Special Health Services Process

1)    School completes the Health Services Request Form (HSR) with the following information:

  • Name of student
  • Name of school
  • Description of medical condition
  • Name of school contact person and phone number
  • Reason for request (nursing services required at school)
  • Complete:  Service(s) Date(s)Time(s)
  • School Contact and if student is ESE or has a 504 plan

2)    A current and completed Authorization for Medication/Treatment Form, signed by     physician and parent is needed when requesting Nursing Services.
3)    Fax completed Medication/Treatment Form and Health Services Request Form to Coordinated Student Health Services at 754-321-2743.
4)    After assessment of student’s needs is done, Coordinated Student Health Services will determine appropriate level of care needed for student.  Coordinated Student Health Services will contact school to arrange for provision of services for student.
5)      Any request for substitute or temporary placement for assistance in classroom, cafeteria, escorting, diapering, toileting, etc., does not require an Authorization for Medication/ Treatment Form.


Whenever a student receiving services is absent or services/training cancelled the school should contact Coordinated Student Health Services Department immediately to cancel nursing services. Without timely notification, the selected Nursing Agency will have to be paid.

Please have schools make parents aware of the need to notify the school if child/student is going to be out, especially if the student has scheduled doctor appointments that are known in advance. This will help cut down on the Agency sending someone when the student will not be there.




  • ALL Trainings are done by RN’s only.  Training on special procedures and/or health conditions require a completed Authorization for Medication/Treatment Form signed by the physician and parent before the training can be initiated. The signed Authorization for Medication/Treatment Form, along with a completed Health Services Request Form, should be faxed to Coordinated Student Health Services to request training. The parent can do the procedure himself or herself until the training is done and the appropriate school staff can do the procedure.

Some examples of Special Procedures are:

  • Clean intermittent catheterization
  • Epi-pen administration
  • Glucometer testing (blood glucose test)
  • Oxygen administration
  • Special feedings-gastrostomy (g-tube), nasogastric, jejunostomy
  • Suctioning-surface, bulb


Some examples of Health Conditions are:

  • Allergic Reaction/Hypersensitivity (with or without Epi-pen)
  • Asthma
  • Cystic Fibrosis
  • Diabetes
  • Seizures
  • Sickle Cell Anemia


Upon receipt of the Authorization for Medication/Treatment Form and Health Services Request Form, Coordinated Student Health Services will contact the school to confirm date and time for training.

Your school’s on-call nurse from the Department of Health-Broward is also available to conduct health trainings. See Section IV on the manual for further contact information.

Sample Individualized Careplan