Wautoma Area School District
Approved 9/28/1989
Revised 03/13/2003
STUDENT INFORMATION – to be completed by District Nurse
Student’s Name:
Grade:
School:
Medication/Route:
Date of Birth:
Date/Dose/Time:
Comments:
CODES:
X – No School
D – Early Release Day
A – Absent
S – Late Start Day
Designated personnel must initial upon administration of medication in proper box
Signature Initials Signature Initials
Legal Reference: Wisconsin State Statute §145.06(1), 252.21
Cross Reference: Board Policy 453.33 Rule-Communicable Diseases-Head Lice
