Request edit access
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Student Health Referral Form
Please complete the form below for student referrals to the district nurse.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Your Name (who is making the referral)
*
Your answer
Student Perm ID
*
Your answer
Student First Name
*
Your answer
Student Last Name
*
Your answer
At what site does the student attend school?
*
Campus Park
Selma Herndon
Yamato Colony
Livingston Middle School
Request a Vision Screening (please indicate your observations below)
Complains/struggles/squints/moves closer to see the board or screen
Complains of eye discomfort, fatigue, frequent eye rubbing/blinking
Short attention span
Avoids reading and other close activities or holds reading materials close to the face
Frequent complaint of headaches
Covers one eye or tilts head to one side / Eye or Eyes turn in or out
Loses place when reading or has difficulty remembering what he or she read
Has glasses - Not wearing, need repair, or lost
SST Meeting
Other:
Request a Hearing Screening (please indicate your observations below)
Limited, poor, or no speech
Frequently inattentive
Difficulty learning
Seems to need everything at a high volume
Fails to respond to conversation-level speech or answers inappropriately (i.e. loud)
SST Meeting
Other:
Other Referral (explain below)
Your answer
Other Information you want to provide related to your referral
Your answer
Who is referring the student?
*
Parent
Teacher
Principal
Counselor
Health Office
Other:
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of LUSD.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
