T.A. Sims Elementary School
Forms and Policies
Medication Forms / Field Trip Info / Immunization Info / Screening Info
FWISD Medication Administration Forms
NOTE: If possible, all medications should be given outside of school hours. Three times a day medications can be given before school, after school and at bedtime.
Medication Administration Request Form
Use this form when the nurse is to administer oral or topical medications to your student.
Self-Administration of Prescribed Asthma-Anaphylaxis Medicine by Student Form
Use this form for students who need to keep their prescribed asthma (inhalers) or anaphylaxis (EPI pen) medication on their person and self administer as prescribed.
Self-Administration of Prescribed Asthma-Anaphylaxis Medicine by Student (Spanish) Form
Este formularies es para los estudiantes que deben seguir tomando medicamentos recetados para el asma o la anafilaxia (EPI pen) en su persona y autoadministrarse según lo recetado.
Specialized Health Care Procedure Authorization Form
Use this form when the nurse will be performing a specialized procedure such as nebulizer treatment for asthma student, or injecting an EPI Pen, etc.
Specialized Health Care Procedure Authorization (Spanish) Form
El formulario se usa cuando la enfermera administrará un procedimiento especializado como nebulizador para medicamentos para el asma, EPI Pen, etc.
NOTE: All medication submitted to the Nurses Office must be in original properly labeled containers from the pharmacy. The pharmacy can supply you with 2 labeled bottles for this purpose. Medications sent in baggies or unlabeled containers will not be given.
Immunization Information
NOTE :: DROP OFF A COPY of your IMMUNIZATION RECORD or EXEMPTION to the Nurse's Office!
MEDICAL EXEMPTION :: If your student cannot receive immunizations for medical reasons, have your doctor fill out the Medical Exemption Form or provide a letter stating which immunizations your student cannot have and why.
NOTE :: A physician licensed to practice medicine in the United States must complete the letter or the form (you cannot use a homeopathic practitioner or chiropractor).
NOTE :: The form/letter is good for 1 school year, then a new form/letter will have to be obtained for the following school year.
REASON OF CONSCIENCE EXEMPTION :: If you choose not to get your child immunized, click Affidavit Request for Exemption from Immunizations for Reasons of Conscience.
NOTE :: This affidavit is good for 2 years, then you will have to reapply.
6th- 7th GRADE IMMUNIZATION REQUIREMENTS
- Varicella Vaccine :: 2 doses (on or after 1st birthday or written proof of chickenpox disease.
- Meningococcal Vaccine - 1 dose.
- Tdap - 1 booster dose Tdap (Tetanus, diphtheria and acelluar pertussis-containing vaccine).
Screeing Information
Acanthosis Nigricans Screening pupils in grades 1, 3, 5, and 7.
Acanthosis Nigricans (AN) is a physical skin finding that may be a marker for high blood insulin levels (hyperinsulinemia), suggesting insulin resistance, that is associated with obesity. The goal of this screening is to identify children with AN and intervene to reduce their risk of developing diabetes.
Hearing Screening pupils in grades K, 1, 3, 5, and 7.
The results of the pure-tone audiometric Sweep-Check Screen are recorded for both the right and left ears. The Sweep-Check Screen is performed at an intensity less than or equal to 25 dB at the following frequencies: 1000, 2000, and 4000 Hertz. The goal is to identify children hearing problems early and refer them to appropriate remedial services.
Vision Screenings pupils in grades K, 1, 3, 5, and 7.
For vision screening a distance acuity for the right and left eyes is recorded. At YMLA we use a Telebinocular for screenings (the same equipment used by TxDPS). This is a stereoscopic instrument used for screening various eye defects and measuring visual acuity. The goal is to identify children with vision problems early and refer them appropriate remedial services.
Spinal Screening pupils in grade 5 (10 y/o girls) and 8 (14 y/o boys).
The goal is to identify children with scoliosis early and refer them to appropriate remedial services.
Field Trip Information
