_____________________________       ___/___/___            _________________     ___/___/___
Student's Name (Last), (First)  (Middle)      Birthday                    School                                  Date

 

In order for a student to self-administer medication for asthma or any airway constricting disease:

• Parent/guardian provides signed, dated authorization for student medication self-administration.
• Physician (person licensed under chapter 148, 150, or 150A, physician, physician's assistant, advanced registered nurse practitioner, or other person licensed or registered to distribute or dispense a prescription drug or device in the course of professional practice in Iowa in accordance with section 147.107, or a person licensed by another state in a health field in which, under Iowa law, licensees in this state may legally prescribe drugs) provides written authorization containing:
  
  • purpose of the medication,
  • prescribed dosage,
  • times or;
  • special circumstances under which the medication is to be administered.
• The medication is in the original, labeled container as dispensed or the manufacturer's labeled container containing the student name, name of the medication, directions for use, and date.
• Authorization is renewed annually.  If any changes occur in the medication, dosage or time of administration, the parent is to notify school officials immediately. The authorization shall be reviewed as soon as practical.

Provided the above requirements are fulfilled, a student with asthma or other airway constricting disease may possess and use the student's medication while in school, at school-sponsored activities, under the supervision of school personnel, and before or after normal school activities, such as while in before-school or after-school care on school-operated property. If the student abuses the self-administration policy, the ability to self- administer may be withdrawn by the school or discipline may be imposed.

Pursuant to state law, the school district or accredited nonpublic school and its employees are to incur no liability, except for gross negligence, as a result of any injury arising from self-administration of medication by the student. The parent or guardian of the student shall sign a statement acknowledging that the school district or nonpublic school is to incur no liability, except for gross negligence, as a result of self-administration of medication by the student as established by Iowa Code § 280.16.

 

 

                                                                                                                                                    
Medication                   Dosage             Route                                                   Time

 

                                                                                                                                               
Purpose of Medication & Administration /Instructions

 

                                                                                                                 /            /          
Special Circumstances                                                               Discontinue/Re-Evaluate/Follow-up Date

 

                                                                                                                 /     /            
Prescriber’s Signature                                                                Date

 

                                                                                                                                                    
Prescriber’s Address                                                                 Emergency Phone

 

• I request the above named student possess and self-administer asthma or other airway constricting disease medication(s) at school and in school activities according to the authorization and instructions.
• I understand the school district and its employees acting reasonably and in good faith shall incur no liability for any improper use of medication or for supervising, monitoring, or interfering with a student's self-administration of medication
• I agree to coordinate and work with school personnel and notify them when questions arise or relevant conditions change.
• I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.
• I agree the information is shared with school personnel in accordance with the Family Education Rights and Privacy Act (FERPA).
• I agree to provide the school with back-up medication approved in this form.
• (Student maintains self-administration record.)

 

                                                                                                            /            /          
Parent/Guardian Signature                                                         Date
(agreed to above statement)                              

                                                                                                                                               
Parent/Guardian Address                                                           Home Phone

 

                                                                                                                                               
                                                                                                Business Phone

 

                                                                                                                                               

 

                                                                                                                                               

 

                                                                                                                                               

Self-Administration Authorization Additional Information                                                  

 

 

Approved    4/11/05                        
Reviewed  11/15/21                                                                       
Revised                   

 

_____________________________       ___/___/___            _________________     ___/___/___
Student's Name (Last), (First),  (Middle)     Birthday                    School                                    Date

School medications and health services are administered following these guidelines:

• Parent has provided a signed, dated authorization to administer medication and/or provide the health service.
• The medication is in the original, labeled container as dispensed or the manufacturer's labeled container.
• The medication label contains the student’s name, name of the medication, directions for use, and date.
• Authorization is renewed annually and immediately when the parent notifies the school that changes are necessary.

 

                                                                                                                                                                          
Medication/Health Care                         Dosage                         Route                           Time at School

 

                                                                                                                                               

                                                                                                                                               
Administration instructions

                                                                                                                                               

                                                                                                                                               
Special Directives, Signs to Observe and Side Effects

 

            /           /          
Discontinue/Re-Evaluate/Follow-up Date

 

                                                                                                /           /           
Prescriber’s Signature                                                    Date

 

                                                                                                                                   
Prescriber's Address                                                      Emergency Phone

I request the above named student carry medication at school and school activities, according to the prescription, instructions, and a written record kept. Special considerations are noted above. The information is confidential except as provided to the Family Education Rights and Privacy Act (FERPA).  I agree to coordinate and work with school personnel and prescriber when questions arise. I agree to provide safe delivery of medication and equipment to and from school and to pick up remaining medication and equipment.

 

                                                                                                            /            /          
Parent's Signature                                                                      Date

 

                                                                                                                                   
Parent's Address                                                                        Home Phone

 

                                                                                                                                   
                                                                                                    Business Phone

Additional Information                                                             

                                                                                                                                               

                                                                                                                                                

                                                                                                                                               

Authorization Form

 

 

Approved 4/10/06                    
Reviewed 11/15/21_______                  
Revised______________

 

Source:  Iowa Department of Public Health (1994).

CONCISE DESCRIPTIONS AND RECOMMENDATIONS FOR EXCLUSION OF CASES FROM SCHOOL

DISEASE * Immunization is available	Usual interval between exposure & first symtoms of disease	MAIN SYMTOMS	Minimum exclusion from school
CHICKENPOX	13 to 17 days	Mild symptoms and fever.  Pocks are “blistery.”  Develop scabs, most on covered parts of body.	7 days from onset of pock or until pocks become dry.
CONJUNCTIVITIS (Pink Eye)	24 to 72 hours	Tearing, redness and puffy lids, eye discharge.	Until treatment begins or physician approves readmission.
ERYTHEMIA INFECTIOSUM (5th Disease)	4 to 20 days	Usual age 5 to 14 years - unusual in adults.  Brief prodrome of low-grade fever followed by Erythemia (slapped cheek) appearance on cheeks, lace-like rash on extremities lasting a few days to 3 weeks.  Rash seems to recur.	After diagnosis no exclusion from school.
GERMAN MEASLES* (Rubella)	14 to 23 days	Usually mild.  Enlarged glands in neck and behind ears.  Brief red rash.	7 days from onset of rash, keep away from pregnant women.
HAEMOPHILUS MENINGITIS	2 to 4 days	Fever, vomiting, lethargy, stiff neck and back.	Until physician permits return.
HEPATITIS A	Variable - 15 to 50 days (avg. 28 to 30 days)	Abdominal pain, nausea, usually fever, skin and eyes may or may not turn yellow.	14 days from onset of clinical disease and at least 7 days from onset of jaundice.
IMPETIGO	1 to 3 days	Inflamed sores, with pus.	48 hours after antibiotic therapy started or until physician permits return.
MEASLES*	10 days to fever 14 days to rash	Begins with fever, conjunctivitis, runny nose, cough, then blotchy red rash.	4 days from onset of rash.
MENINGOCOCCAL MENINGITIS	2 to 10 (commonly 3 to 4) days	Headache, nausea, stiff neck, fever.	Until physician permits return.
MUMPS*	12 to 25 (commonly 18) days	Fever, swelling and tenderness of glands at angle of jaw.	9 days after onset of swollen glands or until swelling disappears.
PEDICULOSIS (Head/Body Lice)	7 days for eggs to hatch	Lice and nits (eggs) in hair.	24 hours after adequate treatment to kill lice and nits.
RINGWORM OF SCALP	10 to 14 days	Scaly patch, usually ring shaped, on scalp.	No exclusion from school.  Exclude from PE, swimming, contact sports.
SCABIES	2 to 6 weeks initial exposure; 1 to 4 days reexposure	Tiny burrows in skin caused by mites.	Until 24 hours after treatment.
SCARLET FEVER SCARLATINA STREP THROAT	1 to 3 days	Sudden onset, vomiting, sore throat, fever, later fine rash (not on face).  Rash usually only with first infection.	24 hours after antibiotics started and no fever.
WHOOPING COUGH* (Pertussis)	7 to 10 days	Head cold, slight fever, cough, characteristic whoop after about 2 weeks.	5 days after starts of antibiotic treatment.

Readmission to school -- It is advisable that school authorities require written permission from the health officer, school physician or attending physician before any pupil is readmitted to class following any disease which requires exclusion, not mere absence, from school.

 

 

Approved: 8/14/95       
Reviewed:   11/15/21           
Revised:     11/11/13              

 

While the school district is not responsible for reporting, the following infectious diseases are required to be reported to the state and local public health offices:

Acquired Immune                           Leprosy                                                           Rubella (German
    Deficiency Syndrome                Leptospirosis                                                                measles)
    (AIDS)                                              Lyme disease                                               Rubeola (measles)
Amebiasis                                          Malaria                                                             Salmonellosis
Anthrax                                                Meningitis                                                      Shigellosis
Botulism                                                   (bacterial or viral)                                    Tetanus
Brucellosis                                          Mumps                                                            Toxic Shock Syndrome
Campylobacteriosis                        Parvovirus B 19                                           Trichinosis
Chlamydia trachomatis                         infection (fifth                                         Tuberculosis
Cholera                                                        disease and other                                Tularemia
Diphtheria                                                   complications)                                       Typhoid fever
E. Coli 0157:h7                                 Pertussis                                                          Typhus fever
Encephalitis                                              (whooping cough)                                  Venereal disease
Giardiasis                                            Plague                                                                          Chancroid
Hepatitis, viral                                    Poliomyelitis                                                              Gonorrhea
    (A,B, Non A-                                   Psittacosis                                                                   Granuloma Inguinale
    Non-B, Unspecified)                   Rabies                                                                           Lymphogranuloma Venereum
Histoplasmosis                                 Reye's Syndrome                                                     Syphilis    
Human Immunodeficiency             Rheumatic fever                                               Yellow fever          
    Virus (HIV) infection                    Rocky Mountain                                                 
    other than AIDS                                    spotted fever
Influenza                                              Rubella (congenital
Legionellosis                                            syndrome)                                                                       

Any other disease which is unusual in incidence, occurs in unusual numbers of circumstances, or appears to be of public health concern, e.g., epidemic diarrhea, food or waterborne outbreaks, acute respiratory illness.

                                                                       

 

Approved: 8/14/95       
Reviewed:   11/15/21             
Revised:   11/11/13                

 

Source:  Iowa Department of Public Health (1994).

     REPORT THE FOLLOWING DISEASES IMMEDIATELY BY TELEPHONE (1-800-362-2736)

Botulism                                                      Poliomyelitis                Yellow Fever

Cholera                                                        Rabies(Human)          Disease outbreak of any public health concern

Diphtheria                                                    Rubella         

Plague                                                         Rubeola(Measles)         

 

REPORT ALL OTHER DISEASES BELOW                                           WEEK ENDING _____________

See other side for list of reportable infectious diseases.

DISEASE	PATIENT	COUNTY OR CITY	DOB	SEX
	Name                                            Parent(if applicable)
	Address
	Attending Physician
	Name                                           Parent (if applicable)
	Address
	Attending Physician
	Name                                           Parent (if applicable)
	Address
	Attending Physician
	Name                                           Parent (if applicable)
	Address
	Attending Physician
	Name                                           Parent (if applicable)
	Address
	Attending Physician

Reporting Physician, Hospital, or Other Authorized Person.

 

_____________________________________________________________

Address

 

_____________________________________________________________

Remarks:

_____________________________________________________________

 

FOR SCHOOLS ONLY:  Report over 10% absent only.  Total enrollment: ____________________
	Monday	Tuesday	Wednesday	Thursday	Friday
No. Absent
% of Enrollment
REPORT NUMBER OF CASES ONLY           __________  Chickenpox                                              __________  Gastroenteritis           __________  Erythema infectiosum ( 5th disease)    __________  influenza-like illness (URI)

 

 

Approved    4/11/05                        
Reviewed  11/15/21                       
Revised  11/11/13                 

 

The Janesville Consolidated School District Emergency Fire Plan includes the following:

      1.   If evacuation is needed immediately, the staff member who has knowledge of the fire shall pull the nearest fire alarm.

      2.   Each employee of the JCSD shall be instructed as to the locations of all fire alarms.

      3.   The evacuation plan includes:

            a. a diagram posted in each room indicating evacuation routes and exits

            b. knowledge by staff members as to alternate routes of escape.

      4.   Evacuation from the building:

            a.   orderly lines-walking no running

            b.   quietly- no talking so change instructions may be easily heard

            c.    teacher or adult supervisor in charge of each group

            d.   notebooks, coats etc. should NOT be taken

            e.    teacher shall take attendance record and/or class register to check to see that all students are present at assembly point following evacuation

            f.    assembly areas shall be away from the school building and not in a drive area where emergency trucks may have to be

      5.   Windows and doors should be closed to prevent fire from drafting

      6.   The secretary/s need to secure all records and any other valuables in a fire proof safe

      7.   No one should reenter the building

      8.      Fire drills will be held a minimum of 4 times per year, as required by State law; 2 during first semester and 2 during second semester.

            a.   the first drill of each semester will be announced in advance

            b.   the second drill will be unannounced and held at different periods during the day

 

 

Approved:  03/25/96  
Reviewed:   11/15/21                            
Revised:    4/11/05 

 

1.   In the event of a tornado:

      A.   A tornado watch will be announced when weather conditions are such as to make formation of tornadoes highly possible.  This is to alert staff and students that they MAY be requested to report to their assigned tornado shelter area.

      B.   A tornado warning is announced when a tornado has been spotted.

            a.   Upon hearing this announcement all staff and students should report immediately to the assigned tornado shelter area.

            b.   If students/staff are on the playground or open area, they will be notified by a staff member and should seek shelter immediately.

2. Tornado shelter areas have been assigned and have been reviewed by the Civil Defense and the insurance company as to safety.  These areas are posted in each room and should be used accordingly.  IF there is any doubt to where you and/or your class should be keep in mind:

• small interior rooms with no windows
• hallways with solid walls and without south or west openings
• small rooms on the north or east sides of the building with
• little or no glass areas, such as restrooms
• hallways with south or west openings- place children as far away as possible from south and west openings
• near the inside walls of north and east rooms with windows

3.   Students should take a book with them and sit/crouch facing the wall with the book over their heads.  If a book is not available, they should cover their heads with their hands/arms.

4.   Because there may be a need to further announcements and the intercom may not be available, IT IS ABSOLUTELY NECESSARY THAT STUDENTS/STAFF REMAIN QUIET!!!!!!

5.   IF THERE IS NOT TIME TO GO TO REGULAR TORNADO SHELTER AREA:

• Go to inside wall of room
• Duck down and cover head or lie down under desks or other heavy furniture

6.   Teachers need to take a grade book and/or attendance sheet with them with exiting from the room.

7.   Tornado Drills will be held a minimum of four times per year, as required by State law.  2 will take place during first semester, and 2 during second semester.

      a.   the first drill of each semester will be announced in advance

2. the second drill will be unannounced and held at different periods during the day

 

 

Approved:  03/25/96  
Reviewed:  11/15/21                             
Revised:   4/11/05 

 

Some students who require special education need special health services in order to participate in the educational program.  These students shall receive special health services in accordance with their individualized educational program.

1. Definitions

            “Assignment and delegation” – occurs when licensed health personnel, in collaboration with the education team, determine the special health services to be provided and the qualifications of individuals performing the health services.  Primary consideration is given to the recommendation of the licensed health personnel.  Each designation considers the student’s special health service.  The rationale for the designation is documented.

            “Co-administration” – the eligible student’s participation in the planning, management and implementation of the student’s special health service and demonstration of proficiency to licensed health personnel.

            “Educational program” – includes all school curricular programs and activities both on and off school grounds.

            “Education team” – may include the eligible student, the student’s parent, administrator, teacher, licensed health personnel, and others involved in the student’s educational program.

            “Health assessment” – health data collection, observation, analysis, and interpretation relating to the eligible student’s educational program.

            “Health instruction” – education by licensed health personnel to prepare qualified designated personnel to deliver and perform special health services contained in the eligible student’s health plan.  Documentation of education and periodic updates shall be on file at school.

            “Individual health plan” – the confidential, written, preplanned and ongoing special health service in the educational program.  It includes assessment, planning, implementation, documentation, evaluation and a plan for emergencies.  The plan is updated as needed and at least annually.  Licensed health personnel develop this written plan with the education team.

            "Licensed health personnel" - includes licensed registered nurse, licensed physician, and other licensed health personnel legally authorized to provide special health services and medications.

            "Prescriber" - licensed health personnel legally authorized to prescribe special health services and medications.

            "Qualified designated personnel" - persons instructed, supervised and competent in implementing the eligible student's health plan.

            "Special health services" - includes, but is not limited to, services for eligible students whose health status (stable or unstable) requires:

• Interpretation or intervention,
• Administration of health procedures and health care, or
• Use of a health device to compensate for the reduction or loss of a body function.

            "Supervision" - the assessment, delegation, evaluation and documentation of special health services by licensed health personnel.  Levels of supervision include situations in which licensed health personnel are:

• physically present.
• available at the same site.
• available on call.

 

B.         Licensed health personnel shall provide special health services under the auspices of the school.  Duties of the licensed personnel include the duty to:

• Participate as a member of the education team.
• Provide the health assessment.
• Plan, implement and evaluate the written individual health plan.
• Plan, implement and evaluate special emergency health services.
• Serve as liaison and encourage participation and communication with health service agencies and individuals providing health care.
• Provide health consultation, counseling and instruction with the eligible student, the student's parent and the staff in cooperation and conjunction with the prescriber.
• Maintain a record of special health services.  The documentation includes the eligible student's name, special health service, prescriber or person authorizing, date and time, signature and title of the person providing the special health service and any unusual circumstances in the provision of such services.
• Report unusual circumstances to the parent, school administration, and prescriber.
• Assign and delegate to, instruct, provide technical assistance and supervise qualified designated personnel.
• Update knowledge and skills to meet special health service needs.

 

C.         Prior to the provision of special health services the following shall be on file:

• Written statement by the prescriber detailing the specific method and schedule of the special health service, when indicated.
• Written statement by the student's parent requesting the provision of the special health service.
• Written report of the preplanning staffing or meeting of the education team.
• Written individual health plan available in the health record and integrated into the IEP or IFSP.

 

D.        Licensed health personnel, in collaboration with the education team, shall determine the special health services to be provided and the qualifications of individuals performing the special health services.  The documented rationale shall include the following:

• Analysis and interpretation of the special health service needs, health status stability, complexity of the service, predictability of the service outcome and risk of improperly performed service.
• Determination that the special health service, task, procedure or function is part of the person's job description.
• Determination of the assignment and delegation based on the student's needs.
• Review of the designated person's competency.
• Determination of initial and ongoing level of supervision required to ensure quality services.

 

E.         Licensed health personnel shall supervise the special health services, define the level of supervision and document the supervision.

 

F.         Licensed health personnel shall instruct qualified designated personnel to deliver and perform special health services contained in the eligible individual health plan.  Documentation of instruction and periodic updates shall be on file at school.

 

G.        Parents shall provide the usual equipment, supplies and necessary maintenance for such.  The equipment shall be stored in a secure area.  The personnel responsible for the equipment shall be designated in the individual health plan.

 

 

Approved  08/12/96  
Reviewed   11/15/21  
Revised            

 

The school district will provide nutrition education and engage in nutrition promotion that:

• Is offered at grade level 5-12 to provide students with the knowledge and skills necessary to promote and protect their health;
• Is part of not only health education classes 5-12, but also classroom instruction in subjects such as math, science, language arts, social studies, and elective subjects;
• Promotes fruits, vegetables, whole-grain products, low-fat and fat-free dairy products, healthy food preparation methods and health-enhancing nutrition practices;
• Emphasizes caloric balance between food intake and physical activity
• Is held for one week in the fall and one week in the spring focusing on nutrition for grade levels K-4, and tailoring it to their way of understanding
   

Physical Education

Janesville Consolidated School District will provide physical education that:

• Is for all students in grades K-12 for the entire school year;
• Is taught by a certified physical education teacher;
• Includes students with disabilities and special health-care needs, providing proper differentiation of instruction; and,
• Engages students in moderate to vigorous activity during at least 50 percent of physical education class time

 

Daily Recess

Elementary school will provide recess for students that:

• Is at least 20 minutes per day;
• Is preferably outdoors;
• Encourages moderate to vigorous physical activity verbally and through the provision of space and equipment; and,
• Discourages extended periods of inactivity.

When activities, such as mandatory school-wide testing, make it necessary for students to remain indoors for long periods of time, the teachers should give students periodic breaks during which they are encouraged to stand and be moderately active.

 

Physical Activity and Punishment

Employees should not use physical activity (e.g., running laps, pushups) or withhold opportunities for physical activity (e.g., recess, physical education) as punishment.

 

Integrating physical activity into the classroom setting

For students to receive the nationally recommended amount of daily physical activity and for students to fully embrace regular physical activity as a personal behavior, students need opportunities for physical activity beyond the physical education class. Toward that end, the school district will:

• Offer classroom health education that complements physical education by reinforcing the knowledge and self-management skills needed to maintain a physically active lifestyle and to reduce time spent on sedentary activities;
• Discourage sedentary activities, such as watching television, playing computer games, extended use of phones, etc.;
• Provide opportunities for physical activity to be incorporated into other subject lessons; and classes, as well as brain breaks to help increase attentiveness;
• Inform students of all extracurricular activities, as well as activities available in the community to them after and before school.

 

School Meals

Meals served through the National School Lunch and Breakfast Programs will:

• be appealing and attractive to children;
• be served in clean and pleasant settings;
• meet, at a minimum, nutrition requirements established by state and federal law:
• offer a variety of fruits and vegetables, legumes and whole grains;
• serve only low-fat (1%) and fat-free milk and nutritionally equivalent non-dairy alternatives (as defined by the USDA);

 

Breakfast

To ensure that all children have breakfast, either at home or at school, in order to meet their nutritional needs and enhance their ability to learn, schools will:

• operate the breakfast program, to the extent possible;

 

Free and Reduced-Priced Meals

The school district will make every effort to eliminate any social stigma attached to, and prevent the overt identification of, students who are eligible for free and reduced-price meals.  Toward this end, the school district may:

• utilize electronic identification and payment systems;
• provide meals at no charge to all children, regardless of income; and,
• promote the availability of meals to all students.

 

Food Safety

All foods made available on campus adhere to food safety and security guidelines.

• All foods made available on campus comply with the state and local food safety and sanitation regulations. Hazard Analysis and Critical Control Points (HACCP) plans and guidelines are implemented to prevent food illness in schools.  http://www.fns.usda.gov/tn/Resources/servingsafe_chapter6.pdf
• For the safety and security of the food and facility, access to the food service operations are limited to child nutrition staff and authorized personnel. 

 

Monitoring

The superintendent will ensure compliance with established school district-wide nutrition and physical activity wellness policies.

JCSD:

• food service staff, at the school or school district level, will ensure compliance with nutrition policies within food service areas and will report on this matter to the superintendent.
• will report on the most recent USDA School Meals Initiative (SMI) review findings and any resulting changes.  If the school district has not received a SMI review from the state agency within the past five years, the school district will request from the state agency that a SMI review be scheduled as soon as possible;
• will have the superintendent develop a summary report every three years on school district-wide compliance with the school district’s established nutrition and physical activity wellness policies, based on input from schools within the school district; and,
• will provide a report to the school board and also distributed to all school wellness committees, parent/teacher organizations, principals and health services personnel in the school district.

 

Policy Review

Monitoring of the Wellness Goal will be continued yearly. As part of that review, the school district will review the nutrition and physical activity policies and practices and the provision of an environment that supports healthy eating and physical activity.  The school district, and individual schools within the school district will, revise the wellness policies and develop work plans to facilitate their implementation.