Health Forms & Information

These forms will allow the Health Services team to provide care for your student while at school. Please feel free to ask your campus clinic staff if you have any questions.

Request to Administer Medication

If your student requires medication at school, please use one of the forms:

Food Allergy & Anaphylaxis Plan

For students with anaphylaxis to food, insects, or other substances, please use one of these forms:

Guidelines for the Care of Students With Food Allergies At-Risk for Anaphylaxis to Implement SB 27 (82nd Legislative Session)

Round Rock ISD food allergy health plans (IHP) will be individualized for all students who have food allergies. Once notified of the student’s allergy, a working partnership with students, parents, student’s physician, school nurse, counselor, food services, and other Round Rock ISD personnel, as appropriate, begins. Upon receipt of signed medical plans and parental consent, the individual health plan (IHP) will be developed. Round Rock ISD requires annual compliance training to teach all staff to recognize an allergic reaction and how to use rescue drugs such as epinephrine auto-injectors. In depth training will be provided to appropriate staff members as the principal and school nurse deems necessary. In the case of severe life threatening allergies, elementary school nurses will send letters to other parents of the class requesting parents to voluntarily refrain from sending the allergen food in their child’s belongings during school or after-school activities, celebrations or parties. The principal will designate a food-allergy friendly area or lunch table. Hand washing guidelines for staff and students will be enforced. The custodial department will be instructed to use commercial wipes and cleaners that remove the allergen from the hard surfaces. Non-food items will be adapted in the curriculum for those classes who have students with food allergies. The transportation department will also be notified, and trained to recognize the specific reactions to life threatening allergies, if applicable. While Round Rock ISD cannot guarantee an allergy-free environment at school, the district is committed to doing everything possible to ensure the safety of every child who has allergies.

Asthma Action Plan

For students with respiratory issues requiring an inhaler, please use this form:

Seizure Care Plan

For students with a seizure disorder, please use this form:

Self-Carry Medications

For our older students, who the parents, the physician, and the health services staff deem able to administer their own emergency medication only, please use this form:

Hopewell Middle School nurse checking a student's blood pressure

Health Services Specialized Forms

Special Diet

If your child has a food allergy or intolerance or a disability that restricts their diet, please supply Emily O’Neil with this SPECIAL MEALS REQUEST FORM (Parts A & B), completed in full and signed by a licensed physician.

Round Rock ISD Food Services

Diabetic Information

For students with type 1 diabetes, please use these forms along with your student’s diabetic school orders from their diabetes care provider to give to the campus nurse.

Authorization for Administration of Diabetes Management and Care Services By An Unlicensed Diabetes Care Assistant (UDCA)

Under HB 984, each school must train other employees to serve as Unlicensed Diabetes Care Assistants who can provide diabetes management and care services if a nurse is not available when a student needs such services. Such services include the administration of insulin or, in an emergency, glucagon. Round Rock ISD has trained staff at each school to provide such services. HB 984 further specifies that an Unlicensed Diabetes Care Assistant exercises his or her judgment and discretion in providing diabetes care services and that nothing in the statute limits the immunity from liability afforded to employees under section 22.0511 of the Texas Education Code.

Round Rock ISD Blood Glucose Monitoring Information and Parental Consent Form
Parents of students in Round Rock ISD have obtained a blood glucose monitoring device, including, but not limited to a “Dexcom” (“device”) and have requested that Round Rock ISD allow the pairing unit (e.g. cell phone, tablet) and the device to access RRISD wifi, and be viewed and monitored by Round Rock ISD employees, including but not limited to nurses (Herein referred to as “Monitoring”). Monitoring will be allowed ONLY as outlined in this Information and Consent Form.

Enteral Tube Feeding

If your student requires enteral feeding, please use these forms:

Special Procedures

If your student requires a special procedure, such as urinary catheterization or tracheal suctioning, please use these forms:

Private Duty Nurse

Round Rock ISD has campus clinic personnel, composed of RNs, and LVNs, providing health services for our students. Occasionally, parents may wish for additional nursing care for their child who has high health care needs. Parents are financially responsible for this additional nursing care.

Agreement of Non-School District Private Duty Attendants:
(Both forms need to be completed and returned to the campus Nurse)

 

Agreement of Non-School District Private Duty Nurses:
(Both forms need to completed and return to the campus Nurse)