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Student Health Care Forms and Information

CCS Health Services Forms Library

NC Immunizatoin Requirements 2022-2023

2022-2023 NC Immunization Requirements Rev. 3_2_2022.docx.pdf 37.31 KB (Last Modified on June 22, 2022)

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Asthma Medication Plan

Asthma Medication Plan Rev. 03-2021.pdf 116.46 KB (Last Modified on March 19, 2021)

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CCS Medication Administration Protocol

Protocol for Medication Administration Reprint 10-2019.pdf 232.61 KB (Last Modified on July 6, 2020)

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Cystic Fibrosis Self-Medication Authorization Form

Cystic-Fibrosis-Self-Medication-Authorization-Form-3-2017.pdf 159.72 KB (Last Modified on July 6, 2020)

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Diabetes Health Care Plan

Diabetes Health Care Plan Rev. 08-2018.pdf 270.87 KB (Last Modified on July 6, 2020)

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Emergency Self-Medication Authorization Form

Emergency-Self-Medication-Authorization-Form.pdf 18.09 KB (Last Modified on July 6, 2020)

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Homebound Descrition of Services

Homebound Services

Homebound Description of Services Rev. 7-2014.pdf 304.32 KB (Last Modified on July 6, 2020)

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Homebound Parent Permission & Release Form

Homebound Services

Homebound Parent Permission Release Form Rev. 7-2014.pdf 271.83 KB (Last Modified on July 6, 2020)

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Homebound Parent Permission & Release Form in Spanish

Homebound Parent Permission Release SPANISH Rev. 7-2014.pdf 202.96 KB (Last Modified on July 6, 2020)

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Homebound Physician's Referral Form

Homebound Physicians Referral Form Rev. 7-2014.pdf 220.48 KB (Last Modified on July 6, 2020)

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Homebound School Referral Form

Homebound School Referral Form Rev. 06-2019.pdf 125.86 KB (Last Modified on July 6, 2020)

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Homebound Student Diagnosed with Emotional Form

Homebound Students Diagnosed with Emotional Disturbance.pdf 71.38 KB (Last Modified on July 6, 2020)

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Mealtime Needs Request Form-Temporary

Unique-Mealtime-Needs-Request-Form-Temporary-Rev.-08-2018.pdf 110.66 KB (Last Modified on July 6, 2020)

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Medical Statement for Students with Unique Mealtime Needs for School Meals

2018-Medical-Statement-Form.pdf 440.65 KB (Last Modified on July 6, 2020)

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NC Health Assessment Transmittal Form

NC-Health-Assessment-Transmittal-Form-January-2016rev.pdf 131.13 KB (Last Modified on July 6, 2020)

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NC Health Assessment Transmittal Form in Spanish

HA-Transmittal-Form-Parent-Sec-SPANISH.pdf 215.49 KB (Last Modified on July 6, 2020)

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Physician's Health Care Orders for School

Physicians Health Care Orders for School Rev. 6-2013.pdf 13.97 KB (Last Modified on July 6, 2020)

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Physician's School Medication Form

Physicians School Medication Form Rev. 05-2018.pdf 368.19 KB (Last Modified on July 6, 2020)

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Seizure Care Plan

Seizures-Care-Plan-Rev.-08-2018.pdf 451.94 KB (Last Modified on July 6, 2020)

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Severe Allergy Medication Plan

Severe-Allergy-Medication-Plan-Rev.-06-2018.pdf 267.58 KB (Last Modified on July 6, 2020)

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Short-term Medication Form

Short-term-Medication-Form-Rev.-05-2018.pdf 271.48 KB (Last Modified on July 6, 2020)

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Shunt Action Plan

Shunt-Action-Plan-Rev.-5-2015.pdf 131.34 KB (Last Modified on July 6, 2020)

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Sickle Cell Action Plan

Sickle-Cell-Action-Plan.pdf 56.59 KB (Last Modified on July 6, 2020)

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Two Way Consent for Exchange of Information

Two Way Consent for Exchange of Information Rev. 08-2017 -New Logo Added.pdf 189.92 KB (Last Modified on July 6, 2020)

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Contact Us

Health Services
Cumberland County Schools
2465 Gillespie Street
Fayetteville, NC 28306
910-678-2406
FAX: 910-483-7835

Shirley Bolden, MSA
Director of Health Services

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