Procedure For Use Of Health Clinic Pass Schools With On-Call Nurse

The following steps are designed to facilitate communication relating to a student’s visit to the health clinic with the parents / guardians and teachers. The Broward County School Board Clinic Pass is to be completed for each clinic visit. The forms are to be distributed to the classrooms at the beginning of the school year and replenished as needed.


  • When a student has a health complaint, the teacher / school representative is to complete the top portion of the Broward County School Board Clinic Pass identifying the student name, date, time, date of birth, teacher name, grade, and reason for referral.
  • When the student presents to the health clinic with a pass, the remainder of the pass is to be completed by the person assigned to the clinic. This person will document the time the student arrived, nature of the complaint, action(s) taken, disposition of the child, and time the student left the clinic. A check is to be placed in the appropriate boxes and the pass is to be signed by the person handling the clinic action(s).
  • The top white copy remains in the clinic. The yellow copy is to be given to the student to take to his parent/guardian. In the event the student is returned to class, the yellow copy will be given to the student to present to the teacher. The teacher will review the copy and return to the student to take to his parent/guardian.
  • All completed clinic passes should be kept in a locked cabinet in a secure place, preferably the school clinic.
  • The clinic passes should be placed in the student’s Cumulative Health Folder by the end of the school year by a principal designee.




The Daily Clinic Log is designed to collect data on students who visit the clinic. The information required is non-confidential.


Start a new form for each day (some schools may need multiple pages per day)

  • The staff person assigned to the clinic will enter the required information for each student encounter.
  • Record the student’s time in, name, grade, teacher, and time out.
  • Place a checkmark in either the illness or injury box as appropriate.
  • Place a checkmark to indicate the disposition of the student (return to class, sent home, 911).
  • Initial at the end of the column and provide a full signature at the bottom of the page.
  • Total the number of students seen in the clinic that day and record at the bottom of the page.


Note: This form is not to be used as a substitute for documentation of care provided.