School Nurse Support Form

If you develop symptoms of COVID-19, test positive for COVID-19, or are in close contact with someone who tests positive for COVID-19 please email covid19reporting@djusd.net or call 530-235-6137.

STUDENTS:

If this is an emergency, please call 911 or have someone take you to the nearest hospital.  If you have trouble breathing, have persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, or have bluish lips or face, call 911 or have someone take you to the nearest hospital.
 
If you need help, and it is not a life threatening emergency, fill out the referral form below.  The usual response time from a district nurse is within 3 business days.  

If you are currently having thoughts of suicide, immediately tell an adult or call 911. If you are unable to do that, call the Suicide Prevention Hotline at 530-756-5000 or 800-273-8255.  After you have received help, please fill out this form so a school staff member can follow up. 

24 Hour support is also available: Teen Line 530-753-0797 and Crisis Text Line Text "HOME" to 741741

TEACHERS/STAFF:

If you are concerned about a student's health, fill out the referral form which will be shared with a school nurse.

If you believe that a student is at risk for self-harm, immediately contact your school counselor and principal and fill out the social-emotional referral form.

PARENTS/GUARDIANS:

If this is an emergency, please call 911 or take your child to the nearest hospital.  If your child has trouble breathing, has persistent pain or pressure in the chest, new confusion, inability to wake or stay awake, or has bluish lips or face, call 911 or take your child to the nearest hospital.

If you are concerned about your child's health and it is not a life threatening emergency, fill out the referral form below. The usual response time from a district nurse is within 3 business days.  



Referrals are confidential and are forwarded by email to the school nurse. Only those individuals with a need to know will be informed of the referral.
 
The usual response time from a district nurse is within 3 business days.  


 
School Nurse Support Form

Your Full Name 

Relationship to Student




Student Full Name 

School 

Grade 

School Nurse

Phone Number (Include Area Code) 

Contact Email 

Student’s Medical Diagnosis (if known)
Student’s Current Medication(s) (if known)
Student’s Current Medical Insurance (if known)
Student’s Primary Health Care Provider (if known)

Last Time Seen by Health Care Provider (if known)

What is Your Health Concern?

Additional Comments

 



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