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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
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

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

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

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

Seizure
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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