Allergies • Special Needs or Procedures • Chronic Illnesses
District Name
Number of Students
with
Allergies on
Campus
Classification / Licensure
Type
Insect Sting
Date Submitted
Peanut
Dairy
Person Completing Report Latex
Campus Name
MONTH
SCHOOL YEAR
Notes:
Soap/Detergent
Tree Nut
Egg
Wheat
Other: list
#
Number of Students Requiring
Number of Students with
Specialized Needs or
Procedures
Chronic Illnesses
Type
Bladder Program
Blood Glucose Testing
Bowel Program
Catheterization by Nurse
or UAP
Catheterization by Self
Dialysis (peritoneal)
Feeding Assistance (oral)
Nebulizer Treatment
Range of Motion Exercises
Postural Drainage
Ostomy Care
Suctioning
Tracheostomy Care
Tube Feedings
Ventilator Assisted Care
Sub-cutaneous
Medications
Intramuscular Medications
Intravenous infusion
Carbohydrates calculations
Insulin Pump
Diapering/Toileting
Occupational Therapy
Hearing Aid Checks
Urine Ketones
Wound Care
Central line or PICC line
care
Physical Therapy
Oxygen Saturation Check
Oxygen Administration
Peak Flow Monitoring
Vagal nerve stim check
Arkansas School Nurse Survey
2015-2016
#
Type
ADD/ADHD
Allergies (Life-threatening)
Anorexia/Bulimia
Asthma
Autism
Blind/Visually Impaired
Cardiovascular
Cerebral Palsy
Cytomegalovirus
Cystic Fibrosis
Deaf/Hearing Impaired
Depression
Diabetes, Type 1
Diabetes, Type 2
Down’s Syndrome
Genetic Disorders, other
Hemophilia/Bleeding
Disorder
Hepatitis B/C
HIV/AIDS
Hypertension
Malignant Disease
Migraine Headaches, with
Prescription
Neuromuscular Disease
Muscular Dystrophy
Multiple Sclerosis
Obesity
Orthopedic Disability ,
(permanent)
Psychiatric Disorder
Renal Disease
Seizure Disorder
Sickle Cell Anemia
Spina Bifida
Substance Abuse (known)
Ulcers
Hydrocephalus
Rheumatoid Arthritis
TBI
Obesity (BMI)
#