Monthly Activities Report

Comprehensive School Health Services Program

Massachusetts Department of Public Health

Month and year in which these health encounters occurred

Month

Year

Enter the month and calendar year that the services were provided. (Do not enter the date you submitted the report. Do not enter the fiscal year or the school year.)

Public school district, school union, charter school, or collaborative

Nonpublic school

reset

School district

Select your school district, school union, charter school or collaborative. If your school is not in the list, scroll to the bottom of the list, select "Other", and enter the name of your school in the box that will appear below.

Submit a single report for the entire school district rather than a separate report for each school. School Unions: Submit one report that includes all the schools in the union and any related regional schools.

* must provide value

Type of encounter	Students	Staff
In-person
Remote (Virtual, telehealth)

Enter the number of encounters for nursing services this month.

Note: The number of in-person encounters is used to calculate the return to class rate which is the number of students returning to class divided by the total number of encounters. Each student visit to the health office or nursing assessment/intervention occurring outside health office (i.e. classroom, playground, cafeteria, etc.) counts as a SINGLE encounter, regardless of the number of procedures done or medications administered during that visit. Mandated screenings DO NOT count as visits. Students' seen more than once during the school day would be counted as a new encounter for every new visit.

1. Returned to class
2. Dismissed from school due to illness:
a. Non-emergency dismissal
b. 911 emergency dismissal
3. Dismissed from school due to injury:
a. Non-emergency dismissal
b. 911 emergency dismissal
4. Dismissed from school due to behavioral health:
a. Non-emergency dismissal
b. 911 emergency dismissal
c. Emergency Mobile Crisis Unit dismissal
5. Other disposition:
a. Stayed in health room
b. Referred to the counselor's office
c. Sent home to return later that day
d. Other
6. TOTAL (automatically calculated)*

*In this form, all numbers shown in red font are automatically calculated and do not indicate an error.

View equation

The number of students returned to class cannot be greater than the total number of in-person student encounters. Please check your data.

Returned-to-class rate		%
Automatically calculated

Type of injury	Students	Staff
Unintentional
Intentional
Intent Unknown`

Type	Students	Staff
Occurring during school-sponsored activities
Occurring during out-of-school activities

Number of emergency doses administered to staff and visitors this month:

Type of Emergency Medications	Staff	Visitors
1. Epinephrine
2. Glucagon
3. Naloxone (Narcan)

A. Number of daily and PRN prescriptions kept on file this month:

	Students
Type of Medication Prescriptions on File	Number of Scheduled Prescriptions*	Number of PRN Prescriptions
1. Analgesics
2. Antibiotics
3. Anticonvulsants
4. Antihypertensives
5. Antihistamines
6. Asthma
7. Epinephrine (non-asthma related)
8. Glucagon
9. Insulin
10. Naloxone (Narcan)
11. Psychotropic
12. Other Prescriptions
Total**

*Scheduled medications are those that are ordered to be given on a scheduled basis (QD, bid, q4h, etc.).

**In this form, all numbers shown in red font are automatically calculated and do not indicate an error.

B. Number of doses administered or supervised by school nurses, this month, for each of the following types of medication, based on usage:

	Students
Type of Medication Administered	Scheduled Doses Administered*	PRN Doses Administered
1. Analgesics
2. Antibiotics
3. Anticonvulsants
4. Antihypertensives
5. Antihistamines
6. Asthma
7. Epinephrine (non-asthma related)
8. Glucagon
9. Insulin
10. Naloxone (Narcan)
11. Psychotropic
12. Other Prescription Medication
13. OTC
Total**

* Scheduled medications are those that are ordered to be given on a scheduled basis (QD, bid, q4h, etc.).

OTC: Count over the counter medications that do not fall into one of the above medication categories

**In this form, all numbers shown in red font are automatically calculated and do not indicate an error.

Type of Communication	Length of Time	# of Communications
Parent / Guardian	< 15 Minutes
	≥ 15 Minutes
School Staff	< 15 Minutes
	≥ 15 Minutes
Community Agencies	< 15 Minutes
	≥ 15 Minutes
Group Meetings (With 2 or more of the above participants)	< 15 Minutes
	≥ 15 Minutes

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