, 2002 Page 91

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MEDICATION ADMINISTRATION NUMBER 506CLASSIFICATION:ADMINISTRATION OF LONG TERM MEDICATION -SCHOOL BOARD POLICY (DEC. 98)On February 25, 1980, the Board of Education adopted the following resolution:WHEREAS, Public Law 94-142 requires that handicapped children receive certain supportiveservices in order to enable them to benefit from special education programs, andWHEREAS, such children often require the administration of medication and/or medical equipmentin order to derive such benefits, therefore, be itRESOLVED, That the administration of such medication and/or medical equipment take place inschool and be performed by School District personnel when such has been shown to be necessaryand cannot be limited to those hours when the youngster is not in school and be itFURTHER RESOLVED, That this policy shall apply only to medication, equipment or machinerynecessary to maintain the pupil in the classroom; equipment requested for acute conditions orrecovery purposes will not be approved, and be itFURTHER RESOLVED, That this policy will be implemented by the procedures appended heretoand will be applicable to all parent-initiated requests to have medication and/or medical equipmentadministered in school to their child, and be itFURTHER RESOLVED , That, when it has been medically determined to be necessary, and inaccordance with laws governing the placement of children with handicapping conditions, everyeffort will be made to place a child requiring medication and/or medical equipment in a schoolwhere there is already a person trained in the administration of such medication and/or medicalequipment.September 1, 2002 Page 92

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MEDICATION ADMINISTRATION: NUMBER 210CLASSIFICATION:USE OF MEDICATION/MEDICAL EQUIPMENTSCHOOL BOARD POLICY (DEC. 98)1. Purpose2. Definition1. The Board of Education recognizes that a number of students have medically certifiedconditions requiring medication, equipment, or machinery to be administered during schoolhours in order to maintain health and to function in the school setting.1. This policy shall apply only to medical measures necessary to maintain a student inschool and which can be administered by school staff. Medication, equipment, andmachinery requested for acute conditions or for recovery purposes shall not be approved .3. Delegation of Responsibility4. CriteriaReferences:PL 94-1421. The Superintendent shall have authorization to determine procedures for staffdevelopment in the use of medication and equipment, assign responsibility for delivery ofservices, and school placement of students with such medical needs .1. Medication shall be administered by the school nurse. In the nurse's absence, medicationshall be administered by the principal or his/her designee.2. All prescriptions and/or medical procedures must be approved by the Division of SchoolHealth Services.3. The Division of School Health Services shall provide instruction to school staff for useof equipment and administration of medication.4. Regulations for the use of medication/medical equipment shall be made available in themanuals of the Division of School Health Services and of the Office of School Operations.Such regulations shall include:1. Administration of medication in school2. Use of medical equipment and/or machinery in school3. Processing of parental requests for in school administration of medication or equipment4. Receipt and storage of medication and/or equipment5. Maintaining records of use of medication and equipment.September 1, 2002 Page 93

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: ADMINISTRATION OF MEDICATION,UTILIZATION OF MEDICALTECHNOLOGYCLASSIFICATION:NUMBER 506.1PRESCRIBED MEDICATION (SEP. 02)I. PURPOSEIdeally, the administration of medication or utilization of equipment should take place at home.However, students with health problems may require medication (administered at prescribed intervals) orsuction, oxygen, or other types of equipment in order to permit them to function at as close to a normallevel as possible in the classroom. Consequently, a need exists to provide these services to students whorequire them to make it possible for them to remain in school.This procedure applies only to medication, equipment, or machinery necessary to maintain thestudent in the classroom, as prescribed by the family health care provider. THE SCHOOL DISTRICTOF PHILADELPHIA DOES NOT DIAGNOSE STUDENT CONDITIONS ORPRESCRIBE MEDICATION/TREATMENT.NO MEDICATION/TREATMENT WILL BE ADMINISTERED IN SCHOOLWITHOUT A COMPLETED AND APPROVED MED-1 (REQUEST FORADMINISTRATION OF MEDICATION OR USE OF SUCTION, OXYGEN OR OTHEREQUIPMENT IN SCHOOL. [SEE NOTE IN II, A, 3 REGARDING PROVISIONALADMINISTRATION OF MEDICATION.]Medication is to be administered by the Certified School Nurse (Certified School Nurse). In theabsence of the Certified School Nurse, it may be administered by the principal or his/her designee.Certified School Nurses will provide instruction for administration of medication or use ofequipment to all school staff.ALL APPROVED REQUESTS WILL EXPIRE ON AUGUST 31 OF EACH YEAR ORWHENEVER A CHANGE IN DOSAGE OR TYPE OF EQUIPMENT IS REQUESTED.THIS PROCEDURE MUST BE CARRIED OUT IN ITS ENTIRETY EVERY YEAR.A WRITTEN ORDER, BY A PHYSICIAN, ON A PRESCRIPTION OR LETTERHEAD ISACCEPTABLE FOR A CHANGE OF DOSE OR EQUIPMENT.II. CRITERIAA. The following criteria have been established as a basis for consideration of requests foradministration of medication in School:1 . The medication cannot be given at home.2. The purpose of the medication is to enable the student to function in the classroom.September 1, 2002 Page 94

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL3. All medication must be prescribed by a qualified health care provider on FormMED-1.No medication or treatment will be administered without form MED-1.[Medication which is packaged and labeled by a registered pharmacistmay be approved and administered by the school nurse for a periodnot to exceed 14 calendar or 10 school days. This will allow the parenttime to get the MED-1 form completed and signed. The school nurse must confirmthe order by calling the prescribing physician. A written order by a physician on aprescription pad or letterhead is acceptable for changes in dosages or changes inequipment.]4. OTC medications require written confirmation by a qualified health care provider ( aprescription blank or letterhead is acceptable. Faxed documentation is alsoacceptable.)5 . Written parental approval is required.6. The prescription (MED-1) must be approved by the Certified School Nurse, orSchool Physician, or School Health Services Coordinator.7. The parent will supply the medication, properly labeled and packaged as describedin II, A,7 below.8. Medication will be retained by the school only if it has been packaged and labeledby a Registered Pharmacist according to accepted pharmaceutical standards. Themedication label must include:• Patient Name• Pharmacy Name• Pharmacy Address and Phone• Prescription Number• Prescription Date (must be current)• Name of Medication, Dosage, Form, and Expiration Date (if relevant)• Instructions for Administration• Name of prescribing health care provider• Medication must be packaged with a Safe-T Closure Cap9. OTC medications must be in the original manufacturer’s container with directionsfor use intact on the label or box.B. The following criteria have been established as a basis for consideration of requests for use ofequipment / machinery in school:1. Similar equipment is kept by the student’s family at home.2. The purpose of the equipment is to enable the student to function in the classroom.3. The equipment/machinery must be prescribed by a qualified healthcare provider onForm MED-1.4. Written parental approval is required.September 1, 2002 Page 95

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL5. The prescription (MED-1) must be approved by the Certified School Nurse, orSchool Physician, or School Health Services Coordinator.6. The parent will supply and service the necessary equipment / machinery.7. Operating instructions must accompany equipment.III. PERSONNEL RESPONSIBLE FOR ADMINISTRATION OF MEDICATIONA. The PRINCIPAL shall:1. Consult with the Certified School Nurse (Certified School Nurse) to select a personto administer/monitor medication when the Certified School Nurse is not in thebuilding.2. Notify the person designated/selected in writing, or in accordance with schoolpolicy for designation of assignments.3. Make provision for the Certified School Nurse to instruct the principal and designeein the proper administration, supervision and monitoring of students and theirmedications.4. Notify the parent that if the Certified School Nurse is not available, AND THEPARENT CANNOT COME TO THE SCHOOL, the principal or the principal’sdesignee, having been trained by the Certified School Nurse, will administer themedication.5. Designate an area for administration of medication which will afford the studentprivacy, and insure safe storage of medication.IV. REQUEST: ROLES AND RESPONSIBILITIES[A parent who requests that administration of medication, suction, oxygen, or other types of equipment beprovided in school shall be referred to the certified school nurse, principal or his / her designee.]A. The certified school nurse, principal or his/her designee will:1. Explain the criteria and process to the parent.2. Issue “Request for Administration of Medication or use of Suction, Oxygen, or otherEquipment in School” (MED 1) to the parent. Review the letters to the parent andphysician which are on the reverse side of the MED-1.3. Advise the parent to have the MED-1 completed by the family health care provider andreturned to the school nurse. Explain that the medication or treatment can ONLY begiven provisionally for ten (10) school days without the MED-1. The MED-1 will thenbe reviewed and approved by the Certified School Nurse, or School Physician, orSchool Health Services Coordinator.4. Obtain written parental consent on the MED-1. If the medication is being administeredprovisionally, the parent must submit a written request, along with the properlypackaged and labeled medication prior to administration.September 1, 2002 Page 96

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALB. The certified school nurse will:1. Review the completed MED-1. All requests shall include:a. the full name and date of birth of the studentb. the date prescribedc. diagnosisd. medication dosage, route of administration, time schedule, and starting andending date.e. possible side effects or contraindications,f. special instructions for school staff regarding activities to be curtailed.g. a listing of any other medication (prescribed or OTC) being taken by thestudent.h. the signature and phone number of the prescribing qualified health careprovideri. the written request and consent of the parent/guardian, including consent tocontact the primary care provider.2. Call the prescribing provider for clarification, when necessary.3. Document any corrections or additions on MED-1, date and sign full signature.4. Complete the appropriate approval process as described.5. Submit a copy of the completed MED-1 to the School Health Services Coordinatorfor medications which are not in the computer.V. RECEIVING THE MEDICATION IN SCHOOLA. The school nurse, principal or his/her a competent designee, will receive the medication,equipment or machinery from the parent in accordance with safe standards which include properlabeling and packaging by the pharmacy.B. Documentation of receipt of the medication/equipment is required.Include the date, name of child, name of medication, amount of medication, and signatures ofthe persons who delivered and who received the medication on Form MED-4.VI. STORAGE OF MEDICATION IN SCHOOLA. Storage of medication must be in a secure area which meets the following criteria:1. Medication and supplies (such as syringes) must be stored in a LOCKED CABINET(preferably in the health office) which is convenient to the person responsible foradministering the medication.2. Medication requiring refrigeration will be stored in the refrigerator in the School HealthRoom.3. Only emergency medication which must be administered quickly to prevent serious harmto the student should be stored in a teacher’s desk or in the principal’s office. Examplesare bee sting kits, asthma inhalers, and/or glucagon.IT IS ALSO PERMISSIBLE FOR STUDENTS WHO REQUIRE THESEEMERGENCY MEDICATIONS, AND WHO ARE CAPABLE OF SELF-September 1, 2002 Page 97

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALADMINISTERING IN ACCORDANCE WITH COMPETENCY BASEDCHECK LIST 'ASSESSMENT CRITERIA FOR STUDENT SELFADMINISTRATION OF MEDICATION', TO CARRY THE MEDICATIONWITH THEM.VII. ROLE OF THE CERTIFIED SCHOOL NURSE[The Certified School Nurse shall be the primary person responsible for administration ofmedication/treatment.] The Certified School Nurse shall:A. Where the Electronic Health Information System (HIS) IS available.1. Enter information for each medication or treatment on the 'Student Med1 Screen'.Use August 31 as the end date.2. Each day, 'Build Daily Med1 Log'.3. Use 'Daily Med1 Log' each day to record that medication was administered.B. Where the Electronic Health Information System is not available1. Record on the (MEH-3)Student Health Record:a. Name of Physicianb. Diagnosisc. Medication and Dosed. Datee. Type of Equipmentf. Date of Approvalg. Date Medication Administration/Equipment startedh. Documentation of any and all relevant activities/encounters.Note: Daily entries on the MEH-3 for medication administration/equipmentuse are not required.2. Enter on the Medication/Equipment Log (MED 3).3. Prepare a Student’s Record of Medication Administered or Equipment Used (MED-2) for each student who receives medication/equipment.a. Complete demographic data.b. Insert the name of the medication/equipment, the dosage, the administrationroute, and special instructions in the first column.c. Insert the time of administration.C. Develop a written individual health plan (IHP) for the student which includes staff developmentfor all persons who need to know.D. Assess the ability of the student to self-administer the medication/equipment and documentthe competencies demonstrated and the dates.September 1, 2002 Page 98

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALE. Orient / instruct the person authorized by the principal to monitor / administermedication/treatment (or observe / monitor self-administration) and document the competenciesdemonstrated and the dates. (See VIII below)F. Assess the status of the student’s health, and continuing need for medication/treatment inaccordance with the IHP.G. Confer periodically with the student/parents/guardians/teacher regarding the student’s responseto the medications/treatments and health care needs.H. Provide written reports to the prescribing health care provider as indicated.(These reports can be given to the parent or sent, with parental consent, directly to theprovider).I. When medication/equipment is discontinued or changed, indicate on MED-2 and MED-3 as wellas on the Student Health Record.ORUsing the Electronic Health Information System go to "Student Med1 Screen". Enter the Line # ofthe medication to move the cursor to that line. Hit enter until the cursor is in the 'End Date' Field.In the 'End Date' Field type the last date given. Hit enter until the cursor returns to the bottomprompt.Enter 'A' for Add. The cursor will move to the next available line. Enter the new medication.J. Inform principal’s designee for medication/treatment administration of any of the abovechanges and document.K. Retain the MED-1, MED-4, and copies of any correspondence in the School Health Room atthe end of the school year.L. Retain the MED-3 and MED-2 in the School Health Room where the electronic system is notavailable..VIII. ORIENTATION TO ADMINISTRATION OF MEDICATIONA. All staff who are designated by the principal to administer or monitor self administration ofmedication/treatment to students shall be oriented/instructed by the Certified School Nurse as tothe plan of care for the individual student.B. Staff must demonstrate competency to the Certified School Nurse prior to administration ofmedication/equipment or supervision of self-administration.C. Competency shall be defined by the Certified School Nurse and shall include as a minimum theability to:1. Understand that information about a student’s medical condition/ medication isconfidential.2. Read and demonstrate understanding of the medication label.3. Follow the directions on the MED-2 (Student’s Record of Medication Administeredor Equipment used) or print out of medication to be given.September 1, 2002 Page 99

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALUse the Electronic Health Information System Daily Med1 Log" if available.OR4. State the times medication/treatment is to be taken.5. Remind the student when to take the medication/treatment.6. Wash hands properly.7. Locate the necessary equipment and medication.8. Procure water for taking oral medication.9. Open the container/bottle, if necessary.10. Co-sign the medication sheet with the student.11. Recognize any changes in a student’s appearance and/or behavior which need to becommunicated to the Certified School Nurse. Inform the Certified School NurseBEFORE allowing the student to take the medication. Do not give.12. Consult the Certified School Nurse if any change occurs in the regular schedule,route, and or dosage of administration. Do not give the medication unless instructedby the Certified School Nurse.13. Receive prior approval from the Certified School Nurse for all medication which is tobe taken on an “as needed” (PRN) basis, except bee sting kits, asthma inhalers, orglucagon.14. Recite the five rights: student, dose, time, route, medication.D. In the event the Certified School Nurse determines that the designatedindividual is incapable of any of the above competencies, the principal shallbe notified and shall select another designee.E. Medication may NOT be pre-poured.IX. ASSESSMENT CRITERIA FOR STUDENT SELF-ADMINISTRATION OF MEDICATIONIn specific cases, individual students will be allowed to be directly responsible for the maintenance andadministration of their medication with minimal supervision. This will occur after a nursing assessment,approval of the parents and family health care provider and instruction of the student about the expectationsrelated to this responsibility.A. To self-medicate/treat, the student must demonstrate the ability to:1. Respond to his/her name.2. Recognize visually his/her name.3. Identify his/her medication.September 1, 2002 Page 100

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL4. Wash hands properly.5. Measure, pour and administer the prescribed dosage of the medication.6. Sign the medication sheet as acknowledgment of having taken themedication/treatment.7. Demonstrate a cooperative attitude in all aspects of self-administration ofmedication/treatment.8. Notify adult when medication is gone.B. To carry medication, the student must, in addition to the above, demonstrate the ability to:1. State the importance of maintaining safe storage of the medication in school,including carrying medications.2. State the importance of not allowing other students to use the medication/equipment.3. State name, dosage, and frequency of medication/treatment.4. State the purpose of medication/treatment.5. State reason/symptom for using PRN medications/treatments.6. State the dangers of exceeding the prescribed dose.7. Identify his/her medication/equipment.8. Perform the procedure9. Notify the school nurse or designated staff that a dose of medication has beentaken.10. Sign the medication sheet as acknowledgment of having taken the medication.ORUsing "Daily Med 1 Log" enter Self Administered.11. State results that should occur after taking PRN medication.12. State appropriate action to take if symptoms not improved e.g., advise schoolpersonnel, contact parent, notify physician.X. UNUSED OR EXPIRED MEDICATIONA. Unused or expired medication must be returned to the parents for disposition.The school nurse should:1. Ask the parent to pick up the medication in person, or send written authorizationwith a responsible adult in place of the parent.September 1, 2002 Page 101

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL2. Record the date, time, amount, and type of medication being sent home on thehealth record (Use 'Health Inquiry and Maintenance Screen H7).3. Obtain the signature of the person receiving the medication and, if it is not theparent, a copy of the written parent authorization. Retain with the MED4.4. If the parent or authorized responsible adult does not pick up medication within 10days of notification, the Certified School Nurse shall destroy / discard unused orexpired portions. THERE MUST BE A WITNESS IF THE MEDICATION IS ACONTROLLED, SUBSTANCE, E.G., RITALIN.5. Record all of the above on the Health Information System, Health Inquiry andMaintenance , Screen H7 (or the MED-2 where the HIS is not available)). Wherethere was a witness, the witness should also sign the MED-2 or be named in H7.XI. APPROVAL OF MEDICATION REQUEST (MED1)Administration of medications / equipment prescribed by a qualified health care provider which fall withinthe parameters specified in the PDR (Physicians Desk Reference) can be approved by the Certified SchoolNurse.No other signature is required.A. When the Medication is initiated by the Certified School Nurse, the Certified School Nurse willindicate the date administration commenced, sign the appropriate section on the MED-1, and:a. Retain the original.b. Forward a copy to the parent.c. Forward a copy to the School Health Services Coordinator for medicationswhich are not on the computer.B. If the prescription is not within the stated parameters, the Certified School Nurse shall contactthe family health care provider.1. If the family health care provider changes the dose, time, or method ofadministration, the Certified School Nurse shall write the changes on the MED-1;date and sign as a verbal order.2. If the family health care provider does not change instructions which fall outsideparameters, the Certified School Nurse will document on the student health record(Screen H7) that the physician was notified that the medication or dosage fallsoutside the parameters. The documentation should include precisely what theprovider was told, and precisely what the provider responded. Use direct quotes.3. Send a letter of confirmation to the prescribing provider detailing the conversationsand any changes or agreements. Send a copy of the letter to the parent.4. Complete the approval process as described in A above , and initiate administrationof medication/equipment.5. Submit a copy of the completed MED-1 with a copy of the confirmation letterattached, to School Health Services, JFK Center.XII. THIS PROCEDURE MUST BE CARRIED OUT IN ITS ENTIRETY EVERY YEAR.XIII. MEDICATION ERRORSIn the event that a medication/treatment error has occurred, the certified school nurse or theprincipal or his/her designee will notify the School Health Services office at 215-875-3490, assoon as possible.September 1, 2002 Page 102

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLESeptember 1, 2002 Page 103

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALMED –2 (SAMPLE MAY NOT BE MOST CURRENT VERSION)September 1, 2002 Page 104

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLE MAY NOT BE MOST CURRENT VERSION)September 1, 2002 Page 105

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALMED – 4 (SAMPLE MAY NOT BE MOST CURRENT VERSION)September 1, 2002 Page 106

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALNON-COMPUTERIZEDHEALTH ROOMTHIS SECTION OF THE SCHOOL NURSE PROCEDURE MANUAL (PAGES 107 - 123) ISAVAILABLE AS A SEPARATE FILE AND WILL BE SENT AS A SEPARATE ATTACHMENTFROM THE REMAINDER OF THE PROCEDURE MANUAL. PLEASE CONTACT SCHOOLHEALTH SERVICES AT 215-875-3490, OR 3749 FOR ANY QUESTIONS.PAGE 107

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALRESOURCESSeptember 1, 2002 Page 124

AMERICAN DIABETES ASSOCIATIONDiabetes Information Service Center1660 Duke StreetAlexandria, Va. 223141-800-232-3472SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALListing of Multiple ResourcesAMERICAN HEART ASSOCIATIONS.E. Pennsylvania Affiliate408 E. 4th StreetBridgeport, Pa. 19405-1823AMERICAN LUNG ASSOCIATIONPhiladelphia & Montgomery County1100 E. Hector StreetConshohocken, Pa. 194281-215-825-3443 or 735-2200CARING FOUNDATION FOR CHILDRENP.O. Box 13449Philadelphia, Pa. 19101-95521-800-464- KIDSEPILEPSY FOUNDATION OF AMERICA4351 Garden City DriveLandover, Md. 207851-800-EFA-4050 Library Service forProfessionals1-800-EFA-1000 General InformationHUMAN GROWTH FOUNDATION7777 Leeburg PikeBox 3090Falls Church, Va. 220431-800-451-6434PHILADELPHIA CITIZENS FOR CHILDRENAND YOUTH7 Benjamin Franklin ParkwayPhiladelphia, Pa. 191031-215-563-5848SHRINERS HOSPITAL3551 N. Broad StreetPhiladelphia, Pa. 191401-215-430-40001-800-281-4050ASTHMA AND ALLERGY FOUNDATION OFAMERICA1125 15th St., N.W., Suite 502Washington, D.C. 200051-202-466-7643DIABETES NURSE SPECIALISTDept. of Public Health/District Health Center #21720 S. Broad StreetPhiladelphia, Pa. 191451-215-685-1840GETTING HEALTH CARE FOR CHILDREN ANDTEENSA Manual for School Counselors and NursesPhiladelphia Citizens for Children andYouthPatricia Redman or Barbara SanchezSept. 19961-215-563-5848NATIONAL HEMOPHILIA FOUNDATION110 Greene Street, Suite 303New York, NY 100121-800-42-HANDIPROGRAM TO IMPROVE EDUCATIONALOUTCOME IN STUDENTS WITH SICKLE CELLDISEASECOMPREHENSIVE SICKLE CELL CENTERThe Children’s Hospital of Philadelphia1-215-590-2232The PHILIP JAISOHN MEMORIAL CENTER4818 N. Broad StreetPhiladelphia, PA 19140224 -2000Medical, Health Care, and Social ServicesAvailableSeptember 1, 2002 Page 125

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: RESOURCES NUMBER 701.0CLASSIFICATION:PUBLIC SCHOOL HEALTH FUND: DEFINITION/PURPOSE AND ELIGIBILITY STANDARDS (SEP. 02)A. Definition/PurposeThe Philadelphia Public School Health Fund is a private foundation which assists with the payment ofcosts for correction of some pupil health problems. Initially, the nurse should ensure that the parent hasexhausted the regular source of health care as well as other funding possibilities prior to seeking assistancefrom the Public School Health Fund. PCCY Child Health Watch and City Health Centers are importantresources for the uninsured or those with insurance limitations.NOTE:Public School Health Fund approval is only for payment for the initial evaluation.B. Eligibility Standards1. The pupil must be enrolled in a Philadelphia Public School.2. Except for routine vision, a report from the treating physician is required. Thereport should include the diagnosis, services for which aid is requested, andthe cost of the service.3. There must be no other available means of obtaining service.4. The family must be approved for financial assistance by the Philadelphia PublicSchool Health Fund prior to provision of any service. Reimbursement will NOTbe made for services which have already been provided, or where the child isalready under treatment. Proof of income is required. (See Form M-106 Requestfor Dental-Medical Vision).5. In some instances (orthodontia, orthopedics, etc.) the family may be expectedto make partial payments to the care provider.C. Services Available1. Routine Vision2. Dental3. Orthodontia4. Other health needs which are standard medical practice, e.g., wigs, prosthesis,helmets, orthopedic appliances, etc., when there is no other available means ofobtaining serviceD. For ALL requests to the Fund the School Nurse/School Nurse Practitioner shall:1. Provide form M106 (Request for Medical or Dental Services) to the family.2. Advise the parent to complete M106 in entirety and attach appropriateproof of income.September 1, 2002 Page 126

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL3. Review the M106 for completeness, accuracy and proof of income. Attach physician’sreports and cost estimates where required. Make certain that proofof income is attached.4. Sign the completed M106.5. Send the M106 and attachments to Public School Health Fund, Room 500,JFK Center.6. Await notification from Public School Health Fund re: eligibility and appointmentprocedure.7. Monitor to see that appointment is kept.8. Record physician’s/dentist’s findings on Pupil Health Record or Dental Record.E. For vision services requested to be paid by the Public School Health Fund (Routineexamination and eyeglasses, if needed) the Certified School Nurse shall:1. Complete M106 prior to submission by writing in:a. Visual acuity without and with correctionb. Parent’s choice of one of three approved resources:1) The Eye Institute - Pa. College of Optometry - 1200 W. SpencerStreet2) Scheie Eye Institute - Presbyterian University of Pa.51 N. 39th Street3) Wills Eye Hospital - 9th and Walnut Streets2. If the application is approved, the School Nurse will receive the appointment card from thePhysical Health Office:a. remind parent of the appointment date, time and place.b. issue M144, Vision Screening Referral to the parent to be completed by theprovider.c. instruct parent to sign permission on the appointment card and to take the card to theprovider.F. For other problems the School Nurse/School Nurse Practitioner shall complete M106as stated and advise the parent:1. to submit a physician’s report, including diagnosis, and a description of servicesfor which aid is being requested, including the estimated cost and vendor names.2. to submit proof of income.3. they may be expected to make partial payments to the care provider.September 1, 2002 Page 127

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: RESOURCES NUMBER 701.2CLASSIFICATION:PUBLIC SCHOOL HEALTH FUND: DENTAL SERVICES(SEP. 01)G. Routine Dental Services:1. Pupils who have no source of routine dental care should be referred to the City ofPhiladelphia Department of Public Health Dental Clinics.2. Routine dental services include: examination, x-rays, fillings, crowns, extractions,prophylaxis and root canal therapy (endodontics).The clinic locations are:CLINIC LOCATIONPHONE NO.1720 S. Broad St., 19145 215-685-182243rd & Chester Ave., 19104 215-685-750644th & Haverford Ave., 19104 215-685-760520th & Berks St., 19121 215-685-2938301 W. Girard Ave., 19123 215-685-3816131 E. Chelten Ave., 19144 215-685-57382230 Cottman Ave., 19149 215-685-06083. Signed parental permission is required at the initial visit. Appointments can be made bycalling the clinic. (A supply of consent forms can be obtained by calling the clinic.)4. If a problem arises which the City Dental Clinic is not equipped to treat, the School Nurse/School Nurse Practitioner should submit documentation and a completed M106 to:Public School Health FundSchool Health ServicesJohn F. Kennedy CenterRoom 500734 Schuylkill Ave.Phila., PA 19146September 1, 2002 Page 128

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: RESOURCES NUMBER 701.3CLASSIFICATION:PUBLIC SCHOOL HEALTH FUND: ORTHODONTIA(SEP. 02)H. Orthodontia:1. The School Nurse/School Nurse Practitioner will:a. Provide form M106 to the family.b. Review the M106 for completeness and accuracy. Make certain that incomeverification is attached. (Copy of latest income tax form 1040)c. Include the name of desired clinic from list below.- Drs. Magill and MankadRittenhouse Plaza, Suite 2061901 Walnut StreetPhone: 215-567-5949- Einstein Northern DivisionYork & Tabor RoadsPhone: 215-456-6600- University of Pa., School of Dental Medicine4001 Spruce StreetPhone: 215-898-8982- Temple University Dental School3223 N. Broad StreetPhone: 215-707-2863d. Sign the completed M106.e. Send M106 for review to:Public School Health FundSchool Health ServicesJohn F. Kennedy CenterRoom 500734 Schuylkill Ave.Phila., PA 191462. After processing and approval. the Fund then sends the form, REQUEST FORFINANCIAL ASSISTANCE FOR CORRECTION OF MALOCCLUSION , back to theschool nurse who then gives it to the parent. (This form is colored yellow)3. The parent then makes an appointment and takes the form with the child to one of theapproved clinics for an evaluation.September 1, 2002 Page 129

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL4. The evaluation/diagnosis is completed by the orthodontist and returned to the school nurse,who sends it to the Public School Health Fund, care of School Health Services, JFKCenter, Room 500.5. The Fund must then give a SECOND AND FINAL APPROVAL , after which , NOTICEOF ELIGIBILITY LETTERS are sent to the:parentschool nursepupil’s filetreating clinic6. The Fund then prepares the FUNDING MEMORANDUM , copies of which are sent to the:treating clinicpupil’s fileparentExecutive Secretary’s file7. Only after the treating clinic receives a copy of the FUNDING MEMORANDUM , may theclinic start treatment and bill the Fund for the treatment rendered.September 1, 2002 Page 130

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSeptember 1, 2002 Page 131

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSTUDENTS WITHSPECIAL NEEDSSeptember 1, 2002 Page 132

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 800.0CLASSIFICATION:LEGAL BASIS / PURPOSE (DEC. 98)I. IntroductionThe School District of Philadelphia has a legal responsibility to provide state mandatedservices to all children. Additional health services may be required for specificpurposes to maintain children with special needs in the least restrictive educationalenvironment and to enhance their educational program.These services are not intended to be clinical or therapeutic. In other words, daily therapyfor the purpose of strengthening, stretching, etc. is not a related service provided bythe School District. Related services are intended to allow the student access tohis/her educational program and to make it possible for the student to benefit fromhis/her educational program. Examples of such services include teaching the studentto use assistive devices that will make it possible for him/her to write, teaching thestudent how to climb and descend stairs safely, developing an adapted physicaleducation program that will accommodate the student’s limitations, providingaccess to intermittent nurse service to assist the student with bladder catheterizationduring school hours, etc.II.Legal BasisThe Individuals with Disabilities in Education Act, 20 U.S.C., Section 1400 ET SEQ),states that “the term ‘related service’ means transportation, and such developmental,corrective, and other supportive services (including ... physical and occupationaltherapy, recreation, and medical and counseling services, except that medicalservices shall be for diagnostic and evaluation purposes only) as may be required toassist a handicapped child to benefit from special education ...”Section 504 of the Rehabilitation Act of 1973, provides that “no otherwise qualifiedhandicapped individual ... shall, solely by reason of ... (the) handicap, be excludedfrom participation in, be denied the benefits of, or be subjected to discriminationunder any program or activity receiving federal financial assistance.” This sectionapplies to the School District, which is, accordingly, obliged to provide “nonacademicand extra-curricular services and activities in such manner as is necessaryto afford handicapped students an equal opportunity for participation in suchservices and activities.” The “non-academic ... services ... may include counselingservices, physical recreational athletics, transportation, health services ... “September 1, 2002 Page 133

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALPA Law (22 PA Code Chapter 14) provides regulations for implementing the federal lawwhich assures the necessary accommodations that will permit a student who has adisability to benefit from his/her educational program or specially designedinstructional program. These students are generally considered Special Educationstudents, and all academic and non-academic services are included in the student’sIndividual Education Plan (IEP).PA Law (22 PA Code Chapter 15, Section 2) provides regulations for implementing thefederal law which assures the necessary accommodations that will permit a studentwith a handicap to have access to his/her educational program. A student whosehandicap significantly limits or prohibits participation in or access to his/hereducational program, and who does not need a specially designed instructionalprogram, may be considered a Protected Handicapped student. Accommodationsfor a Protected Handicapped student are written on a Service Agreement.III.PurposeA. To identify those students with special health and safety needs which impact ontheir ability to learn.B. To identify those students with special health and safety needs who require abarrier-free environment.C. To assist in meeting the requirements of P. L. 94-142 and Section 504 of theRehabilitation Act of 1973.D. To utilize the professional skills of the Certified School Nurse in working withother disciplines to provide an appropriate educational environment and necessaryaccommodations for students with special needs.September 1, 2002 Page 134

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 207CLASSIFICATION:DO NOT RESUSCITATE ORDERS - SCHOOL BOARDPOLICY (DEC. 98)1. Purpose1. This policy is to inform and instruct school personnel and families. The Board ofEducation directs that:2. ImplementationReferences:1. "Do Not Resuscitate" orders offered by parents or legal guardians cannot and shall notbe honored by any School District staff at anytime.2. All procedures for responding to accident and/or illness of students shall be consistentwith this policy.3. Parents or legal guardians who offer "Do Not Resuscitate" orders shall be informed ofthis policy by building principals at the time such orders are presented.School Operations Policy Number 511.0 to 511.4September 1, 2002 Page 135

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 801CLASSIFICATION:SERVICES OF SPECIAL EDUCATION CONSULTANT(SEP. 01)SERVICES OF SPECIAL EDUCATIONMEDICAL CONSULTANTExamination by the Special Education Medical Consultant is a formal evaluation used for thepurpose of determining if a student needs Physical Therapy or Occupational Therapy (PT/OT)services that will make it possible for him/her to access the educational program and/or benefitfrom the educational program. The Special Education Medical Consultant, in consultation with thePhysical Therapist / Occupational Therapist and the Certified School Nurse, will develop a planthat will meet the student’s needs.I. Initial ReferralsA. When the Student Support Team (SST), a private health care provider, or a parentrequest evaluation for PT/OT services during school hours, such a request will bebrought to the attention of the Certified School Nurse.B. The Certified School Nurse will request necessary medical information from thestudent’s primary care provider and other health care providers as indicated. Asigned Request for Release of Information must be obtained from theparent/guardian for each provider from whom records will be requested.C. The Certified School Nurse will contact the Physical/Occupational Therapistassigned to the school where the student is enrolled. If it is not known who thePhysical/Occupational Therapist is, the Certified School Nurse may call SchoolHealth Services at 215-875-3490 to find out who is assigned to provide PT/OTservices to the school.D. Upon being notified of the request, the Physical/Occupational Therapist will arrangeto do an initial screening of the student.E. If the Physical/Occupational Therapist determines that the student may qualify forPT/OT services during school hours, he/she will call the School Health ServicesCoordinator to schedule an evaluation by the Special Education Medical Consultant.F. The Physical/Occupational Therapist will arrange to obtain a Permission toEvaluate form (T-700) to be signed by the parent/guardian.G. The Physical/Occupational Therapist will notify the Certified School Nurse and theparent of the date and time on which the medical evaluation is scheduled.H. If it is determined that the student does not qualify for PT/OT services duringschool hours, the Physical/Occupational Therapist will notify the parent.I. If it is determined that the student qualifies for PT/OT services during school hours,September 1, 2002 Page 136

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALthe Physical/Occupational Therapist will develop the Individual Education Plan(IEP).II.Role of the Certified School Nurse During the EvaluationA. Prior to the day of the evaluation, the Certified School Nurse will:1. Gather pertinent medical information from health care providers.2. Screen the student for vision, hearing and growth.3. Arrange for the student to be released from class at the time of theevaluation.B. At the time of the evaluation, the Certified School Nurse will:1. Have available the student’s school health records and information providedby health care providers.2. Assist the physician as needed.3. Consult with the Special Education Medical Consultant and thePhysical/Occupational Therapist as indicated.4. Sign form S866 (Medical Assessment of Special Education Children).5. Record the results of the evaluation in the student’s school health records.C. After the evaluation, the Certified School Nurse will:1. Distribute copies of form S866 accordingly.2. Notify the parent/guardian (if not present) of referrals recommended by theSpecial Education Medical Consultant.3. Assist the parent/guardian as necessary to follow up on referrals.III.ReevaluationsA. Students who need to be reexamined by the Special Education Medical Consultantare scheduled in accordance with the following criteria:1. On the same year as the IEP review date.2. As determined by the Physical/Occupational Therapist or the SpecialEducation Medical Consultant,3. Upon request by the parent.B. The Certified School Nurse will be notified that an evaluation has been scheduledby the Physical/Occupational Therapist assigned to the school in which the studentis enrolled.September 1, 2002 Page 137

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALI. SUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 807.0CLASSIFICATION:PROTECTED HANDICAPPED STUDENTS: HEARINGPREPARATION (SEP. 01)I. PurposeA. To ensure compliance with the requirements of the law and the Protocol and Guidelinesfor the Delivery of Services to Protected Handicapped Students adopted by the Boardof Education on August 18, 1992.B. To provide all staff with guidelines for managing the preparation for an impartial dueprocess hearing.C. To assist staff in determining which materials should accompany the Due ProcessHearing Request.II.III.CriteriaAn impartial due process hearing is indicated for a student when:A. A parent/guardian requests a hearing to the School District for any reason.B. The School District has not been able to obtain consent for an individual evaluationfrom the parent/guardian.C. The parent/guardian and the School District disagree regarding the identification of astudent as a Protected Handicap Student.D. The parent/guardian and the School District disagree regarding the related aids,services and accommodations the student needs.E. The parent/guardian and the School District disagree as to whether or not the SchoolDistrict is providing the related aids, services and accommodations specified in thestudent’s Service Agreement.F. The parent/guardian and the School District disagree as to whether or not the SchoolDistrict has failed to comply with the procedures in the Protocol and Guidelines forthe Delivery of Services to Protected Handicapped Students.Informal Pre-hearing ConferenceA. When a parent/guardian of a student with special needs informs any School Districtemployee that he/she is in disagreement with the School District regarding theidentification or accommodation of the student as a Protected Handicapped Student,the principal shall be notified at once.B. If the parent intends to request a due process hearing, the principal will obtain therequest in writing.C. Within ten days of the request, the principal will arrange for an informal pre-hearingconference in an attempt to resolve the disagreement. The pre-hearing conference isdesirable but voluntary. Either side may decide to waive the pre-hearing conferenceand proceed directly to the due process hearing.D. If an informal pre-hearing conference is held, the Certified School Nurse will be inattendance along with other staff as deemed necessary by the principal.E. The principal will instruct the staff that every effort will be made to reach anamicable solution.F. The principal, along with the Certified School Nurse, will prepare and provide allstudent records which support the appropriateness of the recommended program.G. If an agreement is reached, the principal will ensure that the Service Agreement isimplemented.H. If an agreement is not reached, the principal will notify the AAO and theCompliance Officer that a due process hearing is indicated.September 1, 2002 Page 138

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALI. The principal will ensure that the parent/guardian receives documentation of the prehearingconference.IV.Due Process HearingA. When a due process hearing is indicated regarding the identification oraccommodation of a student as a Protected Handicapped Student, the CertifiedSchool Nurse will be designated the Case Manager.B. The Certified School Nurse will collect all data, request necessary evaluations,request necessary reports from health care providers, complete necessary forms,document all activities leading up to the due process hearing, and submit the DueProcess Materials Checklist along with necessary documentation to the principal.C. The principal will notify the AAO that a due process hearing is indicated and willforward to the Compliance Officer the Due Process Materials Checklist along withall necessary documentation.D. The Compliance Officer will review all pertinent documentation and requestadditional information if necessary.E. The Compliance Officer will summarize the status of the case in a letter to theparent/guardian with copies to the principal and the AAO, and will send to theparent a copy of the Due Process “Letter to the Parent.”F. The Compliance Officer will forward all pertinent materials to the LegalDepartment.G. The Legal Department will notify the principal and the AAO which school staffmembers need to attend the due process hearing.September 1, 2002 Page 139

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 801.0CLASSIFICATION:REFERRAL TO STUDENT SUPPORT TEAM (SST)(DEC. 98)I. Initial ReferralsA student is initially referred to the SST by any staff member or by the student’s parent. Aparent who wishes his/her child to be assessed by the SST should be assisted to putthe request in writing and to submit it to the principal. A staff member making areferral should complete the appropriate referral form used by the school and shouldsubmit it to the chair or facilitator of the SST.II. The Certified School Nurse as a member of the SST will:A. Review the reason for referral.B. Review the student’s current health record (HIS or MEH-3).C. Verify that a routine physical examination has been done within the past year. Ifabsent or outdated, refer the student to his/her primary care provider.D. Perform vision, hearing and growth screenings.E. Interview the student.F. Complete a Confidential Medical History (S864).G. Complete a Student Health Status form (S865) if indicated.H. Request documented verification and recommendations regarding the student’shealth status and limitations, if any, from the student’s primary physician and otherhealth care providers as indicated. The student must have been examined by theprovider within the past year. A signed Release of Information Form must beobtained from the parent/guardian for each practitioner from whom health recordswill be requested.I. Prepare an individual Health Plan for the student if indicated.J. Record on the referral form significant health and medical data.K. Record on the student’s health record any referrals for additional evaluations(Physical exam, eye exam, etc.)L. Interpret medical and other health-related information for members of the SST.M. Make recommendations to the SST regarding necessary reasonableaccommodations.N. Serve as Case Manager if indicated.O. If the student is identified as a Special Education Student, necessary health-relatedaccommodations must be documented in the IEP.III.ReevaluationsA. Students are referred to the SST for reevaluation at the Individual Education Plan (IEP)review date (every two years) or a sooner if needed.B. The Certified School Nurse, as a member of the SST, will follow the same procedureindicated above to update pertinent health and medical information, if indicated.September 1, 2002 Page 140

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 808.0CLASSIFICATION:PROTECTED HANDICAPPED STUDENTS (SEP. 02)I. DEFINITIONA protected Handicapped Student is one who meets the following criteria under PA Law (22 PACode Chapter 15, Section 2):A. Is of an age at which public education is offered by the School District.B. Has a physical or mental disability which significantly limits or prohibitsparticipation in or access to an aspect of the student’s school program.C. Is not eligible for special education services or programs, or is eligible but is raisinga claim of discrimination.II.PROCEDURE FOR IDENTIFYING A STUDENT AS A PROTECTED HANDICAPPEDSTUDENT AND PROVIDING NECESSARY REASONABLE ACCOMMODATIONS(See section III for examples of reasonable accommodations.)A. A student may be considered for identification as a Protected Handicapped Studentif he/she needs special accommodations in order to have access to or to be able toparticipate in his/her educational program. If a student’s needs are being adequatelymet, there is no need for identification as a Protected Handicapped Student. Theparent/guardian or any member of the school staff, however, may initiate a requestto have the student assessed for possible identification and accommodation as aProtected Handicapped Student.B. Initial Referral:1. A parent/guardian may initiate a request for special accommodations underChapter 15 by sending a request to the school principal either verbally or inwriting. If the initial request is verbal, the parent should be assisted inpreparing and submitting a written request. Upon receipt of the writtenrequest, the Principal will notify the Certified School Nurse and the Chair ofthe Student Support Team.2. Any member of the school staff may initiate a written referral to the StudentSupport Team indicating the student’s needs and circumstances which mightwarrant identification and accommodations under Chapter 15. Upon receiptof the written request, the Chair of the Student Support Team will notify theCertified School Nurse.C. The Certified School Nurse will:1. Serve as a member of the Student Support Team.2. Conduct a nursing assessment of the student’s health history and currenthealth status. School District Forms S864 and S865 should be completed.September 1, 2002 Page 141

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL3. Perform vision, hearing and growth screenings.4. Assess the extent of the student’s handicap which limits his/her access to orparticipation in the educational program.5. Request documented verification and recommendations regarding thestudent’s health status and handicap from the student’s primary physicianand other health care providers as indicated. The student must have beenexamined by the provider within the past year. A signed Release ofInformation Form must be obtained from the parent/guardian for eachpractitioner from whom health records will be requested.6. Prepare an Individual Health Plan for the student.7. Interpret medical and other health-related information for members of theStudent Support Team.8. Make recommendations to the Student Support Team regarding necessaryreasonable accommodations.9. Serve as Case Manager, if the student is identified as a ProtectedHandicapped Student, to facilitate the planning and implementation ofnecessary accommodations.D. The Student Support Team will:1. Include the parent/guardian, principal or his/her designee, the Certified School Nurseand other members of the school staff who need to collaborate in the planning andimplementation of necessary accommodations ( counselor, teachers, schoolpsychologist, etc.)2. Evaluate the student’s needs based on available medical and other health-related data.3. Determine if the student meets the criteria to be classified as a Protected HandicappedStudent.4. Request additional evaluations if indicated.5. Determine which accommodations, if any, the student needs.6. Determine if and how the necessary accommodations can be provided in the student’scurrent school assignment.7. If the student meets the criteria to be identified as a Protected Handicapped Student,prepare a Service Agreement based on what the student needs.8. Plan and implement necessary accommodations. It is expected that every effort will bemade to accommodate the student in his/her current school assignment.9. Advise the principal if necessary accommodations cannot be provided in the currentSeptember 1, 2002 Page 142

school assignment.SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL10. Advise the parent in writing regarding procedural safeguards and the right to dueprocess.11. Carry out this procedure within twenty-five days of the initial request.E. The parent/guardian will:1. Be considered a member of the Student Support Team.2. Provide medical and other health-related records as deemed necessary by theStudent Support Team.F. The principal will:1. Serve on the Student Support Team or appoint a designee.2. Give final approval for recommendations made by the Student SupportTeam before accommodations are implemented.3. Consult the AAO regarding an appropriate school assignment for aProtected Handicapped Student whose needs cannot be accommodated inthe current school assignment.4. Send the Service Agreement to the receiving school if the student isassigned to another school.5. Forward copies of the completed Service Agreement to the Director ofSchool Health Services.G. If the student is identified and accommodated as a Protected Handicapped Student,the Student Support Team will review and revise the Service Agreement at least ona yearly basis, preferably at the beginning of the academic year.H. The parent/guardian will be given a copy of the completed and signed ServiceAgreement. A copy will also be maintained in the student’s confidential schoolhealth record.III.The following are examples of reasonable accommodations.A. An extra set of books for a student who cannot carry books to and from school.B. Access to school nurse services during school days for intermittent bladdercatheterization.C. Access to an elevator .D. Roster to minimize need for stair climbing.IV. Accommodations are NOT considered reasonable if they :A. Require the job description of a school district staff member to be significantlySeptember 1, 2002 Page 143

altered.SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALB. Require a significant alteration in the educational program of the school as a whole.C. Place an unreasonable burden on another student.D. Prevent another student from having access to or participating in his/her educationalprogram.September 1, 2002 Page 144

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 803.0CLASSIFICATION:SPECIAL CASE FILE (SEP. 02)I. DEFINITIONThe Special Case File is a compilation of all students who have health problems whichrequire supportive services in school.II.III.CRITERIAA. All medical and special health problems included in the Special Case File shall beverified by a treating agency.B. All students deemed appropriate by the School Nurse or School Nurse Practitionermay be included.C. The following health problems should be included. However, this list should notbe considered exclusive or exhaustive.1. Allergies2. Asthma3. Blood dyscrasias4. Cardiac problems5. Diabetes6. Seizure disorders7. Orthopedic problems8. Skin conditions9. Renal diseases10. Significant sensory impairmentsPROCEDUREAt the beginning of the school year the Certified School Nurse will:A. Identify students1. Review the Special Case File from the previous school year2. Review student health records (MEH 3 or HIS) on all new admissions tothe school.3. Conference with students, parents, and staff to identify students with healthproblems not previously known to the Certified School Nurse.B. Gather current information1. Send Student Health Status (S865) to parent/guardian of all studentsidentified for Special Case File.2. Review completed Student Health Status for completeness and accuracy.3. Conference with student and/or parent as needed.C. Maintain file1. Alphabetize completed Student Health Status forms by last name of studentand keep in binder.2. Update student HIS if there are significant changes in diagnosis, treatment,recommendations, health provider or emergency contacts.September 1, 2002 Page 145

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALD. Maintain confidentiality1. Review the file with the principal as needed.2. Discuss with the principal whether and how information will be shared withstaff who have contact with the student.3. Share information with appropriate staff on a need to know basis. Includeinstructions for implementation of an emergency plan.E. Forward information1. In schools where there is not a computer, send Student Health Status to newschool to alert the receiving Certified School Nurse when a studenttransfers.2. In all schools, send a copy of the Student Health Status to shared timenurses for students enrolled in shared time programs.IV.PROBLEM MANAGEMENTA student who has been diagnosed with a chronic health condition by a qualified health careprovider will have an Individual Health Plan (IHP) developed in order to manage his/hercondition during the school day.The Nursing Process will be used to develop a management plan, including emergencyplan, which will be updated at the beginning of each school year.A. Use the reverse side of the Student Health Status (S865) to develop an IHP bymeans of the Nursing Process.1. Assessmenta) Gather information, subjective as well as objectiveb) Analyze informationc) Diagnose need(s)2. Plana) Identify the specific action to be takenb) Prioritize the problem(s) that need attention3. Implementationa) Translate plan into actionb) Describe an individualized approach that is systematic and sequential4. Evaluationa) Anticipate goal(s) to be attainedb) Describe how progress will be measuredB. When available a standardized IHP may be used in lieu of the reverse of the S865(Student Health Status). Each phase of the Nursing Process is identified in the IHPwith specific categories that may or may not apply to a particular student.1. Assessmenta) The School Nurse or School Nurse Practitioner will assess thestudent and determine which categories in the assessment section ofthe IHP apply to the student. The nurse will initial each categorythat applies to the student.b) On the back of the IHP form the School Nurse or School NursePractitioner will document the findings of each assessment thatapplies to the student.c) As part of the nursing assessment the School Nurse or SchoolNurse Practitioner will communicate with the student, the parent, theteacher, and the health care provider as appropriate. A signedConsent for Release of Information must be on file before the nursemay release any information to the health care provider. If thestudent’s condition involves a behavior disorder, a completedACTeRS Rating Form will be secured.September 1, 2002 Page 146

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL2. Nursing Diagnosisa) Identification of nursing diagnoses must follow directly fromproblems identified in the assessment.b) The School Nurse or School Nurse Practitioner will initial eachnursing diagnosis that applies to the student.3. Goalsa) Each goal identified must correspond with an identified problemand/or nursing diagnosis.b) The School Nurse or School Nurse Practitioner will initial each goalthat applies to the student.4. Nursing Interventiona) Each nursing intervention selected must contribute toward themeeting of an identified goal.b) The School Nurse or School Nurse Practitioner will initial eachnursing intervention that applies to the student.5. Expected Outcomesa) Expected outcomes should be the direct result of selectedinterventions.b) The School Nurse or School Nurse Practitioner will initial eachexpected outcome that applies to the student.6. Evaluationa) The School Nurse or School Nurse Practitioner will usecommunications with the student, parent, teacher, and health careprovider to evaluate the student’s progress.b) If the student’s condition involves a behavior disorder, the ACTeRSRating Form will also be used to evaluate the student’s progress.c) Documentation will identify each expected outcome as having beenmet, not met, or partially met. A description of the specific behaviorwhich demonstrates how the expected outcome was met, not met, orpartially met must be included.EXAMPLE: Expected Outcome-Student will describe what to doif an asthma attack occurs.Partially met. Student accurately verbalizes that he is to taketwo puffs of his inhaler medication. Student does notconsistently cease strenuous activity when he experienceswheezing.September 1, 2002 Page 147

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSeptember 1, 2002 Page 148

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSeptember 1, 2002 Page 149

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 801.8CLASSIFICATION:EXTENDED SCHOOL YEAR (ESY) (SEP. 02)EXTENDED SCHOOL YEAR (ESY)I. Some students will be assigned to the Extended School Year Program offered during thesummer.II. In order to provide continuity of care for these students, The School Nurse is requested tocomplete the following tasks:• Obtain the list of students from your principal.• Use the Health Information System to review the Health Record of eachstudent.• Update all screens, including H1 or H9, to reflect current health informationfor each student.• Assure that a current MED-1 with an end date of Aug. 31 is documented onthe Health Information System for all students who will receive medicationor special treatment.• Make a hard copy (both sides of the form) of the existing Student HealthStatus Update (S865) for each student. This is to be done regardless ofdocumentation on the HIS. Place in each student's ESY folder.III. Prepare a care summary (using information from the MED 1, the S865 (both sides) andanecdotal information) on Nurses Notes (Screen H7) for each student.NOTE: When creating a care summary for ESY students, sending nurses shouldconsider what information would help them to care for a particular student ifthey were seeing that student for the first time. For example:• Are there conditions which require clinical monitoring?• Is there a “best” position for carrying out a procedure?• Can the student assist with any aspect of a procedure?• Is there something to “watch out” for, e.g., have you noticed thatcertain activities cause respiratory or cardiac distress for a student?.IV. All hard copy materials will be returned to the sending school at the close of the ESYprogram.September 1, 2002 Page 150

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 203.0CLASSIFICATION:PREGNANT STUDENTS (SEP. 02)I. PURPOSEA. Early identification of pregnant students.B. To ensure prompt access to prenatal care.C. To promote positive pregnancy outcomes.D. To encourage continuation of education.II.III.MANAGEMENTThe School Nurse/School Nurse Practitioner will:A. Interview student and assess immediate physical/emotional needs.B. Encourage student to involve parents if they are unaware ofpregnancy.C. Provide emotional support and involve school counselor and/or ELECT teenparenting personnel.D. Refer student for pregnancy test and appropriate medical care.E. Take a baseline blood pressure and weight, and record in nurses notes (HealthInquiry and Maintenance, Screen H7, code PREG).F. Meet with student regularly to evaluate progress and to ascertain whether student iskeeping prenatal appointments.G. Discuss health problems, future child care and educational plans with student.H. Inform student and family that ONLY documented medically/obstetricallycomplicated pregnancies will be considered for Homebound Instruction (seeProcedure 806.1, Homebound Instructional Programs).I. After student delivers, discuss importance of keeping well-baby and post-partumappointments. Answer any questions she may have concerning parenting and childdevelopment.DOCUMENTATIONA. Case management of pregnant students by the School Nurse/School NursePractitioner must be documented on the HIS in Health Inquiry and Maintenance,Screen H7, code PREG.September 1, 2002 Page 151

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 805CLASSIFICATION:TRANSPORTATION REQUESTS FOR MEDICALREASONS (SEP. 02)I. GoalRequests for transportation for students with severe medical needs will be processed in anefficient, professional, and timely manner with schools having maximum discretionin determining how to best serve their students.II.Roles and ResponsibilitiesA. The certified school nurse is the designated case manager for students with severemedical needs who request transportationB. For students in nonpublic schools which do not have assigned School District ofPhiladelphia Nurse Service, the certified school nurse at the neighborhood schoolthat the student is eligible to attend will act as the case manager. All inquiries fromstudents, parents and nonpublic school personnel should be directed to the schoolnurse at the neighborhood school.C. When a request for transportation for students with severe medical needs issubmitted to the school, the school nurse will:1. contact the parent to obtain information regarding the student’s conditionand source of care.2. provide “Request for Transportation for Medical Reasons” to the parent orrequest written information from the student’s physician which explainswhy the student will need transportation. This should include the diagnosis,duration, and reason the student is unable to get to school withouttransportation.3. complete a nursing assessment which includes data on mobility, pain level,medication, frequency of visits to primary care provider (PCP),participation in activities of daily living (ADL), socialization, and otherrelevant information.4. bring the case to the school support team for review and planning.5. participate in the school support team and continue to manage the case.6. when the student attends a nonpublic school which does not have SchoolDistrict of Philadelphia Nurse Service, inform the nurse or other responsibleschool staff at the student’s nonpublic school of the school support team’sdecision.7. In June of each year assess needs for the following year.D. The school support team will:1. review all documentation and determine necessity for transportation,2. contact the School Health Services office (215-875-3490) if medicalconsultation is needed,3. determine eligibility based upon information provided by team members andthe student’s physician,4. if transportation is approved, sign the authorization letter,5. no other approvals are needed.September 1, 2002 Page 152

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALE. The principal or designee will:1. notify parent/guardian of school support team decision,2. sign and forward the authorization letter to:Transportation DepartmentJFK Center, Room 480Attention Mr. Nick Di MatteoIII.Extensions and/or Renewal of ApprovalRequests to extend or renew transportation service beyond the length of time initiallyapproved must be considered through repetition of the above procedure.September 1, 2002 Page 153

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALTHE SCHOOL DISTRICT OF PHILADELPHIAJOHN F. KENNEDY CENTER734 SCHUYLKILL AVENUE - RM. 500PHILADELPHIA, PENNSYLVANIA 19146SCHOOL HEALTH SERVICES(215 )875-3490FAX: (215)875-5036REQUEST FOR TRANSPORTATION FOR MEDICAL REASONS(RETURN TO SCHOOL NURSE)Student’s Name _______________________________________ID#______________________Home Address_________________________________________ Date of Birth______________School ______________________________Location #_________ AAO__________________The above student is requesting transportation to and from school by the School District ofPhiladelphia for medical reasons. This request is under consideration. Please document in detail themedical justification for the same with the following information:1. Diagnosis ________________________________________________________________2. Date of Onset ______________3. Medical reason(s) student cannot walk or take public transit to and from school: ________________________________________________________________________________4. When do you expect the student to be able to get to and from school?_________________________________________________________________________________________5. The student will be picked up and dropped off at a designated school bus stop unless thisis contraindicated. Please give medical reasons student cannot be picked up and droppedoff at a designated bus stop:________________________________________________________________________________________________________________________________________________Name of Physician (Print) ____________________________________Signature of Physician _______________________________________Address __________________________________________________ Phone _______________Date Signed _______________________________To be completed by the student’s physician and returned to theschool nurseSeptember 1, 2002 Page 154

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 805.1CLASSIFICATION:TRANSPORTATION REQUESTS FOR MEDICALREASONS; AUTHORIZATION LETTER (SEP. 02)SAMPLETransportation ServicesJohn F. Kennedy Center734 Schuylkill AvenuePhiladelphia, PA 19146Dear Mr. Lombardi:Date______________The student named below suffers from a medical condition which makes it difficult to walk to school. It is theopinion of the school support team that it is in the best interest of this student to receive transportation to and fromschool.Students Name ID number male_____female______Home Address and Zip CodeParent/Guardian NameSchool Student AttendsHome PhoneEmergency PhoneAAO and Location NumberTYPE OF SERVICE NEEDEDCurb to Curb pick up and deliveryCorner pick up anddelivery at:Nearest designated school bus stop pick up and deliveryMedical concerns that will require interventionSpecial equipment, e.g. harness, seat belts, etc.Free tokensOtherAPPROVED BY:School Support Team MemberSchool NurseSchool Support Team MemberPrincipalSeptember 1, 2002 Page 155

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 806.1CLASSIFICATION:HOMEBOUND INSTRUCTIONAL PROGRAMS (SEP. 02)I. Purpose of Homebound Instructional Programs• The primary function of Homebound Instruction is to provide a continuation of theinstructional program for any student who will be absent from school for a periodof at least four weeks for certified medical reasons.• Homebound Instruction can be provided for the duration of a specific time oflimited illness, e.g., recovering from surgery or for repeated short absences duringepisodes associated with a chronic illness, e.g., severe asthma attack.• The certified school nurse is the designated case manager for all requestedhomebound services and all students on homebound or instruction in the homeservices.II.III.Goal• Requests for Homebound Instruction will be processed in an efficient,professional, and timely manner with the school having maximum discretion indetermining how to best serve their students, and flexibility in the use ofhomebound services.Roles and responsibilitiesA. When a request for homebound services for health reasons is submitted to theschool, the school nurse will:1. contact the parent to obtain information regarding the student’s conditionand source of care.2. provide the parent/guardian with a Physician’s Certification Form to becompleted by the Primary Care Provider (PCP).3. complete a nursing assessment which includes data on mobility, pain level,medication, frequency of visits to the primary care provider (PCP),participation in activities of daily living (ADL), socialization, and otherrelevant information including anticipated length of time homeboundservices will be required.4. complete the Reporting Form for Special Education Students if thestudent is receiving special education services and submit it to theHomebound Office.5. present case to the Comprehensive Support Process to determine eligibilityand planning for services.6. monitor progress and need for ongoing homebound instruction based onmedical evaluation/reports7. document information on the Health Information System (HIS), in ScreenH7 of Health Inquiry and Maintenance, using code HOBD. In H1 screen, inHealth History, add HMBD code and start and end dates. Delete this code(SHIFT-underscore) once Homebound service has ended. Noncomputerizedschools will document the information on the health record forthe student (MEH-3).September 1, 2002 Page 156

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALIV.B. The school support team will:1. (School Support Team members include, but are not limited to, anadministrator or designee, parent, nurse and any relevant staff).2. review all documentation and develop a plan, with input and agreementfrom the family, to service the student.3. develop a plan to transition the student from homebound services to school(if homebound service is approved).4. obtain parent permission for an evaluation for special education (T700) ifdocumentation indicates an evaluation is appropriate.5. complete a CER and, if the student is found to be eligible, an IEP.ORcomplete Protected Handicapped Student evaluation and, if the studentis found to be eligible, a Chapter 15 service agreement.C. The principal or designee will:1. identify a teacher through the T-IV process. If no teacher applies for theposition contact the Homebound Office at : 215-875-3749.2. will record the teacher hours on the EBAR system, regardless of whichschool the student attends..3. monitor teacher hours through use of the S19.D. The Homebound Office will:1. provide training and technical assistance to school staff.Instruction HoursB. If the school support team approves the medical referral for a minimum of four (4)weeks, but less than ten (10) weeks, homebound instruction will consist of:1. Elementary Level-Two (2) one hour sessions weekly.2. Secondary Level-Three (3) one hour sessions weekly.3. Graduating High School Seniors Five (5) one hour sessions weekly.C. If the school support team approves the medical referral for ten (10) weeks or more,homebound instruction will consist of:1. Elementary Level-Five (5) one hour sessions weekly.2. Secondary Level-Five (5) one hour sessions weekly.3. Graduating High School Seniors Five (5) one hour sessions weekly.D. If the school support team approves the medical referral for Chronic Intermittentservice, homebound instruction will consist of:one (1) one hour session for each day missed, not to exceed five (5) one hoursessions in a week.V. Renewal or Extension of Approved ServiceRequests to extend homebound service beyond the length of time initially approved must beconsidered through repetition of the above procedure.A. When Homebound Service is being provided to a student, the following attendanceand payroll procedures must be followed:1. The completed S19 (Daily Time Report) must be turned in to the principalon a bi-weekly basis for review and signature.2. The parent must sign after each instructional session.3. One-half hour for preparation and travel time will be added for each homevisit.4. The principal or his/her designee will compute the preparation allowanceand add it to the instructional hours.B. The Homebound Office is available to give additional support for the effectivedelivery of Homebound Instruction by calling (215) 875-3749.September 1, 2002 Page 157

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLE LETTER (FRONT)The School District Of PhiladelphiaSchool Health ServicesPhysician’s Referral for Homebound InstructionDATE:Dear Physician:The School District of Philadelphia believes that all students benefit from attending regular school.School nurses develop Individual Health Plans (IHP)for students who have special needs. An IHPmay make it possible for your patient to attend school.Consideration for Homebound will be given for students who will not be able to attend school forfour weeks or longer. Maximum Homebound Instruction is five hours per week. Requests shouldbe limited to those patients who absolutely cannot attend school.Please furnish all information requested on the reverse of this letter and any additional informationwhich will facilitate a timely response to this referral.All information will be reviewed by the School Support Team where the final decision regardingthis request will be made.You may contact the school nurse directly at any time.September 1, 2002 Page 158

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALPHYSICIAN’S REFERRAL FOR HOMEBOUND INSTRUCTIONName of Student Address Phone NumberName of Parent/ Guardian Zip Code Student DOBSchool Grade R/S/BSchool NurseSchool Phone NumberDate of Examination_________________Date of Next Appointment ___________________Diagnosis:Date of onset of illness:Date of onset of Injury:Prognosis:What Physical or Clinical findings make it not possible for this student to attend school ?What medication/s is this student taking?_________________________________________________Will the student require medication in school? Yes________ No_________When do you believe this student will be able to return to school ? _______________________What, if any, accommodations do you believe will be necessary to facilitate an early return to school ?Physician’s Name PRINTEDPhysician’s SignaturePhysician’s Address PRINTEDPhysician’s TelephoneSeptember 1, 2002 Page 159

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSeptember 1, 2002 Page 160

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 514.0CLASSIFICATION:SUICIDE PREVENTION/INTERVENTION GUIDELINES(SEP. 02)I. The School District of Philadelphia will use the resources of the School District to assiststudents who may be at risk for suicide.II. The School District considers students as suicidal or potentially suicidal if they exhibit thefollowing behaviors:A. Students who express, verbally or in writing, the desire or intention to self-inflictserious or life-threatening injury.B. Students who intentionally self-inflict or attempt to self-inflict any serious or lifethreateninginjury (including substance overdoses).III. The School District of Philadelphia has developed the following guidelines to provide allstaff with procedures for handling students who may be at risk for suicide.A. The staff member who identifies a potentially suicidal student, or receivesinformation identifying a potentially suicidal student, must immediately notify andinvolve the principal. The nurse and counselor, if they are in the building, mustalso be notified.B. The principal or her/his designee (who may be an assistant principal, counselor or aschool based Student Support Team member) is to take the following steps:1. If the student is violent or out of control contact the Office of Mental health,at (215) 685-6440 and ask to speak to a mental health delegate. Explain thesituation to the mental health delegate and ask for advice. Call “911”, if it issuggested to do so.2. The student is never to be left alone. During this time, the principal ordesignee should provide assurance and support to the student. It isimportant to be calm, open lines of communication and encourage thestudent to share her/his feelings.3. If the student needs immediate medical treatment, follow the procedures forsending the student to the nearest hospital for emergency treatment.4. Contact parents/guardians immediately. Apprise them of the situation andrequest that they come to school at once or go to the hospital or mentalhealth facility if the student has been removed from school.5. When the parents arrive in the school - inform the parents of the situation;stress the seriousness of the incident and the need for further professionalhelp. Give the parents information about appropriate community resources;complete "Report of Emergency Conference” form in Triplicate, giveoriginal to the parents, file one copy and attach the other copy to theCounselor's report and send to the Office of Special Services, JFK Center,734 Schuylkill Ave., Room 581, Philadelphia, PA, 19146; Attention:Behavioral Health.6. The principal or designee must also file a Serious Incident ReportC. Community Resources that might be used in these situations are listed below:1. Crisis Response Centers (CRC) and the SAP team (if applicable) can beused to provide professional intervention for students and their families.2. Suicide and Crisis Intervention Services (215-686-4420) can be consultedin these situations.September 1, 2002 Page 161

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL3. Department of Human Services (215-686-6100) should be contacted when asuicide threat or attempt is associated with child abuse and/or neglect, or thestudent is known to D.H.S.4. Base Service Units and private psychiatric/psychological agencies can beused to provide professional intervention for students and families.5. The parents should be sent a follow-up letter. This letter will indicate thereferrals and recommendations made by the school staff during the parentalconference following the incident.D. If the parents do not come school regarding this incident or refuse to participate, thefollowing procedures are the course of action for the principal or designee.1. Children under 14 years of age may receive an involuntary emergencypsychiatric examination by a physician if the behavior is observed by theschool staff or police.a. Contact the Office of Mental health at (215) 685-6440, to determinewhether an involuntary psychiatric examination is appropriate.b. If an involuntary psychiatric examination is appropriate, the Office ofMental Health can send a mobile emergency team to the school toprovide a “302” petition form and assist the school in completing the“302 “ petition.c. Contact the police for transportation to the Crisis Response Center(CRC) after receiving a verbal or written approval (302 petition form)for the involuntary emergency psychiatric examination from the Officeof Mental health.d. Accompany the student to the CRC {person(s)}who witnessed thebehavior.2. Children 14 years of age and older may authorize his/her own evaluation. Where thestudent refuses to cooperate or where his/her mental condition precludes a rationalunderstanding of the treatment offered, the procedures for an involuntary examinationmust be followed. For an involuntary examination, the student's dangerous conductmust have occurred within the last 30 days.a. A "302" Emergency Involuntary Treatment Form must be completed.If the forms are not in the school, the mobile team can provide them.The petition must be completed by the person or persons with firsthand knowledge of the suicide attempt or ideation.b. The mobile emergency team can advise school staff on how tocomplete a “302” petition.c. School staff can call the Office of Mental Health (215) 685-6440, toarrange for the mobile emergency team to provide assistance at theschool.d. The police should be contacted to transport the child to the hospital assoon as the examination is authorized.3. The Department of Human Services may decline to become involved inmental health matters such as suicide. However, once a psychiatristdetermines that a student needs treatment, out-patient or in-patient, thefailure of the parent(s) or guardian to follow through with treatmentconstitutes reportable child/abuse neglect and the procedures set forth inSchool Operations Policy and Procedure for suspected child abuse must befollowed.4. A student who threatens self-inflicted harm must be sent home with theparent. If the parent declines , DHS must be called..5. The letters of notification must be complete, listing the information providedto the parents, the fact of the non-cooperation of the parents, and signed bythe staff members who made the parental contact(s).September 1, 2002 Page 162

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALE. If the student is receiving treatment, all school services should be coordinated,wherever possible, with the mental health provider treating the student.1. When the student returns to school, following crisis intervention, theComprehensive Support Process (CSP) team, must implement an approvedplan for counseling follow-up. The student's counselor must be involved inthe plan for counseling follow-up.2. If the student is hospitalized as a result of an attempted/threatened suicide,the student's counselor must be involved in the CSP team meeting to planfollow-up services.September 1, 2002 Page 163

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSCHOOL DISTRICT OF PHILADELPHIAOFFICE OF SPECIAL SERVICESREPORT OF EMERGENCY CONFERENCE WITH PARENTS*DATEI/We, ,the parent(s) ofwas/were involved in aconference with school personnel atSchool. I/We havebeen advised that our child appears to be in a crisis situation. I/We havealso been advised that we should seek further professional consultation/help immediately.I/We have been provided resource information.Parent or GuardianParent or GuardianCounselorPrincipalSchool1. Prepare in triplicate2. Give 1 copy to parent3. Maintain 1 copy for file4. Forward 1 copy to the Office of Special Services, JFK Center, 734 Schuylkill Ave.,Room 581, Philadelphia, PA, 19146; Attention: Behavioral HealthSeptember 1, 2002 Page 164

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSAMPLE FOLLOW-UP LETTER TO PARENTSNote:1. Use school stationery2. Prepare in triplicate3. Give 1 copy to parent4. Maintain 1 copy for file5. Forward 1 copy to the Office of Special Services, JFK Center, 734 Schuylkill Ave.,Room 581, Philadelphia, PA, 19146; Attention: Behavioral HealthDATEDear _____________________,This is a follow-up of our conversation concerning your child, _______________on___________, 20___ We are very concerned that he/she may be in a crisis situationwhich warrants immediate, professional help.Below is a list of resources which we discussed. Please contact the counselor for followupplanning.RESOURCES1. ______________________________________________________2. ______________________________________________________3. ______________________________________________________Sincerely,_______________________Principal_______________________Counselor_______________________Telephonecc: Behavioral Health.September 1, 2002 Page 165

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: STUDENTS WITH SPECIAL NEEDS NUMBER 804CLASSIFICATION:VISUALLY IMPAIRED (DEC. 98)I. DefinitionA. Students are accepted into the program for visually impaired (either full-time or itinerantsupport) if they meet State mandated guidelines.A student is Visually Impaired when he or she has:1. Visual acuity of 20/70 (15/50, 6/22) in the better eye after correctionOR2. Reduced peripheral vision to an angle of not greater than 20 degrees. (Centralvision field of 20° or worse).OR3. Major problems related to surgery, injury, progressive disease, or pathology ofthe eye. Examples include visual impairment of physiological origin whichadversely affects educational performance, e.g., retinal problems, maculardegeneration, glaucoma, albinism, Lebers, Stargardts, Marfans, severe myopia orany other condition or syndrome with a visual involvement.II. Basic Information / ProceduresA. A complete Ophthalmologic examination not more than one year old is required. TheOphthalmologist’s report must include a visual acuity, a diagnosis and prognosis.(School Nurse screening is acceptable for referral, but not for placement).NOTE: Visual perception problems do NOT qualify students for services for thevisually impaired.B. Final determination of eligibility for vision services are made by the Itinerant VisionConsultant and Administrator of the Program for the Visually Impaired and will be reportedand documented at MDE.The Itinerant Vision Consultant MUST be present at MDE and IEP meetings.Recommendations made for programs, and/or service without the itinerant's agreement arenot valid.III. Vision Services-Itinerant ProgramThe purpose of the Itinerant Program is to provide a continuum of service for visually impairedchildren in regular grades K-12, and children ages 5-21 years in all types of special educationplacements.Vision Consultants, who visit schools on a frequency basis determined by the individual needs ofthe students, provide itinerant service. The basic role of the Vision Consultant is to provide thenecessary materials and support to help maintain the student in the least restrictive environment.September 1, 2002 Page 166

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALResponsibilities of the Vision Consultant include:• Perform Vision evaluations for those thought to be visually impaired.• Participate as an active member of all School Support Teams for students thought to bevisually impaired, including all IEP conferences.• Provide IEP's (or vision component thereof) for every visually impaired student.• Consult with appropriate staff members of a school regarding educational adjustmentsto meet the visual needs of each student.• Set up and monitor vision stimulation programs to be carried out by the classroomteacher.• Provide large print, Braille and recorded books, tests, magnifiers, and other specialmaterials as needed.• Refer students to community, city, and state agencies that serve the visually impaired.• Determine student eligibility for free eye clinic located at the Overbrook EducationalCenter.IV. Vision Services-Full Time ProgramA full time program exists for blind and partially sighted students at the Overbrook EducationalCenter (OEC). This program serves regular education children in need of a full time adaptiveprogram at the elementary level. OEC also serves desegregation students in grades 1-8.An extensive integrated education program is available which includes an MG program, Macintoshcomputer labs, an extensive music program, an adaptive art program a language arts programfocusing on whole language instruction and an integrated approach to writing.Vision specialists provide support in specific areas such as orientation and mobility, Braille and theuse of an extensive array of adaptive technology for visually impaired students. Speech andhearing services are available where appropriate, as is occupational therapy.V. Referral for Vision Services:For all students thought to be eligible for vision services the School Nurse will:• Contact the parent and discuss the need for a current examination, i.e., within thecurrent calendar year, by an Ophthalmologist.• Assist the parent in accessing this service.• Contact the Vision Consultant regarding the free eye clinic at Overbrook EducationalCenter if resources are not available.• Document this contact in the student health record. Use Main Menu #2, Screen H7.• Issue form M-144 (Report to Parents of Vision Testing) for Ophthalmologicalexamination if most recent examination is more than one year old.• Document results of the Ophthalmological examination in the student health record.Use Main Menu #2, Page H3. Additional documentation may be done on Screen H7.• Obtain form T-700 (Permission to Evaluate) for Functional Vision Evaluation from theVision Consultant in accordance with current evaluation procedures.September 1, 2002 Page 167

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL• Notify Itinerant Vision Services of the results of the Ophthalmological examination.Forward the original completed M-144 to:Itinerant Vision ServicesOverbrook Educational Center, Location 4486720 Lansdowne AvePhiladelphia, PA 19151Telephone: 215-581-5517At all times, the Itinerant Vision Consultant is available for consultation at 215-581-5517-or viavoice mail (call 215-299-8811 and use the option in which a name is entered to reach a voicemailbox.).September 1, 2002 Page 168

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALMISCELLANEOUSSeptember 1, 2002 Page 169

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MISCELLANEOUS NUMBER 809.0CLASSIFICATION:ACCESS BILLING PROCEDURE (SEP. 02)I. INTRODUCTION:The School District of Philadelphia may bill Medical Assistance (MA) through theACCESS program for certain services which are medically necessary. Thesebillable services include many of the services being performed by school nursessuch as: Administration of prescribed medications, tube feedings and urinarycatheterizations.II.CRITERIA FOR ELIGIBILITY:A. The student has Medical Assistance.B. The student has been classified as Special Education, Chapter 14.C. The parents have been notified of the School District’s intent to bill MA and a datedcopy of the letter has been placed into the student's file.D. A medical diagnosis and physician's certification of need are on file. The Requestfor Administration of Medication/Equipment, MED-1), meets this criteria.E. The student must be receiving a service that is specified on the MED1 (daily,weekly, 3 x week). PRN services are billable when the MED1 covering the serviceis on file, i.e. nebulizer treatment.***F. The service must be listed on the student’s Individual Education Plan (IEP). Thefollowing phrasing is to be used to include nursing services on the IEP:"ADMINISTRATION OF MEDICATION/TREATMENT PERPHYSICIAN'S ORDERS, AS PROVIDED BY PARENT AND INCOMPLIANCE WITH SCHOOL DISTRICT POLICY"III. PROCEDURE:The Certified School Nurse will:A. Obtain and review documentation of medical necessity, diagnosis, and physiciansignature on the Request for Administration of Medication/Equipment (MED-1) inall cases.B. Ascertain that the following statement is on the IEP: “Medication/treatment perphysician's orders, as provided by the parent and in compliance with SchoolDistrict Policy.” If it is not listed, the nurse should meet with the IEP Chair/LEArepresentative at the school and make arrangements to have the service added in amanner that maintains the integrity of the IEP.C. Document administration of medication/treatment on computer medication log or,when unavailable, on “Student’s Record of Medication Administered or EquipmentUsed” (MED-2).D. Prepare Service Description Slips at the end of each month for those students thathave been identified as Chapter 14 Access Eligible and submit them to the MedicalAssistance Reimbursement Coordinator for their AAO. The nurse may only bill forthose dates when he/she is in the building providing (or overseeing) the service andthe student is available . Services may not be billed for dates when themedication/treatment is provided by another individual because the nurse is not inthe building..E. Complete all relevant columns on Service Description Slip including: Diagnosis,Date, Therapy or/Evaluation or Collateral, Progress Indicator and Service Time andSeptember 1, 2002 Page 170

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALType . The Activity/Treatment must be written on the service slip for each date ofservice, however a descriptive may be used rather than writing the full sentenceeach time. A one-to-two line monthly summary note must be provided in the sectionlabeled Monthly Progress Summary and should be specific as to the student'sprogress with his/her service . Arrows and ditto marks are not allowed and theDiagnosis section must be completed on each slip (as it does not preprint). Retainthe original white copy of the Service Description Slip in the health room andforward the completed yellow and pink copies to the Medical AssistanceReimbursement Coordinator. White copies must be retained for four years from thedate of service.*** If a student has been determined ACCESS eligible, the school nurse may billACCESS for collateral services provided to support the care of the student, suchas administrative paperwork, telephone calls and conferences with teachers andparents.September 1, 2002 Page 171

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: MISCELLANEOUS NUMBER 1003CLASSIFICATION:CALENDAR OF ACTIVITIES (SEP. 02)I. IntroductionA. The School District of Philadelphia fully recognizes that every community isdifferent from every other school community. However, there are basic servicesand programs that are common to all. This calendar of activities provides a guidefor accomplishing services in a timely fashion.B. A screening program is complete only when follow-up is accomplished. Therefore,parents should be contacted as soon as an individual problem is identified in orderto allow sufficient time to respond.PLEASE NOTE: THE HEALTH INFORMATION SYSTEM, WHEREAVAILABLE, IS THE ONLY STANDARD OF DOCUMENTATION.II.CalendarA. SEPTEMBER1. Write a school health plan. Include a process for teacher referrals. Establishhealth room hours in consultation with the building administrator. Provide atentative weekly schedule of your activities, such as routine hours forscreenings, medications, non-emergency health room hours. Arrange todiscuss your school health plan with the principal and faculty.2. Prepare the Health Room Suite for opening of school, including setting upyour computer, decorating bulletin boards and making health educationmaterial available. Inventory health room supplies.3. Where it is available, use the Health Information System (HIS) to revisit thehealth insurance status of students. Consult with relevant school staff toassure that new information from emergency contact forms is used to revisethe S62 or H1 screens. Where HIS is not available, create a tickler file tomonitor the health insurance of students. Use every parent/guardian/studentcontact to obtain insurance information.4. Review health histories/records of all students new to the school and issueappropriate documents (S865, MED-1, etc.).5. Review incoming MED-1s (Request for Administration of Medication...)for the current year. Interview parents and students. Document all activities.6. Where it is available, use HIS to review immunization data of students byprinting an "Immunization Compliance" report. Where HIS is not available,create a tickler file to monitor provisionally immunized students. Print a listof students who are inadequatelyimmunized and/or who have religious and/or medical exemptions. Discussthe list with the principal. (Inadequately immunized students must beexcluded.)7. Assure that all immunization data is entered on HIS byOctober 1, yearly.8. Review incoming S865s. Interview parents and students.9. Write health plan and emergency plan for each student on the back of theS865. Document all activities on the HIS.10. Review incoming gym excuses. Interview parents and students.11. Begin outreach to ensure all students in mandated grades receive a dentalSeptember 1, 2002 Page 172

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALand/or physical examination by sending a letter and assessment formshome.12. Begin to identify all students with special health needs. Use HIS, whereavailable, by printing a "Chronic Conditions" report.13. Identify School Support Team members and determine meeting schedule.14. Revisit the school plan and add to it any pertinent information fromhealth/emergency plans for students with special health needs, immunizationcompliance reports, or other health issues identified through assessment ofthe school community. Design the school health plan to be a "snapshot" thatquantifies the school health program. Provide the updated plan to thebuilding administrator and keep a copy in the health room for use bysubstitute nurses.B. OCTOBER1. Continue outreach to ensure all students have health insurance.2. Continue outreach to ensure all students in mandated grades receive a dentaland/or physical examination by linking families with their PCP and helpingfamilies enroll in MA, CHIP, and other health insurance programs.3. Begin growth, vision and hearing screening on all entry level grades andnew students.4. Begin to review/identify unresolved student health problems from theprevious year for follow-up. Delete students who are no longer on rollC. NOVEMBER1. Continue outreach to ensure all students have health insurance.2. Continue outreach to ensure all students in mandated grades receive a dentaland/or physical examination by linking families with their PCP and helpingfamilies enroll in MA, CHIP, and other health insurance programs.3. Encourage teachers to refer all students in whom they suspect a problem forscreening. Follow-up on all referrals.4. Begin scoliosis screening in sixth and seventh grades.5. Continue screenings, rescreenings and follow-up on all failures6. Continue case management of students provisionally admitted withincomplete immunizations.D. DECEMBER1. Continue screenings, rescreenings, and follow-up on all failures. Contact allparents or guardians to assess barriers to care. Conduct outreach to ensurethat all students receive service by linking families with their PCP andhelping families enroll in health insurance programs.2. Complete Scoliosis Screening and continue follow-up.3. Consult with the Principal and School Team regarding progress towardachieving goals that were set in the school health plan. Discuss strategies toinsure continued progress. Reinforce Health Room Hours.4. Continue case management of student provisionally admitted withincomplete immunizations.E. JANUARY1. Conduct outreach to ensure that all students receive service by linkingfamilies with their PCP and helping families enroll in health insuranceprograms.2. Continue case management of student provisionally admitted withincomplete immunizations.September 1, 2002 Page 173

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUAL3. Continue screenings, rescreenings, and follow-up on all failures.4. Contact all parents or guardians to assess barriers to care.F. FEBRUARY1. Continue screenings, rescreenings, and follow-up on all failures. Contact allparents or guardians to assess barriers to care. Conduct outreach to ensurethat all students receive service by linking families with their PCP andhelping families enroll in health insurance programs.2. Continue case management of student provisionally admitted withincomplete immunizations.3. Assess accomplishments. Revise plan for achieving program goals4. Enlist the support and assistance of the Student Support Team.G. MARCH-APRIL1. Continue screenings, rescreenings, and follow-up on all failures. Contact allparents or guardians to assess barriers to care. Conduct outreach to ensurethat all students receive service by linking families with their PCP andhelping families enroll in MA, CHIP, and other health insurance programs.2. Review admission requirements re: kindergarten registration for next termwith the Principal, relevant school staff and other members of the StudentSupport Team.3. Identify public school students for camperships (ages 7 to 12) and develop aplan for them to be in compliance with camp requirements for physicalexaminations and immunizations. Follow directions that accompany theapplications. Do not promise attendance until you have actually received areturned application.H. MAY-JUNE1. In consultation with appropriate personnel, identify students who will attendthe Extended School Year (ESY) program and prepare all materials inaccordance with instructions (see School Nurse Procedure #801.8).2. In anticipation of summer programs, review Student MED1 screens toensure that an August 31 end date is entered where appropriate and that allstudents with special health needs or conditions are entered in the HealthHistory Screen (H1, H9) of HIS Main Menu #2, Health Inquiry andMaintenance.3. Review health records of students who are upper level transfers to ensurethat all data, particularly immunizations (Main Menu #1) and healthconditions (H1, H9) have been entered on HIS. In non-computerized healthrooms, review all records and enter same data before transferring studenthealth records (MEH3).4. Prepare and submit Annual Reports.5. Continue to work on follow-up.6. Issue forms for physical examinations, medication, and Pupil Health Statusto relevant students for completion during the summer.7. Make appropriate arrangements to secure the health suite computer and/orhealth records.8. Assess and plan for accommodation of students with special needs forschool opening.September 1, 2002 Page 174

SCHOOL DISTRICT OF PHILADELPHIASCHOOL NURSE PROCEDURE MANUALSUBJECT: COMMUNICABLE DISEASES NUMBER 901CLASSIFICATION:INFECTION CONTROL PRECAUTIONS: CONTACT WITHBODY FLUIDS (APR. 02)I. PURPOSEA. The body fluids of all persons should be considered to contain potentiallyinfectious agents.B. Students and staff in the school environment may be at risk of accidentalexposure to body fluids.II. DEFINITIONA. The term “body fluids” includes: blood, semen, drainage from scrapes andcuts, feces, urine, vomitus, respiratory secretions (nasal discharge).B. Decontamination means the use of physical or chemical means to remove,inactivate or destroy potentially infectious agentsIII. MANAGEMENTA. Direct contact with body fluids should be avoided, if possible. In allcases, disposable gloves may be used as a protection from such contacts. B.Gloves should be removed and appropriately disposed of as soon as theperiod of contact has ended, followed by liberal hand-washing, usingsoap and water. Disposable gloves should not be washed or used in contacts withmultiple persons.1. Appropriate handwashinga. Use soap and warm, running water.b. Wash all surfaces thoroughly, including wrists, palms, back ofhands, fingers and under fingernails.c. Rub hands together for at least 10 to 15 seconds.C. All breaks in skin, bleeding or oozing cuts, or abrasions in either acaregiver or other persons should be covered (gauze, bandages, etc.)whenever possible.D. Unanticipated contact with body fluids should be followed by immediatewashing of hands and other affected areas with soap and water.E. Surfaces contaminated with blood or body fluids should be decontaminated with asolution of one (1) part bleach and ten (10) parts water, using gloves. Materialsused in cleaning up the area should bedisposed of in double plastic bags, as described below (paragraph F).F. All materials used in treating body fluids, either during health care orduring cleaning of the environment should be stored in such a manner asto prevent odor nuisances, leakage, spillage, safety or health hazards, and access byinsects or rodents. This can be accomplished by using twodisposable polyethylene bags or equivalent material with a total bagthickness of at least three mils for onsite storage. The bags should beindividually tied.September 1, 2002 Page 175