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Health Services Forms

Please mail the following forms to Hathaway Brown School, 19600 N. Park Boulevard, Shaker Heights, OH  44122,  ATTN: Jody Duecker.

The full time Registered Nurse, Judy Wilson, can be reached Monday through Friday, during regular school hours, at 216-320-8092.

Emergency Forms - Due May 1
Early Childhood Emergency Care, OTC, Medical Permission Form
Grade K-12 Emergency Care, OTC, Medical Permission Form

Physical Examinations - Due July 15
Physical Examination Form (General Student Form)
OHSAA Physical Form (Student Athlete Form)
Immunization Requirement for Students Entering 7th Grade
Medical, Religious, or Philosophical Exemption Form

Medication at School
Letter to Parents: Medication Policy
Physician and Parent Request for the Administration of Medication by School Personnel

Diabetic Health Care Plan
Physician Authorization/Parent Request for Blood Sugar Testing in the Classroom

Asthma Action Plan
Self-Medication for Asthma Inhalers, Authorization Form

Allergy Action Plan
Authorization for Student Possession and Use of an Epinephrine Autoinjector

Seizure Action Plan

Screenings - Please contact the school nurse at 216-320-8092 if you need a replacement copy of the following nurse-issued forms:
      Vision Screening Referral Report
      Ohio Department of Health, Eye Specialist Report
      Hearing Screening Referral Report
      Postural Screening Referral and Medical Report

Shaker Heights, Ohio Girls K-12 Coed Early Childhood

19600 North Park Boulevard Shaker Heights, Ohio 44122 P: 216.932.4214
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