Healthcare Plan Checklist

Name:

Date of Birth:

School/Teacher:

Grade:

Parent/Guardian:

Address:

Home Phone:
Mother:
Father:

Work Phone:
Mother:
Father:

Other Emergency Contact:

Phone:

Physician:

Phone:

Medical Diagnosis:

Preferred Hospital:

Date Requested

Date Received

1. Referral received from:

2. Parent contact

3. Authorization for release of information signed by parent/guardian

4. Medical/nursing/educational records

5. Nursing assessment: Home visit, school site observation

6. Individualized Health Care Plan complete

7. Emergency Action Plan developed

8. Request for written orders to physician

9. Parent Request for Special Care on file

10. Review of procedure with parent/guardian

11. Staffing/placement meeting

12. Staff/In-service training

13. Transportation plan completed

14. Equipment and supplies checklist